Suture repair of umbilical hernia during caesarean section: a case-control study.

PubMed

Steinemann, D C; Limani, P; Ochsenbein, N; Krähenmann, F; Clavien, P-A; Zimmermann, R; Hahnloser, D

2013-08-01

The objective of this study was to investigate the additional burdens in terms of pain, prolongation of surgery and morbidity which is added to elective caesarean section if umbilical hernia suture repair is performed simultaneously. Secondly, patient's satisfaction and hernia recurrence rate were assessed. Consecutive women with symptomatic umbilical hernia undergoing internal or external suture repair during elective caesarean were included in this retrospective cohort-control study. Data on post-operative pain, duration of surgery and morbidity of a combined procedure were collected. These patients were matched 1:10 to women undergoing caesarean section only. Additionally, two subgroups were assessed separately: external and internal suture hernia repair. These subgroups were compared for patient's satisfaction, cosmesis, body image and recurrence rate. Fourteen patients with a mean age of 37 years were analysed. Internal suture repair (n = 7) prolonged caesarean section by 20 min (p = 0.001) and external suture repair (n = 7) by 34 min (p < 0.0001). Suture repair did not increase morphine use (0.38 ± 0.2 vs. 0.4 ± 02 mg/kg body weight), had no procedure-related morbidity and prolonged hospitalization by 0.5 days (p = 0.01). At a median follow-up of 37 (5-125) months, two recurrences in each surgical technique, internal and external suture repair, occurred (28 %). Body image and cosmesis score showed a higher level of functioning in internal suture repair (p = 0.02; p = 0.04). Despite a high recurrence rate, internal suture repair of a symptomatic umbilical hernia during elective caesarean section should be offered to women if requested. No additional morbidity or scar is added to caesarean section. Internal repair is faster, and cosmetic results are better, additional skin or fascia dissection is avoided, and it seems to be as effective as an external approach. Yet, women must be informed on the high recurrence rate.

A population-based cohort study of the effect of Caesarean section on subsequent fertility.

PubMed

Gurol-Urganci, I; Cromwell, D A; Mahmood, T A; van der Meulen, J H; Templeton, A

2014-06-01

Is there an association between Caesarean section and subsequent fertility? There is no or only a slight effect of Caesarean section on future fertility. Previous studies have reported that delivery by a Caesarean section is associated with fewer subsequent pregnancies and longer inter-pregnancy intervals. The interpretation of these findings is difficult because of significant weaknesses in study designs and analytical methods, notably the potential effect of the indication for Caesarean section on subsequent delivery. Retrospective cohort study of 1 047 644 first births to low-risk women using routinely collected, national administrative data of deliveries in English maternity units between 1 April 2000 and 31 March 2012. Primiparous women aged 15-40 years who had a singleton, term, live birth in the English National Health Service were included. Women with high-risk pregnancies involving placenta praevia, pre-eclampsia, eclampsia (gestational or pre-existing), hypertension or diabetes were excluded from the main analysis. Kaplan-Meier analyses and Cox proportional hazard models were used to assess the effect of mode of delivery on time to subsequent birth, adjusted for age, ethnicity, socio-economic deprivation and year of index delivery. Among low-risk primiparous women, 224 024 (21.4%) were delivered by Caesarean section. The Kaplan-Meier estimate of the subsequent birth rate at 10 years for the cohort was 74.7%. Compared with vaginal delivery, subsequent birth rates were marginally lower after elective Caesarean for breech (adjusted hazard ratio, HR 0.96, 95% CI 0.94-0.98). Larger effects were observed after elective Caesarean for other indications (adjusted HR 0.81, 95% CI 0.78-0.83), and emergency Caesarean (adjusted HR 0.91, 95% CI 0.90-0.93). The effect was smallest for elective Caesarean for breech, and this was not statistically significant in women younger than 30 years of age (adjusted HR 0.98, 95% CI 0.96-1.01). We used birth cohorts from maternity units with good quality parity information. The data are likely to be nationally representative because the characteristics of the deliveries in included and omitted units were similar. There may be residual bias in our adjusted results due to unmeasured maternal factors such as obesity and voluntary absence of conception. Any residual bias would lead to an overestimate of the effect of Caesarean section on fertility, and the true effect is therefore likely to be smaller than the effect reported in our study. Our results provide strong evidence that there is no or only a slight effect of Caesarean section on future fertility. The clinical and social circumstances leading to the Caesarean section have a greater effect on future fertility than the Caesarean section itself. This finding is important in light of rising Caesarean section rates. IG-U is supported by the Lindsay Stewart R&D Centre, Royal College of Obstetricians and Gynaecologists, UK. The authors have no conflicts of interest to declare. n/a.

Readmissions for surgical site infections following caesarean section.

PubMed

El-Achi, Vanessa; Wan, King Man; Brown, James; Marshall, Drew; McGee, Therese

2018-03-05

This retrospective study was conducted to identify the incidence and characteristics associated with readmissions for surgical site infections following caesarean section in a tertiary hospital from 2012 to 2015. Of 6334 patients who underwent caesarean section, 165 (2.6%) were readmitted, most commonly for surgical site infection (25.5%, n = 42). Thirty-seven of these patients (88%) had an emergency caesarean compared to five (12%) following an elective caesarean section. Of the women with surgical site infections, 69% were overweight and 14% had diabetes. Emergency caesarean sections were responsible for the majority of readmissions, particularly in women with co-morbidities that predisposed them to infection. © 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

PubMed

Schäfer, A; Friese, K; Grosch-Wörner, I; Lauper, U; Hebisch, G; Hugger, C

1999-07-01

Studies of caesarean section and the rate of perinatal transmission of HIV-1 (RPT) have reported conflicting results if AZT was not administered simultaneously. To investigate the probable sources of error, 387 singleton pregnancies of HIV-1-infected mothers were enrolled in a prospective, observational study. To avoid contamination of the fetal mouth with maternal blood at caesarean section, the uterus was opened under careful preparation of the fetal membranes, maintaining their integrity as long as possible. To 105 pregnant women AZT was administered at various gestational ages (median 29th week), depending on the stage of the disease of the mother or obstetrical complications. The majority of newborns received AZT for 10 days I.V. Group 1: For those, for whom vaginal delivery was intended (n=163, RPT=20.2%), this could be realized in 82% of the cases only. There was no significant difference in the RPT (23%-19,5%) between emergency caesarean section and vaginal delivery (odds ratio [OR]=1,25; 95% CI 0,41-3,44). Risk factors of fetal HIV infection (p≤0.05) were delivery <37 th week, rupture of membranes (ROM) ≥4 h, labor ≥5 h before delivery, CD4 ≤400 cells/µl, p24 antigenemia, and viral load. Group 2: If an elective caesarean section (n=119) was intended, the RPT (4,2%) was reduced compared to group 1 (OR=0.17; 95% CI 0.04-0,52; p=0.0002); however, in 16% emergency sections had to be performed because labor or ROM occurred before the planned date of elective caesarean section without difference in the RPT (4-5%) (OR 1,35; 95% CI 0,03-14,51). Significant risks (p≤0.05) of fetal infection were preterm labor and viral load. Group 3: If an elec- tive caesarean section under AZT (n=105) was intended, the RPT (1,3%) was significantly different to group 1 (OR=0,08; 95% CI 0.1-0.31; p=0.00003), but not to group 2 (OR=0.44; 95% CI 0.04-2.79). However, an elective caesarean section was feasible only in 74% without significant differences in the RPT (1,3-4%) (OR=2,96; 95% CI 0,04- 235,42). Except for the viral load (p=0.04), no risk factor was associated with fetal infection. Elective and emergency caesarean section, performed early in parturition under surgical care to avoid contamination, significantly decreases the risk of fetal transmission, irrespec-tive of low CD4 cell counts, p24 antigenemia, viral load and ROM, but not preterm labor. Simultaneous administration of AZT in gestation and to the newborn further reduces the risk of peripartal infections and obviously provides additional safety at caesarean sections.

The use of a quality indicator to reduce elective repeat Caesarean section for low-risk women before 39 weeks' gestation: the Eastern Ontario experience.

PubMed

Dunn, Sandra; Sprague, Ann E; Fell, Deshayne B; Dy, Jessica; Harrold, JoAnn; Lamontagne, Bernard; Walker, Mark

2013-04-01

Elective repeat Caesarean section (ERCS) for low-risk women at < 39 weeks' gestation has consistently been associated with increased risks to the neonate, including respiratory morbidity, NICU admission, and lengthier hospital stays than ERCS at 39 to 40 weeks' gestation. The objective of this quality improvement project was to reduce high rates of ERCS < 39 weeks across the Eastern Ontario region. All hospitals within the region providing care during labour and birth (n = 10) were asked to participate. Representatives from each hospital received information about their site-specific rates and knowledge-translation resources to assist them with the project. A benchmark rate for ERCS < 39 weeks was set at 30%. The rates of ERCS < 39 weeks were calculated for two different times (the 2009-2010 and 2010-2011 fiscal years) and the relative difference and 95% confidence intervals were calculated to quantify the magnitude and statistical significance of any change. Qualitative interviews were completed with key informants from each hospital. The proportion of ERCS at < 39 weeks' gestation across the region in the fiscal year 2010-2011 (n = 197/497; 39.6%) was significantly decreased (relative difference: -21%; 95% CI -31% to -8%, P = 0.002) from the previous fiscal year 2009-2010 (n = 229/459; 49.9%). A number of barriers to, and facilitators of, practice change were identified. A reduction in the rate of ERCS < 39 weeks among low-risk women was achieved across the region. Awareness of the issue, possession of site-specific data, and agreement about the evidence and the need for change are critical first steps to improving practice.

Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants.

PubMed

Dahlgren, Leanne S; von Dadelszen, Peter; Christilaw, Jan; Janssen, Patricia A; Lisonkova, Sarka; Marquette, Gerald P; Liston, Robert M

2009-09-01

To determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. We conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term. There were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery. An elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.

[Fewer breech deliveries after implementation of a modified cephalic version protocol].

PubMed

Kuppens, Simone M I; Francois, Anne M H; Hasaart, Tom H M; van der Donk, Maria W P; Pop, Victor J M

2010-01-01

To investigate the effect of implementation of a number of process policy guidelines (protocol), on the success rate of external cephalic version (ECV) for breech presentation. Prospective study. During a 3-year period (2004-2006) a standardized protocol for an ECV consultation was developed, evaluated and adapted. After implementing this modified protocol as 'process policy guidelines', the effect on the rate of successful ECV was prospectively evaluated during the period 1 January 2007-31 July 2008. Success was defined as cephalic presentation (ultrasound) immediately after ECV. A secondary outcome measure was the elective caesarean section rate for breech presentation. The rate of successful ECV increased significantly from 47% (110/236 pregnant women) in the period January 2004-December 2006 to 61% (85/139, p = 0.006) in the period January 2007-July 2008. Patient characteristics were similar in both groups, with the exception of 2 subgroups of term of version. The increase was preferentially found in nulliparous and multiparous women with frank breech. Nulliparity, frank breech, anterior placenta and low birth weight were associated with a lower success rate of ECV. The term of pregnancy at which ECV was performed did not seem to affect the success rate. Implementing the process policy guidelines increased the number of cephalic presentations at delivery and decreased the rate of elective caesarean sections for breech presentation from 39% to 27% (p = 0.03). The number needed to treat to prevent 1 elective caesarean section by ECV according to the process policy guidelines was 8. After implementation of the process policy guidelines, the success rate of ECV increased considerably. The rate of elective caesarean section for breech presentation declined. These findings are in favour of establishing specialized ECV centres in the Netherlands.

Timing of birth for women with a twin pregnancy at term: a randomised controlled trial

PubMed Central

2010-01-01

Background There is a well recognized risk of complications for both women and infants of a twin pregnancy, increasing beyond 37 weeks gestation. Preterm birth prior to 37 weeks gestation is a recognized complication of a twin pregnancy, however, up to 50% of twins will be born after this time. The aims of this randomised trial are to assess whether elective birth at 37 weeks gestation compared with standard care in women with a twin pregnancy affects the risk of perinatal death, and serious infant complications. Methods/Design Design: Multicentred randomised trial. Inclusion Criteria: women with a twin pregnancy at 366 weeks or more without contraindication to continuation of pregnancy. Trial Entry & Randomisation: Following written informed consent, eligible women will be randomised from 36+6 weeks gestation. The randomisation schedule uses balanced variable blocks, with stratification for centre of birth and planned mode of birth. Women will be randomised to either elective birth or standard care. Treatment Schedules: Women allocated to the elective birth group will be planned for elective birth from 37 weeks gestation. Where the plan is for vaginal birth, this will involve induction of labour. Where the plan is for caesarean birth, this will involve elective caesarean section. For women allocated to standard care, birth will be planned for 38 weeks gestation or later. Where the plan is for vaginal birth, this will involve either awaiting the spontaneous onset of labour, or induction of labour if required. Where the plan is for caesarean birth, this will involve elective caesarean section (after 38 and as close to 39 weeks as possible). Primary Study Outcome: A composite of perinatal mortality or serious neonatal morbidity. Sample Size: 460 women with a twin pregnancy to show a reduction in the composite outcome from 16.3% to 6.7% with adjustment for the clustering of twin infants within mothers (p = 0.05, 80% power). Discussion This is a protocol for a randomised trial, the findings of which will contribute information about the optimal time of birth for women with an uncomplicated multiple pregnancy at and beyond 37 weeks gestation. Clinical Trial Registration Current Controlled Trials ISRCTN15761056 PMID:20973989

Sexual violence and mode of delivery: a population-based cohort study.

PubMed

Henriksen, L; Schei, B; Vangen, S; Lukasse, M

2014-09-01

This study aimed to explore the association between sexual violence and mode of delivery. National cohort study. Women presenting for routine ultrasound examinations were recruited to the Norwegian Mother and Child Cohort Study between 1999 and 2008. A total of 74,059 pregnant women. Sexual violence was self-reported during pregnancy using postal questionnaires. Mode of delivery, other maternal birth outcomes and covariates were retrieved from the Medical Birth Registry of Norway. Risk estimations were performed using multivariable logistic regression analysis. Mode of delivery and selected maternal birth outcomes. Of 74,059 women, 18.4% reported a history of sexual violence. A total of 10% had an operative vaginal birth, 4.9% had elective caesarean section and 8.6% had an emergency caesarean section. Severe sexual violence (rape) was associated with elective caesarean section, adjusted odds ratio (AOR) 1.56 (95% CI 1.18-2.05) for nulliparous women and 1.37 (1.06-1.76) for multiparous women. Those exposed to moderate sexual violence had a higher risk of emergency caesarean section, AOR 1.31 (1.07-1.60) and 1.41 (1.08-1.84) for nulliparous and multiparous women, respectively. No association was found between sexual violence and operative vaginal birth, except for a lower risk among multiparous women reporting mild sexual violence, AOR 0.73 (0.60-0.89). Analysis of other maternal outcomes showed a reduced risk of episiotomy for women reporting rape and a higher frequency of induced labour. Women with a history of rape had higher odds of elective caesarean section and induction and significantly fewer episiotomies. © 2014 Royal College of Obstetricians and Gynaecologists.

Empowering surgical nurses improves compliance rates for antibiotic prophylaxis after caesarean birth.

PubMed

Shimoni, Zvi; Kama, Naama; Mamet, Yaakov; Glick, Joseph; Dusseldorp, Natan; Froom, Paul

2009-11-01

Empowering surgical nurses improves compliance rates for antibiotic prophylaxis after caesarean birth. This paper is a report of a study of the effect of empowering surgical nurses to ensure that patients receive antibiotic prophylaxis after caesarean birth. Despite the consensus that single dose antibiotic prophylaxis is beneficial for women have either elective or non-elective caesarean delivery, hospitals need methods to increase compliance rates. In a study in Israel in 2007 surgical nurses were empowered to ensure that a single dose of cefazolin was given to the mother after cord clamping. A computerized system was used to identify women having caesarean births, cultures sent and culture results. Compliance was determined by chart review. Rates of compliance, suspected wound infections, and confirmed wound infections in 2007 were compared to rates in 2006 before the policy change. Relative risks were calculated dividing 2007 rates by those in 2006, and 95% confidence intervals were calculated using Taylor's series that does not assume a normal distribution. Statistical significance was assessed using the chi-square test. The compliance rate was increased from 25% in 2006 to 100% in 2007 (chi-square test, P < 0.001). Suspected wound infection rates decreased from 16.8% (186/1104) to 12.6% (137/1089) after the intervention (relative risk 0.75, 95% confidence interval, 0.61-0.92). Surgical nurses can ensure universal compliance for antibiotic prophylaxis in women after caesarean birth, leading to a reduction in wound infections.

[Caesarean section and anal incontinence].

PubMed

Kalis, V; Stipán, J; Chaloupka, P; Karbanová, J; Rokyta, Z

2008-04-01

Summary of the impact of Caesarean section on anal incontinence. Review. Department of Gynaecology and Obstetrics, Charles University and University Hospital Plzen. Review of the current international literature. Currently, Caesarean section is not considered to reduce symptoms of anal incontinence. If there is any reduction of symptoms, that remains only for a short term (40% in 3 months after the delivery in the largest trial). In a long term, virtually in no trial has been observed any difference, and others, non-obstetrical factors (particularly aging) prevail. Current knowledge does not allow to assess sufficiently pros and cons of Caesarean compared to vaginal delivery. High risk groups, that would profit from elective Ceasarean, have not been clearly identified yet.

Validation of a prediction model for predicting the probability of morbidity related to a trial of labour in Quebec.

PubMed

Chaillet, Nils; Bujold, Emmanuel; Dubé, Eric; Grobman, William A

2012-09-01

Pregnant women with a history of previous Caesarean section face the decision either to undergo an elective repeat Caesarean section (ERCS) or to attempt a trial of labour with the goal of achieving a vaginal birth after Caesarean (VBAC). Both choices are associated with their own risks of maternal and neonatal morbidity. We aimed to determine the external validity of a prediction model for the success of trial of labour after Caesarean section (TOLAC) that could help these women in their decision-making. We used a perinatal database including 185,437 deliveries from 32 obstetrical centres in Quebec between 2007 and 2011 and selected women with one previous Caesarean section who were eligible for a TOLAC. We compared the frequency of maternal and neonatal morbidity between women who underwent TOLAC and those who underwent an ERCS according to the probability of success of TOLAC calculated from a published model of prediction. Of 8508 eligible women, including 3113 who underwent TOLAC, both maternal and neonatal morbidities became less frequent as the predicted chance of VBAC increased (P < 0.05). Women undergoing a TOLAC were more likely to have maternal morbidity than those who underwent an ERCS when the predicted probability of VBAC was less than 60% (relative risk [RR] 2.3; 95% CI 1.4 to 4.0); conversely, maternal morbidity was not different between the two groups when the predicted probability of VBAC was at least 60% (RR 0.8; 95% CI 0.6 to 1.1). Neonatal morbidity was similar between groups when the probability of VBAC success was 70% or greater (RR 1.2; 95% CI 0.9 to 1.5). The use of a prediction model for TOLAC success could be useful in the prediction of TOLAC success and perinatal morbidity in a Canadian population. Neither maternal nor neonatal morbidity are increased with a TOLAC when the probability of VBAC success is at least 70%.

Variable uptake of recommended interventions to reduce mother-to-child transmission of HIV in Australia, 1982-2005.

PubMed

Giles, Michelle L; McDonald, Ann M; Elliott, Elizabeth J; Ziegler, John B; Hellard, Margaret E; Lewin, Sharon R; Kaldor, John M

2008-08-04

To analyse the uptake of interventions known to reduce the risk of perinatal HIV transmission among Australian women with HIV infection (who knew their HIV status before delivery), and identify predictors of uptake. Retrospective analysis of perinatal HIV surveillance data in Australia. Women reported as having HIV infection and having given birth to a child (1982-2005) were identified through three mechanisms: an informal network of clinicians (1982-1993); an active surveillance program through paediatricians (since 1993); and state health department reports of children born to women newly diagnosed with HIV (since 1995). Uptake of interventions - avoidance of breastfeeding (after 1985), use of zidovudine during pregnancy (after 1994), and elective caesarean section (after 1999). Factors associated with uptake of these interventions were identified by univariate and multivariate analyses. 367 live births were reported in 291 women with HIV infection. Among the subgroup diagnosed with HIV infection before delivery, 4/255 (1.6%) elected to breastfeed (post 1985), 44/185 (24%) did not receive zidovudine (after 1994), and 41/118 (35%) did not have an elective caesarean section (after 1999). In multivariate analysis, there were significant differences in uptake of zidovudine and elective caesarean section according to year of birth and state in which the birth took place. In Australia between 1982 and 2005, uptake of interventions to reduce mother-to-child transmission of HIV was high. There were significant differences associated with use of zidovudine and mode of delivery according to location of delivery and year of birth.

High weight gain during pregnancy increases the risk for emergency caesarean section - Population-based data from the Swedish Maternal Health Care Register 2011-2012.

PubMed

Nilses, Carin; Persson, Margareta; Lindkvist, Marie; Petersson, Kerstin; Mogren, Ingrid

2017-03-01

The aim was to investigate maternal background factors' significance in relation to risk of elective and emergency caesarean sections (CS) in Sweden. Population-based, retrospective, cross-sectional study. The Swedish Maternal Health Care Register (MHCR) is a national quality register that collects data on pregnancy, delivery and postpartum period. All women registered in MHCR 2011 to 2012 were included in the study sample (N = 178,716). The risk of elective and emergency caesarean section in relation to age, parity, education, country of origin, weight in early pregnancy and weight gain during pregnancy was calculated in logistic regression models. Multiparous women demonstrated a doubled risk of elective CS compared to primiparous women, but their risk for emergency CS was halved. Overweight and obesity at enrolment in antenatal care increased the risk for emergency CS, irrespective of parity. Weight gain above recommended international levels (Institute of Medicine, IOM) during pregnancy increased the risk for emergency CS for women with normal weight, overweight or obesity. There is a need of national guidelines on recommended weight gain during pregnancy in Sweden. We suggest that the usefulness of the IOM guidelines for weight gain during pregnancy should be evaluated in the Swedish context. Copyright © 2016 Elsevier B.V. All rights reserved.

Hyperbaric vs. isobaric bupivacaine for spinal anaesthesia for elective caesarean section: a Cochrane systematic review.

PubMed

Sng, B L; Han, N L R; Leong, W L; Sultana, R; Siddiqui, F J; Assam, P N; Chan, E S; Tan, K H; Sia, A T

2018-04-01

Both isobaric and hyperbaric bupivacaine have been used for spinal anaesthesia for elective caesarean section, but it is not clear if one is better than the other. The primary objective of this systematic review was to determine the effectiveness and safety of hyperbaric bupivacaine compared with isobaric bupivacaine administered during spinal anaesthesia for elective caesarean section. We included 10 studies with 614 subjects in the analysis. There was no evidence of differences either in the risk of conversion to general anaesthesia, with a relative risk (95%CI) of 0.33 (0.09-1.17) (very low quality of evidence), or in the need for supplemental analgesia, the relative risk (95%CI) being 0.61 (0.26-1.41) (very low quality of evidence). There was also no evidence of a difference in the use of ephedrine, the amount of ephedrine used, nausea and vomiting, or headache. Hyperbaric bupivacaine took less time to reach a sensory block height of T4, with a mean difference (95%CI) of -1.06 min (-1.80 to -0.31). Due to the rarity of some outcomes, dose variability, use of adjuvant drugs and spinal technique used, future clinical trials should look into using adequate sample size to investigate the primary outcome of the need for supplemental analgesia. © 2017 The Association of Anaesthetists of Great Britain and Ireland.

Prevention of mother-to-child transmission of HIV: challenges for the current decade.

PubMed Central

Newell, M. L.

2001-01-01

In June 2001 the United Nations Special Assembly on HIV/AIDS set reduction targets of 20% and 50% for the numbers of children newly infected with HIV by 2005 and 2010 respectively. Are these targets achievable? Antiretroviral monotherapy during pregnancy, delivery, and the neonatal period can reduce the rate of mother-to-child transmission of HIV-1 by two-thirds in non-breastfeeding populations. Shorter and simpler regimens of monotherapy have been associated with a reduction of 50% in such transmission among non-breastfeeding populations and of up to 40% in breastfeeding populations. Delivery by elective caesarean section is associated with a halving of the risk of mother-to-child transmission. However, breastfeeding poses a substantial additional risk of acquisition of HIV, and if prolonged it more than doubles the overall rate of transmission. Rates below 2% are being reported from settings where combination therapy is applied during pregnancy and delivery, delivery is by elective caesarean section, and breastfeeding does not take place. In breastfeeding populations where elective caesarean delivery is not an option but peripartum antiretroviral therapy is used, rates at six weeks are about 10% but can be 25% or more after 18 months of breastfeeding. More widely applicable interventions are being developed, such as cleansing of the birth canal and antiretroviral therapy during the breastfeeding period. PMID:11799446

[Elective caesarean: impact of evolution neonatal respiration].

PubMed

Jonguitud Aguilar, Adriana

2011-04-01

The number of Caesarean births has increased worldwide. Respiratory distress syndrome is associated with caesarean delivery, especially in the absence of labor. During the latter stages of pregnancy physiologic changes occur that are accelerated with the onset of labor, which is accompanied by changes in hormones and mediators in the mother and fetus. An acceleration in the evacuation of lung liquid is held in this period, largely dependent sodium channels sensitive to amiloride than are found in the alveolar epithelium. The failure of these mechanisms can lead to newborn severe respiratory difficulty and require intensive care, mechanical ventilation and surfactant. We need to develop preventive and therapeutic strategies to improve outcomes in this vulnerable population.

Does a Caesarean section increase the time to a second live birth? A register-based cohort study.

