Caesarean section is an obstetric operation when vaginal birth would expose the mother or fetus to unacceptable risk. Appropriate access can prevent avoidable harm, but the clinical need for surgery should guide decisions rather than a predetermined institutional rate. WHO emphasizes medically justified care and recommends consistent monitoring of caesarean use.¹

Global estimates show growth in caesarean delivery alongside persistent inequalities in access. National and regional trends reflect differences in population characteristics, clinical practice, and health systems, making a single rate insufficient to explain whether care is appropriate.² At hospital level, identifying the indications recorded for surgery can provide a starting point for examining local practice and planning detailed audit.

Caesarean delivery also has implications beyond the current pregnancy. A systematic review describes associations with maternal pelvic floor outcomes, childhood health, and complications in subsequent pregnancies, while recognizing limitations in establishing causality from observational evidence.³ These competing considerations reinforce the need for individualized counselling and clear documentation of the reason for delivery.

Previous caesarean section frequently contributes to subsequent operative births. Guidance on vaginal birth after caesarean delivery supports assessment of suitability, counselling about benefits and risks, and consideration of the resources required for safe intrapartum care.⁴ A previous scar alone therefore does not describe the complete decision process. The nature of the scar, obstetric circumstances, preferences, and capacity for emergency intervention all matter.

Labour dystocia and concern about fetal status are other important indications. Contemporary guidance on labour management distinguishes normal variation from arrest and places emphasis on appropriate assessment before operative delivery.⁵ Broader caesarean guidance similarly addresses clinical assessment, informed discussion, procedural care, and recovery.⁶ Consistent operational definitions are needed so that categories such as fetal distress, prolonged labour, and oligohydramnios remain interpretable across studies.

Evidence from a population-based investigation in Bangladesh illustrates that caesarean indications occur within a wider context of clinical and socioeconomic determinants.⁷ WHO recommendations on non-clinical interventions recognize the contribution of professional practice, organizational systems, and women's information needs to potentially avoidable surgery.⁸ These influences cannot be inferred directly from a small hospital series, but they identify relevant questions for subsequent investigation.

For standardized audit, the Robson classification groups women using routinely recorded obstetric characteristics and permits comparisons within and between facilities.⁹ Repeated caesarean delivery also deserves attention because systematic evidence associates increasing numbers of operations with greater maternal morbidity.¹⁰ Gestational age is relevant to planning birth, and recommendations on induction at or beyond term provide context for evaluating post-date presentations.¹¹

This study described selected indications for caesarean section among women at Lady Reading Hospital, Peshawar, and examined their distribution by age, parity, gestational age, and socioeconomic status. Its purpose was to characterize the enrolled surgical population and identify patterns warranting further clinical review.

This cross-sectional study was conducted in the Department of Obstetrics and Gynaecology, Lady Reading Hospital, Peshawar, from 22 September 2022 to 21 March 2023. A total of 121 women undergoing caesarean section were enrolled using consecutive non-probability sampling. The reported WHO software calculation used an expected post-date pregnancy proportion of 13%, a 95% confidence level, and 6% absolute precision. Eligible women were aged 18–40 years, had an ultrasound-confirmed singleton pregnancy, and had a gestational age above 36 weeks based on the last menstrual period. Women of any parity were eligible. Congenital fetal anomalies detected on ultrasound and uterine rupture were exclusion criteria. Institutional ethical approval and written informed consent were reported; the approval identifier was not supplied. Although recruitment allowed women aged 18–40 years, the reported age categories began at 20 years. This difference requires confirmation against the recruitment records. Maternal age, parity, gestational age, and socioeconomic status were documented using a structured proforma. Poor socioeconomic status was defined as monthly family income below PKR 20,000. The recorded indications were repeat caesarean section, fetal distress, prolonged labour, oligohydramnios, and post-date pregnancy. The source manuscript refers to operational definitions, but their complete thresholds were not included. It is also unclear whether indications were mutually exclusive or how a primary indication was assigned when more than one was present. Data were analysed in SPSS version 25. Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentages. Indications were stratified by age, parity, gestational age, and socioeconomic status. Chi-square tests were reported, with p < 0.05 considered statistically significant. The analyses were unadjusted and involved multiple comparisons without a reported multiplicity correction. Small subgroup counts should therefore be interpreted cautiously. A two-sided Fisher exact sensitivity check calculated from the reported parity-by-fetal-distress counts gave p = 0.042, supporting the direction of the reported Pearson chi-square result. Because recruitment included only caesarean deliveries, this sample cannot estimate the hospital's caesarean rate among all births.

