Do All Hospitals Need Cesarean Delivery Capability?

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Original Research

Do All Hospitals Need Cesarean Delivery Capability?

J Fam Pract. 2002 February;51(2):129-134

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References

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Perinatal mortality

The perinatal mortality rate for the population was 11.4 per 1000 births (95% CI, 5.1-17.8 by Poisson distribution), comparable to the 1991 nationwide peri-natal mortality rate of 12.8/1000.¹⁴ Nine of the 13 neonatal deaths were caused by intrauterine fetal demise before labor (Table 2). The Zuni-Ramah Hospital–based perinatal mortality rate of 1.2/1000 was comparable with the 1.3/1000 perinatal mortality rate for women in the National Birth Center study even though Zuni-Ramah Hospital accepts higher-risk patients.¹⁵

TABLE 2
PERINATAL MORTALITY IN ZUNI-RAMAH POPULATION

Age (wk)	Weight (g)	Site	Cause
Intrauterine Fetal Death
31	1410	GIMC	Unexplained
39	3130	GIMC	Unexplained
35	1540	GIMC	Unexplained; IUGR
35	1690	GIMC	Unexplained; IUGR
21	330	GIMC	PPROM
21	560	GIMC	PPROM
41	3040	GIMC	Oligohydramnios and post dates. Two days prior, refused induction with amniotic fluid volume index of 3.8
28	1290	Alb	Abruption
32	Unknown	Zuni	Necrotizing/calcifying encephalopathy (probable CMV) with severe IUGR
Early Neonatal Death (< 7 days)
38	2805	Alb	Osteogenesis imperfecta
31	Unknown	Alb	Potter’s syndrome
Late Neonatal Death (7 to 27 days)
35	1590	GIMC	Pulmonary interstitial emphysema caused by respiratory failure of unknown etiology/IUGR
41	3220	GIMC	Sepsis at 12 days; had been discharged home as healthy infant
Alb denotes Albuquerque tertiary-care hospital; CMV, cytomegalovirus; GIMC, Gallup Indian Medical Center; IUGR, intrauterine growth restriction; PPROM, preterm premature rupture of membranes.

Neonatal morbidity

Measures of neonatal morbidity are summarized in Table 3. The frequency of 5-minute Apgar scores below 7, low birthweight, and prematurity compares favorably with 1996 US rates.¹³ The rate of assisted ventilation (intubation or bag-mask) for the entire population (4.6%, n = 52) is greater than the 1996 nationwide rate (2.9%), although the difference is of questionable clinical significance, since international studies have demonstrated a range for assisted ventilation of 1% to 10% of hospital births.¹⁶ Neonatal Intensive Care Unit (NICU) transfer occurred in 27 (2.4%) of deliveries from non-tertiary-care sites. Thirteen (1.8%) babies born at Zuni-Ramah were transferred to Albuquerque for NICU care because of respiratory distress (n = 10) or neonatal anomalies (n = 3). The 3 cases of low Apgar scores at Zuni-Ramah were attributed to pneumothorax, respiratory distress syndrome of prematurity, and sepsis with meconium aspiration.

TABLE 3
NEONATAL MORBIDITY IN ZUNI-RAMAH POPULATION, BASED ON LIVE BIRTHS

	Zuni-Ramah Hospital (N=732)	Zuni-Ramah Population (n = 1128)	1996 US Population
5-minute Apgar score < 7	3 (0.41%), P = .023	6 (0.54%), P = .014	1.4%
Assisted ventilation	19 (2.6%), P = 0.62	52 (4.6%), P < .001	2.9%
Birthweight < 2500 g	14 (1.9%), P < .001	61 (5.4%), P < .001	11%
Preterm (37 weeks)	22 (3.0%), P < .001	75 (6.7%), P = .36	7.4%
P values are based on comparison with the US population. US population figures for 1996 were extracted from Ventura SJ, Martin JA, Curtin SC, Mathews TJ. Report of Final Natality Statistics, 1996. Monthly vital statistics report; vol 46, no 11, supp. Hyattsville, Md: National Center for Health Statistics, 1998.

Obstetric risk factors

The study population had a greater incidence of pregnancy-induced hypertension (14.5% vs 2.6% by 1996 ACOG criteria¹⁷), chronic hypertension (2.7% vs 0.7%¹⁵), and diabetes (9.2% vs 2.6%¹⁵) than the average US obstetric population. Gestational diabetes was diagnosed according to National Diabetes Data Group criteria:¹⁸ 7.1% had gestational diabetes (class A₁ and A₂ ) and 2.1% had type 2 antepartum diabetes (classes B and C).

Outcomes of obstetric emergencies at zuni-ramah hospital

We reviewed all cases of placental abruption, uterine inversion, umbilical cord prolapse, and fetal distress at Zuni-Ramah Hospital to identify potentially preventable adverse outcomes caused by lack of operative facilities (Table W1). Umbilical cord prolapse and uterine inversion each occurred once and were appropriately managed, with excellent outcomes. In 3 of the 4 cases of placental abruption, there were clearly no adverse outcomes caused by lack of on-site operative facilities, as patients were expectantly managed upon arrival to the referral hospital (cases 3 and 4) or presented to Zuni-Ramah Hospital as an intrauterine demise (case 5).

The fourth patient with placental abruption (case 6) presented at Zuni-Ramah with vaginal bleeding, severe variable decelerations, and a 10-point drop from baseline hematocrit. She was scheduled to labor at GIMC because of a history of prior cesarean but presented to the Zuni-Ramah emergency room with vaginal bleeding. She was transferred to GIMC for an anticipated cesarean delivery; however, on arrival the patient rapidly progressed and gave birth to an infant vaginally with Apgar scores of 3 and 9. Her infant had a neonatal seizure and magnetic resonance imaging evidence of sagittal sinus thrombosis. The infant had a normal neurologic evaluation, developmental assessment, and electroencephalogram at 15 months.

We reviewed 5 cases of urgent transfer for fetal distress. These were differentiated from the 8 intrapartum transfers for NRFHTs based on the severity of fetal heart monitor tracings. Four of the 5 women who had been transferred for fetal distress gave birth to healthy infants vaginally more than 2 hours after arrival at the referral institution. One patient who was urgently transferred for repetitive late decelerations is discussed below.