Cesarean section (CS) is one of the most frequently performed surgical procedures in obstetric practice and serves as a critical intervention to reduce maternal and fetal morbidity and mortality.¹ Indicated when vaginal delivery poses risks to the mother or fetus, CS has transformed modern obstetric care by offering a controlled alternative in complicated pregnancies. However, the rising global and national trends in cesarean deliveries have sparked concerns over their judicious use, especially given the World Health Organization’s (WHO) recommendation of an optimal CS rate of 10–15% for achieving the best maternal and neonatal outcomes. Rates above this threshold, particularly in private urban facilities, are often linked with non-medical factors such as patient preference, medico-legal pressures, and provider convenience, leading to concerns over unnecessary surgical interventions and associated complications like infection, hemorrhage, and long-term reproductive issues².In India, the disparity in CS rates across rural and urban, public and private healthcare settings presents a complex scenario. Urban and private hospitals often report cesarean rates exceeding 40%, whereas rural and government centers sometimes fail to provide timely CS in emergencies due to limited access to trained professionals, infrastructure, and referral networks³. This dual burden reflects systemic healthcare inequities, where overuse in affluent areas coexists with underutilization in under-resourced regions, thereby affecting maternal and neonatal outcomes on both ends of the spectrum.CS procedures are broadly categorized into elective and emergency types, each with distinct clinical implications. Elective CS is planned and conducted before the onset of labor for indications such as previous CS, breech presentation, or placenta previa. These are usually performed under optimized conditions, leading to reduced perioperative risks and better maternal preparedness⁴. On the other hand, emergency CS is performed in response to urgent obstetric complications such as fetal distress, obstructed labor, or placental abruption. These are often done under stressful and time-constrained conditions, increasing the risk of surgical complications like hemorrhage, infections, uterine rupture, and adverse psychological outcomes.Neonatal outcomes also differ significantly between elective and emergency CS.⁵ While elective CS ensures fetal maturity and minimizes birth trauma, it can be associated with respiratory morbidities such as transient tachypnea due to absence of labor-mediated physiological adaptations. Emergency CS, however, often involves neonates compromised by intrapartum complications, leading to low Apgar scores, NICU admissions, and sometimes, perinatal mortality.The maternal psychological experience also varies. Women undergoing elective CS often report better emotional readiness and recovery, whereas emergency CS can result in psychological distress, postpartum depression, and dissatisfaction due to lack of control and fear during labor.⁶ These psychosocial factors are particularly important in postpartum care and maternal mental health.⁷Given the increasing reliance on CS and the regional disparities in access and outcomes, a nuanced understanding of the differences between elective and emergency cesarean deliveries is vital.

AIM

To compare maternal and fetal outcomes in antenatal women undergoing elective and emergency cesarean section.

This hospital-based cross-sectional study was conducted in the Department of Obstetrics and Gynaecology at S.P. Medical College and its Associate Group of Hospitals in Bikaner, Rajasthan, located in the north-western region of India. The study spanned a duration of six months, from September 2024 to February 2025. The study population comprised pregnant women admitted for both elective and emergency cesarean sections at the obstetric unit during the study period. A simple random sampling method was employed to select participants to ensure unbiased representation.

Inclusion criteria for the study were as follows: women aged 18 years and above, those who provided informed consent to participate, and those undergoing either elective or emergency lower segment cesarean section (LSCS), excluding cases involving classical cesarean sections. Additionally, only pregnancies beyond 32 weeks of gestation were considered eligible for inclusion. Conversely, the exclusion criteria included patients who declined to give consent, those undergoing classical cesarean sections, women below the age of 18 years, and pregnancies less than 32 weeks of gestation. This study design aimed to ensure the inclusion of cases representative of standard obstetric practice while excluding high-risk and preterm cases that could introduce bias in the analysis of maternal and neonatal outcomes.

Table 1:Distribution of the cases according to the age groups

Most patients in both emergency and elective cesarean groups were aged 20–24 years, with elective cases showing a slightly higher average age. The age difference between groups showed a near-significant trend (p = 0.054), suggesting a possible but not statistically strong variation.

Table 2: Distribution of the cases according to the Booking Status

A significant majority of emergency cases were unbooked (72%), while most elective cases were booked (57%), highlighting a clear contrast in prenatal care planning. This difference was statistically significant (p = 0.0001), indicating a strong association between booking status and type of cesarean delivery.