The study included 121 women undergoing caesarean section. Reported mean age was 30.8 ± 6.2 years, mean parity was 2.5 ± 1.2, and mean gestational age was 39.4 ± 2.0 weeks. Fifty-seven women (47.1%) were aged 20–30 years and 64 (52.9%) were aged 31–40 years. Ninety-nine (81.8%) had parity 1–3, and 22 (18.2%) had parity 4–6. Poor socioeconomic status was recorded in 39 women (32.2%).

Repeat caesarean section was the most frequent listed indication, occurring in 33 women (27.3%). Oligohydramnios was recorded in 26 (21.5%), post-date pregnancy in 22 (18.2%), prolonged labour in 20 (16.5%), and fetal distress in 12 (9.9%). The five counts total 113, rather than 121. Their completeness and mutual exclusivity cannot be established from the supplied manuscript, so no additional indication has been assigned to the eight-count difference.

No statistically significant associations were reported between the listed indications and maternal age or socioeconomic status. Fetal distress was more frequent in women with parity 4–6 than in those with parity 1–3: 5/22 (22.7%) versus 7/99 (7.1%), with p = 0.026. This was an unadjusted comparison; a two-sided Fisher exact check of the reported counts gave p = 0.042.

Gestational age was associated with prolonged labour and oligohydramnios in the reported analyses (p = 0.002 for each). Prolonged labour occurred in 12/69 women at 37–39 weeks (17.4%), 0/30 at 40–41 weeks, and 8/22 at 42–43 weeks (36.4%). Oligohydramnios occurred in 14/69 (20.3%), 12/30 (40.0%), and 0/22, respectively. The gestational-age table did not provide a post-date pregnancy row, so no stratified values for that indication have been inferred.

Table 1. Baseline characteristics of participants (n = 121)

Table 2. Recorded caesarean section indications (n = 121)

Table 4. Indications stratified by parity

Table 5. Indications stratified by socioeconomic status

Table 6. Indications stratified by gestational age

Figure 1. Recorded indication percentages among 121 enrolled women. Categories require completeness verification.

Figure 2. Prolonged labour and oligohydramnios by gestational age. Values are within-group percentages.