PubMed

O'Neill, Sinéad M; Khashan, Ali S; Henriksen, Tine B; Kenny, Louise C; Kearney, Patricia M; Mortensen, Preben B; Greene, Richard A; Agerbo, Esben

2014-11-01

Does a primary Caesarean section influence the rate of, and time to, subsequent live birth compared with vaginal delivery? Caesarean section was associated with a reduction in the rate of subsequent live birth, particularly among elective and maternal-requested Caesareans indicating maternal choice plays a role. Several studies have examined the relationship between Caesarean section and subsequent birth rate with conflicting results primarily due to poor epidemiological methods. This Danish population register-based cohort study covered the period from 1982 to 2010 (N = 832 996). All women with index live births were followed until their subsequent live birth or censored (maternal death, emigration or study end) using Cox regression models. In all 577 830 (69%) women had a subsequent live birth. Women with any type of Caesarean had a reduced rate of subsequent live birth (hazard ratio [HR] 0.86, 95% confidence intervals [CI] 0.85, 0.87) compared with spontaneous vaginal delivery. This effect was consistent when analyses were stratified by type of Caesarean: emergency (HR 0.87, 95% CI 0.86, 0.88), elective (HR 0.83, 95% CI 0.82, 0.84) and maternal-requested (HR 0.61, 95% CI 0.57, 0.66) and in the extensive sub-analyses performed. Lack of biological data to measure a woman's fertility is a major limitation of the current study. Unmeasured confounding and limited availability of data (maternal BMI, smoking, access to fertility services and maternal-requested Caesarean section) as well as changes in maternity care over time may also influence the findings. This is the largest study to date and shows that Caesarean section is most likely not causally related to a reduction in fertility. Maternal choice to delay or avoid childbirth is the most plausible explanation. Our findings are generalizable to other middle- to high-income countries; however, cross country variations in Caesarean section rates and social or cultural differences are acknowledged. Funding was provided by the National Perinatal Epidemiology Centre, Cork, Ireland and conducted as part of the Health Research Board PhD Scholars programme in Health Services Research (Grant No. PHD/2007/16). L.C.K. is a Science Foundation Ireland Principal Investigator (08/IN.1/B2083) and the Director of the SFI funded Centre, INFANT (12/RC/2272). The authors have no competing interests to declare. © The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Appropriateness of elective caesarean deliveries in a perinatal network: a cross-sectional study

PubMed Central

2014-01-01

Background The overall caesarean rate in France has increased from 14.3% in 1994–1996 to 21.0% in 2010. This increased rate is a concern in all developed countries: delivery by caesarean induces both short- and long-term maternal complications, and its use requires careful reflection. The principal objective of this work was to describe the global appropriateness of indications for caesareans among a selected sample of planned caesareans performed within the Auvergne perinatal health network. The secondary objectives were to describe the inappropriate planned caesarean risk according to the maternity unit level and the impact of this medical assessment on the global caesarean rate in this network. Methods This audit among maternity units belonging to the Auvergne perinatal network in France included women who had a planned caesarean at term, were nulliparous or primiparous, and had a singleton pregnancy in cephalic presentation or a twin pregnancy with twin 1 in cephalic presentation. We used the French guidelines issued from 1998 through 2010 as our benchmark for appropriateness. Result We analysed 192 cases (100% of the records eligible for the audit). The rate of appropriate caesareans among these planned caesareans was 65.6%. Among the inappropriate caesareans, the rate of “maternal-preference” caesareans was 12.0% and the rate of “provider-preference” caesareans 22.4%. The risk of an inappropriate caesarean did not differ statistically between the level I and level II maternity wards, each compared to the level III hospital. The overall caesarean rate in our entire network decreased from 20.5% to 18.5% (p < 0.001) in the year after the audit. It also decreased in 8 of the network’s 10 maternity units, although the difference was statistically significant only in 2. Conclusions About one third of planned caesareans were inappropriate in our sample and our audit appeared to have some effect on medical practice in the short run. PMID:24716672

Spinal anaesthesia for caesarean section: comparison of 22-gauge and 25-gauge Whitacre needles with 26-gauge Quincke needles.

PubMed

Shutt, L E; Valentine, S J; Wee, M Y; Page, R J; Prosser, A; Thomas, T A

1992-12-01

We have studied 150 women undergoing elective Caesarean section under spinal anaesthesia. They were allocated randomly to have a 22-gauge Whitacre, a 25-gauge Whitacre or a 26-gauge Quincke needle inserted into the lumbar subarachnoid space. The groups were compared for ease of insertion, number of attempted needle insertions before identification of cerebrospinal fluid, quality of subsequent analgesia and incidence of postoperative complications. There were differences between groups, but they did not reach statistical significance. Postdural puncture headache (PDPH) was experienced by one mother in the 22-gauge Whitacre group, none in the 25-gauge Whitacre group and five in the 26-gauge Quincke group. Five of the six PDPH occurred after a single successful needle insertion. Seven of the 15 mothers in whom more than two needle insertions were made experienced backache, compared with 12 of the 129 receiving two or less (P < 0.001). We conclude that the use of 22- and 25-gauge Whitacre needles in elective Caesarean section patients is associated with a low incidence of PDPH and that postoperative backache is more likely when more than two attempts are made to insert a spinal needle.

Adhesion formation after previous caesarean section-a meta-analysis and systematic review.

PubMed

Shi, Z; Ma, L; Yang, Y; Wang, H; Schreiber, A; Li, X; Tai, S; Zhao, X; Teng, J; Zhang, L; Lu, W; An, Y; Alla, N R; Cui, T

2011-03-01

The optimal technique for performing caesarean section with respect to minimising postoperative adhesions has not been determined. To evaluate adhesion formation for three common caesarean section techniques in women undergoing repeat caesarean section surgeries. A database was constructed from Medline, EMBASE, Cochrane Library, National Science Digital Library, China Biological Medicine Database and through contact with experts in this field from January 1990 to May 2010. Studies were included if they examined adhesion formation in repeat caesarean sections as a primary objective, delineated a clear study design, specified an adhesion scoring system, and had sufficient patient exclusion criteria. We abstracted data regarding adhesion formation. The Mantel-Haenszel random-effects model was employed for all analyses using odds ratio or inverse variance, along with 95% CI. Thirty-three qualified studies including 4423 women were analysed. There were 406 adhesions among 571 women and 238 adhesions among 596 women in the Stark's caesarean section (also known as Misgav-Ladach method) group and modified Stark's caesarean section group, respectively, with pooled OR 4.69 (95% CI 3.32-6.62; P < 0.01, 12 studies); 1173 adhesions among 1555 women and 1179 adhesions among 1625 women in Stark's caesarean section group and classic lower-segment caesarean section group, respectively, with pooled odds ratio 1.28 (95% CI 0.97-1.68; P = 0.08, 21 studies); and 29 adhesions from 102 women and 115 adhesions from 193 women in modified Stark's caesarean section group and classic lower-segment caesarean section group, respectively, with pooled odds ratio 0.28 (95% CI 0.10-0.82; P = 0.02, two studies). Closure of the peritoneum in modified Stark's caesarean section resulted in less adhesion formation and should be recommended. © 2010 The Authors Journal compilation © RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology.

Spinal anaesthesia for a caesarean section in a patient with paraneoplastic cerebellar ataxia

PubMed Central

Tuna, Ayca Tas; Sahin, Fatih; Kotan, Dilcan; Erdem, Ali Fuat; Baykara, Meltem; Duzcan, Tuba

2017-01-01

Paraneoplastic cerebellar ataxia (PCA) is most frequently observed in gynaecological cancers, small cell lung cancer, breast cancer, Hodgkin's lymphoma, cancer testis or malignant thymoma. In the literature, there is no data related to the effects of PCA during pregnancy or reports on the effects of anaesthesia in patients with PCA. We present management of a pregnant woman with PCA who was suddenly unable to walk with PCA and for whom effective spinal anaesthesia was performed for an elective caesarean section with no complications. PMID:28515524

Achondroplasia: anaesthetic challenges for caesarean section.

PubMed

Dubiel, L; Scott, G A; Agaram, R; McGrady, E; Duncan, A; Litchfield, K N

2014-08-01

Pregnancy in women with achondroplasia presents major challenges for anaesthetists and obstetricians. We report the case of a woman with achondroplasia who underwent general anaesthesia for an elective caesarean section. She was 99cm in height and her condition was further complicated by severe kyphoscoliosis and previous back surgery. She was reviewed in the first trimester at the anaesthetic high-risk clinic. A multidisciplinary team was convened to plan her peripartum care. Because of increasing dyspnoea caesarean section was performed at 32weeks of gestation. She received a general anaesthetic using a modified rapid-sequence technique with remifentanil and rocuronium. The intraoperative period was complicated by desaturation and high airway pressures. The woman's postoperative care was complicated by respiratory compromise requiring high dependency care. Copyright © 2014 Elsevier Ltd. All rights reserved.

Sequential compression device with thigh-high sleeves supports mean arterial pressure during Caesarean section under spinal anaesthesia.

PubMed

Adsumelli, R S N; Steinberg, E S; Schabel, J E; Saunders, T A; Poppers, P J

2003-11-01

This study investigated the use of a Sequential Compression Device (SCD) with thigh-high sleeves and a preset pressure of 50 mm Hg that recruits blood from the lower limbs intermittently, as a method to prevent spinal hypotension during elective Caesarean section. Possible association of arterial pressure changes with maternal, fetal, haemodynamic, and anaesthetic factors were studied. Fifty healthy parturients undergoing elective Caesarean section under spinal anaesthesia were randomly assigned to either SCD (n=25) or control (n=25) groups. A standardized protocol for pre-hydration and anaesthetic technique was followed. Hypotension was defined as a decrease in any mean arterial pressure (MAP) measurement by more than 20% of the baseline MAP. Systolic (SAP), MAP and diastolic (DAP) arterial pressure, pulse pressure (PP), and heart rate (HR) were noted at baseline and every minute after the spinal block until delivery. A greater than 20% decrease in MAP occurred in 52% of patients in the SCD group vs 92% in the control group (P=0.004, odds ratio 0.094, 95% CI 0.018-0.488). There were no significant differences in SAP, DAP, HR, and PP between the groups. SCD use in conjunction with vasopressor significantly reduced the incidence of a 20% reduction of MAP.

Reduction of severity of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine: a randomised comparison of prophylactic granisetron and ondansetron.

PubMed

Tan, T; Ojo, R; Immani, S; Choroszczak, P; Carey, M

2010-01-01

The incidence of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine may be 60-100%, and is a common cause of maternal dissatisfaction. Ondansetron has been shown to reduce pruritus but the effect is short-lived. The objective of this randomized double-blind trial was to evaluate the anti-pruritic efficacy of granisetron compared with ondansetron. Eighty ASA I or II women undergoing elective caesarean section received spinal anaesthesia with 0.5% hyperbaric bupivacaine 10 mg, fentanyl 25 microg and preservative-free morphine 150 microg. After delivery of the baby and clamping of the umbilical cord, they were randomised to receive granisetron 3mg i.v. (group G) or ondansetron 8 mg i.v. (group O). The two groups were similar for age, gestational age, height and weight. According to visual analogue pruritus scores, patients in group G experienced less pruritus at 8h (P=0.003) and 24h (P=0.01). Fewer patients in group G (n=8) than group O (n=18) required rescue anti-pruritic medication (P=0.03). Satisfaction scores were also higher in group G than in group O (P=0.03). There was no difference in overall incidence of pruritus, nausea and vomiting, and visual analogue pain scores between the two groups. Administration of granisetron 3mg i.v. reduces the severity of pruritus and the use of rescue anti-pruritic medication, and improves satisfaction but does not reduce the overall incidence of pruritus in women who have received subarachnoid morphine 150 microg compared to ondansetron 8 mg i.v. Copyright 2009 Elsevier Ltd. All rights reserved.

Behavioural, educational and respiratory outcomes of antenatal betamethasone for term caesarean section (ASTECS trial)

PubMed Central

Stutchfield, Peter Roy; Whitaker, Rhiannon; Gliddon, Angela E; Hobson, Lucie; Kotecha, Sailesh; Doull, Iolo J M

2013-01-01

Objectives To determine whether antenatal betamethasone prior to elective term caesarean section (CS) affects long term behavioural, cognitive or developmental outcome, and whether the risk of asthma or atopic disease is reduced. Design A questionnaire based follow-up of a multicentre randomised controlled trial (Antenatal Steroids for Term Elective Caesarean Section, BMJ 2005). Setting Four UK study centres from the original trial. Participants 862 participants from the four largest recruiting centres, 92% of the original study. 824 (96%) were traced and 799 (93%) were successfully contacted. Fifty-one percent (407/799) completed and returned the questionnaire. The children were aged 8–15 years (median 12.2 years, 52% girls). 386 gave consent to contact schools with 352 (91%) reports received. Main outcome measures Questionnaires including a strengths and difficulties questionnaire, International Study of Asthma and Allergies in Childhood, general health and school performance. Results There were no significant differences between children whose mothers received betamethasone and controls for the mean total strengths and difficulties questionnaire scores and subscores for hyperactivity, emotional symptoms, prosocial behaviour, conduct or peer problems. 25 (12%) children whose mothers received betamethasone had reported learning difficulties compared with 27 (14%) control children. The proportion of children who achieved standard assessment tests KS2 exams level 4 or above for mathematics, English or science was similar as were the rates of ever reported wheeze (30% vs 30%), asthma (24% vs 21%), eczema (34% vs 37%) and hay fever (25% vs 27%). Conclusions Antenatal betamethasone did not result in any adverse outcomes or reduction in asthma or atopy. It should be considered for elective CS at 37–38 weeks of gestation. Trial registration: Original trial was preregistration, the trial publication is BMJ. 2005 Sep 24;331(7518):662. PMID:23424017

A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report.

PubMed

Tsivos, Dimitris; Malik, Fozia; Arambage, Kirana; Hagan, Philip; Lee, Cheng

2009-02-12

A 32-year-old Caucasian primigravida was admitted for elective Caesarean Section at 36 weeks and 6 days with the diagnosis of preeclampsia. Traction of the umbilical cord after delivery of a healthy baby resulted in uterine inversion. The placenta was found to be densely adherent to the posterior uterine wall. Piecemeal excision of the placenta as close as possible to the uterine lining was then performed. In this way we were able to control a massive post partum hemorrhage and preserve the fertility of the patient.

Increased xanthine oxidase during labour--implications for oxidative stress.

PubMed

Many, A; Roberts, J M

1997-11-01

Xanthine dehydrogenase/oxidase (XDH/XO) produces uric acid. When in the oxidase form, this production is coupled with the generation of free radicals. Hypoxia-reperfusion enhances conversion of XDH to XO. Since the placenta is exposed to short periods of hypoxia reperfusion during labour, 17 placentae of pregnancy terminated by elective caesarean section and five placentae of pregnancies terminated by caesarean section during labour were examined for XDH/XO activity. It was found that XO activity was higher in the placentae of labouring women (P = 0.003), which suggests that labour enhances conversion of XDH to XO, facilitating free radical production.

Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany

PubMed Central

David, Matthias; Borde, Theda; Brenne, Silke; Henrich, Wolfgang; Breckenkamp, Jürgen; Razum, Oliver

2015-01-01

Objective The frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants. Methods A standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers’ antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status. Results The caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants. Conclusion Unlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history. PMID:25985437

The differences between pregnant women who request elective caesarean and those who plan for vaginal birth based on Health Belief Model.

PubMed

Darsareh, Fatemeh; Aghamolaei, Teamur; Rajaei, Minoo; Madani, Abdoulhossain; Zare, Shahram

2016-12-01

Although vaginal birth is the safest type of childbirth, sometimes caesarean is necessary for the safety of the mother or the infant. The problem is that low-risk, healthy women are choosing caesarean as a birth option despite the fact that it is fraught with possible complications. To determine the differences and identify the predictors for the way women plan their childbirth based on Health Belief Model. A cross-sectional study was conducted in Bandar abbas city, Iran, from May to October 2015. The study recruited eligible women who self identified themselves as requesting a caesarean or vaginal birth in their response to a questionnaire. Of 470 recruited women, 183 (38.9%) planned to have a caesarean without medical indication. Maternal characteristics (age, level of education, occupational status, involvement in a medical profession, and household income) and obstetric variables (health provider type, place of prenatal care, and the number of children planned for the future) influenced the decisions made by the women. There was a significant difference between women planning a caesarean and those planning vaginal birth in terms of childbirth knowledge. Significant differences were observed regarding maternal self-efficacy, with women planning a caesarean reporting significantly lower self-efficacy than women planning a vaginal birth. Women planning a caesarean birth were also significantly less likely to perceive themselves as being at risk for caesarean-related side effects than women planning a vaginal birth. Comprehensive childbirth knowledge can lead to positive maternal attitude towards vaginal birth and may improve birth confidence. Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Implications of caesarean section for children's school achievement: A population-based study.

PubMed

Smithers, Lisa G; Mol, Ben W; Wilkinson, Chris; Lynch, John W

2016-08-01

Caesarean birth is one of the most frequently performed major obstetrical interventions. Although there is speculation that caesarean at term may have consequences for children's later health and development, longer-term studies are needed. We aimed to evaluate risks to poor school achievement among children born by caesarean section compared with spontaneous vaginal birth. This population-based observational study involved linkage of routinely collected perinatal data with children's school assessments. Perinatal data included all children born in South Australia from 1999 to 2005. Participants were children born by elective caesarean (exposed, n = 650) or vaginal birth (unexposed, n = 2959), to women who previously had a caesarean delivery. School assessments were reported via a standardised national assessment program for children attending grade three (at ~eight years of age). Assessments included reading, writing, spelling, grammar and numeracy and were categorised according to performing at above or ≤National Minimum Standards (NMS). Statistical analyses involved augmented inverse probability weighting (apiw) and accounted for a range of maternal, perinatal and sociodemographic characteristics. Children performing ≤NMS for vaginal birth versus caesarean section were as follows: reading 144/640 (23%) and 688/2921 (24%), writing 69/636(11%) and 351/2917 (12%), spelling 128/646 (20%) and 684/2937 (23%), grammar 132/646 (20%) and 655/2937 (22%), and numeracy 151/634 (24%) and 729/2922 (25%). Both the raw data and the aipw analyses suggested little differences in school achievement between children born by caesarean versus vaginal birth. Analyses that carefully controlled for a wide range of confounders suggest that caesarean section does not increase the risk of poor school outcomes at age eight. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany.

PubMed

David, Matthias; Borde, Theda; Brenne, Silke; Henrich, Wolfgang; Breckenkamp, Jürgen; Razum, Oliver

2015-01-01

The frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants. A standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers' antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status. The caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants. Unlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history.

Tubercular uterocutaneous fistula after caesarean section: A case report.

PubMed

Jindal, Aditi; Chaudhary, Himanshu; Thakur, Monika

2018-01-01

A 29-year-old patient had undergone an elective lower-segment caesarean section (LSCS) five months previously at a district hospital. The operation and the immediate postoperative period were uneventful. After five months she presented back with a fistulous opening. A fistulogram revealed a connection between the uterus and the skin. Fistulous tract excision was planned. Intraoperatively there was communication between the skin and the uterine cavity, with extensive necrosis of the uterine wall. The patient gave her informed consent for excision of the fistulous tract and/or total abdominal hysterectomy. During surgery, it was deemed that there was no scope for excision, so the decision was made for a total abdominal hysterectomy. Histopathological examination confirmed tuberculosis and the patient responded well to anti-tubercular drugs. This case report describes a rare presentation of tubercular uterocutaneous fistula after caesarean section.

Mode of delivery following successful external cephalic version: comparison with spontaneous cephalic presentations at delivery.

PubMed

Kuppens, Simone M I; Hutton, Eileen K; Hasaart, Tom H M; Aichi, Nassira; Wijnen, Henrica A; Pop, Victor J M

2013-10-01

To compare the obstetric outcomes of pregnant women after successful external cephalic version (ECV) (cases) with a large group of pregnant women with a spontaneously occurring cephalic fetal position at delivery (controls). We conducted a retrospective matched cohort study in a teaching hospital in the Netherlands. Delivery outcomes of women with a successful ECV were compared with those of women with spontaneously occurring cephalic presentations, controlling for maternal age, parity, gestational age at delivery, and onset of labour (spontaneous or induced). Exclusion criteria were a history of Caesarean section, delivery at < 35 weeks, and elective Caesarean section. The primary outcome was the prevalence of Caesarean section and instrumental delivery in both groups; secondary outcomes were the characteristics of cases requiring intervention such as Caesarean section or instrumental delivery. Women who had a successful ECV had a significantly higher Caesarean section rate than the women in the control group (33/220 [15%] vs. 62/1030 [6.0 %]; P < 0.001). There was no difference in the incidence of instrumental delivery (20/220 [9.1%] vs. 103/1030 [10%]). Comparison of characteristics of women in the cases group showed that nulliparity, induction of labour, and occiput posterior presentation were associated with Caesarean section and instrumental deliveries. Compared with delivery of spontaneous cephalic presenta-tions, delivery of cephalic presenting babies following successful ECV is associated with an increased rate of Caesarean section, especially in nulliparous women and women whose labour is induced.

Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology.

PubMed

Smith, Ian; Kranke, Peter; Murat, Isabelle; Smith, Andrew; O'Sullivan, Geraldine; Søreide, Eldar; Spies, Claudia; in't Veld, Bas

2011-08-01

This guideline aims to provide an overview of the present knowledge on aspects of perioperative fasting with assessment of the quality of the evidence. A systematic search was conducted in electronic databases to identify trials published between 1950 and late 2009 concerned with preoperative fasting, early resumption of oral intake and the effects of oral carbohydrate mixtures on gastric emptying and postoperative recovery. One study on preoperative fasting which had not been included in previous reviews and a further 13 studies published since the most recent review were identified. The searches also identified 20 potentially relevant studies of oral carbohydrates and 53 on early resumption of oral intake. Publications were classified in terms of their evidence level, scientific validity and clinical relevance. The Scottish Intercollegiate Guidelines Network scoring system for assessing level of evidence and grade of recommendations was used. The key recommendations are that adults and children should be encouraged to drink clear fluids up to 2 h before elective surgery (including caesarean section) and all but one member of the guidelines group consider that tea or coffee with milk added (up to about one fifth of the total volume) are still clear fluids. Solid food should be prohibited for 6 h before elective surgery in adults and children, although patients should not have their operation cancelled or delayed just because they are chewing gum, sucking a boiled sweet or smoking immediately prior to induction of anaesthesia. These recommendations also apply to patients with obesity, gastro-oesophageal reflux and diabetes and pregnant women not in labour. There is insufficient evidence to recommend the routine use of antacids, metoclopramide or H2-receptor antagonists before elective surgery in non-obstetric patients, but an H2-receptor antagonist should be given before elective caesarean section, with an intravenous H2-receptor antagonist given prior to emergency caesarean section, supplemented with 30 ml of 0.3 mol l(-1) sodium citrate if general anaesthesia is planned. Infants should be fed before elective surgery. Breast milk is safe up to 4 h and other milks up to 6 h. Thereafter, clear fluids should be given as in adults. The guidelines also consider the safety and possible benefits of preoperative carbohydrates and offer advice on the postoperative resumption of oral intake.

Planned vaginal delivery versus Caesarean section for breech presentation in Ile-Ife, Nigeria.

PubMed

Orji, E O; Ajenifuja, K O

2003-11-01

The optimum mode of breech delivery remains a matter of controversy among obstetricians worldwide. To determine whether term breech babies born by planned vaginal delivery are at higher risk of neonatal mortality and morbidity than those born by planned caesarean delivery. A hospital based non-experimental comparison of outcome of breech delivery. Ife State Hospitals Complex, Ile-Ife. Two hundred and fourty four singleton breech deliveries occurring at term. They include low 5-minute Apgar score, birth trauma, maternal and perinatal morbidity and mortality. The perinatal mortality was not significantly different in both groups: OR 2.7 (95% C.I. 0.3-26.8). The low 5-minute Apgar scores were higher in the planned vaginal delivery OR 9.0 (95% C.I. 1-73.4), but the traumatic morbidity was not (OR 1.8, 95% C.I. 0.2-20.1). Maternal morbidity occurred more in the planned Caesarean delivery group OR 0.4 (95% C.I. 0.2-0.9). Given appropriate selection criteria and management protocol, the outcome from elective caesarean section might not be better than from planned vaginal delivery.

Maternal and neonatal effects of methoxyflurane, nitrous oxide and lumbar epidural anaesthesia for Caesarean section.

PubMed

Palahniuk, R J; Scatliff, J; Biehl, D; Wiebe, H; Sankaran, K

1977-09-01

General anaesthetic techniques continue to be used for Caesarean section despite the possible increased incidence of foetal acidosis and neonatal depression. Two techniques of general anaesthesia (methoxyflurane-oxygen and nitrous oxide-oxygen) and lumbar epidural anaesthesia were compared in 37 patients under-going elective Caesarean section. Apgar scores at birth were similar in all three groups. Neurophysiological testing of the neonates at six hours and twenty-four hours of age revealed a superiority for the methoxyflurane-oxygen and lumbar epidural techniques, although the babies in the epidural group tended to be hypotonic. Cord blood gas analysis showed the babies in the methoxyflurane group to have a higher PaO2 with less metabolic acidosis than the babies from the other two groups. The maternal effects of the three anaesthetic techniques were similar, with only a small rise in serum fluroide levels noted in the methoxyflurane group.

A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report

PubMed Central

2009-01-01

Background A 32-year-old Caucasian primigravida was admitted for elective Caesarean Section at 36 weeks and 6 days with the diagnosis of preeclampsia. Case presentation Traction of the umbilical cord after delivery of a healthy baby resulted in uterine inversion. The placenta was found to be densely adherent to the posterior uterine wall. Piecemeal excision of the placenta as close as possible to the uterine lining was then performed. Conclusion In this way we were able to control a massive post partum hemorrhage and preserve the fertility of the patient. PMID:19210798

Speed of spinal vs general anaesthesia for category-1 caesarean section: a simulation and clinical observation-based study.

PubMed

Kathirgamanathan, A; Douglas, M J; Tyler, J; Saran, S; Gunka, V; Preston, R; Kliffer, P

2013-07-01

Controversy exists as to whether effective spinal anaesthesia can be achieved as quickly as general anaesthesia for a category-1 caesarean section. Sixteen consultants and three fellows in obstetric anaesthesia were timed performing spinal and general anaesthesia for category-1 caesarean section on a simulator. The simulation time commenced upon entry of the anaesthetist into the operating theatre and finished for the spinal anaesthetic at the end of intrathecal injection and for the general anaesthetic when the anaesthetist was happy for surgery to start. In the second clinical part of the study, the time from intrathecal administration to 'adequate surgical anaesthesia' (defined as adequate for start of a category-1 caesarean section) was estimated in 100 elective (category-4) caesarean sections. The median (IQR [range]) times (min:s) for spinal procedure, onset of spinal block and general anaesthesia were 2:56 (2:32-3:32 [1:22-3:50]), 5:56 (4:23-7:39 [2:9-13:32]) and 1:56 (1:39-2:9 [1:13-3:12]), respectively. The limiting factor in urgent spinal anaesthesia is the unpredictable time needed for adequate surgical block to develop. Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland.

A rare cause of hypertension in pregnancy: Phaeochromocytoma.

PubMed

Shah, Sonali; Edwards, Lindsay; Robinson, Andrew; Crosthwaite, Amy; Houlihan, Christine; Paizis, Kathy

2017-06-01

A 26-year-old primigravida at 35 weeks' gestation was transferred to our institution from a regional hospital for management of presumed preeclampsia. Due to the labile nature of her hypertension, further investigation was undertaken which revealed a right-sided phaeochromocytoma. Alpha blockade was commenced, and an uncomplicated elective caesarean delivery was performed at 38 weeks' gestation under spinal anaesthetic. The patient underwent an elective right laparoscopic adrenalectomy six weeks post-partum. This case highlights the importance of investigating young women for secondary causes of hypertension to avoid mislabelling as essential or gestational hypertension.

Deciding on the mode of birth after a previous caesarean section - An online survey investigating women's preferences in Western Switzerland.

PubMed

Bonzon, Magali; Gross, Mechthild M; Karch, André; Grylka-Baeschlin, Susanne

2017-07-01

promoting vaginal births after caesarean section (VBAC) for eligible women and increasing rates of successful VBACs are the best strategies to reduce the number of repeat caesarean sections (CS). Knowledge of factors that are associated with women's decision-making around mode of birth after CS is important when developing strategies to promote VBAC. This study assessed which factors are associated with women's preferences for VBAC versus elective repeat caesarean section (ERCS) in a new pregnancy after one previous caesarean in Switzerland. cross-sectional web-survey. Western Switzerland. French-speaking women living in Western Switzerland, with one previous CS who gave birth subsequently to a child after a complication-free pregnancy were eligible to participate in the survey. Of 393 women who started the survey in November/December 2014, 349 were included: 227 who planned a VBAC and 122 who planned an ERCS at term. univariable and multivariable analyses were conducted to describe and compare women who had planned a VBAC with women who had planned an ERCS in a pregnancy following a CS. Logistic regression modelling was used to investigate predictors that were associated with a preference for a VBAC at term. Analyses were performed with SPSS 22 and Stata 13. of the women planning a VBAC, 62.6% VBAC gave birth vaginally. Predictors which were significantly associated with increased odds of women choosing a VBAC: duration since previous birth in years (OR=1.11 95% CI [1.03-1.20], p=0.010), having had midwifery care during pregnancy (OR=2.09, 95% CI [1.08-4.05], p=0.029), being advised by their healthcare provider to attempt a VBAC (OR=4.20, 95% CI [1.75-10.09], p=0.001), preference for VBAC during the third trimester of their pregnancy (OR=3.98, 95% CI [1.77-8.93], p=0.001), and wishing to let the child choose the moment of birth (OR=1.46, 95% CI[1.22-1.74], p<0.001). The importance of safety for the mother decreased the odds of women preferring a VBAC (OR=0.74, 95% CI [0.60-0.90], p=0.003) while a motivation for more immediate bonding with the baby after birth increased the odds of preferring a VBAC at term (OR=1.25, 95% CI [1.06-1.46], p=0.007). caregivers' recommendations about mode of birth after CS, women's preferences during the third trimester and midwifery care during pregnancy were found to be the most important predictors for preferring a VBAC at term. These results indicate that midwifery antenatal care might be a key factor for fostering women's preference for a VBAC. women with a history of CS who feel ambivalent about the mode of birth are likely to benefit from access to midwifery support. Copyright © 2017 Elsevier Ltd. All rights reserved.

