Rationalizing the use of caesarean section in Egypt through implementing 10 group Classification system

Will follow here the NICE guidelines (16)

1- Breech presentation

Cs should be offered to pregnant women with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been unsuccessful

On the other hand, Women who have an uncomplicated singleton breech pregnancy at 36 weeks' gestation should be offered external cephalic version Except ( women in labour and women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding or medical conditions.

2- Cs in multiple pregnancy

This include twin pregnancy (with all variants ) and triple pregnancy

A)    Twin pregnancy ( dichorionic diamniotic or monochorionic diamniotic )

1-     Discus and explain to women with an uncomplicated twin pregnancy planning their mode of birth that planned vaginal birth and planned caesarean section are both safe choices for them and their babies if all of the following apply:

·        the pregnancy remains uncomplicated and has progressed beyond 32 weeks

·        there are no obstetric contraindications to labor

·        the first baby is in a cephalic (head-first) presentation

·        there is no significant size discordance between the twins.

2-     Caesarean section is recommended to women if the first twin is not cephalic at the time of planned birth either full term or preterm between 26 and 32 weeks

3-     Offer an individualized assessment of mode of birth to women in suspected, diagnosed or established preterm labor before 26 weeks taking into account the complications of cs and neonatal standards.

B)      Twin pregnancy: monochorionic monoamniotic

Offer a caesarean section to women with a monochorionic monoamniotic twin pregnancy:

·        at the time of planned birth

·        after any complication is diagnosed in her pregnancy requiring earlier delivery

·        if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies (unless the first twin is close to vaginal birth and a senior obstetrician advises continuing to vaginal birth)

 C )       Triplet pregnancy  Cs should be done in cases of

·       At the time of planned birth

·         After any complication is diagnosed in her pregnancy requiring earlier delivery

·       If she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies.

3- Placenta Previa

Women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia) should be offered CS.

4- Morbidly adherent placenta Morbidly adherent placenta

Cs is the role here however obstetrician should ensure that:

•  A consultant obstetrician and a consultant anaesthetist are present

•  An experienced paediatrician is present

•  A senior haematologist is available for advice

•  A critical care bed is available

•  Sufficient cross-matched blood and blood products are readily available.

All hospitals should have a locally agreed protocol for managing morbidly adherent placenta that sets out how these elements of care should be provided and the decision with conservative surgery of hysterectomy should be balanced .

5- Predicting CS for cephalopelvic disproportion before labour

Is not accurate method for assessment and should not be considered indication of cs .

6- Mother-to-child transmission of maternal infection

-HIV/AIDS

-  Do not offer a CS in the following conditions( as the risk of transmission is the same with vaginal and cs delivery )

•  if Women on highly active anti-retroviral therapy (HAART) with a viral load of less than 400 copies per ml

•  Women on any anti-retroviral therapy with a viral load of less than 50 copies per ml.

-  Offer a CS to women with HIV who:

•  are not receiving any anti-retroviral therapy

•  are receiving any anti-retroviral therapy and have a viral load of 400 copies per ml or more.

- Hepatitis B virus

Not an indication for cs

- Hepatitis C virus

Alone is not indication for cs

Cs indicated if it is co-infected with HIV

-Herpes simplex virus Herpes simplex virus

Cs is indicated in primary genital infection in the third trimester

7-    Other emerging factor for conduct of cs

Legal aspects

Over the past decades, the mode of delivery has increasingly become a matter of risk- orientated, defensive obstetric practice. This must largely be seen as a consequence of the increase in guidelines and regulations. The costs of damage claims can at present can be very high in the whole world an in in Egypt in addition to legal responsibilities. (15)

Maternal request for CS

Cesarean delivery on maternal request that is defined as an elective cesarean in the absence of any medical or obstetric contraindication for attempting vaginal delivery (17,18)—is the most frequently cited reason for the increasing incidence of cesarean sections . C certainly, recent years have seen an increase in mothers expressing a wish for cesarean delivery on the basis of assumed advantages compared to vaginal delivery (15)

CS on maternal request is usually a result of anxiety about childbirth and it should be notice that the newly coined term “tocophobia” is mainly used in Scandinavia and the Anglo-American countries to describe strong fear of spontaneous childbirth.. The incidence of this unfortunately named condition is cited as between 6% and 10% (19,20

). every effort should be done including referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner however  if after discussion and perinatal mental  health