Repeat caesarean section was the most frequent listed indication, followed by oligohydramnios and post-date pregnancy. These proportions describe the 121 women already selected for caesarean delivery; they do not estimate the hospital's caesarean rate or the proportion of operations that were avoidable. WHO emphasizes providing surgery according to clinical need.1 Global estimates show increasing use alongside unequal access, so a high contribution from one indication cannot alone establish overuse or unmet need in the surrounding population.12 Previous caesarean section deserves particular attention because the first operation can influence subsequent reproductive care. Long-term evidence links caesarean birth with outcomes in later pregnancies, supporting counselling that considers future pregnancy plans.3 Professional guidance supports individualized assessment of vaginal birth after caesarean delivery in appropriately equipped settings.4 The present manuscript does not report scar characteristics, previous surgical indications, counselling, attempted vaginal birth, or maternal preferences. Its repeat-caesarean proportion therefore cannot identify women who could safely have avoided surgery. A standardized classification would make this finding more useful. A systematic review of the Robson system identified practical strengths but also challenges from missing data, misclassification, and inconsistent definitions.12 A review of audit and feedback reported reductions in caesarean rates in included studies, but all were uncontrolled and at high risk of bias, preventing confident causal attribution.13 Classification should therefore support careful review of practice and outcomes rather than serve as a guarantee that a lower rate represents better care. There is relevant evidence from Pakistan. Gilani and colleagues used modified Robson criteria at a teaching hospital in Islamabad and identified women with a previous caesarean as the major contributor to the overall surgical rate.14 That study included a denominator of all deliveries, unlike the present case series. A recent European synthesis also identified previous caesarean as an important contributor while documenting substantial regional variation.15 These comparisons support reviewing repeat surgery locally, but differences in populations and access prevent direct transplantation of another institution's target rate. Prolonged labour accounted for 16.5% of the enrolled women and was concentrated in the 42–43-week subgroup. Current labour guidance requires appropriate criteria for diagnosing arrest and assessment of progress before operative delivery.15 NICE caesarean guidance also emphasizes documented clinical assessment and informed discussion.6 Without cervical findings, contraction adequacy, induction history, and duration thresholds, the study cannot determine whether the recorded prolonged-labour category consistently represented labour arrest. The association with gestational age remains descriptive. Induction evidence provides context for the post-date and prolonged-labour findings. In the ARRIVE trial, induction at 39 weeks in low-risk nulliparous women reduced caesarean delivery compared with expectant management, but did not significantly reduce the primary composite adverse perinatal outcome.16 This shows that induction does not invariably increase surgery, although its population differs from the present surgical sample. The INDEX trial compared induction at 41 weeks with expectant management until 42 weeks and found identical caesarean rates despite differences in perinatal outcomes.17 SWEPIS found no significant difference in its primary composite perinatal outcome but was stopped early after more perinatal deaths in the expectant-management group; caesarean proportions did not differ significantly.18 These trials examine delivery timing among eligible women, rather than indications among women who already underwent surgery. They cannot establish whether earlier induction would have prevented any individual operation in this series. WHO recommendations on induction at or beyond term provide a framework for reviewing local delivery planning against documented gestational age and clinical circumstances.11 Oligohydramnios accounted for 21.5% of cases and was most frequent in the 40–41-week subgroup. A systematic review associated isolated oligohydramnios at term with more induction, caesarean delivery, and some short-term neonatal outcomes, while the single randomized comparison of induction and expectant management found no significant outcome differences.19 Diagnostic method also matters. Cochrane evidence found that using the amniotic fluid index rather than the single deepest pocket increased diagnoses of oligohydramnios and induction without improving measured peripartum outcomes.20 The present study needs the ultrasound method, threshold, membrane status, and fetal-growth findings to support interpretation. Evidence comparing trial of labour after caesarean with elective repeat surgery describes low absolute frequencies of serious adverse outcomes but different maternal and neonatal risk profiles.22 This supports individualized counselling rather than a blanket inference that repeat surgery is either necessary or avoidable. Regional research from Bangladesh likewise shows that indication patterns must be considered alongside wider determinants of access and delivery care.17 WHO-supported non-clinical interventions may assist appropriate use, but the present study did not test information, professional review, or organizational changes.18. Prospective use of the WHO Robson framework, together with indication-specific information, would allow the contribution of each obstetric group to be evaluated across all births.9 Evidence linking repeated caesareans with increasing maternal morbidity strengthens the rationale for documenting outcomes and future reproductive plans.10 Interpretation nevertheless remains limited by consecutive sampling, referral-centre selection, unadjusted comparisons, and sparse subgroup cells. The five listed indication counts total 113 rather than 121; category completeness and possible overlap must be clarified. Transparent observational reporting requires resolution of this discrepancy and clear handling of missing information.22 Future audits should include all deliveries, a consistent primary-indication hierarchy, and maternal and neonatal outcomes before drawing conclusions about avoidable surgery.

Repeat caesarean section was the most frequent listed indication among the 121 enrolled surgical patients, followed by oligohydramnios and post-date pregnancy. Higher parity was associated with fetal distress, while gestational age was associated with prolonged labour and oligohydramnios in unadjusted analyses. The sample cannot estimate the hospital caesarean rate or establish causal determinants. The incomplete indication total requires source-data confirmation. Larger prospective audits including all deliveries and standardized classification would better inform clinical improvement.

Authors Contribution

Sara conceptualized the study, designed the research question, obtained ethical approval, and supervised the overall project. Maryam Shafi developed the methodology, including the sampling strategy, data collection proforma, and statistical analysis plan. Haseena Mehboob conducted the investigation, including participant enrollment, clinical data collection, and documentation of caesarean indications. Robina Jan performed data curation, including data entry, verification, cleaning, and maintenance of the study database in SPSS version 25. Ikram Ullah drafted the manuscript, performed the statistical analysis, prepared tables and figures, critically revised the manuscript for important intellectual content, and handled journal correspondence. All authors reviewed and approved the final manuscript and agreed to be accountable for all aspects of the work

Funding:  No funding received.

Conflict of Interest: No conflict of Interest