Maternal and anaesthesia-related risk factors and incidence of spinal anaesthesia-induced hypotension in elective caesarean section: A multinomial logistic regression.

PubMed

Fakherpour, Atousa; Ghaem, Haleh; Fattahi, Zeinabsadat; Zaree, Samaneh

2018-01-01

Although spinal anaesthesia (SA) is nowadays the preferred anaesthesia technique for caesarean section (CS), it is associated with considerable haemodynamic effects, such as maternal hypotension. This study aimed to evaluate a wide range of variables (related to parturient and anaesthesia techniques) associated with the incidence of different degrees of SA-induced hypotension during elective CS. This prospective study was conducted on 511 mother-infant pairs, in which the mother underwent elective CS under SA. The data were collected through preset proforma containing three parts related to the parturient, anaesthetic techniques and a table for recording maternal blood pressure. It was hypothesized that some maternal (such as age) and anaesthesia-related risk factors (such as block height) were associated with occurance of SA-induced hypotension during elective CS. The incidence of mild, moderate and severe hypotension was 20%, 35% and 40%, respectively. Eventually, ten risk factors were found to be associated with hypotension, including age >35 years, body mass index ≥25 kg/m 2 , 11-20 kg weight gain, gravidity ≥4, history of hypotension, baseline systolic blood pressure (SBP) <120 mmHg and baseline heart rate >100 beats/min in maternal modelling, fluid preloading ≥1000 ml, adding sufentanil to bupivacaine and sensory block height >T 4 in anaesthesia-related modelling ( P < 0.05). Age, body mass index, weight gain, gravidity, history of hypotension, baseline SBP and heart rate, fluid preloading, adding sufentanil to bupivacaine and sensory block hieght were the main risk factors identified in the study for SA-induced hypotension during CS.

An observational prospective cohort study of incidence and characteristics of failed spinal anaesthesia for caesarean section.

PubMed

Sng, B L; Lim, Y; Sia, A T H

2009-07-01

A prospective cohort study was performed in 800 parturients undergoing elective caesarean section under spinal anaesthesia from May 2005 to April 2006 in a large maternity hospital in Singapore, in order to determine the incidence of and risk factors for total and partial failure of spinal anaesthesia. A routine single-shot spinal technique using intrathecal 0.5% heavy bupivacaine 2.0 mL (10 mg) and morphine 100 microg was administered with a 27-gauge Whitacre spinal needle via a 20-gauge introducer. Demographic, surgical and anaesthetic data were collected to determine risk factors for failure of spinal anaesthesia. Incidence of total failure requiring conversion to general anaesthesia was 0.5% (4 cases) in which three cases had inadequate block (loss of sensation to cold less than T6) and one case had no sensory block. Thirty-three parturients (4.1%) required intravenous fentanyl and seven (0.9%) required Entonox for intraoperative analgesic supplementation. Postpartum sterilization (P<0.001) was an independent risk factor for partial failure requiring intravenous fentanyl and Entonox. Spinal anaesthesia using bupivacaine 10 mg with morphine 100 microg produces reliable anaesthesia for elective caesarean section. Postpartum sterilization involves exteriorisation of the uterus with additional surgical manipulation and hence may necessitate analgesic supplementation. The initial use of a combined spinal-epidural technique or the addition of intrathecal fentanyl or clonidine or an increased dose of local anaesthetic may be considered to decrease the incidence of intraoperative pain.

Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience.

PubMed

Wrench, I J; Allison, A; Galimberti, A; Radley, S; Wilson, M J

2015-05-01

The widespread adoption of enhanced recovery programmes in various surgical specialties has resulted in patient benefits including reduced morbidity, reduced length of stay and an earlier return to normal activities. This evidence, along with the increased financial pressures in the UK National Health Service, has led many units to consider introducing such a programme for obstetric surgery. We report our experience in setting up an enhanced recovery programme for women undergoing elective caesarean section and a prospective analysis of factors that influence length of stay. An enhanced recovery pathway was designed by a multidisciplinary team and introduced in March 2012. Factors influencing length of stay were determined using a log normal model. The proportion of women discharged on Day 1 increased from 1.6% in the first quarter of 2012 to 25.2% in the first quarter of 2014. The 30-day readmission rate was 4.4% for those discharged on Day 1 and 5.6% for Day 2. Earlier gestation, multiple birth, intention to breast feed, longer surgery and more time in the post-anaesthesia recovery unit were all independently associated with a longer postoperative stay. Women presenting for obstetric surgery with the indication "one previous caesarean section" were more likely to leave hospital earlier compared to most other indications. An enhanced recovery programme was successfully introduced into our unit. Many of the interventions were straightforward and could be adopted easily elsewhere. Copyright © 2015 Elsevier Ltd. All rights reserved.

Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double-blinded, placebo-controlled trial.

PubMed

Impey, Lawrence; Pandit, Meghana

2005-05-01

External cephalic version (ECV) reduces the incidence of breech presentation at term and caesarean section for non-cephalic births. Tocolytics may improve success rates, but are time consuming, may cause side effects and have not been proven to alter caesarean section rates. The aim of this trial was to determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt. To determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt. Randomised, double-blinded, placebo-controlled trial. UK teaching hospital. One hundred and twenty-four women with a breech presentation at term who had undergone an unsuccessful attempt at ECV. Relative risks with 95% confidence intervals for categorical variables and a t test for continuous variables. Analysis was by intention to treat. Incidence of cephalic presentation at delivery. Secondary outcomes were caesarean section and measures of neonatal and maternal morbidity. The use of tocolysis for a repeat attempt at ECV significantly increases the incidence of cephalic presentation at delivery (RR 3.21; 95% CI 1.23-8.39) and reduces the incidence of caesarean section (RR 0.33; 95% CI 0.14-0.80). The effects were most marked in multiparous women (RR for cephalic presentation at delivery 9.38; 95% CI 1.64-53.62). Maternal and neonatal morbidity remain unchanged. The use of tocolysis increases the success rate of repeat ECV and reduces the incidence of caesarean section. A policy of only using tocolysis where an initial attempt has failed leads to a relatively high success rate with minimum usage of tocolysis.

Women's preferences and mode of delivery in public and private hospitals: a prospective cohort study.

PubMed

Mazzoni, Agustina; Althabe, Fernando; Gutierrez, Laura; Gibbons, Luz; Liu, Nancy H; Bonotti, Ana María; Izbizky, Gustavo H; Ferrary, Marta; Viergue, Nora; Vigil, Silvia I; Zalazar Denett, Gabriela; Belizán, José M

2016-02-08

Rates of caesarean section have steadily increased in most middle- and high-income countries over the last few decades without medical justification. Maternal request is one of the frequently cited non-medical factors contributing to this trend. The objectives of this study were to assess pregnant women's preferences regarding mode of delivery and to compare actual caesarean section rates in the public and private sectors. A prospective cohort study was conducted in two public and three private hospitals in Buenos Aires, Argentina. 382 nulliparous pregnant women (183 from the private sector and 199 from the public sector) aged 18 to 35 years, with single pregnancies over 32 weeks of gestational age were enrolled during antenatal care visits between October 2010 and September 2011. We excluded women with pregnancies resulting from assisted fertility, women with known pre-existing major diseases or, with pregnancy complications, or with a medical indication of elective cesarean section. We used two different approaches to assess women's preferences: a survey using a tailored questionnaire, and a discrete choice experiment. Only 8 and 6% of the healthy nulliparous women in the public and private sectors, respectively, expressed a preference for caesarean section. Fear of pain and safety were the most frequently expressed reasons for preferring caesarean section. When reasons for delivery mode were assessed by a discrete choice experiment, women placed the most emphasis on sex after childbirth. Of women who expressed their preference for vaginal delivery, 34 and 40% ended their pregnancies by caesarean section in public and private hospitals, respectively. The preference for caesarean section is low among healthy nulliparous women in Buenos Aires. The reasons why these women had a rate of more than 35% caesarean sections are unlikely related to their preferences for mode of delivery.

Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial.

PubMed

Montgomery, Alan A; Emmett, Clare L; Fahey, Tom; Jones, Claire; Ricketts, Ian; Patel, Roshni R; Peters, Tim J; Murphy, Deirdre J

2007-06-23

To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section. Randomised trial, conducted from May 2004 to August 2006. Four maternity units in south west England, and Scotland. 742 pregnant women with one previous lower segment caesarean section and delivery expected at >or=37 weeks. Non-English speakers were excluded. Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher. Total score on decisional conflict scale, and mode of delivery. Women in the information programme (adjusted difference -6.2, 95% confidence interval -8.7 to -3.7) and the decision analysis (-4.0, -6.5 to -1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups. Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722.

Effect of Ketofol on Pain and Complication after Caesarean Delivery under Spinal Anaesthesia: A Randomized Double-blind Clinical Trial.

PubMed

Jaafarpour, Molouk; Vasigh, Aminolah; Khajavikhan, Javaher; Khani, Ali

2017-03-01

Pain is the key concern of women after caesarean delivery that may interfere with breastfeeding. The aim of this study was to assess effect of ketofol (ketamine/propofol combination) on pain and complication after caesarean delivery under spinal anaesthesia. In this randomized double-blind clinical trial, 92 parturient scheduled for elective caesarean delivery under spinal anaesthesia were included. The simple random sampling method was used to place subjects in four groups of ketamine (0.25 mg/kg), propofol (0.25 mg/kg), ketofol (25 mg ketamine plus 25 mg propofol) and placebo (saline). The drugs were administered intravenously immediately after clamping the umbilical cord. Visual Analog Scale (VAS) was used to determine the intensity of pain. Complications after surgery including shivering, nausea and vomiting as well as onset of breastfeeding were recorded. The mean score of pain, morphine consumption and time of breastfeeding in the ketofol group were significantly lower than other groups at various intervals (p<0.05, p<0.001). The frequencies of shivering, nausea, vomiting, retention and pruritus in the ketofol group were significantly lower than other groups (p<0.001, p<0.05). The effective role of ketofol on reducing pain and complication after caesarean delivery indicated that it can be considered as a safe and alternative drug in these patients.

Maternal and anaesthesia-related risk factors and incidence of spinal anaesthesia-induced hypotension in elective caesarean section: A multinomial logistic regression

PubMed Central

Fakherpour, Atousa; Ghaem, Haleh; Fattahi, Zeinabsadat; Zaree, Samaneh

2018-01-01

Background and Aims: Although spinal anaesthesia (SA) is nowadays the preferred anaesthesia technique for caesarean section (CS), it is associated with considerable haemodynamic effects, such as maternal hypotension. This study aimed to evaluate a wide range of variables (related to parturient and anaesthesia techniques) associated with the incidence of different degrees of SA-induced hypotension during elective CS. Methods: This prospective study was conducted on 511 mother–infant pairs, in which the mother underwent elective CS under SA. The data were collected through preset proforma containing three parts related to the parturient, anaesthetic techniques and a table for recording maternal blood pressure. It was hypothesized that some maternal (such as age) and anaesthesia-related risk factors (such as block height) were associated with occurance of SA-induced hypotension during elective CS. Results: The incidence of mild, moderate and severe hypotension was 20%, 35% and 40%, respectively. Eventually, ten risk factors were found to be associated with hypotension, including age >35 years, body mass index ≥25 kg/m2, 11–20 kg weight gain, gravidity ≥4, history of hypotension, baseline systolic blood pressure (SBP) <120 mmHg and baseline heart rate >100 beats/min in maternal modelling, fluid preloading ≥1000 ml, adding sufentanil to bupivacaine and sensory block height >T4in anaesthesia-related modelling (P < 0.05). Conclusion: Age, body mass index, weight gain, gravidity, history of hypotension, baseline SBP and heart rate, fluid preloading, adding sufentanil to bupivacaine and sensory block hieght were the main risk factors identified in the study for SA-induced hypotension during CS. PMID:29416149

Mode of delivery and the probability of subsequent childbearing: a population-based register study.

PubMed

Elvander, C; Dahlberg, J; Andersson, G; Cnattingius, S

2015-11-01

To investigate the relationship between mode of first delivery and probability of subsequent childbearing. Population-based study. Nationwide study in Sweden. A cohort of 771 690 women who delivered their first singleton infant in Sweden between 1992 and 2010. Using Cox's proportional-hazards regression models, risks of subsequent childbearing were compared across four modes of delivery. Hazard ratios (HRs) were calculated, using 95% confidence intervals (95% CIs). Probability of having a second and third child; interpregnancy interval. Compared with women who had a spontaneous vaginal first delivery, women who delivered by vacuum extraction were less likely to have a second pregnancy (HR 0.96, 95% CI 0.95-0.97), and the probabilities of a second childbirth were substantially lower among women with a previous emergency caesarean section (HR 0.85, 95% CI 0.84-0.86) or an elective caesarean section (HR 0.82, 95% CI 0.80-0.83). There were no clinically important differences in the median time between first and second pregnancy by mode of first delivery. Compared with women younger than 30 years of age, older women were more negatively affected by a vacuum extraction with respect to the probability of having a second child. A primary vacuum extraction decreased the probability of having a third child by 4%, but having two consecutive vacuum extraction deliveries did not further alter the probability. A first delivery by vacuum extraction does not reduce the probability of subsequent childbearing to the same extent as a first delivery by emergency or elective caesarean section. © 2014 Royal College of Obstetricians and Gynaecologists.

Post-traumatic stress disorder managed successfully with hypnosis and the rewind technique: two cases in obstetric patients.

PubMed

Slater, P M

2015-08-01

Two obstetric patients presenting with post-traumatic stress disorder in the antenatal period are discussed. The first patient had previously had an unexpected stillborn delivered by emergency caesarean section under general anaesthesia. She developed post-traumatic stress disorder and presented for repeat caesarean section in her subsequent pregnancy, suffering flashbacks and severe anxiety. Following antenatal preparation with hypnosis and a psychological method called the rewind technique, she had a repeat caesarean section under spinal anaesthesia, successfully managing her anxiety. The second patient suffered post-traumatic stress disorder symptoms after developing puerperal psychosis during the birth of her first child. Before the birth of her second child, she was taught self-hypnosis, which she used during labour in which she had an uneventful water birth. These cases illustrate the potential value of hypnosis and alternative psychological approaches in managing women with severe antenatal anxiety. Copyright © 2015 Elsevier Ltd. All rights reserved.

Fathers' care of the newborn infant after caesarean section in Chile: A qualitative study.

PubMed

Ayala, Ana; Christensson, Kyllike; Velandia, Marianne; Erlandsson, Kerstin

2016-06-01

In Chilean hospitals the current model of care after caesarean section is to separate newborn infants from both parents. The care of newborn infants and the parents' experience immediately after caesarean section requires further exploration. To describe fathers' experiences and perceptions of being the primary caregiver to their newborn infant during the first 90 minutes after caesarean section in a public general maternity hospital setting in Santiago de Chile. The questionnaire was one part of a larger research programme named: "Caregiving Models after Elective Caesarean Section - Parents' perceptions and effects on infants' wellbeing". Four open ended questions were used to gather written text on the experiences and perceptions of 95 fathers who were the primary caregiver to their newborn infant. Ethical approval was obtained from the Ethics Committee, Scientific Assessment Metropolitan Health Service South East. Systematic text condensation according to Malterud's description was used for analysis of the written text. Two themes were identified: "understanding the first moment of life" and "shared responsibility for future family life" with each theme divided into six categories. This study concludes by arguing that in situations where the mother is unavailable or unable to provide basic care, the father should be supported to care for the newborn infant. Parents should be made aware of the benefits of this caring model especially when mother and baby have been separated after birth. Copyright © 2016 Elsevier B.V. All rights reserved.

Routes of administration of antibiotic prophylaxis for preventing infection after caesarean section.

PubMed

Nabhan, Ashraf F; Allam, Nahed E; Hamed Abdel-Aziz Salama, Mohamed

2016-06-17

Post-caesarean section infection is a cause of maternal morbidity and mortality. Administration of antibiotic prophylaxis is recommended for preventing infection after caesarean delivery. The route of administration of antibiotic prophylaxis should be effective, safe and convenient. Currently, there is a lack of synthesised evidence regarding the benefits and harms of different routes of antibiotic prophylaxis for preventing infection after caesarean section. The aim of this review was to assess the benefits and harms of different routes of prophylactic antibiotics given for preventing infectious morbidity in women undergoing caesarean section. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 January 2016) and reference lists of retrieved studies. We included randomised controlled trials (RCTs) comparing at least two alternative routes of antibiotic prophylaxis for caesarean section (both elective and emergency). Cross-over trials and quasi-RCTs were not eligible for inclusion. Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data from the included studies. These steps were checked by a third review author. We included 10 studies (1354 women). The risk of bias was unclear or high in most of the included studies.All of the included trials involved women undergoing caesarean section whether elective or non-elective. Intravenous antibiotics versus antibiotic irrigation (nine studies, 1274 women) Nine studies (1274 women) compared the administration of intravenous antibiotics with antibiotic irrigation. There were no clear differences between groups in terms of this review's maternal primary outcomes: endometritis (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.70 to 1.29; eight studies (966 women) (low-quality evidence)); wound infection (RR 0.49, 95% CI 0.17 to 1.43; seven studies (859 women) (very low-quality evidence)). The outcome of infant sepsis was not reported in the included studies.In terms of this review's maternal secondary outcomes, there were no clear differences between intravenous antibiotic or irrigation antibiotic groups in terms of postpartum febrile morbidity (RR 0.87, 95% CI 0.48 to 1.60; three studies (264 women) (very low-quality evidence)); or urinary tract infection (RR 0.74, 95% CI 0.25 to 2.15; five studies (660 women) (very low-quality evidence)). In terms of adverse effects of the treatment on the women, no drug allergic reactions were reported in three studies (284 women) (very low-quality evidence), and there were no cases of serious infectious complications reported (very low-quality evidence). There was no clear difference between groups in terms of maternal length of hospital stay (mean difference (MD) 0.28 days, 95% CI -0.22 to 0.79 days, (random-effects analysis), four studies (512 women). No data were reported for the number of women readmitted to hospital. For the baby, there were no data reported in relation to oral thrush, infant length of hospital stay or immediate adverse effects of the antibiotics on the infant. Intravenous antibiotic prophylaxis versus oral antibiotic prophylaxis (one study, 80 women) One study (80 women) compared an intravenous versus an oral route of administration of prophylactic antibiotics, but did not report any of this review's primary or secondary outcomes. There was no clear difference between irrigation and intravenous antibiotic prophylaxis in reducing the risk of post-caesarean endometritis. For other outcomes, there is insufficient evidence regarding which route of administration of prophylactic antibiotics is most effective at preventing post-caesarean infections. The quality of evidence was very low to low, mainly due to limitations in study design and imprecision. Furthermore, most of the included studies were underpowered (small sample sizes with few events). Therefore, we advise caution in the interpretation and generalisability of the results.For future research, there is a need for well-designed, properly-conducted, and clearly-reported RCTs. Such studies should evaluate the more recently available antibiotics, elaborating on the various available routes of administration, and exploring potential neonatal side effects of such interventions.

Perfusion index derived from a pulse oximeter can predict the incidence of hypotension during spinal anaesthesia for Caesarean delivery.

PubMed

Toyama, S; Kakumoto, M; Morioka, M; Matsuoka, K; Omatsu, H; Tagaito, Y; Numai, T; Shimoyama, M

2013-08-01

Hypotension during spinal anaesthesia for Caesarean delivery is a result of decreased vascular resistance due to sympathetic blockade and decreased cardiac output due to blood pooling in blocked areas of the body. Change in baseline peripheral vascular tone due to pregnancy may affect the degree of such hypotension. The perfusion index (PI) derived from a pulse oximeter has been used for assessing peripheral perfusion dynamics due to changes in peripheral vascular tone. The aim of this study was to examine whether baseline PI could predict the incidence of spinal anaesthesia-induced hypotension during Caesarean delivery. Parturients undergoing elective Caesarean delivery under spinal anaesthesia with hyperbaric bupivacaine 10 mg and fentanyl 20 μg were enrolled in this prospective study. The correlation between baseline PI and the degree of hypotension during spinal anaesthesia and also the predictability of spinal anaesthesia-induced hypotension during Caesarean delivery by PI were investigated. Baseline PI correlated with the degree of decreases in systolic and mean arterial pressure (r=0.664, P<0.0001 and r=0.491, P=0.0029, respectively). The cut-off PI value of 3.5 identified parturients at risk for spinal anaesthesia-induced hypotension with a sensitivity of 81% and a specificity of 86% (P<0.001). The change of PI in parturients with baseline PI ≤ 3.5 was not significant during the observational period, while PI in parturients with baseline PI>3.5 demonstrated marked decreases after spinal injection. We demonstrated that higher baseline PI was associated with profound hypotension and that baseline PI could predict the incidence of spinal anaesthesia-induced hypotension during Caesarean delivery.

Fetal laceration during caesarean section and its medico-legal sequelae.

PubMed

Esposito, Ciro; Escolino, Maria; Paternoster, Mariano; Buccelli, Claudio; Graziano, Vincenzo; Falco, Marianna; Alicchio, Francesca; Cerulo, Mariapina; Settimi, Alessandro; Savanelli, Antonio

2015-04-01

Fetal laceration is a recognized complication of caesarean delivery. The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal incised wounds during caesarean delivery. During a five-year period, we observed 25 cases of fetal lacerations caused by the scalpel during hysterotomy. In 20 of these cases, we observed these lesions as consultants for the Neonatologic Care Unit; the other five cases came under our care after an insurance claim for damages against the gynaecologist. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary, and only 16 of the 25 mothers had signed an informed consent before surgery. With regard to the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using single stitches in nine cases, and with biological glue in 11 cases. Concerning the five cases that underwent legal proceedings against the gynaecologist, a clinical examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon to evaluate the degree of biological damage. In all five cases, the result of the legal challenge was monetary compensation for the physical and moral damage caused by the gynaecologists to the patients and their parents. Accidental fetal lesions may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be informed about the risk of the occurrence of fetal lacerations during caesarean delivery in order to avoid legal complications. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Term elective induction of labour and perinatal outcomes in obese women: retrospective cohort study.

PubMed

Lee, V R; Darney, B G; Snowden, J M; Main, E K; Gilbert, W; Chung, J; Caughey, A B

2016-01-01

To compare perinatal outcomes between elective induction of labour (eIOL) and expectant management in obese women. Retrospective cohort study. Deliveries in California in 2007. Term, singleton, vertex, nonanomalous deliveries among obese women (n = 74 725). Women who underwent eIOL at 37 weeks were compared with women who were expectantly managed at that gestational age. Similar comparisons were made at 38, 39, and 40 weeks. Results were stratified by parity. Chi-square tests and multivariable logistic regression were used for statistical comparison. Method of delivery, severe perineal lacerations, postpartum haemorrhage, chorioamnionitis, macrosomia, shoulder dystocia, brachial plexus injury, respiratory distress syndrome. The odds of caesarean delivery were lower among nulliparous women with eIOL at 37 weeks [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.34-0.90] and 39 weeks (OR 0.77, 95% CI 0.63-0.95) compared to expectant management. Among multiparous women with a prior vaginal delivery, eIOL at 37 (OR 0.39, 95% CI 0.24-0.64), 38 (OR 0.65, 95% CI 0.51-0.82), and 39 weeks (OR 0.67, 95% CI 0.56-0.81) was associated with lower odds of caesarean. Additionally, eIOL at 38, 39, and 40 weeks was associated with lower odds of macrosomia. There were no differences in the odds of operative vaginal delivery, lacerations, brachial plexus injury or respiratory distress syndrome. In obese women, term eIOL may decrease the risk of caesarean delivery, particularly in multiparas, without increasing the risks of other adverse outcomes when compared with expectant management. © 2015 Royal College of Obstetricians and Gynaecologists.

Efficacy of low-dose bupivacaine in spinal anaesthesia for Caesarean delivery: systematic review and meta-analysis.

PubMed

Arzola, C; Wieczorek, P M

2011-09-01

Spinal anaesthesia is the preferred anaesthetic technique for elective Caesarean deliveries. Hypotension is the most common side-effect and has both maternal and neonatal consequences. Different strategies have been attempted to prevent spinal-induced hypotension, including the use of low-dose bupivacaine. We conducted a systematic search for randomized controlled trials comparing the efficacy of spinal bupivacaine in low dose (LD ≤8 mg) with conventional dose (CD >8 mg) for elective Caesarean delivery. Thirty-five trials were identified for eligibility assessment, 15 were selected for data extraction, and 12 were finally included in the meta-analysis. We investigated sources of heterogeneity, subgroup analysis, and meta-regression for confounding variables (baricity, intrathecal opioids, lateral vs sitting position, uterine exteriorization, and study population). Sensitivity analysis was performed to test the robustness of the results. In the LD group, the need for analgesic supplementation during surgery was significantly higher [risk ratio (RR)=3.76, 95% confidence interval (95% CI)=2.38-5.92] and the number needed to treat for an additional harmful outcome (NNTH) was 4 (95% CI=2-7). Furthermore, the LD group exhibited a lower risk of hypotension (RR=0.78, 95% CI=0.65-0.93) and nausea/vomiting (RR=0.71, 95% CI=0.55-0.93). Conversion to general anaesthesia occurred only in the LD group (two events). Neonatal outcomes (Apgar score, acid-base status) and clinical quality variables (patient satisfaction, surgical conditions) showed non-significant differences between LD and CD. This meta-analysis demonstrates that low-dose bupivacaine in spinal anaesthesia compromises anaesthetic efficacy (risk of analgesic supplementation: high grade of evidence), despite the benefit of lower maternal side-effects (hypotension, nausea/vomiting: moderate grade of evidence).

Regardless of where they give birth, women living in non-metropolitan areas are less likely to have an epidural than their metropolitan counterparts.

PubMed

Powers, Jennifer R; Loxton, Deborah J; O'Mara, Ashleigh T; Chojenta, Catherine L; Ebert, Lyn

2013-06-01

Can differences in Australian birth intervention rates be explained by women's residence at the time of childbearing?. Data were collected prospectively via surveys in 1996, 2000, 2003, 2006 and 2009 from women, born between 1973 and 1978, of the Australian Longitudinal Study on Women's Health. Analysis included data from 5886 women who had given birth to their first child between 1994 and 2009. Outcome measures were self-report of birth interventions: pharmacological pain relief (epidural and spinal block analgesia, inhalational analgesia and intramuscular injections), surgical births (an elective or emergency caesarean section) and instrumental births (forceps and ventouse). Primiparous women residing in non-metropolitan areas of Australia experienced fewer birth interventions than women residing in metropolitan areas: 43% versus 56% received epidural analgesia; 8% versus 11% had elective caesarean sections; and 16% versus 18% had emergency caesarean sections. Differences in maternal age and private health insurance status at first birth accounted for differences in surgical birth rates but did not fully explain differences in epidural analgesia. Non-metropolitan women had fewer birth interventions, particularly epidural analgesia, than metropolitan women. Differences in maternal age and private health insurance do not fully explain the differences in epidural analgesia rates, suggesting care provided to labouring women may differ by area of residence. The difference in epidural analgesia rates may be due to lack of choice in maternity services, however it could also be due to differing expectations leading to differences in birth interventions for primiparous women living in metropolitan and non-metropolitan areas. Copyright © 2012 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Thirty years of the World Health Organization's target caesarean section rate: time to move on.

