{'fraction_non_alphanumeric': 0.019492868462757527, 'fraction_numerical': 0.007765451664025357, 'mean_word_length': 5.085824493731919, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Changing trends in the indications of obstetric hysterectomies in teaching rural hospital

Obstetric hysterectomy (OH) means surgical removal of uterus during ante partum, intra partum or postpartum period due to various obstetric complications. OH, still poses a major obstetrical morbidity in the developing world due to lack of human, infrastructural and monetary resources. Irrespective of attempts like good antenatal care and delivery planning in modern obstetrics to prevent major obstetric complications; unfortunately, OH needs to be performed at times even today.


INTRODUCTION
Obstetric hysterectomy (OH) means surgical removal of uterus during ante partum, intra partum or postpartum period due to various obstetric complications. OH, still poses a major obstetrical morbidity in the developing world due to lack of human, infrastructural and monetary resources. Irrespective of attempts like good antenatal care and delivery planning in modern obstetrics to prevent major obstetric complications; unfortunately, OH needs to be performed at times even today. rate of caesarean section which was around 100% in the beginning. The first OH was performed by Horatio R. Storer in 1868 for obstruction in birth canal by a uterine tumor, but patient died on the third post-operative day. 1 Eduardo Porro was the first to perform OH on a patient who survived it. Up to 1922, 25% of caesarean deliveries were performed as Porro's caesarean hysterectomies.
Patients requiring OH represent large proportion of critical patients coming to obstetrics units. Its management involves coordinated team work, anesthetic skills, promptness, round the clock blood transfusion services, good operative skills and post-operative critical management. The study of these cases gives opportunity to improve the above aspects as well as to extend the necessary preventive services to the needy. Majority of indications for OH are Atonic postpartum hemorrhage, ruptured uterus and placental disorders.
In the present study the patients undergoing OH at Shri. Bhausaheb Hire Govt. Medical College and Hospital, Dhule in two different period intervals were analysed to find out the changing trends in incidence and the indications.

METHODS
This study was conducted in the Department of Obstetrics and Gynecology, Shri. Bhausaheb Hire Government Medical College and Hospital, Dhule, Maharashtra, India. This hospital caters mainly for the patients from tribal and rural areas. Study design was retrospective in nature where data was collected from labor ward and operation theatre records. The surgical removal of the uterus at the time of planned or unplanned caesarean delivery or at exploratory laparotomy or in the immediate postpartum period was considered as obstetric hysterectomy (OH). All the patients' records subjected to OH from January 1994 to September 2001 (Group A) and from January 2006 to December 2015 (Group B) were collected and analyzed. The data collected and analyzed was total no. of deliveries, number of caesarean sections, no. of OH, age of mother, parity, indication for OH and associated co morbidities during above two period intervals. Study was approved by Institutional ethical committee.

Statistical analysis
Quantitative analysis of the data was done. Descriptive analysis which includes frequency distribution showing number and percentages were generated for each identified variable. Statistical tests like Chi Square and probability were applied when indicated and the occurrences were compared. However, OH among women undergone caesarean deliveries was not significantly reduced. Higher proportion of OH among women more than 30 years of age was noted. The difference in the proportion was statistically non-significant. High proportion of OH among multiparous women was observed. The difference in the proportion was statistically significant. As uterine rupture was indication for OH in 2/3 rd cases of Gr. A, prolonged or obstructed labor and malpresentations were common associated risk factors than Gr. B. Over the years it was observed that uterine rupture as the cause for OH was reduced significantly in the recent past, while miscellaneous causes such as broad ligament hematoma, sepsis and ectopic pregnancy etc were increased during recent years. It was noted that OH was significantly reduced among prolonged or obstructed labor and fetal malpresentations cases. Most cases among malpresentations were neglected cases of transverse lie with hand prolapsed. There is no significant change in preeclampsia as a risk factor.

DISCUSSION
From Table 6, it is obvious that the incidence of OH has reduced by more than three folds in Gr. B and this is statistically significant (p<0.0001).
Similar statistically significant decline in incidence of OH is seen in patients delivered vaginally.
The incidence of OH at our institute is comparable with that of various series worldwide with definitive decline in the incidence over the years.
This reduction in incidence is mainly due to reduction in frequency of number of uterine rupture cases from 78.16% in Gr. A to 43.24% in Gr. B as shown in Table 7.  A. Rupture uterus is still the leading indication for OH in Gr. B. This suggests increased incidence of caesarean deliveries over the period leading to more cases of abnormal placentation and scar rupture during VBAC. Even though there is reduction in the incidence of OH in Gr. B, it is still more than that of developed countries. Hence there is further need to improve infrastructure and provide qualified manpower in peripheral hospitals so that definitive management of high risk cases is made available at First Referral Units rather than referring them to tertiary health care facilities.

CONCLUSION
Over the years the incidence of OH has statistically reduced with significant reduction in incidence of uterine rupture and prolonged or obstructed labor. The incidence of rupture uterus has increased in scarred uterus, while reduced in vaginal deliveries. There is no reduction in preeclampsia as risk factor. There is increase in the incidence of uncontrolled PPH and placental causes leading to OH. OH is a lifesaving procedure but decision should be prompt and performed by an experienced surgeon. Every obstetrician should be trained to perform this procedure.