Exploring the impact of indication on variation in rates of intrapartum caesarean section in six Palestinian hospitals: a prospective cohort study

Abstract Background Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. Methods Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. Results Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40–0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. Conclusion The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary

Evaluation of Accuracy of Episiotomy Incision in a Governmental Maternity Unit in Palestine: An Observational Study

Episiotomy should be cut at certain internationally set criteria to minimize risk of obstetric anal sphincter injuries (OASIS) and anal incontinence. The aim of this study was to assess the accuracy of cutting right mediolateral episiotomy (RMLE). An institution-based prospective cohort study was undertaken in a Palestinian maternity unit from February 1, to December 31, 2016. Women having vaginal birth at gestational weeks ≥24 or birthweight ≥1000 g and with intended RMLE were eligible (n=240). Transparent plastic films were used to trace sutured episiotomy in relation to the midline within 24-hour postpartum. These were used to measure incisions’ distance from midline, and suture angles were used to classify the incisions into RMLE, lateral, and midline episiotomy groups. Clinical characteristics and association with OASIS were compared between episiotomy groups. A subanalysis by profession (midwife or trainee doctor) was done. Less than 30% were RMLE of which 59% had a suture angle of <40° (equivalent to an incision angle of <60°). There was a trend of higher OASIS rate, but not statistically significant, in the midline (16%, OR: 1.7, CI: 0.61–4.5) and unclassified groups (16.5%, OR: 1.8, CI: 0.8–4.3) than RMLE and lateral groups (10%). No significant differences were observed between episiotomies cut by doctors and midwives. Most of the assessed episiotomies lacked the agreed criteria for RMLE and had less than optimal incision angle which increases risk of severe complications. A well-structured training program on how to cut episiotomy is recommended

Incidence and risk factors of unanticipated pathology in cases of hysterectomy for benign lesion a cross-section study in Al Shifa Medical Complex

Objective: To measure the incidence of unanticipated gynecologic malignancies among women who underwent hysterectomy for benign indications. Methods: We conducted a data analysis of hysterectomy cases from the medical files as well as from pathology reports in the pathology department in Al Shifa Medical Complex. Cases were abstracted from 1st January 2019 to 30th December 2020. Preoperative surgical indications included abnormal uterine bleeding (AUB), fibroid, endometrial malignancy, ovarian mass, prolapse, molar pregnancy, and adenomyosis. Results: During the study period, 195 women underwent a hysterectomy. More than 50% were performed for fibroid and abnormal uterine bleeding (AUB). The incidence of unanticipated gynecologic malignancy among hysterectomies performed for benign indications was 3.06% (6 cases). Three of them underwent hysterectomy due to post-menopausal bleeding with no preoperative endometrial sampling. Main risk factor were age, anemia, previous medical disorder, lack of equipments, and insufficient preoperative investigations or risks assessments that we considered it an important factor for the development and concealment of pre-existing malignant growth which will lead to future complicated medical plan and management to control the situation. Conclusion: Unanticipated pathology in this study was mainly due to incomplete preoperative assessment and workup including diagnostic imaging modalities and D&C biopsy. This workup should be done for all cases before hysterectomy, especially in old-age women with postmenopausal bleeding. Our study indicates that even in cases that are expected to be benign, nothing should be overlooked, and detailed preoperative evaluations should be performed