PubMed

Robson, Stephen J; de Costa, Caroline M

2017-03-06

It has been 30 years since the World Health Organization first recommended a "maximum" caesarean section (CS) rate of 15%. There are demographic differences across the 194 WHO member countries; recent analyses suggest the optimal global CS rate is almost 20%. Attempts to reduce CS rates in developed countries have not worked. The strongest predictor of caesarean delivery for the first birth of "low risk" women appears to be maternal age; a factor that continues to increase. Most women whose first baby is born by caesarean delivery will have all subsequent children by caesarean delivery. Outcomes that informed the WHO recommendation primarily relate to maternal and perinatal mortality, which are easy to measure. Longer term outcomes, such as pelvic organ prolapse and urinary incontinence, are closely related to mode of birth, and up to 20% of women will undergo surgery for these conditions. Pelvic floor surgery is typically undertaken for older women who are less fit for surgery. Serious complications such as placenta accreta occur with repeat caesarean deliveries, but the odds only reach statistical significance at the third or subsequent caesarean delivery. However, in Australia, parity is falling, and only 20% of women will have more than two births. We should aim to provide CS to women in need and to continue including women in the conversation about the benefits and disadvantages, both short and long term, of birth by caesarean delivery.

Comparison of Efficacy and Safety of Intramuscular Piroxicam and Tramadol for Post-operative Pain in Patients Undergoing Caesarean Delivery.

PubMed

Thippeswamy, Tejashree; Krishnaswamy, Bhuvana; Bengalorkar, Girish M; Mariyappa, Narayanaswamy

2016-11-01

Post-caesarean section pain can be both stressful and unfavourable. Effective and rapid reduction of pain facilitates early ambulation and care of the new born. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and opioids are used for pain relief but they are associated with adverse effects both in the mother and the child. To evaluate efficacy and safety of piroxicam and tramadol in post-caesarean section pain. Primigravidae who underwent elective caesarean section received either piroxicam 20mg or tramadol 100mg intra-muscularly, following recovery from anaesthesia. Severity of pain was assessed using Visual Analogue Scale (VAS) and side-effects to study drugs were noted. Rescue analgesic butorphanol 2mg was administered if VAS score was more than four. Patient's satisfaction score was assessed at 12 hours post-operatively. Mean age in piroxicam and tramadol groups were 23.32±3.43 and 22.03±2.0 years respectively. Significant reduction in pain was observed at 2, 4, 8, 12 and 24 hours in both groups (p<0.001). Pain relief was significant at 2, 4 and 8 hours in piroxicam group compared to tramadol. Twenty-one and 12 patients in tramadol and piroxicam groups received rescue analgesic respectively. Sedation and nausea was significantly higher in tramadol group (p<0.001), 46.66% of patients graded their satisfaction score as good and 15% as excellent in piroxicam group. Intra-muscular piroxicam was effective in reducing post-caesarean section pain for 24 hours with minimal side-effects compared to tramadol.

Delivery mode and neonatal outcome after a trial of external cephalic version (ECV): a prospective trial of vaginal breech versus cephalic delivery.

PubMed

Reinhard, Joscha; Sänger, Nicole; Hanker, Lars; Reichenbach, Lena; Yuan, Juping; Herrmann, Eva; Louwen, Frank

2013-04-01

To examine the delivery mode and neonatal outcome after a trial of external cephalic version (ECV) procedures. This is an interim analysis of an ongoing larger prospective off-centre randomised trial, which compares a clinical hypnosis intervention against neuro-linguistic programming (NLP) of women with a singleton breech foetus at or after 37(0/7) (259 days) weeks of gestation and normal amniotic fluid index. Main outcome measures were delivery mode and neonatal outcome. On the same day after the ECV procedure two patients (2 %), who had unsuccessful ECVs, had Caesarean sections (one due to vaginal bleeding and one due to pathological CTG). After the ECV procedure 40.4 % of women had cephalic presentation (n = 38) and 58.5 % (n = 55) remained breech presentation. One patient remained transverse presentation (n = 1; 1.1 %). Vaginal delivery was observed by 73.7 % of cephalic presentation (n = 28), whereas 26.3 % (n = 10) had in-labour Caesarean sections. Of those, who selected a trial of vaginal breech delivery, 42.4 % (n = 14) delivered vaginally and 57.6 % (n = 19) delivered via Caesarean section. There is a statistically significant difference between the rate of vaginal birth between cephalic presentation and trial of vaginal breech delivery (p = 0.009), however, no difference in neonatal outcome was observed. ECV is a safe procedure and can reduce not only the rate of elective Caesarean sections due to breech presentation but also the rate of in-labour Caesarean sections even if a trial of vaginal breech delivery is attempted.

Carbetocin versus oxytocin for prevention of post-partum haemorrhage at caesarean section in the United Kingdom: An economic impact analysis.

PubMed

van der Nelson, Helen A; Draycott, Tim; Siassakos, Dimitrios; Yau, Christopher W H; Hatswell, Anthony J

2017-03-01

To determine the economic impact of the introduction of carbetocin for the prevention of postpartum haemorrhage (PPH) at caesarean section, compared to oxytocin. The model is a decision tree conducted from a UK National Health Service perspective. 1500 caesarean sections (both elective and emergency) were modelled over a 12 month period. Efficacy data was taken from a published Cochrane meta-analysis, and costs from NHS Reference costs, the British National Formulary and the NHS electronic Medicines Information Tool. A combination of hospital audit data and expert input from an advisory board of clinicians was used to inform resource use estimates. The main outcome measures were the incidence of PPH and total cost over a one year time horizon, as a result of using carbetocin compared to oxytocin for prevention of PPH at caesarean section. The use of carbetocin compared to oxytocin for prevention of PPH at caesarean section was associated with a reduction of 30 (88 vs 58) PPH events (>500ml blood loss), and a cost saving of £27,518. In probabilistic sensitivity analysis, carbetocin had a 91.5% probability of producing better outcomes, and a 69.4% chance of being dominant (both cheaper and more effective) compared to oxytocin. At list price, the introduction of carbetocin appears to provide improved clinical outcomes along with cost savings, though this is subject to uncertainty regarding the underlying data in efficacy, resource use, and cost. Crown Copyright © 2017. Published by Elsevier B.V. All rights reserved.

Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Study.

PubMed

Lakshmi, Sj Dhivya; Abraham, Reena

2016-12-01

Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used to reduce heavy menstrual blood loss. To analyse the effectiveness of Tranexamic Acid (TXA) in reducing blood loss during elective caesarean section. This interventional, randomized, parallel group study was done in the Department of Obstetrics and Gynaecolgy, PSG IMSR, Coimbatore, from June 2014 to May 2015. It was conducted on 120 women undergoing caesarean section. They were allocated to either Study or Control group by computer generated random number tables. TXA was given prior to surgery in study group in addition to the routine care {10 units of oxytocin added to the intravenous drip soon after baby delivery} whereas, the control group had routine care alone. Blood loss was measured in both groups by gravimetric method. Haemoglobin before and after surgery was estimated and the percentage of difference was compared. Primary outcome variables were volume of blood loss and percentage fall in haemoglobin before and after surgery. Secondary outcomes were duration of surgery, proportion of subjects with >500ml of blood loss, need for additional uterotonics and side effects. Unpaired t-test and Chi-square test were used to compare the outcome variables. There was significant reduction in blood loss calculated from placental delivery till end of surgery: 347.17ml in study group versus 517.72ml in control group (p<0.001). Another parameter studied was the percentage of fall in haemoglobin before and after surgery and the number of subjects who had more than 10% fall in haemoglobin. 9.3% of subjects in study group and 39% of subjects in control group had more than 10% fall in haemoglobin (p<0.01). There were no immediate post-operative complications to the mother and neonate. TXA significantly reduced the amount of blood loss during Lower Segment Caesarean Section (LSCS). Use of TXA was not associated with adverse effects. Thus, TXA can be used safely and effectively in subjects undergoing LSCS.

Intrathecal Midazolam as an Adjuvant in Pregnancy-Induced Hypertensive Patients Undergoing an Elective Caesarean Section: A Clinical Comparative Study

PubMed Central

Dodawad, Ravichandra; G. B., Sumalatha; Pandarpurkar, Sandeep; Jajee, Parashuram

2016-01-01

Background A pain-free postoperative period is essential following a caesarean section so new mothers may care for and bond with their neonates. Intrathecal adjuvants are often administered during this procedure to provide significant analgesia, but they may also have bothersome side effects. Intrathecal midazolam produces effective postoperative analgesia with no significant side effects. Objectives This prospective, randomized, double-blind study was designed to compare the analgesic efficacy and safety of intrathecal midazolam vs. plain bupivacaine as an adjunct to bupivacaine in pregnancy-induced hypertension patients scheduled for elective caesarean section. Methods Sixty patients diagnosed with pregnancy-induced hypertension on regular treatment who were scheduled for a caesarean section were randomly allocated into two groups: a control group (Group BC, n = 30) and a midazolam group (Group BM, n = 30). Both groups received 10 mg (2 mL) of 0.5% hyperbaric bupivacaine. Group BC received 0.4 mL of distilled water, while group BM received 0.4 mL (2 mg) of midazolam intrathecally. The duration of postoperative analgesia, analgesic requirements during the first 24 hours after surgery, onset times and durations of sensory and motor blocks, incidence of hypotension, vasopressor requirements, and side effects were recorded. Results Postoperative analgesia was significantly longer in the midazolam group compared to the control group (201.5 minutes vs. 357.6 minutes). The mean onset times of the sensory and motor blocks were significantly faster (P < 0.01) in the midazolam group compared to the control group. The mean times to attain the maximum sensory level and motor blocks were also significantly faster in the midazolam group compared to the control group (P < 0.05). The incidence of hypotension was 6.6% in the midazolam group and 36.6% in the control group, which was highly significant. In addition, the number of patients with side effects was significantly lower in the midazolam group compared to the control group. Conclusions Intrathecal midazolam 2 mg provides significantly longer and effective postoperative analgesia with no side effects. PMID:27847698

VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION: CURRENT TRENDS AND OUTLOOK IN GHANA.

PubMed

Seffah, J D; Adu-Bonsaffoh, K

2014-01-01

The optimal mode of subsequent delivery of women with prior caesarean birth remains a subject of intense research and debate in contemporary obstetric practice especially in low resource settings like West Africa where there are obvious systemic and management-related challenges associated with trial of scar. However, there is evidence that vaginal birth after caesarean section (VBAC) is safe in appropriately selected women in addition to adequate intrapartum monitoring and ready access to theatre when emergency CS is indicated. The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of trial of labour after caesarean section (TOLAC) in the mist of inherent challenges in deciding the optimal mode of childbirth for women with a previous caesarean birth. The secondary objective was to relate evidence based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth. This was a retrospective study of the records of patients who had had a prior caesarean delivery and who then proceeded to deliver the next babies at the Korle Bu Teaching Hospital (KBTH) between Jan 2010 and Dec 2014. The data on demography, antenatal care, labour and delivery and outcomes were collected from the Labour and Recovery wards and the Biostatistics unit of the Maternity unit of the Hospital. Excluded were women with a previous CS who had multiple pregnancies and those with incomplete notes as well as those whose delivery plans were not predetermined antenatally.. The data were analyzed using SPSS version 20. There were 53,581 deliveries during the study period. Vaginal delivery was obtained in 31,870 (59.5%) pregnancies and 21,711(40.5%) had CS. Also, 6261 (11.7%) had had a prior CS and 2472 (39.5%) of these were selected for TOLAC while 2119 (33.8) were scheduled for planned repeat CS. There was an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for TOLAC. There was a statistically significant difference between women who had successful or failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min. Birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. However, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS. . There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.

[Non elective cesarean section: use of a color code to optimize management of obstetric emergencies].

PubMed

Rudigoz, René-Charles; Huissoud, Cyril; Delecour, Lisa; Thevenet, Simone; Dupont, Corinne

2014-06-01

The medical team of the Croix Rousse teaching hospital maternity unit has developed, over the last ten years, a set of procedures designed to respond to various emergency situations necessitating Caesarean section. Using the Lucas classification, we have defined as precisely as possible the degree of urgency of Caesarian sections. We have established specific protocols for the implementation of urgent and very urgent Caesarean section and have chosen a simple means to convey the degree of urgency to all team members, namely a color code system (red, orange and green). We have set time goals from decision to delivery: 15 minutes for the red code and 30 minutes for the orange code. The results seem very positive: The frequency of urgent and very urgent Caesareans has fallen over time, from 6.1 % to 1.6% in 2013. The average time from decision to delivery is 11 minutes for code red Caesareans and 21 minutes for code orange Caesareans. These time goals are now achieved in 95% of cases. Organizational and anesthetic difficulties are the main causes of delays. The indications for red and orange code Caesarians are appropriate more than two times out of three. Perinatal outcomes are generally favorable, code red Caesarians being life-saving in 15% of cases. No increase in maternal complications has been observed. In sum: Each obstetric department should have its own protocols for handling urgent and very urgent Caesarean sections. Continuous monitoring of their implementation, relevance and results should be conducted Management of extreme urgency must be integrated into the management of patients with identified risks (scarred uterus and twin pregnancies for example), and also in structures without medical facilities (birthing centers). Obstetric teams must keep in mind that implementation of these protocols in no way dispenses with close monitoring of labour.

Evaluation of 25-gauge Quincke and 24-gauge Gertie Marx needles for spinal anaesthesia for caesarean section.

PubMed

Imarengiaye, C O; Edomwonyi, N P

2002-07-01

To compare the insertion characteristics and rate of complications between 25-gauge Quincke and 24-gauge Gertie Marx needles. Prospective, randomized study. University of Benin Teaching Hospital; a university-affiliated tertiary centre. Parturients (ASA 1 and 2) scheduled for elective caesarean section. They were randomly assigned to receive spinal anaesthesia with either 25-gauge Quincke needle or 24-gauge Gertie Marx needle. The patients with abnormal spaces, coagulopathy, infection, pre-eclampsia/eclampsia or obesity were excluded. The number of attempts at successful identification of the spinal space, intraoperative complications, incidence of postdural puncture headache (PDPH), non-postdural puncture headache (NPDPH) and backache. Sixty women were studied. The 24-gauge Gertie Marx needle resulted in more successful location of the spinal space on the second attempt (P<0.05). Non-postdural puncture headache was seen in 43% of the study population. PDPH was seen in 10% of the Quincke group and none in the Gertie Marx group. There was no difference in the incidence of backache in both groups. The ease of insertion and low incidence of PDPH with the Gertie Marx needle may encourage trainee anaesthetists to use this needle for caesarean section.

Manual displacement of the uterus during Caesarean section.

PubMed

Kundra, P; Khanna, S; Habeebullah, S; Ravishankar, M

2007-05-01

Ninety ASA 1 and 2 pregnant women with term singleton pregnancies and no maternal and fetal complications, scheduled for elective or emergency Caesarean section, were randomly allocated to group LT (15 degrees left lateral table tilt, n = 45) and group MD (leftward manual displacement, n = 45). Subarachnoid block was established with a 25-gauge spinal needle at the L3-L4 interspace using 1.5 ml of 0.5% hyperbaric bupivacaine. A median sensory level of T6 was observed in both groups but the incidence of hypotension was markedly lower in group MD when compared to group LT (4.4% vs 40%; p < 0.001) with a significant reduction in mean (SD) ephedrine requirement (6 (0) vs 11.3 (4.9) mg; p < 0.001). The mean (SD) fall in systolic blood pressure was 28.8 (7.3) mmHg in group LT and 20 (12.7) mmHg in group MD. The time to maximum fall in systolic blood pressure was similar in both groups (4.5 min). We conclude that manual displacement of the uterus effectively reduces the incidence of hypotension and ephedrine requirements when compared to 15 degrees left lateral table tilt in parturients undergoing Caesarean section.

An unanticipated cardiac arrest and unusual post-resuscitation psycho-behavioural phenomena/near death experience in a patient with pregnancy induced hypertension and twin pregnancy undergoing elective lower segment caesarean section.

PubMed

Panditrao, Mridul M; Singh, Chanchal; Panditrao, Minnu M

2010-09-01

A case report of a primigravida, who was admitted with severe pregnancy induced hypertension (BP 160/122 mmHg) and twin pregnancy, is presented here. Antihypertensive therapy was initiated. Elective LSCS under general anaesthesia was planned. After the birth of both the babies, intramyometrial injections of Carboprost and Pitocin were administered. Immediately, she suffered cardiac arrest. Cardio pulmonary resucitation (CPR) was started and within 3 minutes, she was successfully resuscitated. The patient initially showed peculiar psychological changes and with passage of time, certain psycho-behavioural patterns emerged which could be attributed to near death experiences, as described in this case report.

Trending elective preterm deliveries using administrative data.

PubMed

Korst, Lisa M; Fridman, Moshe; Lu, Michael C; Fleege, Laura; Mitchell, Connie; Gregory, Kimberly D

2013-01-01

We propose a methodology for identifying and analysing 'elective' preterm births (PTBs) using administrative data, and apply this methodology to California data with the objective of providing a framework to further explore the potential rationales for early delivery. Using the California linked birth cohorts for 1999, 2002 and 2005, singleton PTBs were identified using birth certificate gestational age ≥ 24 and <37 weeks. Through a hierarchical scheme that first removed cases with standard or 'hard' indications for early delivery (e.g. severe preeclampsia, placenta previa), cases of 'elective' PTB were identified with coding for medical intervention, that is, elective caesarean or labour induction. We calculated rates of elective PTB, with subanalyses of early (<34 weeks of gestational age) and late PTB (34 to <37 weeks of gestational age) using hierarchical logistic regression models. Of 1 387 565 singleton deliveries, 99 614 (7.2%) were preterm. Elective PTBs increased 27.7% over the 6-year study period, with nearly all cases confined to the late PTB stratum; elective late PTB rates rose from 10.5% to 13.5% of all late PTBs (P < 0.0001). Indications for delivery in this Elective Group ('soft indications') included prior pelvic floor repair, mental health conditions, fetal anomalies, malpresentation and oligohydramnios. Six per cent of patients with a late PTB had a medical intervention with no hard or soft indication for delivery. Using administrative data, we developed a method for identifying and trending the proportion of PTBs that is 'elective'. This method can be used to explore and monitor potential strategies for the prevention of elective PTB. © 2012 Blackwell Publishing Ltd.

Birth by Caesarean Section and the Risk of Adult Psychosis: A Population-Based Cohort Study

PubMed Central

O’Neill, Sinéad M.; Curran, Eileen A.; Dalman, Christina; Kenny, Louise C.; Kearney, Patricia M.; Clarke, Gerard; Cryan, John F.; Dinan, Timothy G.; Khashan, Ali S.

2016-01-01

Despite the biological plausibility of an association between obstetric mode of delivery and psychosis in later life, studies to date have been inconclusive. We assessed the association between mode of delivery and later onset of psychosis in the offspring. A population-based cohort including data from the Swedish National Registers was used. All singleton live births between 1982 and 1995 were identified (n = 1 345 210) and followed-up to diagnosis at age 16 or later. Mode of delivery was categorized as: unassisted vaginal delivery (VD), assisted VD, elective Caesarean section (CS) (before onset of labor), and emergency CS (after onset of labor). Outcomes included any psychosis; nonaffective psychoses (including schizophrenia only) and affective psychoses (including bipolar disorder only and depression with psychosis only). Cox regression analysis was used reporting partially and fully adjusted hazard ratios (HR) with 95% confidence intervals (CI). Sibling-matched Cox regression was performed to adjust for familial confounding factors. In the fully adjusted analyses, elective CS was significantly associated with any psychosis (HR 1.13, 95% CI 1.03, 1.24). Similar findings were found for nonaffective psychoses (HR 1.13, 95% CI 0.99, 1.29) and affective psychoses (HR 1.17, 95% CI 1.05, 1.31) (χ2 for heterogeneity P = .69). In the sibling-matched Cox regression, this association disappeared (HR 1.03, 95% CI 0.78, 1.37). No association was found between assisted VD or emergency CS and psychosis. This study found that elective CS is associated with an increase in offspring psychosis. However, the association did not persist in the sibling-matched analysis, implying the association is likely due to familial confounding by unmeasured factors such as genetics or environment. PMID:26615187

Vaginal birth after cesarean: new insights on maternal and neonatal outcomes.

PubMed

Guise, Jeanne-Marie; Denman, Mary Anna; Emeis, Cathy; Marshall, Nicole; Walker, Miranda; Fu, Rongwei; Janik, Rosalind; Nygren, Peggy; Eden, Karen B; McDonagh, Marian

2010-06-01

To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC). Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses. We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery). Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.

Efficacy of caesarean scar defect repair in improving postmenstrual bleeding and factors associated with poor effect.

PubMed

Xu, He-Yang; Yang, Meng-Yi; Zhang, Xuyin; Wang, Qing; Yi, Xiao-Fang; Ding, Jing-Xin; Hua, Ke-Qin

2017-11-01

Caesarean scar defect (CSD) can cause postmenstrual bleeding. Defect repair is an effective technique to improve this symptom, but there are still a few patients getting little improvement. This retrospective study evaluates the efficacy of scar repair and explores the factors associated with poor effect. In total, 123 patients were involved in the final analysis. All of them complained about menstruation period >7 days due to postmenstrual bleeding. Before surgery, 87.8% of patients had a menstruation period more than 10 days and 20.3% had a period more than 15 days. After surgery, a normal menstruation period (< =7 days) was achieved in 46.3% (95%CI 37.3%-55.6%) of patients and a menstruation period lasting no more than 10 days was achieved in 74.8% (95%CI 66.2%-82.2%). Through multivariate logistic analysis, four factors were found dependently associated with poor effect (defined as menstruation period >10 days after surgery): repeated caesarean section (OR 9.75, 95%CI 2.30-41.36, 0.002) was a risk factor, while defect volume >600 mm 3 (OR 0.14, 95%CI 0.03-0.56, 0.006), interval from caesarean section to symptom emerging >3 months (OR 0.25, 95%CI 0.07-0.94, 0.041) and straight or retroflexed uterus (OR 0.19, 95%CI 0.05-0.79, 0.022) were protective factors. Impact statement What is already known on this subject? Caesarean scar defect can cause postmenstrual bleeding. Defect repair can improve this symptom, but there are still a few patients getting little improvement after surgery. What do the results of this study add? Defect volume >600 mm 3 , interval from caesarean section to symptom emerging >3 months and straight or retroflexed uterus are protective factors of poor effect (defined as menstruation period >10 days after surgery), and repeated caesarean section is a risk factor. What are the implications of these findings for clinical practice and/or further research? These findings may help in counselling the patients and in medical decision. Further researches are needed to explore other factors associated with surgical effect and build prediction models.

4th Stage Transvaginal omental herniation during VBAC complicated by shoulder dystocia: a unique presentation of uterine rupture

PubMed Central

2013-01-01

Background Uterine rupture is a common complication in women attempting their first virginal birth after caesarean section (VBAC) but the risk diminishes with subsequent VBACs. It occurs in rates of 0.5-9% and is influenced by various factors. Case presentation A unique case of uterine rupture in a Kenyan woman of African descent during a repeat VBAC complicated by shoulder dystocia was discovered during the 4th stage of labour when omentum was noted protruding through the vagina. She had delivered 4 years earlier by caesarean section. Conclusion It is not common to experience uterine rupture among women attempting repeat VBAC. When it occurs, it may not always follow the known pattern intra-partum and is often associated with poor foetal outcome. PMID:23521920

Preterm birth

PubMed Central

2010-01-01

Introduction Preterm birth occurs in about 5% to 10% of all births in resource-rich countries, but in recent years the incidence seems to have increased in some countries, particularly in the USA. We found little reliable evidence for incidence in resource-poor countries. The rate in northwestern Ethiopia has been reported to vary from 11% to 22%, depending on the age group of mothers studied, and is highest in teenage mothers. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in women at high risk of preterm delivery? What are the effects of interventions to improve neonatal outcome after preterm rupture of membranes? What are the effects of treatments to stop contractions in preterm labour? What are the effects of elective compared with selective caesarean delivery for women in preterm labour? What are the effects of interventions to improve neonatal outcome in preterm delivery? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 58 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: amnioinfusion for preterm rupture of membranes; antenatal corticosteroids; antibiotic treatment; bed rest; beta mimetics; calcium-channel blockers; elective caesarean; enhanced antenatal care programmes; magnesium sulphate; oxytocin receptor antagonists (atosiban); progesterone; prophylactic cervical cerclage; prostaglandin inhibitors (e.g., indometacin); selective caesarean; and thyrotropin-releasing hormone (TRH) (plus corticosteroids).

Preterm birth

PubMed Central

2011-01-01

Introduction Preterm birth occurs in about 5% to 10% of all births in resource-rich countries, but in recent years the incidence seems to have increased in some countries, particularly in the USA. We found little reliable evidence for incidence in resource-poor countries. The rate in northwestern Ethiopia has been reported to vary from 11% to 22%, depending on the age group of mothers studied, and is highest in teenage mothers. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in women at high risk of preterm delivery? What are the effects of interventions to improve neonatal outcome after preterm rupture of membranes? What are the effects of treatments to stop contractions in preterm labour? What are the effects of elective compared with selective caesarean delivery for women in preterm labour? What are the effects of interventions to improve neonatal outcome in preterm delivery? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 58 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: amnioinfusion for preterm rupture of membranes, antenatal corticosteroids, antibiotic treatment, bed rest, beta-mimetics, calcium channel blockers, elective caesarean, enhanced antenatal care programmes, magnesium sulphate, oxytocin receptor antagonists (atosiban), progesterone, prophylactic cervical cerclage, prostaglandin inhibitors (e.g., indometacin), selective caesarean, and thyrotropin-releasing hormone (TRH) (plus corticosteroids). PMID:21463540

[Cesarean after labor induction: Risk factors and prediction score].

PubMed

Branger, B; Dochez, V; Gervier, S; Winer, N

2018-05-01

The objective of the study is to determine the risk factors for caesarean section at the time of labor induction, to establish a prediction algorithm, to evaluate its relevance and to compare the results with observation. A retrospective study was carried out over a year at Nantes University Hospital with 941 cervical ripening and labor inductions (24.1%) terminated by 167 caesarean sections (17.8%). Within the cohort, a case-control study was conducted with 147 caesarean sections and 148 vaginal deliveries. A multivariate analysis was carried out with a logistic regression allowing the elaboration of an equation of prediction and an ROC curve and the confrontation between the prediction and the reality. In univariate analysis, six variables were significant: nulliparity, small size of the mother, history of scarried uterus, use of prostaglandins as a mode of induction, unfavorable Bishop score<6, variety of posterior release. In multivariate analysis, five variables were significant: nulliparity, maternal size, maternal BMI, scar uterus and Bishop score. The most predictive model corresponded to an area under the curve of 0.86 (0.82-0.90) with a correct prediction percentage ("well classified") of 67.6% for a caesarean section risk of 80%. The prediction criteria would make it possible to inform the woman and the couple about the potential risk of Caesarean section in urgency or to favor a planned Caesarean section or a low-lying attempt on more objective, repeatable and transposable arguments in a medical team. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Observational study comparing non-invasive blood pressure measurement at the arm and ankle during caesarean section.

