Is a rising caesarean section rate inevitable?

Objective To determine the indications for singleton caesarean sections in Scotland in 1994. Design Prospective survey of singleton caesarean sections using information provided by clinicians entering data onto a computer in labour wards. Setting Twenty-three consultant-led obstetric units in Scotland. Population Women undergoing caesarean section in participating Scottish maternity units during 1994. Results Using routinely collected data it was found that the caesarean section rate varied by maternal age, parity, gestation, history of previous section and hospital of delivery, but there was no difference by area of deprivation. 87.4% (8369/9573) of Scottish caesarean sections were included in the survey of which 8098 were in women with singleton pregnancies. Most singleton caesarean sections were undertaken in primiparae (50.5%), 31.2% were in women with a history of previous section and 18.3% were in multiparous women who had not had a previous section; 38.9% of the operations were elective, 13.9% were emergencies before labour and 47.2% were emergencies during labour. Four main indications-elective section for breech presentation (10.7% of all sections); emergency caesarean section before labour because of fetal problems (2.8%); emergency caesarean section during labour for fetal distress and/or failure to progress (30.3%); repeat section for reasons other than above (16.2%) accounted for 60% of all caesarean sections in women with no other recorded complications. 7.7% of all singleton caesarean sections (19.8% of elective operations) were associated with maternal request for the operation. Discussion The survey has identified why caesarean sections are performed by Scottish obstetricians and highlighted some areas where there would be scope to increase the vaginal delivery rate. Before this can be attempted, agreement must be reached by clinicians about effective management of particular problems. Women also need to have ready access to evidenced-based information about caesarean section.