Caesarean birth rates worldwide. A search for determinants.

High caesarean birth rates are an issue of international public health concern. Determinants of caesarean birth are reviewed in order to formulate strategies to reduce these high rates. A strong independent profession of highly qualified midwives, who care for women with low-risk pregnancies, may contribute to a relatively low caesarean birth rate. Different clinical policies which influence the intervention rate, are discussed for the most frequent reasons to perform caesarean section: dystocia, repeat caesarean birth, breech delivery and foetal distress. The risks and safety of caesarean birth differ from place to place in this world. As the relative safety of the procedure is an important factor contributing to the rise of caesarean birth, the fact that this has only been achieved in some parts of the world should restrict the indications to perform the operation in the best interests of pregnant women.

PIP: High cesarean birth rates are a matter of concern to international public health. Determinants of cesarean birth are reviewed and different clinical policies are discussed for the most frequent reasons to perform cesarean section: dystocia, repeat cesarean birth, breech delivery, and fetal distress. The most frequent indication for cesarean section is dystocia, although in some cases of the lesser degrees of cephalopelvic disproportion, symphysiotomy can be practiced. Repeat cesarean births account for a high percentage of the total number of operations. Of 45,425 births to women with previous cesarean sections in California in 1986, 89% had a repeat cesarean birth in subsequent pregnancies. However, a trial of vaginal labor is safe for women with a history of cesarean birth. The risks involved in breech delivery have led to an increasing number of elective cesarean sections. The use of the operation should be less liberal when the maternal mortality rate after the operation exceeds 1-2/1000. For that reason, one should be reluctant to perform an operation for fetal distress, which often cannot be diagnosed properly. Strong arguments call for reluctance in applying new indications for cesarean section, for instance, in all triplets pregnancies, in order to prevent vertical transmission of HIV-infection, or a transverse lie in a second twin. The mortality rate after cesarean section in women in a Nigerian teaching hospital (0.6%) is still six times higher than the mortality rate after the operation in the West (0.1%). Serious maternal morbidity after the operation occurs in 9-15% of cesarean sections in the Third World. Cesarean section can also lower fertility rates compared to vaginal birth. In other parts of the world, cesarean section has not yet become the safe procedure as it is considered in the West, thus alternative procedures should be performed such as version and extraction, vaginal breech or instrumental delivery, and symphysiotomy.

Findings in 200 consecutive asymptomatic women, having a laparoscopic sterilization.

Laparoscopic findings in 200 asymptomatic, healthy women having a sterilization were recorded; 148 patients (74%) had no abnormality and 52 patients had abnormalities comprising pelvic adhesions (14%), uterine fibromyomas (5%), endometriosis (3%) and ovarian or parovarian cysts (2%).

PIP: To place diagnostic laparoscopy in perspective, laparoscopic findings in 200 consecutive healthy women having laparoscopic sterilization by clips or rings were recorded. The subjects all had regular menses and a normal pelvic exam. 148 had no pathology on laparoscopy. 52 remaining women had adhesions (28, 14%), hydrosalpinx (3), ovarian cyst (3), endometriosis (5), fibromyomas (10, 5%), parovarian cyst (1), benign bladder tumor (1), and carcinoid bowel tumor (1). 43% of the adhesions were moderate or severe; 26% were associated with history of appendectomy; 68% were located outside the small pelvis. These findings are comparable to those published in 2 other series. They are relevant to management to patients complaining of chronic pain or infertility.

[Perforation of the uterus caused by copper-containing IUD's]. / Perforatie van de uteruswand door koperhoudende IUD's.

PIP: Case reports are presented for 2 patients in whom copper-containing IUDs had penetrated through the uterine wall into the abdominal cavity. It is pointed out with reference to reports in the literature that laparoscopic removal is frequently impossible and may also be dangerous because of the marked peritoneal reaction surrounding the copper part of the IUD. The results could be adhesions and infiltration. A scheme is proposed for the treatment of patients who are suspected of perforation by a copper-containing IUD. Authors' modified)^ieng

[An unknown type of IUD without strings]. / Een IUD zonder teugel van onbekend type.

PIP: A 24-year-old Vietnamese boat refugee went to a physician to have her IUD removed. There was no control thread, and X-rays showed an IUD of unknown type in situ. The IUD could not be removed with a Wilbaut hook, so curettage was performed to extract the IUD, which could not be identified. It is possible that other Vietnamese refugees are using the same type of IUD.^ieng