PubMed

Drake, M J P; Hill, J S

2013-05-01

Upper-arm non-invasive blood pressure measurement during caesarean section can be uncomfortable and unreliable because of movement artefact in the conscious parturient. We aimed to determine whether ankle blood pressure measurement could be used instead in this patient group by comparing concurrent arm and ankle blood pressure measured throughout elective caesarean section under regional anaesthesia in 64 term parturients. Bland-Altman analysis of mean difference (95% limits of agreement [range]) between the ankle and arm was 11.2 (-20.3 to +42.7 [-67 to +102]) mmHg for systolic arterial pressure, -0.5 (-21.0 to +19.9 [-44 to +91]) mmHg for mean arterial pressure and -3.8 (-25.3 to +17.8 [-41 to +94]) mmHg for diastolic arterial pressure. Although ankle blood pressure measurement is well tolerated and allows greater mobility of the arms than measurement from the arm, the degree of discrepancy between the two sites is unacceptable to allow routine use of ankle blood pressure measurement, especially for systolic arterial pressure. However, ankle blood pressure measurement may be a useful alternative in situations where arm blood pressure measurement is difficult or impossible. Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland.

Central neuraxial opioid analgesia after caesarean section: comparison of epidural diamorphine and intrathecal morphine.

PubMed

Caranza, R; Jeyapalan, I; Buggy, D J

1999-04-01

In a prospective, randomized, double-blind study in 55 women undergoing elective caesarean section under spinal anaesthesia, we compared epidural diamorphine 3 mg (2 distinct boluses, group ED) with single-dose intrathecal morphine 0.2 mg (group SM), in terms of analgesic efficacy, patient satisfaction and side-effects at 2, 3, 4, 8, 12, 16, 24 and 28 h postoperatively. There were no significant differences between groups in pain (assessed by 100 mm visual analogue scale), incidence of pruritus, sedation or respiratory depression measured by continuous pulse oximetry. However, time to first request for supplementary oral analgesia was longer in SM than in ED (mean +/- SD: 22.3+/-12.0 h vs. 13.8+/-6.5 h, P=0.04). The incidence of nausea or vomiting was significantly higher in SM than ED (73% vs. 41%, P=0.01). In ED, the mean +/- SD time to requirement of the second bolus was 6.7+/-3.2 h. There was a high level of satisfaction in both groups. We conclude that two boluses of epidural diamorphine 3 mg and single-dose intrathecal morphine 0.2 mg provide satisfactory analgesia after caesarean section, but spinal morphine was associated with both delayed requirement for supplementary analgesia and a higher incidence of nausea and vomiting.

Maternal and neonatal outcomes after implementation of a hospital policy to limit low-risk planned caesarean deliveries before 39 weeks of gestation: an interrupted time-series analysis.

PubMed

Hutcheon, J A; Strumpf, E C; Harper, S; Giesbrecht, E

2015-08-01

To evaluate the extent to which implementing a hospital policy to limit planned caesarean deliveries before 39 weeks of gestation improved neonatal health, maternal health, and healthcare costs. Retrospective cohort study. British Columbia Women's Hospital, Vancouver, Canada, in the period 2005-2012. Women with a low-risk planned repeat caesarean delivery. An interrupted time series design was used to evaluate the policy to limit planned caesarean deliveries before 39 weeks of gestation, introduced on 1 April 2008. Composite adverse neonatal health outcome (respiratory morbidity, 5-minute Apgar score of <7, neonatal intensive care unit admission, mortality), postpartum haemorrhage, obstetrical wound infection, out-of-hour deliveries, length of stay, and healthcare costs. Between 2005 and 2008, 60% (1204/2021) of low-risk planned caesarean deliveries were performed before 39 weeks of gestation. After the introduction of the policy, the proportion of planned caesareans dropped by 20 percentage points (adjusted risk difference of 20 fewer cases per 100 deliveries; 95% CI -25.8, -14.3) to 41% (1033/2518). The policy had no detectable impact on adverse neonatal outcomes (2.2 excess cases per 100; 95% CI -0.4, 4.8), maternal complications, or healthcare costs, but increased the risk of out-of-hours delivery from 16.2 to 21.1% (adjusted risk difference 6.3 per 100; 95% CI 1.6, 10.9). We found little evidence that a hospital policy to limit planned caesareans before 39 weeks of gestation reduced adverse neonatal outcomes. Hospital administrators intending to introduce such policies should anticipate, and plan for, modest increases in out-of-hours and emergency-timing. © 2015 Royal College of Obstetricians and Gynaecologists.

Predicting intrapartum fetal compromise using the fetal cerebro-umbilical ratio.

PubMed

Sabdia, S; Greer, R M; Prior, T; Kumar, S

2015-05-01

The aim of this study was to explore the association between the cerebro-umbilical ratio measured at 35-37 weeks and intrapartum fetal compromise. This retrospective cross sectional study was conducted at the Mater Mothers' Hospital in Brisbane, Australia. Maternal demographics and fetal Doppler indices at 35-37 weeks gestation for 1381 women were correlated with intrapartum and neonatal outcomes. Babies born by caesarean section or instrumental delivery for fetal compromise had the lowest median cerebro-umbilical ratio 1.60 (IQR 1.22-2.08) compared to all other delivery groups (vaginal delivery, emergency delivery for failure to progress, emergency caesarean section for other reasons or elective caesarean section). The percentage of infants with a cerebro-umbilical ratio <10th centile that required emergency delivery (caesarean section or instrumental delivery) for fetal compromise was 22%, whereas only 7.3% of infants with a cerebro-umbilical ratio between the 10th-90th centile and 9.6% of infants with a cerebro-umbilical ratio > 90th centile required delivery for the same indication (p < 0.001). A lower cerebro-umbilical ratio was associated with an increased risk of emergency delivery for fetal compromise, OR 2.03 (95% CI 1.41-2.92), p < 0.0001. This study suggests that a low fetal cerebro-umbilical ratio measured at 35-37 weeks is associated with a greater risk of intrapartum compromise. This is a relatively simple technique which could be used to risk stratify women in diverse healthcare settings. Copyright © 2015 Elsevier Ltd. All rights reserved.

The effect of distant reiki on pain in women after elective Caesarean section: a double-blinded randomised controlled trial

PubMed Central

vanderVaart, Sondra; Berger, Howard; Tam, Carolyn; Goh, Y Ingrid; Gijsen, Violette M G J; de Wildt, Saskia N; Taddio, Anna

2011-01-01

Introduction Approximately 25% of all babies in North America are delivered via Caesarean section (C-section). Though a common surgical procedure, C-section recovery can be painful. Opioids, specifically codeine, are commonly used to ease pain; however, its active metabolite, morphine, passes into breast milk, and may produce unwanted side effects in neonates; therefore, alternatives to opioids are being sought. Reiki is an ancient Japanese form of healing where practitioners transfer healing energy through light touch and positive healing intention. Although 1.2 million Americans use reiki to reduce pain or depression, there is a lack of strong evidence supporting its effectiveness. A recent systematic review showed existing studies to be of poor methodological quality, with the common limitation of lack of blinding. To overcome this issue, the authors used distant reiki to assess its effectiveness in reducing pain following an elective C-section. Methods In this randomised, double-blinded study, women who underwent an elective C-section were allocated to either usual care (control, n=40) or three distant reiki sessions in addition to usual care (n=40). Pain was assessed using a visual analogue scale (VAS). The primary endpoint was the Area Under the VAS-Time Curve (AUC) for days 1–3. Secondary measures included: the proportion of women who required opioid medications and dose consumed, rate of healing and vital signs. Results AUC for pain was not significantly different in the distant reiki and control groups (mean±SD; 212.1±104.7 vs 223.1±117.8; p=0.96). There were no significant differences in opioid consumption or rate of healing; however, the distant reiki group had a significantly lower heart rate (74.3±8.1 bpm vs 79.8±7.9 bpm, p=0.003) and blood pressure (106.4±9.7 mm Hg vs 111.9±11.0 mm Hg, p=0.02) post surgery. Conclusion Distant reiki had no significant effect on pain following an elective C-section. Clinical Trial Registration Number ISRCTN79265996. PMID:22021729

Inflammation and neuropathic attacks in hereditary brachial plexus neuropathy

PubMed Central

Klein, C; Dyck, P; Friedenberg, S; Burns, T; Windebank, A; Dyck, P

2002-01-01

Objective: To study the role of mechanical, infectious, and inflammatory factors inducing neuropathic attacks in hereditary brachial plexus neuropathy (HBPN), an autosomal dominant disorder characterised by attacks of pain and weakness, atrophy, and sensory alterations of the shoulder girdle and upper limb muscles. Methods: Four patients from separate kindreds with HBPN were evaluated. Upper extremity nerve biopsies were obtained during attacks from a person of each kindred. In situ hybridisation for common viruses in nerve tissue and genetic testing for a hereditary tendency to pressure palsies (HNPP; tomaculous neuropathy) were undertaken. Two patients treated with intravenous methyl prednisolone had serial clinical and electrophysiological examinations. One patient was followed prospectively through pregnancy and during the development of a stereotypic attack after elective caesarean delivery. Results: Upper extremity nerve biopsies in two patients showed prominent perivascular inflammatory infiltrates with vessel wall disruption. Nerve in situ hybridisation for viruses was negative. There were no tomaculous nerve changes. In two patients intravenous methyl prednisolone ameliorated symptoms (largely pain), but with tapering of steroid dose, signs and symptoms worsened. Elective caesarean delivery did not prevent a typical postpartum attack. Conclusions: Inflammation, probably immune, appears pathogenic for some if not all attacks of HBPN. Immune modulation may be useful in preventing or reducing the neuropathic attacks, although controlled trials are needed to establish efficacy, as correction of the mutant gene is still not possible. The genes involved in immune regulation may be candidates for causing HBPN disorders. PMID:12082044

Influences on vaginal birth after caesarean section: A qualitative study of Taiwanese women.

PubMed

Chen, Mei-Man; McKellar, Lois; Pincombe, Jan

2017-04-01

Vaginal birth is a safe mode of birth for most women who have had a prior caesarean with a transverse incision. Despite the evidence, most Taiwanese women who have had a previous caesarean are rarely offered the opportunity to consider any possibility other than a repeat caesarean. This study explored factors affecting Taiwanese women's decisionmaking regarding vaginal birth after cesarean. Ajzen's Theory of Planned Behaviour provided the theoretical framework to underpin the study, which adopted an interpretive descriptive methodology. Sequential semi-structured interviews were conducted with 29 women who had a previous caesarean and were pregnant between 34 and 38 weeks gestation, ten women who attempted vaginal birth in the third to fifth day postpartum, and 25 women in the fourth week postpartum. Boyatzis' method of thematic analysis was used to identify themes and codes. This paper reports the findings of the prenatal interviews with 29 participants. The major factor influencing women's decision-making was to avoid negative outcomes for themselves and their babies. Three thematic codes describe influences on the women's decisions: 'past experience of childbirth', 'anticipating the next experience of normal birth' and 'contemplation on the process of childbirth'. Women who have had a previous caesarean section are prepared to have a vaginal birth but are not always supported to carry out this decision. Changing the models of antenatal care is recommended as a strategy to overcome this difficulty therefore empowering women to make a meaningful choice about VBAC after a CS. Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Placental heat shock proteins: no immunohistochemical evidence for a differential stress response in preterm labour.

PubMed

Divers, M J; Bulmer, J N; Miller, D; Lilford, R J

1995-01-01

The aetiology of idiopathic preterm labour remains obscure. The hypothesis that a stress response induced by low-grade bacterial infection in utero-placental tissues was investigated. Distribution of cognate and inducible isoforms of heat shock proteins (HSP) 70 kD, HSP 60 kD and HSP 90 kD were investigated in an immunohistochemical study of placental and decidual tissues before and after labour at varying gestations. Subjects were pregnant women undergoing singleton delivery after idiopathic preterm labour at less than 34 weeks' gestation (n = 23); spontaneous term labour at 37-42 weeks' gestation (n =24); preterm caesarean sections at less than 34 weeks' gestation for preeclampsia or intrauterine growth retardation (n=14); elective caesarean section at 37-42 weeks' gestation for cephalopelvic disproportion (n = 6). HSP expression was constant throughout the third trimester of pregnancy and did not change following the onset of labour, regardless of gestational age. A stress response in decidual tissues as determined by immunohistochemical analysis is apparently not associated with preterm labour.

Birth by caesarean section and school performance in Swedish adolescents- a population-based study.

PubMed

Curran, Eileen A; Kenny, Louise C; Dalman, Christina; Kearney, Patricia M; Cryan, John F; Dinan, Timothy G; Khashan, Ali S

2017-04-17

Our objective was to assess the impact of obstetric mode of delivery, and in particular birth by Caesarean section (CS), on school performance in adolescents using a large, population-based cohort. We extracted data from the Swedish Medical Birth Register and National School Register. We included all live singleton births in Sweden from 1982-1995 (n = 1,489,925). School grades were reported on a scale from 0 to 320, scores less than 160 (i.e. "pass") were considered to be "poor school performance." Mode of delivery was categorised as: unassisted vaginal delivery (VD), assisted VD, elective CS and emergency CS. We measured the association between mode of delivery and "poor school performance" using logistic regression. We then used quantile regression to assess the association between mode of delivery and school performance across the distribution of scores. We adjusted for maternal age, parity, small and large for gestational age, gestational age, maternal country of birth, maternal depression, non-affective disorder or bipolar disorder, parental income at time of birth, and parental social welfare at time of birth. We also conducted sensitivity analyses to investigate the association further. With logistic regression analysis, the adjusted odds ratio (aOR) of assisted VD and poor school performance, compared to unassisted VD, was 1.06 (95% CI: 1.03-1.08). For elective CS it was 1.06 (95% CI:1.03-1.09) and for emergency CS it was 1.12 (95% CI: 1.09-1.15). With quantile regression, assisted VD showed little difference in scores, when compared to unassisted VD, at any point across the distribution. Elective CS was associated with a 1-3 point decrease in scores, and emergency CS was associated with a 2-5 point decrease in scores. A slight association was found between birth by CS and school performance. However, the effect was quite small and given the complex nature of the relationship, should be interpreted with caution.

Birth by Caesarean Section and the Risk of Adult Psychosis: A Population-Based Cohort Study.

PubMed

O'Neill, Sinéad M; Curran, Eileen A; Dalman, Christina; Kenny, Louise C; Kearney, Patricia M; Clarke, Gerard; Cryan, John F; Dinan, Timothy G; Khashan, Ali S

2016-05-01

Despite the biological plausibility of an association between obstetric mode of delivery and psychosis in later life, studies to date have been inconclusive. We assessed the association between mode of delivery and later onset of psychosis in the offspring. A population-based cohort including data from the Swedish National Registers was used. All singleton live births between 1982 and 1995 were identified (n= 1,345,210) and followed-up to diagnosis at age 16 or later. Mode of delivery was categorized as: unassisted vaginal delivery (VD), assisted VD, elective Caesarean section (CS) (before onset of labor), and emergency CS (after onset of labor). Outcomes included any psychosis; nonaffective psychoses (including schizophrenia only) and affective psychoses (including bipolar disorder only and depression with psychosis only). Cox regression analysis was used reporting partially and fully adjusted hazard ratios (HR) with 95% confidence intervals (CI). Sibling-matched Cox regression was performed to adjust for familial confounding factors. In the fully adjusted analyses, elective CS was significantly associated with any psychosis (HR 1.13, 95% CI 1.03, 1.24). Similar findings were found for nonaffective psychoses (HR 1.13, 95% CI 0.99, 1.29) and affective psychoses (HR 1.17, 95% CI 1.05, 1.31) (χ(2)for heterogeneityP= .69). In the sibling-matched Cox regression, this association disappeared (HR 1.03, 95% CI 0.78, 1.37). No association was found between assisted VD or emergency CS and psychosis. This study found that elective CS is associated with an increase in offspring psychosis. However, the association did not persist in the sibling-matched analysis, implying the association is likely due to familial confounding by unmeasured factors such as genetics or environment. © The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Elective caesarean section versus vaginal delivery. Whither the end of traditional obstetrics?

PubMed

Husslein, P

2001-11-01

No other topic has dominated the obstetrical discussion to the same extent as caesarean section. Nor has any other aspect of obstetrics been subject to a comparable degree of professional controversy,quite recently the topic has been discussed in this journal by Ludwig and Loeffler. For some caesarean section remains a major surgical procedure with a corresponding level of risk, which must only be employed in the presence of specific complications and in conjunction with a clearly defined set of indications; others consider caesarean section quite simply to be the most efficient and straightforward means to deliver as well as the one attended by the least amount of risk. Opinion among those most immediately affected is likewise divided: For many women the experience of vaginal birth is among the most fulfilling of their entire life - comparable only to sexuality-related moments of ecstasy - other women come to regard birth as the worst thing that ever happened to them an experience attended by pain, fear, loneliness, perhaps even long lasting negative consequences. There can be no doubt that, this question also affects the foundations of patriarchal thinking, still so firmly embedded in peoples' minds: Are doctors to determine what exactly takes place in the delivery room and in the operating theatre, or will the patient - in obstetrics, the parturient - be enabled to assert her right to self-determination also in the medical context; especially in light of the fact that said right can currently be exercised in an almost unlimited fashion throughout the rest of one's adult life? It is against the wider background of this ongoing controversy that the ensuing article will seek to defuse the emotional charge characterising some of the commonly employed arguments and instead revert to a more rational and factually based approach to this question.

Duration of motor block with intrathecal ropivacaine versus bupivacaine for caesarean section: a meta-analysis.

PubMed

Malhotra, R; Johnstone, C; Halpern, S; Hunter, J; Banerjee, A

2016-08-01

Bupivacaine is a commonly used local anaesthetic for spinal anaesthesia for caesarean section, but may produce prolonged motor block, delaying discharge from the post-anaesthesia care unit. Ropivacaine may have a shorter time to recovery of motor function compared with bupivacaine. We performed a meta-analysis to assess the time difference in duration of motor block with intrathecal ropivacaine compared with bupivacaine for caesarean section. We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases for randomised controlled trials comparing ropivacaine with bupivacaine in parturients undergoing elective caesarean section under spinal anaesthesia. The primary outcome was the duration of motor block. Secondary outcomes included the time to onset of sensory block, need for conversion to general anaesthesia and the incidence of hypotension. Thirteen trials comprising 743 spinal anaesthetics were included. Intrathecal ropivacaine resulted in a reduced duration of motor block, regressing 35.7min earlier compared with intrathecal bupivacaine (P<0.00001). There was no difference in the time to onset of sensory block (P=0.25) or the incidence of hypotension (P=0.10). Limited data suggested no difference in the rate of conversion to general anaesthesia, but an earlier request for postoperative analgesia with ropivacaine. Compared with bupivacaine, intrathecal ropivacaine is associated with more rapid recovery of motor block despite similar sensory properties and no increased rate of conversion to general anaesthesia. This may be useful in centres in which recovery of motor block is a criterion for discharge from the post-anaesthesia care unit. However, small numbers of trials and significant heterogeneity limit the interpretation of our results. Copyright © 2016 Elsevier Ltd. All rights reserved.

Women's and men's negative experience of child birth-A cross-sectional survey.

PubMed

Nystedt, Astrid; Hildingsson, Ingegerd

2018-04-01

A negative birth experience may influence both women and men and can limit their process of becoming a parent. This study aimed to analyze and describe women's and men's perceptions and experiences of childbirth. A cross-sectional study of women and their partners living in one Swedish county were recruited in mid pregnancy and followed up two months after birth. Women (n=928) and men (n=818) completed the same questionnaire that investigated new parents' birth experiences in relation to socio-demographic background and birth related variables. Women (6%) and men (3%) with a negative birth experiences, experienced longer labours and more often emergency caesarean section compared to women (94%) and men (97%) with a positive birth experience. The obstetric factors that contributed most strongly to a negative birth experience were emergency caesarean and was found in women (OR 4.7, 95% CI 2.0-10.8) and men (OR 4.5, Cl 95% 1.4-17.3). In addition, pain intensity and elective caesarean section were also associated with a negative birth experiences in women. Feelings during birth such as agreeing with the statement; 'It was a pain to give birth' were a strong contributing factor for both women and men. A negative birth experience is associated with obstetric factors such as emergency caesarean section and negative feelings. The content of negative feelings differed between women and men. It is important to take into account that their feelings differ in order to facilitate the processing of the negative birth experience for both partners. Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Where are the Sunday babies? II. Declining weekend birth rates in Switzerland.

PubMed

Lerchl, Alexander; Reinhard, Sarah C

2008-02-01

Birth dates from almost 3 million babies born between 1969 and 2005 in Switzerland were analyzed for the weekday of birth. As in other countries but with unprecedented amplitude, a very marked non-random distribution was discovered with decreasing numbers of births on weekends, reaching -17.9% in 2005. While most of this weekend births avoidance rate is due to fewer births on Sundays (up to -21.7%), the downward trend is primarily a consequence of decreasing births on Saturdays (up to -14.5%). For 2005, these percentages mean that 3,728 fewer babies are born during weekends than could be expected from equal distribution. Most interestingly and surprisingly, weekend birth-avoiding rates are significantly correlated with birth numbers (r = 0.86), i.e. the lower the birth number per year, the lower the number of weekend births. The increasing avoidance of births during weekends is discussed as being a consequence of increasing numbers of caesarean sections and elective labor induction, which in Switzerland reach 29.2 and 20.5%, respectively, in 2004. This hypothesis is supported by the observation that both primary and secondary caesarean sections are significantly correlated with weekend birth avoidance rates. It is therefore likely that financial aspects of hospitals are a factor determining the avoidance of weekend births by increasing the numbers of caesarean sections.

Where are the Sunday babies? II. Declining weekend birth rates in Switzerland

NASA Astrophysics Data System (ADS)

Lerchl, Alexander; Reinhard, Sarah C.

2008-02-01

Birth dates from almost 3 million babies born between 1969 and 2005 in Switzerland were analyzed for the weekday of birth. As in other countries but with unprecedented amplitude, a very marked non-random distribution was discovered with decreasing numbers of births on weekends, reaching -17.9% in 2005. While most of this weekend births avoidance rate is due to fewer births on Sundays (up to -21.7%), the downward trend is primarily a consequence of decreasing births on Saturdays (up to -14.5%). For 2005, these percentages mean that 3,728 fewer babies are born during weekends than could be expected from equal distribution. Most interestingly and surprisingly, weekend birth-avoiding rates are significantly correlated with birth numbers ( r = 0.86), i.e. the lower the birth number per year, the lower the number of weekend births. The increasing avoidance of births during weekends is discussed as being a consequence of increasing numbers of caesarean sections and elective labor induction, which in Switzerland reach 29.2 and 20.5%, respectively, in 2004. This hypothesis is supported by the observation that both primary and secondary caesarean sections are significantly correlated with weekend birth avoidance rates. It is therefore likely that financial aspects of hospitals are a factor determining the avoidance of weekend births by increasing the numbers of caesarean sections.

The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth

PubMed Central

2012-01-01

Background Women’s fears and attitudes to childbirth may influence the maternity care they receive and the outcomes of birth. This study aimed to develop profiles of women according to their attitudes regarding birth and their levels of childbirth related fear. The association of these profiles with mode and outcomes of birth was explored. Methods Prospective longitudinal cohort design with self report questionnaires containing a set of attitudinal statements regarding birth (Birth Attitudes Profile Scale) and a fear of birth scale (FOBS). Pregnant women responded at 18-20 weeks gestation and two months after birth from a regional area of Sweden (n = 386) and a regional area of Australia (n = 123). Cluster analysis was used to identify a set of profiles. Odds ratios (95% CI) were calculated, comparing cluster membership for country of care, pregnancy characteristics, birth experience and outcomes. Results Three clusters were identified – ‘Self determiners’ (clear attitudes about birth including seeing it as a natural process and no childbirth fear), ‘Take it as it comes’ (no fear of birth and low levels of agreement with any of the attitude statements) and ‘Fearful’ (afraid of birth, with concerns for the personal impact of birth including pain and control, safety concerns and low levels of agreement with attitudes relating to women’s freedom of choice or birth as a natural process). At 18 -20 weeks gestation, when compared to the ‘Self determiners’, women in the ‘Fearful’ cluster were more likely to: prefer a caesarean (OR = 3.3 CI: 1.6-6.8), hold less than positive feelings about being pregnant (OR = 3.6 CI: 1.4-9.0), report less than positive feelings about the approaching birth (OR = 7.2 CI: 4.4-12.0) and less than positive feelings about the first weeks with a newborn (OR = 2.0 CI 1.2-3.6). At two months post partum the ‘Fearful’ cluster had a greater likelihood of having had an elective caesarean (OR = 5.4 CI 2.1-14.2); they were more likely to have had an epidural if they laboured (OR = 1.9 CI 1.1-3.2) and to experience their labour pain as more intense than women in the other clusters. The ‘Fearful’ cluster were more likely to report a negative experience of birth (OR = 1.7 CI 1.02- 2.9). The ‘Take it as it comes’ cluster had a higher likelihood of an elective caesarean (OR 3.0 CI 1.1-8.0). Conclusions In this study three clusters of women were identified. Belonging to the ‘Fearful’ cluster had a negative effect on women’s emotional health during pregnancy and increased the likelihood of a negative birth experience. Both women in the ‘Take it as it comes’ and the ‘Fearful’ cluster had higher odds of having an elective caesarean compared to women in the ‘Self determiners’. Understanding women’s attitudes and level of fear may help midwives and doctors to tailor their interactions with women. PMID:22727217

A retrospective cohort study of mode of delivery among public and private patients in an integrated maternity hospital setting

PubMed Central

Murphy, Deirdre J; Fahey, Tom

2013-01-01

Objective To examine the associations between mode of delivery and public versus privately funded obstetric care within the same hospital setting. Design Retrospective cohort study. Setting Urban maternity hospital in Ireland. Population A total of 30 053 women with singleton pregnancies who delivered between 2008 and 2011. Methods The study population was divided into those who booked for obstetric care within the public (n=24 574) or private clinics (n=5479). Logistic regression analyses were performed to examine the associations between operative delivery and type of care, adjusting for potential confounding factors. Main outcome measures Caesarean section (scheduled or emergency), operative vaginal delivery (vacuum or forceps), indication for caesarean section as classified by the operator. Results Compared with public patients, private patients were more likely to be delivered by caesarean section (34.4% vs 22.5%, OR 1.81; 95% CI 1.70 to 1.93) or operative vaginal delivery (20.1% vs 16.5%, OR 1.28; 95% CI 1.19 to 1.38). The greatest disparity was for scheduled caesarean sections; differences persisted for nulliparous and parous women after controlling for medical and social differences between the groups (nulliparous 11.9% vs 4.6%, adjusted (adj) OR 1.82; 95% CI 1.49 to 2.24 and parous 26% vs 12.2%, adj OR 2.08; 95% CI 1.86 to 2.32). Scheduled repeat caesarean section accounted for most of the disparity among parous patients. Maternal request per se was an uncommonly reported indication for caesarean section (35 in each group, p<0.000). Conclusions Privately funded obstetric care is associated with higher rates of operative deliveries that are not fully accounted for by medical or obstetric risk differences. PMID:24277646

Elective induction versus spontaneous labour in Latin America

PubMed Central

Guerra, Gláucia Virgínia; Souza, João Paulo; Faúndes, Aníbal; Morais, Sirlei Siani; Gülmezoglu, Ahmet Metin; Passini, Renato; Parpinelli, Mary Angela; Carroli, Guillermo

2011-01-01

Abstract Objective To assess the frequency of elective induction of labour and its determinants in selected Latin America countries; quantify success in attaining vaginal delivery, and compare rates of caesarean and adverse maternal and perinatal outcomes after elective induction versus spontaneous labour in low-risk pregnancies. Methods Of 37 444 deliveries in women with low-risk pregnancies, 1847 (4.9%) were electively induced. The factors associated with adverse maternal and perinatal outcomes among cases of spontaneous and induced onset of labour were compared. Odds ratios for factors potentially associated with adverse outcomes were calculated, as were the relative risks of having an adverse maternal or perinatal outcome (both with their 95% confidence intervals). Adjustment using multiple logistic regression models followed these analyses. Findings Of 11 077 cases of induced labour, 1847 (16.7%) were elective. Elective inductions occurred in 4.9% of women with low-risk pregnancies (37 444). Oxytocin was the most common method used (83% of cases), either alone or combined with another. Of induced deliveries, 88.2% were vaginal. The most common maternal adverse events were: (i) a higher postpartum need for uterotonic drugs, (ii) a nearly threefold risk of admission to the intensive care unit; (iii) a fivefold risk of postpartum hysterectomy, and (iv) an increased need for anaesthesia/analgesia. Perinatal outcomes were satisfactory except for a 22% higher risk of delayed breastfeeding (i.e. initiation between 1 hour and 7 days postpartum). Conclusion Caution is mandatory when indicating elective labour induction because the increased risk of maternal and perinatal adverse outcomes is not outweighed by clear benefits. PMID:21897486

Birth in Brazil: national survey into labour and birth

PubMed Central

2012-01-01

Background Caesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction. Methods Nationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients’ medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson’s groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design. Discussion This study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it’s consequences on postnatal health. PMID:22913663

Hidden costs associated with the universal application of risk management in maternity care.