Table 3:Distribution of the cases according to the gravida

Nullipara women constituted the majority in emergency cases (62%), whereas primipara women were most common in elective cases (36%). The parity distribution difference was highly significant (p = 0.0001), indicating first-time mothers were more likely to undergo emergency cesarean deliveries.

Table 4:Distribution of the cases according to the History of previous CS

A history of previous cesarean section was significantly more common in elective cases (53%) compared to emergency cases (14%). This highly significant difference (p = 0.0001) suggests prior CS strongly influences the decision for planned elective cesarean deliveries.

Table 5:Distribution of the cases according to the Intraoperative Complication

Intraoperative complications were more frequent in elective cesarean sections (24%) than in emergencies (13%), with notable issues like bladder injury (4%) and adhesions (10%) occurring only in the elective group. Although PPH and blood transfusion rates were slightly higher in emergencies, the overall complication pattern differed significantly between the two groups.

Table 6:Distribution of the cases according to the Postoperative Complication

Post-operative complications were slightly more common in emergency cesarean sections (15%) compared to elective ones (9%), with higher rates of fever and blood transfusion in the emergency group. No maternal deaths or UTIs were reported in either group, and wound infections occurred only in emergencies.

Table 7:Distribution of the cases according to the APGAR Score at 1 Min. and 5 Min.

Newborns delivered by elective cesarean had significantly higher APGAR scores at both 1 and 5 minutes compared to those born via emergency CS. The statistically significant differences (p = 0.0001) suggest better immediate postnatal outcomes in elective deliveries.

Table 8:Distribution of the cases according to the NICU Admission

NICU admissions were significantly higher in the emergency group (43%) compared to the elective group (24%), reflecting increased neonatal complications in emergency deliveries. This difference was statistically significant (p = 0.007), indicating greater need for intensive care in emergency-born newborns.

Table 9:Distribution of the cases according to the fetal outcome

Table 9 shows the distribution of cases according to fetal outcomes in Group A (Emergency) and Group B (Elective). In the Emergency group, 91% of the newborns were alive and 9% expired. In the Elective group, 98% of the newborns were alive  and only 2% expired. A p-value of 0.091, suggesting that the differences in fetal outcomes between the two groups were not statistically significant.

In our study, the mean maternal age in the elective group was 26.68 years, compared to 24.94 years in the emergency group. Although not statistically significant, the trend indicates that older women are more likely to undergo planned CS. These findings were supported by Prah et al⁸. who found similar demographic trends, mean age was higher in women undergoing elective cesarean section (30.7±4.79 years) compared to emergency cesarean section (29.24±5.26 years) with p-value <0.001 which is statistically significant. In our study 28% of emergency cases were booked, while 57% of elective cases were booked (p = 0.0001). These findings supported by Nag et al., in which, 263 (90%) of emergency group were booked and 198 (95.2%) of elective group were booked (p = 0.04).

In our study 62 cases of emergency were nulliparous compared to only 34 cases in elective cesarean section (p = 0.0001). These findings were similar to Saini et al⁹., where 61 cases (59.8%) of emergency LSCS and 41 cases (40.1%) of elective cesarean section were nulliparous.

In our study the most common indication in group A (emergency CS) were fetal distress (35) and MSL with FD (35%) followed by eclampsia (16%) and the most common indication in group B (elective CS) were previous LSCS (39%) followed by primi breech with refused vaginal delivery (10%) and previous 2 LSCS (10%). Similar findings showed in Nag et al.¹⁰, in which emergency LSCS mostly done for fetal distress 120 cases (41%) and MSL 6 cases (9%) and elective LSCS most commonly done for previous LSCS (41%) and mal-presentation (26%). On the contrary findings from Thakur et al.¹¹, showed emergency LSCS was most commonly done for previous LSCS (46.44%) and for meconium stained liquor (11.82%). However similar observation founds for elective cesarean section in which most common indication was previous LSCS (78.87%) and breech (11.21%).

In our study A history of previous CS was present in (53%) of elective compared to (14%) of emergency cases (p = 0.0001). These findings were supported by Prah et al⁸., in which elective cesarean section were most frequently performed for previous cesarean section (78.5%).

