Delivery by caesarean section

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7318.930/a (Published 20 October 2001) Cite this as: BMJ 2001;323:930

Increased numbers of caesareans do not match diagnoses of fetal distress

  1. Ashis Banerjee, senior house officer public health,
  2. James Hollinshead, senior house officer public health (james.hollinshead@wsha.nhs.uk),
  3. Edward Williams, consultant public health
  1. Public Health Department, West Sussex Health Authority, Worthing, West Sussex BN12 6BT
  2. Department of Maternal Fetal Medicine
  3. Division of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
  4. St Michael's Hospital, Bristol BS2 8EG
  5. Northwick Park Hospital, Harrow HA1 3JU
  6. Chelsea and Westminster Hospital, London SW10 9NH
  7. Leicester Royal Infirmary, Leicester LE1 5WW
  8. Poole Hospital, Poole BH15 2JB
  9. Northwick Park Hospital, Harrow HA1 3JU
  10. Department of Obstetrics and Gynaecology, Luton and Dunstable Hospital, Luton, Bedfordshire LU4 0DZ
  11. Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire St Pierre, Free University of Brussels, Brussels 1000, Belgium
  12. AlgoPlus Consulting Limited, Halifax, Canada B3J 1H6
  13. Department of Public Health, Unit of Perinatal and Paediatric Epidemiology, University of Liverpool, Liverpool L69 3GB
  14. Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford OX3 9DU
  15. Maternity Unit, Bradford Hospitals NHS Trust, Bradford BD9 6RJ
  16. BMJ

    EDITOR—MacKenzie and Cooke say that the main documented indication for intrapartum caesarean section is fetal distress.1 Tuffnell et al looked at how the interval between the decision to perform an emergency caesarean section and the time of delivery affected fetal outcome.2 They concluded that a delayed decision to delivery time was an unusual cause of neonatal problems.

    To help put these papers into context, we looked at the West Sussex births database of 152 284 births between 1980 and 1999. Over this period, the diagnosis of fetal distress has doubled from 6.4% to 13% of all births, and the percentage of caesarean sections has increased from 9.7% to 20.2% of all births. The proportion of caesarean sections where a diagnosis of fetal distress is recorded has increased from 15.4% to 19.3% of all caesarean sections. This implies that increasing numbers of caesarean sections are being performed for fetal distress. The doubling in the rate of diagnosis of fetal distress is unlikely to reflect a true increase in the incidence of this condition. There is no evidence that changes in maternal health or clinical care could explain such a dramatic rise. This implies that the diagnosis of fetal distress is imprecise.

    We then investigated if the diagnosis of fetal distress was a valid test in predicting poor fetal outcome, which was defined as a one minute Apgar score of less than 5. From 1980 to 1999, only 18% of cases diagnosed with fetal distress subsequently had a poor fetal outcome (table). Over the same period, 74% of babies born with an Apgar score of less than 5 did not have a prepartum diagnosis of fetal distress. Therefore, the diagnosis of fetal distress is not a sensitive test for predicting poor fetal outcome (sensitivity 26%, specificity 92%). This is true …

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