PubMed

McIntyre, Meredith J; Chapman, Ysanne; Francis, Karen

2011-05-01

This paper presents a critical analysis of risk management in maternity care and the hidden costs associated with the practice in healthy women. Issues of quality and safety are driving an increased emphasis by health services on risk management in maternity care. Medical risk in pregnancy is known to benefit 15% or less of all pregnancies. Risk management applied to the remaining 85% of healthy women results in the management of risk in the absence of risk. The health cost to mothers and babies and the economic burden on the overall health system of serious morbidity has been omitted from calculations comparing costs of uncomplicated caesarean birth and uncomplicated vaginal birth. The understanding that elective caesarean birth is cost-neutral when compared to a normal vaginal birth has misled practitioners and contributed to over use of the practice. For the purpose of informing the direction of maternity service policy it is necessary to expose the effect the overuse of medical intervention has on the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources in the absence of clinical need.

Injection speed of spinal anaesthesia for Caesarean delivery in Asian women and the incidence of hypotension: A randomised controlled trial.

PubMed

Chiang, Chun Fai; Hasan, M Shahnaz; Tham, Sin Wan; Sundaraj, Sebastian; Faris, Ahmad; Ganason, Nagappan

2017-06-01

The purpose of this investigation was to determine if a slower speed of spinal anaesthesia injection would reduce the incidence of hypotension. Randomised controlled trial. Tertiary level hospital in Malaysia. 77 patients undergoing elective Caesarean delivery. Differing speeds of spinal injection. Systolic blood pressure was assessed every minute for the first 10min and incidence of hypotension (reduction in blood pressure of >30% of baseline) was recorded. The use of vasopressor and occurrence of nausea/vomiting were also recorded. 36 patients in SLOW group and 41 patients in FAST group were recruited into the study. There was no significant difference in blood pressure drop of >30% (p=0.497) between the two groups. There was no difference in the amount of vasopressor used and incidence of nausea/vomiting in both groups. In our study population, there was no difference in incidence of hypotension and nausea/vomiting when spinal injection time is prolonged beyond 15s to 60s. ClinicalTrials.govNCT02275897. Registered on 15 October 2014. Copyright © 2017 Elsevier Inc. All rights reserved.

Increased chemerin concentrations in fetuses of obese mothers and correlation with maternal insulin sensitivity.

PubMed

Barker, Gillian; Lim, Ratana; Rice, Gregory E; Lappas, Martha

2012-11-01

The aim of this study was to determine the effect of maternal obesity and gestational diabetes mellitus (GDM) on (i) the circulating concentrations of chemerin in cord and maternal plasma, and (ii) gene expression and release of chemerin from human placenta and adipose tissue. Chemerin concentrations were measured in maternal and cord plasma from 62 normal glucose tolerant women (NGT) and 69 women with GDM at the time of term elective Caesarean section. Placenta and adipose tissue expression and release of chemerin was measured from 22 NGT and 22 GDM women. There was no effect of maternal obesity or GDM on maternal chemerin concentrations. Chemerin concentrations were significantly higher in cord plasma from women with maternal obesity. Cord chemerin concentrations in NGT women negatively correlated with the concentrations of maternal insulin sensitivity. There was no effect of GDM on maternal and cord chemerin concentrations, and on the release of chemerin from placenta and adipose tissue. At the time of term Caesarean section, preexisting maternal obesity, and its associated insulin resistance, is associated with higher cord plasma chemerin concentrations.

How safe is GP obstetrics? An assessment of antenatal risk factors and perinatal outcomes in one rural practice.

PubMed

Kirke, Andrew B

2010-01-01

Approximately one-fifth of Western Australian women deliver their babies in rural and remote regions of the state. The medical workforce caring for these women is predominantly non-specialist GP obstetricians. This article explores how safe is rural GP obstetrics. It reviews one rural obstetric practice in detail. In particular it asks these questions: What are the antenatal risk factors? What are the obstetric outcomes for the mother? What are the obstetric outcomes for the baby? This study is an audit of the author's obstetric practice over a two-year period from July 2007 to June 2009. The audit criteria included all obstetric patients managed by the author through to delivery and immediate post-partum care. Hospital and practice notes for 195 singleton pregnancies were reviewed. Antenatal risk factors, intrapartum events and immediate post-partum events for all patients cared for by the author through to delivery were recorded and compared with averages for Western Australia from published 2007 figures. The maternal population had mean age of 28.5 years, 2.1% were Aboriginal. Body mass index (BMI) at booking was a mean of 27.1 (range 18-40). Those with a BMI > 40 were referred elsewhere. Significant antenatal risks included smoking (14.9%), previous caesarean section (14.4%), hypertension (13.3%), pre-eclampsia (5.1%) and gestational diabetes (8.2%). Intrapartum there were high rates of induction (33.5%), epidural/spinal (34.7%) and shoulder dystocia (3.6%). Type of delivery was predominantly spontaneous vaginal (65.6%), vacuum (14.9%), forceps (2.6%), elective caesarean (9.7%) and non-elective caesarean (8.7%). Post-partum events included post-partum haemorrhage (10.3%), transfusion (1.5%), retained placenta (2.1%), neonatal jaundice (21.1%), neonatal seizures (1.5%) neonatal sepsis (1.5%) and neonatal special care or intensive care (SCU/NICU) admission (9.8%). The audit population was a group of relatively low risk pregnant women. Despite referral of more complicated patients to specialist services either in Kalgoorlie or to Perth, there remained a significant number of women who developed antenatal risk factors. There was a high rate of induction of labour, which reflected the high rates of hypertension and diabetes, both relative indicators for induction at term. There was a reassuringly high rate of spontaneous vaginal delivery and low rates of elective and non-elective caesarian section. Post-partum clinically significant events still occurred for mother and baby, although not at rates higher than expected elsewhere. The results of this audit show that in a rural setting where options for referral may be less than in an urban setting, it is still possible to practice obstetrics safely. These results support the hypothesis that it is safe to practice GP obstetrics particularly in a rural setting. An unexpected result in this audit was the high rate of gestational diabetes, which is significantly greater than the average published for Western Australia. Further investigation of rates of gestational diabetes in other rural populations is warranted to explore this further.

Human immunodeficiency virus (HIV) in pregnancy: a review of the guidelines for preventing mother-to-child transmission in Malaysia.

PubMed

Azwa, Iskandar; Khong, Su Yen

2012-12-01

Mother-to-child transmission (MTCT) of human immunodefi ciency virus (HIV) is a devastating consequence of HIV infection during pregnancy and is largely preventable. Evidence-based interventions such as universal antenatal screening, provision of antiretroviral therapy, delivery by elective caesarean section and avoidance of breastfeeding have ensured that the rates of MTCT remain low in Malaysia. This review discusses the most recent advances in the management of HIV infection in pregnancy with emphasis on antiretroviral treatment strategies and obstetric care in a middle income country.

Failure of communication: a patient's story.

PubMed

Stanford, Susanna E R; Bogod, David G

2016-12-01

The first author, a patient who underwent elective caesarean section and felt pain necessitating conversion to general anaesthesia, describes the experience with particular reference to the perceived poor communication between her and her anaesthetist. This extended from the preoperative visit to the information provided to her general practitioner after discharge. She makes several suggestions which would have made her experience, and those of other patients in similar circumstances, less traumatic. The second author, who had no involvement in events and works in a different Trust, comments upon the events from the perspective of an obstetric anaesthetist. Copyright © 2016 Elsevier Ltd. All rights reserved.

Combined use of hyperbaric and hypobaric ropivacaine significantly improves hemodynamic characteristics in spinal anesthesia for caesarean section: a prospective, double-blind, randomized, controlled study.

PubMed

Quan, ZheFeng; Tian, Ming; Chi, Ping; Li, Xin; He, HaiLi; Luo, Chao

2015-01-01

To observe the hemodynamic changes of parturients in the combined use of hyperbaric (4 mg) and hypobaric (6 mg) ropivacaine during spinal anesthesia for caesarean section in this randomized double-blind study. Parturients (n = 136) undergoing elective cesarean delivery were randomly and equally allocated to receive either combined hyperbaric and hypobaric ropivacaine (Group A) or hyperbaric ropivacaine (Group B). Outcome measures were: hemodynamic characteristics, maximum height of sensory block, time to achieve T8 sensory blockade level, incidence of complications, Apgar scores at 1 and 5 min, and neonatal blood gas analysis. Group A had a lower level of sensory blockade (T6 [T6-T7]) and longer time to achieve T8 sensory blockade level (8 ± 1.3 min) than did patients in Group B (T3 [T2-T4] and 5 ± 1.0 min, respectively; P < 0.001, both). The incidence rates for hypotension, nausea, and vomiting were significantly lower in Group A (13%, 10%, and 3%, respectively) than Group B (66%, 31%, and 13%; P < 0.001, P = 0.003, P = 0.028). Combined use of hyperbaric (4 mg) and hypobaric (6 mg) ropivacaine significantly decreased the incidences of hypotension and complications in spinal anesthesia for caesarean section by extending induction time and decreasing the level of sensory blockade. Chinese Clinical Trial Register ChiCTR-TRC-13004622.

Combined Use of Hyperbaric and Hypobaric Ropivacaine Significantly Improves Hemodynamic Characteristics in Spinal Anesthesia for Caesarean Section: A Prospective, Double-Blind, Randomized, Controlled Study

PubMed Central

Quan, ZheFeng; Tian, Ming; Chi, Ping; Li, Xin; He, HaiLi; Luo, Chao

2015-01-01

Purpose To observe the hemodynamic changes of parturients in the combined use of hyperbaric (4 mg) and hypobaric (6 mg) ropivacaine during spinal anesthesia for caesarean section in this randomized double-blind study. Methods Parturients (n = 136) undergoing elective cesarean delivery were randomly and equally allocated to receive either combined hyperbaric and hypobaric ropivacaine (Group A) or hyperbaric ropivacaine (Group B). Outcome measures were: hemodynamic characteristics, maximum height of sensory block, time to achieve T8 sensory blockade level, incidence of complications, Apgar scores at 1 and 5 min, and neonatal blood gas analysis. Results Group A had a lower level of sensory blockade (T6 [T6-T7]) and longer time to achieve T8 sensory blockade level (8 ± 1.3 min) than did patients in Group B (T3 [T2-T4] and 5 ± 1.0 min, respectively; P < 0.001, both). The incidence rates for hypotension, nausea, and vomiting were significantly lower in Group A (13%, 10%, and 3%, respectively) than Group B (66%, 31%, and 13%; P < 0.001, P = 0.003, P = 0.028). Conclusions Combined use of hyperbaric (4 mg) and hypobaric (6 mg) ropivacaine significantly decreased the incidences of hypotension and complications in spinal anesthesia for caesarean section by extending induction time and decreasing the level of sensory blockade. Trial Registration Chinese Clinical Trial Register ChiCTR-TRC-13004622 PMID:25970485

Is Ureaplasma spp. the leading causative agent of acute chorioamnionitis in women with preterm birth?

PubMed

Kikhney, J; von Schöning, D; Steding, I; Schulze, J; Petrich, A; Hiergeist, A; Reischl, U; Moter, A; Thomas, A

2017-02-01

Aim of this study was to detect microorganisms in fetal membranes and placental tissue in preterm chorioamnionitis by combining fluorescence in situ hybridization (FISH) with broad range PCR. The combination of the two molecular techniques enables identification and localization of the microorganisms within the tissue, confirming their clinical relevance. In a prospective cohort study, we compared 31 women with preterm premature rupture of membranes or preterm labour and preterm delivery by caesarean section with a control group of 26 women undergoing elective caesarean section at term. Fetal membranes and placental tissue were analysed by FISH and broad range 16S rRNA-gene PCR and sequencing. For 20 women in the preterm group, caesarean section was performed because of a clinical diagnosis of chorioamnionitis. Microorganisms were detected in the tissues by both molecular techniques in 11 out of 20 women. Among those, Ureaplasma spp. was most abundant, with five cases that remained culture-negative and would have been missed by routine diagnostic procedures. Other infections were caused by Staphylococcus aureus, Streptococcus mitis or Escherichia coli. FISH and PCR were negative for all women without suspected chorioamnionitis and for the control group. Combination of FISH with broad-range PCR and sequencing permitted unambiguous identification of the causative microorganisms in chorioamnionitis. The high prevalence of Ureaplasma spp. should lead to a re-evaluation of its clinical significance and possible therapeutic consequences. Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Qualitative website analysis of information on birth after caesarean section.

PubMed

Peddie, Valerie L; Whitelaw, Natalie; Cumming, Grant P; Bhattacharya, Siladitya; Black, Mairead

2015-08-19

The United Kingdom (UK) caesarean section (CS) rate is largely determined by reluctance to augment trial of labour and vaginal birth. Choice between repeat CS and attempting vaginal birth after CS (VBAC) in the next pregnancy is challenging, with neither offering clear safety advantages. Women may access online information during the decision-making process. Such information is known to vary in its support for either mode of birth when assessed quantitatively. Therefore, we sought to explore qualitatively, the content and presentation of web-based health care information on birth after caesarean section (CS) in order to identify the dominant messages being conveyed. The search engine Google™ was used to conduct an internet search using terms relating to birth after CS. The ten most frequently returned websites meeting relevant purposive sampling criteria were analysed. Sampling criteria were based upon funding source, authorship and intended audience. Images and written textual content together with presence of links to additional media or external web content were analysed using descriptive and thematic analyses respectively. Ten websites were analysed: five funded by Government bodies or professional membership; one via charitable donations, and four funded commercially. All sites compared the advantages and disadvantages of both repeat CS and VBAC. Commercially funded websites favoured a question and answer format alongside images, 'pop-ups', social media forum links and hyperlinks to third-party sites. The relationship between the parent sites and those being linked to may not be readily apparent to users, risking perception of endorsement of either VBAC or repeat CS whether intended or otherwise. Websites affiliated with Government or health services presented referenced clinical information in a factual manner with podcasts of real life experiences. Many imply greater support for VBAC than repeat CS although this was predominantly conveyed through subtle use of words rather than overt messages, with the exception of the latter being apparent in one site. Websites providing information on birth after CS appear to vary in nature of content according to their funding source. The most user-friendly, balanced and informative websites appear to be those funded by government agencies.

Improving the care pathway for women who request Caesarean section: an experience-based co-design study.

PubMed

Kenyon, Sara L; Johns, Nina; Duggal, Sandhya; Hewston, Ruth; Gale, Nicola

2016-11-09

Maternal request for Caesarean section is controversial and yet the NICE Caesarean section Guideline recommends that that if this is requested, following discussion of the risks and benefits, women should be supported in their choice. There was a desire to improve the pathway at Birmingham Women's NHS Foundation Trust. Experience-based co-design methodology uses service user and clinicians experiences collected using qualitative methods to jointly re-design services. Firstly semi-structured interviews were conducted to elicit the views and experiences of health care professionals and women who requested Caesarean section (with and without medical indication). Analysis identified key themes arising from the health care professionals' interviews and 'touch points' (key moments or events related to the experience of care) arising from the interviews with women.. Separate workshops were then held with each group to ensure these resonated and to identify key areas for service improvement. At the first joint workshop a pathway using 'audio clips' demonstrating women's agreed 'touch points' prompted discussion and joint working began to change the pathway. A final second workshop was held to agree changes to the pathway. Interviews were conducted with health care professionals (n = 22, 10 consultant obstetricians and 12 midwives) and women (n = 15). The women's 'touch points' included repetition of request, delay in the decision for Caesarean section to be made, feeling judged, and that information was poor with similar findings identified from the health care professionals. Joint working resulted in a revised pathway for women who request Caesarean section. Changes to the pathway for women as a result of the work include written information about 'The way your baby may be born' which is given to the woman followed by a discussion about mode of birth around the 16 week appointment. If the woman wishes to have a Caesarean section, referral is made to appropriate health care professionals (e.g., Consultant Midwife, counsellor) only if support and information would be useful. If Caesarean section is requested, woman is referred to a consultant obstetrician for an appointment at 20/40, with a decision by 28/40. Recording this in the notes minimises repeated challenge described by women. Final consent and timing of Caesarean section remain as recommended. This has resulted in changes to the pathway agreed by a co-design process and which are acceptable to both health care professionals and women. Use of such methodologies should be considered more frequently when implementing service change.

Cost-effectiveness analysis alongside a pilot study of prophylactic negative pressure wound therapy.

PubMed

Heard, Christopher; Chaboyer, Wendy; Anderson, Vinah; Gillespie, Brigid M; Whitty, Jennifer A

2017-02-01

Negative pressure wound therapy (NPWT) is increasingly used prophylactically following surgery despite limited evidence of clinical or cost-effectiveness. To evaluate whether NPWT is cost-effective compared to standard care, for the prevention of surgical site infection (SSI) in obese women undergoing elective caesarean section, and inform development of a larger trial. An economic evaluation was conducted alongside a pilot randomised controlled trial at one Australian hospital, in which women were randomised to NPWT (n = 44) or standard care (n = 43). A public health care provider perspective and time horizon to four weeks post-discharge was adopted. Cost-effectiveness assessment was based on incremental cost per SSI prevented and per quality-adjusted life year (QALY) gained. Patients receiving NPWT each received health care costing AU$5887 (±1038) and reported 0.069 (±0.010) QALYs compared to AU$5754 (±1484) and 0.066 (±0.010) QALYs for patients receiving standard care. NPWT may be slightly more costly and more effective than standard care, with estimated incremental cost-effectiveness ratios (ICERs) of AU$1347 (95%CI dominant- $41,873) per SSI prevented and AU$42,340 (95%CI dominant- $884,019) per QALY gained. However, there was considerable uncertainty around these estimates. NPWT may be cost-effective in the prophylactic treatment of surgical wounds following elective caesarean section in obese women. Larger trials could clarify the cost-effectiveness of NPWT as a prophylactic treatment for SSI. Sensitive capture of QALYs and cost offsets will be important given the high level of uncertainty around the point estimate cost-effectiveness ratio which was close to conventional thresholds. ACTRN12612000171819. Copyright © 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

Evaluation of surgical and anaesthesia response times for crash caesarean sections--an audit of a Singapore hospital.

PubMed

Lim, Y; Shah, M K; Tan, H M

2005-11-01

The Royal College of Obstetricians and Gynaecologists published the "Organisational Standards for Maternity Services" in 1995, in which they proposed that there be a maximum decision-to-delivery time of 30 minutes for urgent caesarean sections (CS). In 1997, our institution established a protocol for extremely urgent ("crash") CS to expedite delivery time and to conform to this standard. The objective of this prospective audit was to determine the surgical and anaesthesia response times in our institution after the protocol had been implemented. The audit was conducted in KK Women's and Children's Hospital from February 2003 to January 2004, over a 12-month period. Upon activation of a "crash" CS, the attending anaesthetist was required to record the decision-to-anaesthesia time, decision-to-delivery time and the perinatal outcome. Ninety-eight cases of "crash" CS were identified from a total of 3629 elective and non-elective CS, with 80 cases having complete data. The mean decision-to-delivery interval was 7.7 min+/-3.0 (SD) with 100% of deliveries made within 17 minutes. The mean decision-to-anaesthesia time was 3.5 min+/-2.0 (SD) with all the patients anaesthetised within 10 minutes. The majority (88.8%) of the patients had general anaesthesia for "crash" CS while the rest had successful epidural block extension. There was no significant difference in the decision-to-delivery interval or mean cord blood pH with respect to the type of anaesthesia given. We achieved 100% deliveries within the proposed 30-minute decision-to-delivery time interval by implementing a protocol for "crash" CS. Both general anaesthesia and extension of existing epidural block are acceptable modes of anaesthesia and do not delay delivery of the fetus.

Vaginal birth after caesarean delivery in Chinese women and Western immigrants in Shanghai.

PubMed

Minsart, Anne-Frederique; Liu, Hau; Moffett, Shannon; Chen, Crystal; Ji, Ninni

2017-05-01

Recent studies show a steep rise in caesarean sections in China. Most couples are now eligible to apply for a second child. This retrospective cohort study compares the prevalence of trial of labour and vaginal birth after caesarean section among Chinese and foreign women in Shanghai. In total, 135 of 368 women underwent trial of labour (36.68%), and of those, 77 (57.04%) had a vaginal birth. After inclusion in a multivariate model, factors associated with trial of labour were maternal age <35 years with an adjusted odds ratio of 2.58 (1.49-4.46), absence of a history of ≥3 abortions (2.22 (1.08-4.57)), and European citizenship (1.94 (1.05-3.59)). The prevalence of trial of labour and vaginal birth seems to mirror rates found in countries of origin, but despite a high rate of caesarean section, Chinese women had a higher rate of vaginal birth after caesarean section than North American and Australian women, in particular. Impact statement What is already known on this subject: Caesarean section (CS) rates are rising worldwide. Repeat CS contributes largely to these rates, although vaginal birth after CS (VBAC) rates varies widely between countries. What the results of this study add: North American and Australian women who deliver in Shanghai have low rates of attempted trial of labour after CS (TOLAC) and VBAC, with European women having the highest rate of TOLAC, followed by Chinese women. Implications for clinical practice and/or further research: These findings might reflect different levels of acceptance in line with respective national trends. Studies evaluating the influence of cultural norms on birth preferences after CS are needed. Further research is also needed to assess the overall acceptance of TOLAC in the context of the softening of the one-child policy in China.

Vaginal delivery of breech presentation.

PubMed

Kotaska, Andrew; Menticoglou, Savas; Gagnon, Robert

2009-06-01

To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2. Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3. Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4. With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5. Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) RECOMMENDATIONS: LABOUR SELECTION CRITERIA: 1. For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2. Contraindications to labour include a. Cord presentation (II-3A) b. Fetal growth restriction or macrosomia (I-A) c. Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d. Clinically inadequate maternal pelvis (III-B) e. Fetal anomaly incompatible with vaginal delivery (III-B) 3. Vaginal breech delivery can be offered when the estimated fetal weight is between 2500 g and 4000 g. (II-2B) LABOUR MANAGEMENT: 4. Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5. Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6. In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7. Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8. A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9. The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) DELIVERY TECHNIQUE: 11. The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12. An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13. The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14. The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15. Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16. Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17. At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18. Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19. Nuchal arms may be reduced by the Løvset or Bickenbach manoeuvres. (III-B) 20. The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) SETTING AND CONSENT: 21. In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22. The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23. Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24. Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25. The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26. Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B).

Comparison of double intravenous vasopressor automated system using nexfin versus manual vasopressor bolus administration for maintenance of haemodynamic stability during spinal anaesthesia for caesarean delivery: A randomised double-blind controlled trial.

PubMed

Sng, Ban Leong; Du, Wei; Lee, Man Xin; Ithnin, Farida; Mathur, Deepak; Leong, Wan Ling; Sultana, Rehena; Han, Nian-Lin R; Sia, Alex Tiong Heng

2018-05-01

Hypotension is a common side effect of spinal anaesthesia during caesarean delivery and is associated with maternal and foetal adverse effects. We developed an updated double intravenous vasopressor automated (DIVA) system that administers phenylephrine or ephedrine based on continuous noninvasive haemodynamic monitoring using the Nexfin device. The aim of our present study is to compare the performance and reliability of the DIVA system against Manual Vasopressor Bolus administration. A randomised, double-blind controlled trial. Single-centre, KK Women's and Children's Hospital, Singapore. Two hundred and thirty-six healthy women undergoing elective caesarean delivery under spinal anaesthesia. The primary outcome was the incidence of maternal hypotension. The secondary outcome measures were reactive hypertension, total vasopressor requirement and maternal and neonatal outcomes. The DIVA group had a significantly lower incidence of maternal hypotension, with 39.3% (46 of 117) patients having any SBP reading less than 80% of baseline compared with 57.5% (65 of 113) in the manual vasopressor bolus group (P = 0.008). The DIVA group also had fewer hypotensive episodes than the manual vasopressor bolus group (4.67 versus 7.77%; P < 0.0001). There was no difference in the incidence of reactive hypertension or the total vasopressor requirement. The DIVA group had less wobble in system performance. Maternal and neonatal outcomes were similar. The DIVA system achieved better control of maternal blood pressure after spinal anaesthesia than manual vasopressor bolus administration. Clinicaltrials.gov identifier: NCT02277730.

Increased frequency of gestational and delivery-related complications in women of 35 years of age and above.

PubMed

Bereczky, L-K; Kiss, Sz-L; Szabó, B

2015-02-01

This retrospective study evaluated gestational and delivery-related characteristics focusing on women aged 35 and above (≥ 35 years). Data were collected on maternal (n = 8,407) and newborn records during a 4-year admission period (2008-11) at the County Emergency Hospital, Tîrgu-Mureş, Romania. The prevalence of preterm deliveries increased in all age groups, from 19.5% to 27.8% (p = 0.006) in mothers ≥ 35 years. Twinning rate showed a highly significant increase, being 2.6% in 2008 and 9.5% in 2011 (p = 0.005), while caesarean delivery incidence increased from 46.3% to 51.0% in women aged ≥ 35. Our study revealed a highly significant decrease of mean gestational age and mean fetal weight, as well as a higher incidence of comorbidities and pregnancy-related complications in those aged ≥ 35 years. We assume that comorbidities, maternal and fetal indications to perform caesarean section (CS), in the more mature age group, were a main determinant of the elective or iatrogenic preterm deliveries, which might have contributed to further complications; moreover, previous CSs were likely a promoting factor for further CSs.

Ethnic disparities in repeat caesarean rates at Auckland Hospital.

PubMed

Wise, Michelle R; Anderson, Ngaire H; Sadler, Lynn

2013-10-01

New Zealand guidelines recommend that information regarding childbirth choices be given to women with previous caesarean, so they can make informed decisions about their care. We hypothesised that rates of trial of labour (TOL) and vaginal birth after caesarean (VBAC) would vary by women's ethnicity. To estimate the association of ethnicity with TOL and VBAC rates. Clinical data were used to identify women who gave birth at Auckland Hospital in 2006-2009 with history of previous caesarean eligible for TOL. Multivariable models were used to estimate the association of women's characteristics (ethnicity, age, socio-economic status (SES), height, body mass index, lead maternity carer, diabetes, hypertension, haemorrhage, labour induction, gestational age) with rates of TOL and VBAC. In the study cohort of 2400 women, the TOL rate was 39.5%; the VBAC rate was 57.4%. Pacific women were twice as likely to have TOL, while Asian and non-New Zealand European women were half as likely to have VBAC, compared with New Zealand European women. Women in more deprived areas were more likely to have TOL, but SES was not associated with VBAC rates. Women under the care of private obstetricians were least likely to have TOL or VBAC. There are ethnic disparities in TOL and VBAC rates at our hospital. Strategies need to be developed to ensure that women of all ethnicities have access to both options for mode of delivery. © 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Instrumental delivery of the fetal head at the time of elective repeat cesarean: a randomized pilot study.

PubMed

Bofill, J A; Lencki, S G; Barhan, S; Ezenagu, L C

2000-01-01

We sought to ascertain whether the routine use of instruments, forceps or vacuum, at the time of elective repeat cesarean delivery, permits a delivery that is as safe for mother and infant and as easy for mother and physician as traditional manual delivery of the fetal head. In this prospective study 44 women undergoing elective repeat cesarean were randomized to deliver by Vacuum (V), Forceps (F), or by Manual (M) means. Groups were compared with regard to demographic variables and maternal and neonatal outcomes. Deliveries were timed from entry into the uterus until full delivery of the infant. Maternal pain scores were assessed using a 10-cm visual analog scale. There were no differences in demographic variables except that the M group had fewer women with up to two cesareans. A large percentage of women in each group were delivered with the randomized instrument. Use of the V did not demonstrate fewer extensions of the uterine incision or lesser amounts of blood loss as measured by serial hemoglobin determinations. There was a trend for the F group to require a longer period of time for delivery (p = 0.061). Women in the V group reported significantly lower pain scores (p = 0.015). There were no serious neonatal injuries. The routine use of instruments at the time of elective repeat cesarean delivery appears safe and effective.

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial.

PubMed

Tracy, Sally K; Hartz, Donna L; Tracy, Mark B; Allen, Jyai; Forti, Amanda; Hall, Bev; White, Jan; Lainchbury, Anne; Stapleton, Helen; Beckmann, Michael; Bisits, Andrew; Homer, Caroline; Foureur, Maralyn; Welsh, Alec; Kildea, Sue

2013-11-23

Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. Our results show that for women of any risk, caseload midwifery is safe and cost effective. National Health and Medical Research Council (Australia). Copyright © 2013 Elsevier Ltd. All rights reserved.

The value of routine haemoglobin concentration measurement before caesarean section.

PubMed

Vashisht, A; Yentis, S

2005-02-01

Women undergoing caesarean section routinely have a haemoglobin concentration check before delivery. We compared the haemoglobin concentration of 311 women taken at their 32-?34 week antenatal visit with their preoperative level. A significant rise from 11.04 g/dL to 11.51 g/dL was seen (mean (95% CI) 0.47 (0.37-0.57 g/dL)). This increase was most marked in the 201 women having emergency procedures, and there was a significant negative correlation between the 32 and 34 weeks level and the net change in haemoglobin concentration (r=-0.366 (P<0.001)). From our results we suggest that in women with an otherwise uncomplicated pregnancy, and a satisfactory haemoglobin concentration at 32-34 weeks, a repeat estimation of the blood count is unnecessary before operative delivery.

Undiagnosed phaeochromocytoma masquerading as eclampsia

PubMed Central

Petrie, Joanne; Lockie, Christopher; Paolineli, Alex; Stevens, Michele; Smith, Mark; Mitchell, Catharine; Dubrey, Simon William

2012-01-01

The authors report the case of a previously well 34-year-old woman presenting with a hypertensive crises and a grand-mal seizure following elective caesarean section. Initial treatment of extreme hypertension, of a presumed eclamptic aetiology, with magnesium and labetalol was complicated by intermittent profound hypotensive episodes. This was accompanied by severe biventricular failure and fluctuating systemic vascular resistance. Abdominal ultrasound revealed a left suprarenal mass. A diagnosis of phaeochromocytoma was confirmed on abdominal CT and urinary assays. The patient was stabilised with α and β blockade, was successfully extubated and subsequently had the tumour surgically excised. The cardiac function returned to normal on echocardiography and she has made a complete recovery. PMID:22665869

The value of decision tree analysis in planning anaesthetic care in obstetrics.

PubMed

Bamber, J H; Evans, S A

2016-08-01

The use of decision tree analysis is discussed in the context of the anaesthetic and obstetric management of a young pregnant woman with joint hypermobility syndrome with a history of insensitivity to local anaesthesia and a previous difficult intubation due to a tongue tumour. The multidisciplinary clinical decision process resulted in the woman being delivered without complication by elective caesarean section under general anaesthesia after an awake fibreoptic intubation. The decision process used is reviewed and compared retrospectively to a decision tree analytical approach. The benefits and limitations of using decision tree analysis are reviewed and its application in obstetric anaesthesia is discussed. Copyright © 2016 Elsevier Ltd. All rights reserved.

Comparison of the Effects of Thiopental Sodium and Propofol on Haemodynamics, Awareness and Newborns During Caesarean Section Under General Anaesthesia.

PubMed

Çakırtekin, Vedat; Yıldırım, Ahmet; Bakan, Nurten; Çelebi, Nevin; Bozkurt, Özkan

2015-04-01

To compare the effects of propofol and thiopental on haemodynamics, awareness and newborns in pregnant women undergoing elective caesarean section. Seventy pregnant women were assigned into two equal groups. For anaesthesia induction, 2 mg kg(-1) propofol (Group P) and 5 mg kg(-1) thiopental (Group T) were administered. Maternal haemodynamic parameters and bispectral index (BIS) values were recorded before induction, in 1-minute intervals within the first 10 minutes after induction and in 5-minute intervals thereafter, during skin incision, uterine incision, removal of infant, uterine sutures, skin sutures, eye opening and extubation in all cases. Cord blood gas analysis and 1- and 5-minute APGAR scores were recorded. In all cases, a keyword was spelled to ear during removal of the infant, and at the first postoperative hour, patients were questioned. Important time periods of surgery and anaesthesia and also the first postoperative hour haemodynamic values, pain scores, nausea and vomiting were noted. The demographic data were similar among cases. In Group T, systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and mean arterial pressure (MAP) at the first 2 minutes after induction and heart rate (HR) at almost all time points were significantly higher. BIS values from induction to the eighth minute and skin incision, uterine incision and removal of the infant were lower in Group P. No patient remembered the keyword spelled, while 4 patients reported dreaming during general anaesthesia. The effects of propofol and thiopental sodium on 1- and 5-minute APGAR scores, cord blood gas values and postoperative visual analogue scale (VAS) scores were similar. Propofol is a more appropriate anaesthetic agent than thiopental in anaesthesia for caesareans, since it provides better anaesthestic depth and more rapid recovery.

B Butterfly Campaign: A social marketing campaign to promote normal childbirth among first-time pregnant women.

PubMed

Darsareh, Fatemeh; Aghamolaei, Teamur; Rajaei, Minoo; Madani, Abdoulhossain; Zare, Shahram

2018-06-18

The steep increase and inappropriateness of caesarean birth represent a healthcare problem in Iran. The purpose of study was to evaluate the effect of a campaign based on social marketing to promote normal childbirth. The study was designed as a prospective case control study. The social marketing campaign was implemented from March 2016 to January 2017. A demographic data questionnaire, obstetrical history questionnaire, maternal knowledge assessment questionnaire, and maternal health belief questionnaire comprised the instruments for this study. Only women planning a caesarean birth without any medical indications for the caesarean were enrolled in the study as a case. Those who met the same inclusion criteria and did not want to participate in the campaign were assigned to the control group. In total, 350 first-time pregnant women who composed the campaign group (n=194) and control group (n=156) completed the study. The mean baseline level of knowledge and Health Belief Model component score did not differ between the two groups at baseline. However, after the campaign, knowledge scores, perceived severity, perceived susceptibility, self-efficacy, and cues to action scores differed significantly between the campaign and control groups. The follow-up of all participants in both groups showed that 35.6% (n=69) of participants in the campaign group chose natural birth as their birth method, whereas only 13.5% (n=21) in the control group delivered their newborn vaginally. The B Butterfly social marketing campaign successfully targeted first-time pregnant women who chose to have unnecessary elective cesarean births. Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Video ethnography during and after caesarean sections: methodological challenges.

PubMed

Stevens, Jeni; Schmied, Virginia; Burns, Elaine; Dahlen, Hannah G

2017-07-01

To describe the challenges of, and steps taken to successfully collect video ethnographic data during and after caesarean sections. Video ethnographic research uses real-time video footage to study a cultural group or phenomenon in the natural environment. It allows researchers to discover previously undocumented practices, which in-turn provides insight into strengths and weaknesses in practice. This knowledge can be used to translate evidence-based interventions into practice. Video ethnographic design. A video ethnographic approach was used to observe the contact between mothers and babies immediately after elective caesarean sections in a tertiary hospital in Sydney, Australia. Women, their support people and staff participated in the study. Data were collected via video footage and field notes in the operating theatre, recovery and the postnatal ward. Challenges faced whilst conducting video ethnographic research included attaining ethics approval, recruiting vast numbers of staff members and 'vulnerable' pregnant women, and endeavouring to be a 'fly on the wall' and a 'complete observer'. There were disadvantages being an 'insider' whilst conducting the research because occasionally staff members requested help with clinical tasks whilst collecting data; however, it was an advantage as it enabled ease of access to the environment and staff members that were to be recruited. Despite the challenges, video ethnographic research enabled the provision of unique data that could not be attained by any other means. Video ethnographic data are beneficial as it provides exceptionally rich data for in-depth analysis of interactions between the environment, equipment and people in the hospital environment. The analysis of this type of data can then be used to inform improvements for future care. © 2016 John Wiley & Sons Ltd.

[Late preterm infants in Spain: Experience of the 34-36 Neonatal Group].

PubMed

García-Reymundo, Mercedes; Demestre, Xavier; Calvo, María José; Ginovart, Gemma; Jiménez, Ana; Hurtado, José Antonio

2018-05-01

Late preterm (LP) infants (34 -36 weeks of gestation) are the largest group of preterm infants and also the least studied so far. In order to improve their care and reduce the impact of their increased morbidity and mortality, it is essential to know the current situation in Spain. Clinical-epidemiological variables of the LP population of 34 participating hospitals were prospectively collected from 1 April 2011 to 31 March 2016, and were then compared with the Minimum Perinatal Data Set for term births in the database. Of the 9,121 LP studied, 21.7% of 34, 30.8% of 35, and 47.5% of 36 weeks of gestation. The mortality rate was 2.8%. More than one-quarter (27.7%) were multiple pregnancies. Maternal disease were identified in 47.1% and 41.4% were pathological gestation. Just under half (47.9%) were by Caesarean section and 18.8% were of unknown origin or unjustified. No known cause of prematurity was found in 29%, and 3.1% were recognized as unjustified?caesarean?. Just under half (47%) of the LP were breastfed, and 58.6% required admission to neonatology, with 15.2% to Neonatal Intensive Care Unit. Coded diagnoses were recorded in 46.2%, with the most frequent being jaundice, 43.5%, hypoglycaemia, 30%, and respiratory disorders with 28.7%. The large sample of LP studied helps us to highlight the higher neonatal mortality and morbidity that this population suffers and the unavoidable relationship of its incidence with multiparity, maternal aging, and the still numerous inductions of labour and unjustified elective caesareans. Copyright © 2017 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Prophylaxis and treatment of HIV-1 infection in pregnancy: Swedish recommendations 2010.

PubMed

Navér, Lars; Albert, Jan; Belfrage, Erik; Flamholc, Leo; Gisslén, Magnus; Gyllensten, Katarina; Josephson, Filip; Karlström, Olof; Lindgren, Susanne; Pettersson, Karin; Svedhem, Veronica; Sönnerborg, Anders; Westling, Katarina; Yilmaz, Aylin; Swedish Reference Group for Antiviral Therapy

2011-07-01

Prophylaxis and treatment with antiretroviral drugs and the use of elective caesarean section have resulted in a very low mother-to-child transmission of human immunodeficiency virus (HIV) during recent years. The availability of new antiretroviral drugs, updated general treatment guidelines and increasing knowledge of the importance of drug resistance, have necessitated regular revisions of the "Prophylaxis and treatment of HIV-1 infection in pregnancy" recommendations. For these reasons, The Swedish Reference Group for Antiviral Therapy (RAV) updated the 2007 recommendations at an expert meeting that took place on 25 March 2010. The most important revisions from the previous recommendations are: (1) it is recommended that treatment during pregnancy starts at the latest at gestational week 14-18; (2) ongoing efficient treatment at confirmed pregnancy may, with a few exceptions, be continued; (3) lopinavir/r and atazanavir/r are equally recommended protease inhibitors; (4) if maternal HIV RNA is >50 copies/ml close to delivery, a planned caesarean section, intravenous zidovudine, oral nevirapine for the mother and post-exposure prophylaxis for the infant with 3 antiretroviral drugs are recommended; (5) for delivery at <34 gestational weeks, intravenous zidovudine and oral nevirapine for the mother and at 48-72 h for the infant is recommended, in addition to other prophylaxis; (6) intravenous zidovudine is not recommended when HIV RNA is <50 copies/ml and a caesarean section is performed; (7) it is recommended that prophylaxis for the infant is started within 4 h; (8) prophylactic zidovudine for the infant may be administered twice daily instead of 4 times a day, as was the case previously; and (9) the number of sampling occasions for the infant has been decreased.

Prophylaxis and treatment of HIV-1 infection in pregnancy: Swedish recommendations 2013.

PubMed

Navér, Lars; Albert, Jan; Böttiger, Ylva; Carlander, Christina; Flamholc, Leo; Gisslén, Magnus; Josephson, Filip; Karlström, Olof; Lindborg, Lena; Svedhem-Johansson, Veronica; Svennerholm, Bo; Sönnerborg, Anders; Yilmaz, Aylin; Pettersson, Karin

2014-06-01

Prophylaxis and treatment with antiretroviral drugs and elective caesarean section delivery have resulted in very low mother-to-child transmission of HIV during recent years. Updated general treatment guidelines and increasing knowledge about mother-to-child transmission have necessitated regular revisions of the recommendations for the prophylaxis and treatment of HIV-1 infection in pregnancy. The Swedish Reference Group for Antiviral Therapy (RAV) updated the recommendations from 2010 at an expert meeting on 11 September 2013. The most important revisions are the following: (1) ongoing efficient treatment at confirmed pregnancy may, with a few exceptions, be continued; (2) if treatment is initiated during pregnancy, the recommended first-line therapy is essentially the same as for non-pregnant women; (3) raltegravir may be added to achieve rapid reduction in HIV RNA; (4) vaginal delivery is recommended if at > 34 gestational weeks and HIV RNA is < 50 copies/ml and no obstetric contraindications exist; (5) if HIV RNA is < 50 copies/ml and delivery is at > 34 gestational weeks, intravenous zidovudine is not recommended regardless of the delivery mode; (6) if HIV RNA is > 50 copies/ml close to delivery, it is recommended that the mother should undergo a planned caesarean section, intravenous zidovudine, and oral nevirapine, and the infant should receive single-dose nevirapine at 48-72 h of age and post-exposure prophylaxis with 2 drugs; (7) if delivery is preterm at < 34 gestational weeks, a caesarean section delivery should if possible be performed, with intravenous zidovudine and oral nevirapine given to the mother, and single-dose nevirapine given to the infant at 48-72 h of age, as well as post-exposure prophylaxis with 2 additional drugs.

Comparison of two different approaches to hypotension following spinal anaesthesia for Caesarean delivery: effects on neonatal and maternal wellbeing.

PubMed

Zasa, Michele; Conci, Eleonora; Marchignoli, Alessandro; Pini, Rita; Passeri, Lorenzo; Fanelli, Guido; Cornini, Andrea

2015-04-27

Maternal hypotension during spinal anaesthesia for Caesarean delivery is a common event, with potential detrimental consequences. We led a prospective, randomized study to compare the effects of two strategies on neonatal and maternal wellbeing. Parturients scheduled for elective Caesarean section in spinal anaesthesia were preoperatively studied with a supine stress test. Those with a positive test were enrolled in the study and received a solution of 0.5% hyperbaric bupivacaine 12.5 mg and 0.02% morphine 200 µg intrathecally. Patients received a 37.5 mg/h preventive intravenous (IV) infusion of ephedrine (Pharmacologic Group), or a 15° left lateral tilt (Non-Pharmacologic Group). In Pharmacolgic Group hypotension was treated for 20% drops in systolic blood pressure; in Non-Pharmacolgic Group only severe hypotension - defined as a 40% drop in systolic blood pressure - was treated. Thirty-six patients were studied. Study groups were statistically similar in terms of demographic variables and intraoperative times. No statistical differences were found in terms of umbilical arterial blood base excess [-1.4 (-3.7 to -0.3) mEq/l Pharmacologic Group vs. -1.7 (-2.7 to -1.0) mEq/l Non-Pharmacologic Group; p=0.815] and other umbilical blood gas values. Apgar scores were statistically similar between study groups. Treatment for hypotension was required by 13 (72.2%) patients in Pharmacologic Group and 9 (50%) patients in Non-Pharmacologic Group (p=0.171). No differences were found at the analysis of serial changes in vital signs. Both studied strategies guaranteed a comparable safe outcome in terms of maternal and neonatal wellbeing. (www.actabiomedica.it).

The effect of economic downturn on the volume of surgical procedures: A systematic review.

PubMed

Fujihara, Nasa; Lark, Meghan E; Fujihara, Yuki; Chung, Kevin C

2017-08-01

Economic downturn can have a wide range of effects on medicine at both individual and national levels. We aim to describe these effects in relation to surgical volume to guide future planning for physician specialization, patient expectations in the face of economic crises, or estimating healthcare expenditure. We hypothesized that because of high out-of-pocket costs, cosmetic procedure volumes would be most affected by economic decline. A systematic review was conducted using MEDLINE, Embase, and ABI/INFORMS. The main search terms were "economic recession" and "surgical procedures, operative". Studies were included if surgical volumes were measured and economic indicators were used as predictors of economic conditions. Twelve studies were included, and the most common subject was cosmetic (n = 5), followed by orthopedic (n = 2) and cardiac surgeries (n = 2). The majority of studies found that in periods of economic downturn, surgical volume decreased. Among the eight studies using Pearson's correlation analysis, there were no significant differences between cosmetic procedures and other elective procedures, indicating that cosmetic procedures may display trends similar to those of non-cosmetic elective procedures in periods of economic downturn. Surgical volume generally decreased when economic indicators declined, observed for both elective and non-elective surgery fields. However, a few specific procedure volumes such as vasectomy and caesarean section for male babies increased during the economic downturn. Knowledge of these trends can be useful for future surgical planning and distribution of healthcare resources. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Why 'down under' is a cut above: a comparison of rates of and reasons for caesarean section in England and Australia

PubMed Central

2014-01-01

Background Most studies examining determinants of rising rates of caesarean section have examined patterns in documented reasons for caesarean over time in a single location. Further insights could be gleaned from cross-cultural research that examines practice patterns in locations with disparate rates of caesarean section at a single time point. Methods We compared both rates of and main reason for pre-labour and intrapartum caesarean between England and Queensland, Australia, using data from retrospective cross-sectional surveys of women who had recently given birth in England (n = 5,250) and Queensland (n = 3,467). Results Women in Queensland were more likely to have had a caesarean birth (36.2%) than women in England (25.1% of births; OR = 1.44, 95% CI = 1.28-1.61), after adjustment for obstetric characteristics. Between-country differences were found for rates of pre-labour caesarean (21.2% vs. 12.2%) but not for intrapartum caesarean or assisted vaginal birth. Compared to women in England, women in Queensland with a history of caesarean were more likely to have had a pre-labour caesarean and more likely to have had an intrapartum caesarean, due only to a previous caesarean. Among women with no previous caesarean, Queensland women were more likely than women in England to have had a caesarean due to suspected disproportion and failure to progress in labour. Conclusions The higher rates of caesarean birth in Queensland are largely attributable to higher rates of caesarean for women with a previous caesarean, and for the main reason of having had a previous caesarean. Variation between countries may be accounted for by the absence of a single, comprehensive clinical guideline for caesarean section in Queensland. PMID:24767675

Differences between native and immigrant women in Taiwan in factors associated with caesarean section: A prospective observational study.

PubMed

Weng, Shiue-Shan; Lin, Chen-Li; Tai, Chen-Jei; Chien, Li-Yin

2017-01-01

This study aimed to examine the association of social support, social factors, and maternal complications with caesarean deliveries in native and immigrant women, and to explore the association between acculturation and caesarean deliveries in immigrant women in Taiwan. This prospective panel study was conducted from August 2012 through April 2014 and included 222 native and 147 immigrant pregnant women in Taiwan. Caesarean rates did not differ significantly between native and immigrant women, including the overall caesarean rate (28.8%, 32.0%), medically indicated caesarean (22.5%, 24.5%), and caesarean without medical indications (6.3%, 7.5%). Results of multiple logistic regression models revealed that maternal complications and household activity support were positively associated with caesarean deliveries. Both native and immigrant women with high levels of informational support were less likely to receive caesareans. Immigrant women who were older than 35 years, had a middle level socioeconomic status, and perceived a high level of acceptance of caesarean in Taiwan were more likely to have caesarean deliveries. Informational support was a protective factor for caesarean delivery, whereas household activity support offered by the family was positively associated with caesarean delivery. Perceived acceptance level in mainstream society could affect immigrant women's use of caesarean delivery.

Association between mode of delivery and astigmatism in preschool children.

PubMed

Liu, Fengyang; Yang, Xubo; Tang, Angcang; Liu, Longqian

2018-03-01

To determine whether mode of delivery has any impact on astigmatism. This case-control study was performed in the Department of Ophthalmology in 2015. Exposure was mode of delivery [vaginal delivery (VD) or caesarean section (CS), which here included both elective and emergency CS]. Outcome was astigmatism (≥2.5 D), which was determined by cycloplegic refraction. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were computed to assess the associations between mode of delivery and astigmatism from logistic regression models. Of the 659 children studied here (341 boys; mean age, 4.37 years), 440 were born by CS and 219 by VD. The incidence of severe astigmatism (≥2.5 D) in the CS and VD groups was 22.06% and 13.24%, respectively. Children delivered by CS had a 77.9% higher risk of severe astigmatism compared with vaginally delivered children (OR = 1.779; 95% CI, 1.121 to 2.824). After dividing CS into elective CS and emergency CS, children delivered by elective CS had an 87.3% increased risk of severe astigmatism (OR = 1.873; 95% CI, 1.157 to 3.032), but children delivered by emergency CS did not differ from vaginally delivered children. In addition, the children whose mothers had histories of breastfeeding had a 44.6% lower risk of severe astigmatism than children whose mother did not breastfeed them (OR = 0.554, 95% CI, 0.335-0.914). Birth by CS, especially elective CS, increases the risk of severe astigmatism (≥2.50 D) in childhood. © 2017 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Women's involvement in the decision to be delivered by caesarean section in Sub Saharan Africa.

PubMed

Nnaji, G A; Okafor, C; Muoghalu, K; Onyejimbe, U N; Umeononihu, O S

2012-01-01

The aim of this study is to determine the degree and nature of women's involvement in the decision to deliver by Caesarean section. A cross sectional descriptive multi-centre study on post partum women who were delivered by Caesarean section in the three study centres. The five most common indicators for Caesarean section include cephalo-pelvic disproportion, prolonged labour, malpresentation, pregnancy induced hypertension and ante partum haemorrhage, which accounted for 70% of the indications for Caesarean section. The commonest influence on respondents' decision to have Caesarean section was physician factors, followed by religious and cultural factors. Husbands influenced majority of the respondents during decision for Caesarean section. The respondents' agreement with decision for Caesarean section varied significantly as the number of previous Caesarean section, being highest among women with 4 previous Caesarean section. In conclusion, the majority of women were found to be involved in the decision to have Caesarean section, and the most influential factors on them during the decision process were physician factors and husband's presence. In this environment, the greater the number of previous Caesarean section a woman has had in the past the more likely would she accept Caesarean section in subsequent deliveries as a better option. There is need for further studies to determine the effect of socio-demographic factors on decision to have caesarean section as well as satisfaction of the outcome.

The Path to Presidency: Tips for Teaching Elementary Students about the Election Process

ERIC Educational Resources Information Center

Conrad, Marika

2016-01-01

Teaching about presidential elections at the elementary level can seem a bit daunting at times. Students are quick to share their strong opinions on the current candidates running for office. These opinions often involve repeating feelings and phrases shared by parents around the dinner table the night before. For the average seven- or…

Decreased risk of prematurity after elective repeat cesarean delivery in Hispanics.

PubMed

Vilchez, Gustavo; Chelliah, Anushka; Bratley, Elaine; Bahado-Singh, Ray; Sokol, Robert

2015-01-01

The current recommendation is to delay elective repeat cesarean deliveries (ERCD) until 39 weeks to decrease prematurity risks. Prior reports suggest accelerated maturity of fetuses according to race (African-Americans and Asians). To analyze the effect of the Hispanic ethnicity on the prematurity risk after ERCD. The US Natality Database from 2004 to 2008 was reviewed. Inclusion criteria were singleton delivery, no trial of labor, repeat cesarean. Exclusion criteria were fetal anomalies, history of diabetes/hypertension related disorders. Outcomes analyzed were Apgar score, assisted ventilation, intensive care admission, surfactant/antibiotic use and seizures. Two groups were identified: non-Hispanic Whites (NHW) and Hispanic Whites (HW). Regression analysis was performed to calculate adjusted odds ratios. Deliveries at 36-40 weeks were studied with 40 weeks as the reference group. A total of 930421 ERCDs were identified, 396823 NHW and 236733 HW. For NHW, the risk of prematurity was lower at 39 weeks. For HW, there was no difference in the risks of prematurity at/beyond 38 weeks. There appears to be accelerated maturity with no increase in prematurity risk at 38 weeks in HW delivered by ERCD. Ethnicity can be considered for patient counseling and decision making regarding optimal timing of elective interventions.

[Delivery of the IUGR fetus].

PubMed

Perrotin, F; Simon, E G; Potin, J; Laffon, M

2013-12-01

The purpose of this paper is to review available data regarding the management of delivery in intra uterine growth retarded fetuses and try to get recommendations for clinical obstetrical practice. Bibliographic research performed by consulting PubMed database and recommendations from scientific societies with the following words: small for gestational age, intra-uterine growth restriction, fetal growth restriction, very low birth weight infants, as well as mode of delivery, induction of labor, cesarean section and operative delivery. The diagnosis of severe IUGR justifies the orientation of the patient to a referral centre with all necessary resources for very low birth weight or premature infants Administration of corticosteroids for fetal maturation (before 34 WG) and a possible neuroprotective treatment by with magnesium sulphate (before 32-33 WG) should be discussed. Although elective caesarean section is common, there is no current evidence supporting the use of systematic cesarean section, especially when the woman is in labor. Induction of labor, even with unfavorable cervix is possible under continuous FHR monitoring, in favorable obstetric situations and in the absence of severe fetal hemodynamic disturbances. Instrumental delivery and routine episiotomy are not recommended. For caesarean section under spinal anesthesia, an adequate anesthetic management must ensure the maintenance of basal blood pressure. Compared with appropriate for gestational age fetus, IUGR fetus is at increased risk of metabolic acidosis or perinatal asphyxia during delivery. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway.

PubMed

Trevisan, P

2002-10-01

Anaesthetic management of a parturient with predicted difficult airway presenting for caesarean section (CS) is not a straightforward decision: general anaesthesia should be avoided because intubation can be impossible and a "cannot intubate, cannot ventilate" scenario might ensue, on the other hand regional techniques can be unsuccessful or, though rarely, have complications that require emergency intubation. The case is presented of a primigravida admitted to hospital at 37 weeks' gestation with hypertension, intrauterine growth retardation and oligohydramnios. After a few days' observation, it was decided to proceed with an elective CS. The preoperative airway examination revealed a poor mouth opening with an interdental distance of 20 mm and a Mallampati class IV. The patient was classified as a case of difficult intubation and the following anaesthetic options were considered: epidural anaesthesia, spinal anaesthesia and awake fibreoptic intubation followed by general anaesthesia. The pros and the cons of these techniques were explained to the patient and it was suggested that awake fibreoptic intubation was the safest option. The patient gave her consent, so an uneventful nasal awake fibreoptic intubation was carried out under local anaesthesia. This case report offers the opportunity to underline the risk to perform a central blockade in a parturient with predicted difficult intubation, arguing that the safest course of action is an awake fibrescopic intubation, besides some controversial points to safely perform awake fibreoptic intubation in obstetric patients are discussed.

The genital herpes problem in pregnancy.

PubMed

Guerra, B; Puccetti, C; Cervi, F

2012-10-01

Genital herpes is a common sexually transmitted infection. In reproductive age it involves the additional risk of vertical transmission to the neonate. Rates of transmission are affected by the viral type and whether the infection around delivery is primary or recurrent. Neonatal herpes is a rare but very severe complication of genital herpes infection and is caused by contact with infected genital secretions at the time of labor. Maternal acquisition of herpes simplex virus (HSV) in the third trimester of pregnancy carries the highest risk of neonatal transmission. Prevention of neonatal herpes depends on preventing acquisition of genital HSV infection during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery. Uninfected woman should be counselled about the need of avoiding sexual contact during the third trimester. Elective caesarean section before the onset of labor is the choice mode of delivery for women with genital lesions or with prodromal symptoms near the term, even if it offers only a partial protection against neonatal infection. Antiviral suppressive therapy is used from 36 weeks of gestation until delivery in pregnant women with recurrences to prevent genital lesions at the time of labor so reducing the need of caesarean sections. Currently, routine maternal serologic screening is not yet recommended. Because most mothers of infants who acquire neonatal herpes lack histories of clinically evident genital herpes, researchers should focus on the recognition of asymptomatic primary genital HSV infections.

Rising rates, changing relationships: caesarean section and its correlates in South Korea, 1988-2000.

PubMed

Lee, Sang-Il; Khang, Young-Ho; Yun, Sungcheol; Jo, Min-Woo

2005-06-01

To examine the trends in the relationship between caesarean section rates in South Korea and its correlates. Five rounds (1988, 1991, 1994, 1997 and 2000) of population-based National Fertility and Family Health Survey of South Korea. South Korea. Sample Mothers (N= 9184) aged 15-44 years. Caesarean rates were calculated according to correlates and then directly adjusted to five-year age and parity groups. Distribution of all samples (9184 mothers) was standard, producing age- and parity-adjusted caesarean rates. Linear trends of correlates with caesarean rates were examined for ordinal variables such as education, income, urbanisation level (area of residence) and level of prenatal visits. Age- and parity-adjusted caesarean section rates. As caesarean rates rose by year, the relationship of caesarean section with education, occupation and area of residence has been reversed. Associations between caesarean rates, income level, place of delivery and level of prenatal visit were found in 1988 but disappeared by 2000. In 2000, relatively low caesarean rates were found in variables that will be more prevalent in the future, such as higher maternal education, higher maternal occupation and residence in big cities. Caesarean rates may have reached a plateau in South Korea. No maternal or health service factors were detected to further increase the proportion of caesarean deliveries.

National Rates of Uterine Rupture are not Associated with Rates of Previous Caesarean Delivery: Results from the Nordic Obstetric Surveillance Study.

PubMed

Colmorn, Lotte B; Langhoff-Roos, Jens; Jakobsson, Maija; Tapper, Anna-Maija; Gissler, Mika; Lindqvist, Pelle G; Källen, Karin; Gottvall, Karin; Klungsøyr, Kari; Bøhrdahl, Per; Bjarnadóttir, Ragnhild I; Krebs, Lone

2017-05-01

Previous caesarean delivery and intended mode of delivery after caesarean are well-known individual risk factors for uterine rupture. We examined if different national rates of uterine rupture are associated with differences in national rates of previous caesarean delivery and intended mode of delivery after a previous caesarean delivery. This study is an ecological study based on data from a retrospective cohort in the Nordic countries. Data on uterine rupture were collected prospectively in each country as part of the Nordic obstetric surveillance study and included 91% of all Nordic deliveries. Information on the comparison population was retrieved from the national medical birth registers. Incidence rate ratios by previous caesarean delivery and intended mode of delivery after caesarean were modelled using Poisson regression. The incidence of uterine rupture was 7.8/10 000 in Finland and 4.6/10 000 in Denmark. Rates of caesarean (21.3%) and previous caesarean deliveries (11.5%) were highest in Denmark, while the rate of intended vaginal delivery after caesarean was highest in Finland (72%). National rates of uterine rupture were not associated with the population rates of previous caesarean but increased by 35% per 1% increase in the population rate of intended vaginal delivery and in the subpopulation of women with previous caesarean delivery by 4% per 1% increase in the rate of intended vaginal delivery. National rates of uterine rupture were not associated with national rates of previous caesarean, but increased with rates of intended vaginal delivery after caesarean. © 2017 John Wiley & Sons Ltd.

Diuretics for transient tachypnoea of the newborn.

PubMed

Kassab, Manal; Khriesat, Wadah M; Anabrees, Jasim

2015-11-21

Transient tachypnoea of the newborn (TTN) results from delayed clearance of lung liquid and is a common cause of admission of full-term infants to neonatal intensive care units. The condition is particularly common after elective caesarean section. Conventional treatment involves appropriate oxygen administration and continuous positive airway pressure in some cases. Most infants receive antibiotic therapy. Hastening the clearance of lung liquid may shorten the duration of the symptoms and reduce complications. To determine whether diuretic administration reduces the duration of oxygen therapy and respiratory symptoms and shortens hospital stay in term infants presenting with transient tachypnoea of the newborn. An updated search was carried out in September 2015 of the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library issue 9, 2015), MEDLINE via Ovid, EMBASE, PubMed, and CINAHL via OVID. We included randomised and quasi-randomised controlled trials that compared the effect of diuretics administration versus placebo or no treatment in infants of less than seven days of age, born at 37 or more weeks of gestation with the clinical picture of transient tachypnoea of the newborn. We extracted and analysed data according to the methods outlined in the latest Cochrane Handbook for Systematic Reviews of Interventions. Two review authors assessed trial quality in each potentially eligible manuscript and two review authors extracted data. Our previous systematic review included two trials enrolling a total of 100 infants with transient tachypnoea of the newborn (Wiswell 1985; Karabayir 2006). The updated search revealed no new trials. Wiswell 1985 randomised 50 infants to receive either oral furosemide (2 mg/kg body weight at time of diagnosis followed by a 1 mg/kg dose 12 hours later if the tachypnoea persisted) or placebo. Karabayir 2006 randomised 50 infants to receive either intravenous furosemide (2 mg/kg body weight) or an equal volume of normal saline placebo. Neither trial reported on the need for respiratory support. Neither trial demonstrated a statistically significant impact of furosemide on transient tachypnoea of the newborn regarding duration of symptoms or length of hospitalisation. Diuretics cannot be recommended as treatment for transient tachypnoea of the newborn and it should not be used unless additional data become available. This finding suggests that either furosemide is not effective in promoting resorption of lung fluid, or factors other than delayed resorption of this fluid contribute to the pathogenesis of transient tachypnoea of the newborn. The question remains as to whether furosemide given to the infant (or even to the mother before caesarean section) might shorten the duration of the illness. As elective caesarean section continues at a high level, these two interventions might be worthy of trials.

Post dural puncture headache after spinal anaesthesia for caesarean section: a comparison of 25 g Quincke, 27 g Quincke and 27 g Whitacre spinal needles.

PubMed

Shaikh, Jan Muhammad; Memon, Amna; Memon, Muhammad Ali; Khan, Majida

2008-01-01

To compare the frequency and severity of post dural puncture headache in obstetric patients using 25G Quincke, 27G Quincke and 27G Whitacre spinal needles. Comparative, randomized, double-blind, interventional study. Liaquat University Hospital Hyderabad from October 2005 to December 2006. 480 ASA I-II full term pregnant women, 18 to 45 years of age, scheduled for elective Caesarean section, under spinal anaesthesia, were randomized into three groups: Group I (25G Quincke spinal needle: n=168), Group II (27G Quincke spinal needle: n=160) and Group III (27G Whitacre spinal needle: n=152). Spinal anaesthesia was performed with 1.5-2.0 ml 0.75% hyperbaric bupivacaine using 25G Quincke spinal needle (Group I), 27G Quincke spinal needle (Group II) and 27G Whitacre spinal needle (Group III) at L3-4 inter-vertebral space. Each patient was assessed daily for four consecutive days following Caesarean section. Frequency and severity and of postdural puncture headache (PDPH) were recorded. Data were analyzed using SPSS-11. Frequency of PDPH following the use of 25G Quincke (Group I), 27G Quincke (Group II) and 27G Whitacre (Group III) spinal needles was 8.3% (14/168), 3.8% (6/160) and 2.0% (3/152) respectively. In Group I, PDPH was mild in 5 patients, moderate in 7 patients and severe in 2 patients. In Group II, it was mild in 2, moderate in 3 and severe in 1 patient. In group III, it was mild in 2 and moderate in 1 patient. Severe PDPH did not occur in Group III. Most of the patients with PDPH developed it on 1st and 2nd postoperative day. When using a 27G Whitacre spinal needle, the frequency and severity of PDPH was significantly lower than when a 25G Quincke or 27G Quincke needle was used.

Closed-loop double-vasopressor automated system vs manual bolus vasopressor to treat hypotension during spinal anaesthesia for caesarean section: a randomised controlled trial.

PubMed

Sng, B L; Tan, H S; Sia, A T H

2014-01-01

Hypotension necessitating vasopressor administration occurs commonly during caesarean section under spinal anaesthesia. We developed a novel vasopressor delivery system that automatically administers phenylephrine or ephedrine based on continuous non-invasive arterial pressure monitoring. A phenylephrine bolus of 50 μg was given at 30-s intervals when systolic blood pressure fell < 90% of baseline; an ephedrine bolus of 4 mg was given instead if systolic pressure fell < 90% of baseline together with a heart rate < 60 beats.min(-1). The control group used manual boluses of either phenylephrine 100 μg or ephedrine 8 mg, administered at 1-min intervals based on the same thresholds for systolic pressure and heart rate. This randomised, controlled, double-blinded trial involved 213 healthy women who underwent elective caesarean delivery under spinal anaesthesia using 11 mg hyperbaric bupivacaine with 15 μg fentanyl and 100 μg morphine. The automated vasopressor group had better systolic pressure control, with 37/106 (34.9%) having any beat-to-beat systolic pressure reading < 80% of baseline compared with 63/107 (58.9%) in the control group (p < 0.001). There was no difference in the incidence of reactive hypertension, defined as systolic pressure > 120% of baseline, with 8/106 (7.5%) in the automated vasopressor group vs 14/107 (13.1%) in the control group, or total dose of vasopressors. The automated vasopressor group had lower median absolute performance error of 8.5% vs control of 9.8% (p = 0.013), and reduced incidence of nausea (1/106 (0.9%) vs 11/107 (10.3%), p = 0.005). Neonatal umbilical cord pH, umbilical lactate and Apgar scores were similar. Hence, our system afforded better control of maternal blood pressure and reduced nausea with no increase in reactive hypertension when compared with manual boluses. © 2013 The Association of Anaesthetists of Great Britain and Ireland.

An audit of pregnancy outcomes in solid organ transplant recipients at a metropolitan hospital.

PubMed

Fang, Yunjing E; Nayyar, Roshini; Diplock, Hayley

2018-04-22

Pregnancies in patients with solid organ transplants have higher rates of complications and caesarean sections (CS). To perform an audit of the pregnancy outcomes in transplant recipients, to determine the rate of CS in our cohort, the appropriate skin incision for CS in these patients and to formulate recommendations for preoperative planning. This is a retrospective cohort study. All patients who had a solid organ transplant were identified from the obstetrics database. The operation records of the transplant recipients who delivered by CS were reviewed and the de-identified data were evaluated for pregnancy outcomes. This cohort consisted of 22 women: six had simultaneous pancreas and kidney (SPK) transplants and 16 had kidney transplants. Over a ten-year period, four women had two pregnancies and one had a twin pregnancy, thus 27 babies were born. The rate of CS was 58% (n = 15) and the surgical approach in 13 of these patients was by Pfannenstiel incision. One patient had an elective midline incision at the first CS, which was repeated in the next pregnancy. Two CS were complicated by bladder injury, both occurring in SPK recipients. Patients with solid organ transplants have a higher rate of CS and SPK patients may be at a higher risk of bladder injuries during CS. Our data suggest that Pfannenstiel skin incision is still suitable for these patients. We recommend reviewing the operative details of the transplant operation and a pelvic magnetic resonance imaging for pre-operative planning. © 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data.

PubMed

Ye, J; Zhang, J; Mikolajczyk, R; Torloni, M R; Gülmezoglu, A M; Betran, A P

2016-04-01

Caesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality. Ecological study using longitudinal data. Worldwide country-level data. A total of 159 countries were included in the analyses, representing 98.0% of global live births (2005). Nationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio-economic development by means of human development index (HDI) using fractional polynomial regression models. Maternal mortality ratio and neonatal mortality rate. Most countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5-10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%. Although caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality. The caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality. © 2015 The Authors BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.

Caesarean delivery and risk of childhood leukaemia: a pooled analysis from the Childhood Leukemia International Consortium (CLIC)

PubMed Central

Marcotte, Erin L; Thomopoulos, Thomas P; Infante-Rivard, Claire; Clavel, Jacqueline; Petridou, Eleni Th; Schüz, Joachim; Ezzat, Sameera; Dockerty, John D; Metayer, Catherine; Magnani, Corrado; Scheurer, Michael E; Mueller, Beth A; Mora, Ana M; Wesseling, Catharina; Skalkidou, Alkistis; Rashed, Wafaa M; Francis, Stephen S; Ajrouche, Roula; Erdmann, Friederike; Orsi, Laurent; Spector, Logan G

2017-01-01

Summary Background Results from case-control studies have shown an increased risk of acute lymphoblastic leukaemia (ALL) in young children born by caesarean delivery, and prelabour caesarean delivery in particular; however, an association of method of delivery with childhood leukaemia subtypes has yet to be established. We therefore did a pooled analysis of data to investigate the association between childhood leukaemia and caesarean delivery. Methods We pooled data from 13 case-control studies from the Childhood Leukemia International Consortium done in nine countries (Canada, Costa Rica, Egypt, France, Germany, Greece, Italy, New Zealand, and the USA) for births from 1970-2013. We analysed caesarean delivery overall and by indications that probably resulted in prelabour caesarean delivery or emergency caesarean delivery. We used multivariable logistic regression models, adjusted for child's birthweight, sex, age, ethnic origin, parental education, maternal age, and study, to estimate odds ratios (ORs) and 95% CIs for the risk of ALL and acute myeloid leukaemia (AML) in children aged 0-14 years at diagnosis. Findings The studies provided data for 8780 ALL cases, 1332 AML cases, and 23 459 controls, of which the birth delivery method was known for 8655 (99%) ALL cases, 1292 (97%) AML cases, and 23 351 (>99%) controls. Indications for caesarean delivery were available in four studies (there were caesarean deliveries for 1061 of 4313 ALL cases, 138 of 664 AML cases, and 1401 of 5884 controls). The OR for all indications of caesarean delivery and ALL was 1.06 (95% CI 0.99–1.13), and was significant for prelabour caesarean delivery and ALL (1.23 [1.04-1.47]; p=0.018). Emergency caesarean delivery was not associated with ALL (OR 1.02 [95% CI 0.81-1.30]). AML was not associated with caesarean delivery (all indications OR 0.99 [95% CI 0.84-1.17]; prelabour caesarean delivery 0.83 [0.54-1.26]; and emergency caesarean delivery 1.05 [0.63-1.77]). Interpretation Our results suggest an increased risk of childhood ALL after prelabour caesarean delivery. If this association is causal, maladaptive immune activation due to an absence of stress response before birth in children born by prelabour caesarean delivery could be considered as a potential mechanism. PMID:27063976

The Content and Tendencies of the Active Political Involvement of College Students (Based on the Elections of 2011 and 2012)

ERIC Educational Resources Information Center

Zernov, D. V.; Lukonina, E. S.

2014-01-01

Until quite recently, young people were extremely passive in political life. This has been repeatedly noted in sociological studies and in the scientific literature. In particular, young people used to be extremely reluctant to take part in elections. For example, in the age group between eighteen and thirty, 47 percent took part in the election…

WHO Global Survey on Maternal and Perinatal Health in Latin America: classifying caesarean sections

PubMed Central

2009-01-01

Background Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time. Methods We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates. Results The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively. Conclusion The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care. PMID:19874598

Getting the first birth right: A retrospective study of outcomes for low-risk primiparous women receiving standard care versus midwifery model of care in the same tertiary hospital.

PubMed

Wong, Nola; Browne, Jenny; Ferguson, Sally; Taylor, Jan; Davis, Deborah

2015-12-01

There is national and international concern for increasing obstetric intervention in childbirth and rising caesarean section rates. Repeat caesarean section is a major contributing factor, making primiparous women an important target for strategies to reduce unnecessary intervention and surgeries in childbirth. The aim was to compare outcomes for a cohort of low risk primiparous women who accessed a midwifery continuity model of care with those who received standard public care in the same tertiary hospital. A retrospective comparative cohort study design was implemented drawing on data from two databases held by a tertiary hospital for the period 1 January 2010 to 31 December 2011. Categorical data were analysed using the chi-squared statistic and Fisher's exact test. Continuous data were analysed using Student's t-test. Comparisons are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05. Data for 426 women experiencing continuity of midwifery care and 1220 experiencing standard public care were compared. The study found increased rates of normal vaginal birth (57.7% vs. 48.9% p=0.002) and spontaneous vaginal birth (38% vs. 22.4% p=<0.001) and decreased rates of instrumental birth (23.5% vs. 28.5% p=0.050) and caesarean sections (18.8% vs. 22.5% p=0.115) in the midwifery continuity cohort. There were also fewer interventions in this group. No differences were found in neonatal outcomes. Strategies for reducing caesarean section rates and interventions in childbirth should focus on primiparous women as a priority. This study demonstrates the effectiveness of continuity midwifery models, suggesting that this is an important strategy for improving outcomes in this population. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Caesarean delivery and risk of childhood leukaemia: a pooled analysis from the Childhood Leukemia International Consortium (CLIC).

PubMed

Marcotte, Erin L; Thomopoulos, Thomas P; Infante-Rivard, Claire; Clavel, Jacqueline; Petridou, Eleni Th; Schüz, Joachim; Ezzat, Sameera; Dockerty, John D; Metayer, Catherine; Magnani, Corrado; Scheurer, Michael E; Mueller, Beth A; Mora, Ana M; Wesseling, Catharina; Skalkidou, Alkistis; Rashed, Wafaa M; Francis, Stephen S; Ajrouche, Roula; Erdmann, Friederike; Orsi, Laurent; Spector, Logan G

2016-04-01

Results from case-control studies have shown an increased risk of acute lymphoblastic leukaemia (ALL) in young children born by caesarean delivery, and prelabour caesarean delivery in particular; however, an association of method of delivery with childhood leukaemia subtypes has yet to be established. We therefore did a pooled analysis of data to investigate the association between childhood leukaemia and caesarean delivery. We pooled data from 13 case-control studies from the Childhood Leukemia International Consortium done in nine countries (Canada, Costa Rica, Egypt, France, Germany, Greece, Italy, New Zealand, and the USA) for births from 1970-2013. We analysed caesarean delivery overall and by indications that probably resulted in prelabour caesarean delivery or emergency caesarean delivery. We used multivariable logistic regression models, adjusted for child's birthweight, sex, age, ethnic origin, parental education, maternal age, and study, to estimate odds ratios (ORs) and 95% CIs for the risk of ALL and acute myeloid leukaemia (AML) in children aged 0-14 years at diagnosis. The studies provided data for 8780 ALL cases, 1332 AML cases, and 23 459 controls, of which the birth delivery method was known for 8655 (99%) ALL cases, 1292 (97%) AML cases, and 23 351 (>99%) controls. Indications for caesarean delivery were available in four studies (there were caesarean deliveries for 1061 of 4313 ALL cases, 138 of 664 AML cases, and 1401 of 5884 controls). The OR for all indications of caesarean delivery and ALL was 1·06 (95% CI 0·99-1·13), and was significant for prelabour caesarean delivery and ALL (1·23 [1·04-1·47]; p=0·018). Emergency caesarean delivery was not associated with ALL (OR 1·02 [95% CI 0·81-1·30]). AML was not associated with caesarean delivery (all indications OR 0·99 [95% CI 0·84-1·17]; prelabour caesarean delivery 0·83 [0·54-1·26]; and emergency caesarean delivery 1·05 [0·63-1·77]). Our results suggest an increased risk of childhood ALL after prelabour caesarean delivery. If this association is causal, maladaptive immune activation due to an absence of stress response before birth in children born by prelabour caesarean delivery could be considered as a potential mechanism. National Cancer Institute. Copyright © 2016 Elsevier Ltd. All rights reserved.

Adaptation, postpartum concerns, and learning needs in the first two weeks after caesarean birth.

PubMed

Weiss, Marianne; Fawcett, Jacqueline; Aber, Cynthia

2009-11-01

The purpose of this Roy Adaptation Model-based study was to describe women's physical, emotional, functional and social adaptation; postpartum concerns; and learning needs during the first two weeks following caesarean birth and identify relevant nursing interventions. Studies of caesarean-delivered women indicated a trend toward normalisation of the caesarean birth experience. Escalating caesarean birth rates mandate continued study of contemporary caesarean-delivered women. Mixed methods (qualitative and quantitative) descriptive research design. Nursing students collected data from 233 culturally diverse caesarean-delivered women in urban areas of the Midwestern and Northeastern USA between 2002-2004. The focal stimulus was the planned or unplanned caesarean birth; contextual stimuli were cultural identity and parity. Adaptation was measured by open-ended interview questions, fixed choice questionnaires about postpartum concerns and learning needs and nurse assessment of post-discharge problems. Potential interventions were identified using the Omaha System Intervention Scheme. More positive than negative responses were reported for functional and social adaptation than for physical and emotional adaptation. Women with unplanned caesarean births and primiparous women reported less favourable adaptation than planned caesarean mothers and multiparas. Black women reported lower social adaptation, Hispanic women had more role function concerns and Black and Hispanic women had more learning needs than White women. Post-discharge nursing assessments revealed that actual problems accounted for 40% of identified actual or potential problems or needs. Health teaching was the most commonly recommended postpartum intervention strategy followed by case management, treatment and surveillance interventions. Caesarean-delivered women continue to experience some problems with adapting to childbirth. Recommended intervention strategies reflect the importance of health teaching following hospital discharge. Women who experience caesarean birth require comprehensive assessment during the early postpartum period. Nurses should devise strategies to continue care services for these women following hospital discharge.

Is neonatal head circumference related to caesarean section for failure to progress?

PubMed

de Vries, Bradley; Bryce, Bianca; Zandanova, Tatiana; Ting, Jason; Kelly, Patrick; Phipps, Hala; Hyett, Jon A

2016-12-01

There is global concern about rising caesarean section rates. Identification of risk factors could lead to preventative measures. To describe the association between neonatal head circumference and (i) caesarean section for failure to progress, (ii) intrapartum caesarean section overall. This was a retrospective cohort study of 11 687 singleton live births with cephalic presentation, attempted vaginal birth and at least 37 completed weeks gestation from January 2005 to June 2009. Neonatal head circumference was grouped into quartiles and multiple logistic regressions performed. The rates of caesarean section for failure to progress were 4.1, 6.4, 8.8 and 14.3% in successive head circumference quartiles. Rates of intrapartum caesarean section overall were 8.7, 12.1, 15.8 and 21.5%. The odds ratios for caesarean section for failure to progress were: 1.00, 1.33 (95% CI 1.02- 1.73), 1.54 (1.18-2.02) and 1.93 (1.44-2.57) for successive head circumference quartiles after adjusting for multiple demographic and clinical factors. The adjusted odds ratios for intrapartum caesarean section for any indication were: 1.00, 1.52 (95% CI 1.24-1.87), 1.99 (1.62-2.46) and 2.38 (1.89-3.00), respectively. There is a strong positive relationship between head circumference quartile and both caesarean section for failure to progress and caesarean for any indication. If this finding is confirmed using ultrasound measurements, there is potential for head circumference to be incorporated into predictive models for intrapartum caesarean section with a view to offering interventions to reduce the risk of caesarean section. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Risk of maternal and neonatal complications in subsequent pregnancy after planned caesarean section in a first birth, compared with emergency caesarean section: a nationwide comparative cohort study.

PubMed

Kok, N; Ruiter, L; Hof, M; Ravelli, A; Mol, B W; Pajkrt, E; Kazemier, B

2014-01-01

To compare the difference in risks of neonatal and maternal complications, including uterine rupture, in a second birth following a planned caesarean section versus emergency caesarean section in the first birth. Prospective cohort study. Population-based cohort in the Netherlands. Linked data set of outcomes for term caesarean section in a first birth followed by a consecutive delivery. We conducted a prospective cohort analysis using data from the Dutch Perinatal Registry. We included primiparous women who gave birth to term singleton infants through planned or emergency caesarean from January 2000 through December 2007, and who had a second singleton delivery during the same period (n = 41,109). Odds ratios and adjusted odds ratios were calculated. Maternal and neonatal complications, specifically uterine rupture, in second births associated with planned and emergency caesareans in the first birth. Women with a history of a planned caesarean section in the first birth (n = 11,445) had a 0.24% risk for uterine rupture, compared with a 0.16% risk for women with a history of emergency caesarean section (n = 29,664; aOR 1.4, 95% CI 0.8-2.4). In multivariate logistic regression, women with planned caesareans in a first birth had a significantly increased risk of stillbirth (aOR 1.5, 95% CI 1.0-2.2) and postpartum haemorrhage (aOR 1.1, 95% CI 1.0-1.2) in second births, compared with women with emergency caesareans in the first birth. We found a moderately increased risk of postpartum haemorrhage and a small to moderately increased risk of uterine rupture and stillbirth as a long-term effect of prior planned caesarean delivery on second births. © 2013 Royal College of Obstetricians and Gynaecologists.

Techniques for assisting difficult delivery at caesarean section.

PubMed

Waterfall, Heather; Grivell, Rosalie M; Dodd, Jodie M

2016-01-31

Caesarean section involves making an incision in the woman's abdomen and cutting through the uterine muscle. The baby is then delivered through that incision. Difficult caesarean birth may result in injury for the infant or complications for the mother. Methods to assist with delivery include vacuum or forceps extraction or manual delivery utilising fundal pressure. Medication that relaxes the uterus (tocolytic medication) may facilitate the birth of the baby at caesarean section. