Developing countries are exhibiting a trend towards later childbearing. Advanced age of the mother is a greater risk for their pregnancy outcome. 6 Pregnant women are also more prone to medical conditions that can adversely influence their health and that of their fetuses. Medical risks are related to an ageing reproductive system and an ageing body with decrease fertility and may be associated with pregnancy complications like hypertension, GDM, IUGR and many more and in elderly primigravida even the rate of the caesarean section also increased [1,2].

Maternal age at delivery and cesarean section rates are increasing. In older women, the decision on delivery mode may be influenced by a reported increased risk of surgical interventions during labor and complications with increasing maternal age [3].

It is not clear whether the increase in CS is caused by medical complications increasing with maternal age, or by maternal age per se. Evidence exists showing that even the rate of elective CS without medical indication increases with advancing maternal age. Health providers’ perception of maternal age as a risk factor may lower  the  threshold  for  CS  in advanced maternal age. In older women, a decision about  mode of delivery might be influenced by studies reporting an excess risk of prolonged labor, fetal distress, intrapartum CS, and operative vaginal deliveries [4,5,6].

The purpose of this study was to determine the Incidence of Cesarian Section in elderly gravida which would help us subsequently, in delineating the management of elderly gravid. 

AIMS AND OBJECTIVES

• To determine the Incidence of Cesarean Section in elderly gravida in tertiary care hospital.

• To determine the Indication of Cesarean Section in elderly gravida in tertiary care hospital.

This prospective study was carried out in the department of Obstetrics and Gynaecology at Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla for one year period from 1st July 2018 to 30th June 2019. 

Selection of Patients

All participants were divided into two groups

Group 1 (Study Group)

• All pregnant women with age 35 years or more.

• Patient admitted in labor room. 

• Women consenting for participation in the study.

Group 2 (Control Group)

• Every pregnant woman with age ≥20 to ˂35 years, who gets enrolled in the labor room admission register next to a case, was taken as a control.

Data Collection

Written consent was taken and counseling about the study was done of the women willing to participate in the study. Confirmation of pregnancy was done. Demographic information like age, socioeconomic status, indication and incidence of Cesarean Section was gathered. Comparative data of the two groups was subjected to statistical analysista.

A prospective study was conducted in the department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla, to study the pregnancy outcome at maternal age 35 years and older. Group 1 consisted of 415 subjects >35 years of age and Group 2 consisted of 415 subjects 20-34 years of age delivering in this hospital during one year period from 1st July 2018 to 30th June 2019. 

There were 6922 deliveries during this period, out of which 415 (6.00%) were in the age group 35 years and older.

It was observed that out of 415 subjects in the study group, 349 (84.10%) were in the age group of 35-39 years and 66 (15.90%) were in the age group of 40 years and above. The oldest patient was 44 years old. Mean age was 37.80+1.83 years. In the control group subjects were in the age group of 20-34 years of age. It was observed that out of 415 subjects in the control group, 117 (42.65%).

were in the age group of 20-24 years, 148 (35.66%) were in the age group of 25- 29 years and 90 (21.69%) were in the age group of 30- 34 years (Table-1).

Table 1: Age Distribution in Study and Control Group

In the Study Group out of 415 subjects, 87 had early pregnancy loss. Out of remaining 328 subjects, 28.96% landed in caesarean section. 16.16% had emergency LSCS, while 12.80% had elective LSCS.

In Control Group out of 415 subjects, 21 had early pregnancy loss. Out of remaining 394 subjects, 16.75% had caesarean section. 14.47% had emergency LSCS and 2.28% had elective LSCS. The p-value for elective LSCS and total LSCS was significant (Table 2).

Table 2: Type of Caesarean Section

It was observed that out of 415 subjects in both study and control group, 95 (28.96%) and 66 (16.75%) had caesarean section respectively. 26 (27.37%) and 18 (27.2%) had LSCS for acute fetal distress in study and control group respectively. The p-value was not significant (0.99). 9 (9.47%) subjects in study group and 18 (27.3%) in control group had LSCS for breech. The p-value was significant (0.003). 9 (9.47%%) subjects in the study group and none in the control group had LSCS for twin pregnancy with first twin breech. The p-value was significant (<0.05). 

9(9.47%%) subjects in the study group and none in the control group had LSCS for IUGR. The p-value was significant (<0.05) (Table 3).

Table 3: Indications for Caesarean Section

A prospective controlled study was conducted in The Department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla, to study the pregnancy outcome at maternal age 35 years and older. Study group consisted  of 415 subjects >35 years of age and control group consisted of 415 subjects 20-34 years of age delivering in this hospital during one year period from 1st July 2018 to 30th June 2019. There were 6922 deliveries during this period, out of which 415 (6.00%) were in the age group 35 years and older. 

In the present study the percentage of pregnant women aged >35 years was 6.00% In the studies conducted by Giri et al. [7] and Pawde et al. [8], the percentage was 4.53% and 9.63% respectively. The present study was conducted in Himachal Pradesh. Most of the women complete their family by the age of 24-25 years.

In the present study 28.96% subjects had caesarean section in the study group. It was comparable to Dixit and Mehendale, [9] (23.30%). The present study was conducted at a tertiary care center where high-risk cases come. Incidence was less as compared to that of study by Sahu et al. [10] (49.00%). 

The rate of caesarean section was 16.74% in control group. Elderly pregnancies are premium pregnancies. These women had attained their pregnancy at the age of decreasing fertility and often after years of infertility. This in turn influenced the decision in favour of caesarean section in an attempt to reduce the adverse maternal and perinatal outcome.

Women were induced so as to avoid adverse maternal and perinatal outcome. The incidence of caesarean section in the present study was 19.48% in 35-39 years age group which is less as compared to studies by Luke et al. [11] (24.8%). The incidence of caesarean section was less in the present study in women >40 years (40.91%) as compared to study by Luke et al. [11] (58.7%), as the sample size was small as compared to their study. This increase in the rate of caesarean section could be due to physician’s anxiety regarding the outcome of these "premium pregnancies". Even at the slightest maternal or fetal indication decision to intervene was undertaken.

Incidence of caesarean section was more in the study group (28.97%, p value=0.00009) as compared to control group (16.75%) and was statistically significant. The rate of elective caesarean section was higher in study group (12.80%) as compared to control group (2.28%) and was statistically significant. The most common indication for emergency caesarean section was acute fetal distress in both study group (49.06%, p value=0.06) and control group (31.58%) and was not statistically significant.

1. Tuck, Susan M., et al. “Pregnancy outcome in elderly primigravidae with and without a history of infertility.” BJOG: An International Journal of Obstetrics & Gynaecology, vol. 95, no. 3, March 1988, pp. 230-237. http://dx.doi.org/10.1111/j.1471-0528.1988.tb06862.x. 

2. Bako, Babagana, et al. “Pregnancy outcome in elderly primigravidae at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria.” International Journal of Medicine and Medical Sciences vol. 3, no. 7, 2013, pp. 476-480. https://internationalscholarsjournals.org/articles/3334426715092013.

3. Kovac, Jason R, et al. “The effects of advanced paternal age on fertility.” Asian Journal of Andrology, vol. 15, no. 6, August 2013, pp. 723-728. http://dx.doi.org/10.1038/aja.2013.92.

4. Herstad, Lina, et al. “Elective cesarean section or not? maternal age and risk of adverse outcomes at term: A population-based registry study of low-risk primiparous women.” BMC Pregnancy and Childbirth, vol. 16, no. 1, August 2016. http://dx.doi.org/10.1186/s12884-016-1028-3.

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6. Bell, Jacqueline S., et al. “Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? a retrospective analysis of routinely collected data.” BJOG: An International Journal of Obstetrics & Gynaecology, vol. 108, no. 9, September 2001, pp. 910-918. http://dx.doi.org/10.1111/j.1471-0528.2001.00214.x. 

7. Giri, Amrita et al. “Advanced maternal age and obstetric outcome.” Nepal Medical College Journal, vol. 15, no. 2 2012, pp. 87-90. https://pubmed.ncbi.nlm.nih.gov/24696922/.

8. Pawde, Anuya A., et al. “Pregnancy in women aged 35 years and above: A prospective observational study.” The Journal of Obstetrics and Gynecology of India, vol. 65, no. 2, October 2014, pp. 93-96. http://dx.doi.org/10.1007/s13224-014-0616-2.

9. Dixit, P. V., and M. A. Mehendale. “Study of Pregnancy Outcome in Elderly Gravida”. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, vol. 6, no. 12, Nov. 2017, pp. 5384-5389, http://dx.doi.org/10.18203/2320-1770.ijrcog20175247.

10. Sahu, T. M., et al. “Advanced Maternal Age and Obstetric Outcome.” The Journal of Obstetrics and Gynecology of India, vol. 57, no. 4, 2007 pp. 320-323. https://jogi.co.in/storage/files/advanced-maternal-age-and-obstetric-outcome.pdf.

11. Luke, Barbara, and Morton B. Brown. “Elevated risks of pregnancy complications and adverse outcomes with increasing maternal age.” Human Reproduction, vol. 22, no. 5, February 2007, pp. 1264-1272. http://dx.doi.org/10.1093/humrep/del522.