In our study duration of hospital stay was significantly longer for emergency cesarean section (8.11±3.0 days) compared to elective cesarean section (7.42 ±1.48 days) with p value- 0.040. Similar observations drawn by Nag et al.¹⁰ in which average duration of hospital stay in emergency LSCS was 4.7 days compared to 4.57 days in elective cesarean section group. Which reflect that there is a need for longer stay in emergency LSCS due to higher complication rates. Similar findings drawn by Suwal et al¹². where mean duration of hospital stay for emergency cesarean section was 4.69±1.874 than 4.32±1.094 in elective cesarean section with p-value 0.044.

In our study total number of postoperative complication were 13% in emergency CS compared to 24% in elective CS in which need of blood transfusions was done in 9% cases in emergency CS and 6% in elective CS and PPH was seen in 3% cases in emergency and 2% cases of elective CS. However, adhesions (10%) and bladder injury (4%) found to be more common in elective CS than emergency CS. These findings were supported by Nag et al.¹⁰ who observed that need of blood transfusion were (4.8% vs 3.8%) more common in emergency CS however adhesions (37.6% vs 44.8%) and advancement of bladder (17.8% vs 20.7%) were more common in elective CS.

In present study total number of postoperative complication were 15% in emergency CS compared to 9% in elective CS; likewise wound infection were (1% vs 0%), fever (4% vs 1%), blood transfusion (10% vs 8%) are more common in emergency LSCS than elective LSCS. However, no cases of UTI and maternal death observe in either of the groups. Similar findings by Dernal et al.¹³ showed that PPH (18.8% vs 6.4%), wound infection (33.5% vs 7%), fever (11% vs 3.5%) and UTI (16.4% vs 2.3%), blood transfusion (14% vs 7.6%) were more common in emergency LSCS than elective LSCS. Bharti et al¹⁴. also observed similar findings where wound infection (4% vs 1%), fever (6% vs 1.5%) and UTI (8% vs 1.5%) were more common in emergency LSCS than elective LSCS.

In our study APGAR score at 1 minute were 6.92 ± 1.45 vs 7.66 ± 0.83 in emergency vs elective cesarean section respectively with p-value 0.0001 and APGAR score at 5 minutes were 8.16±1.42 vs 8.87±0.60 in emergency vs elective cesarean section respectively with p-value 0.0001. Similar trend supported by Nag et al.¹⁰ in which APGAR scores at 1 minute and at 5 minutes in emergency LSCS were 7 ± 1.4 and 8.6±0.6 and in elective LSCS it was 8±0.7 and 8.96 ± 0.37 with p-value <0.001 shows difference that is statistically significant which implies that emergency LSCS often associated with Low APGAR score.

In our study 24% new born in elective LSCS and 43% new born in emergency LSCS at NICU admission with p-value 0.007. These findings were supported by Nag et al¹⁰. in which NICU admission required more frequent in emergency than elective (32.5% vs 16.6%). Also Bharti et al. in which NICU admission more frequent in emergency than elective (18.5% vs 13.5%) the difference was not statistically significant (p=0.173).

In our study 91 and 98 new born were born alive and 9 and 2 new born were expired in emergency LSCS and elective LSCS respectively. These findings supported by Agarwal S. et al¹⁵. in which found that 1575 born alive and 69 had early neonatal death in emergency LSCS and 527 new born were alive and only 2 new born expired in elective LSCS indicating more adverse fetal outcome with emergency LSCS.

The present study concludes that emergency cesarean sections were associated with significantly higher rates of maternal and neonatal complications compared to elective cesarean sections. Emergency procedures were more frequently performed in younger, unbooked, and nulliparous women, often under critical obstetric conditions like fetal distress, meconium-stained liquor, and eclampsia. These factors contributed to poor outcomes, including longer hospital stays, increased need for blood transfusions, higher incidence of intraoperative and postoperative complications, and greater neonatal morbidity such as low APGAR scores and higher NICU admission rates. In contrast, elective cesarean, often performed for indications such as previous LSCS or malpresentation, were associated with better preparedness, fewer complications, and improved neonatal outcomes. These findings emphasize the critical importance of early antenatal registration, routine check-ups, and timely obstetric interventions to identify high-risk pregnancies and reduce the burden of emergency cesarean sections. Strengthening antenatal care systems and promoting institutional deliveries are essential strategies to improve maternal and fetal health outcomes in regions like North-Western Rajasthan.

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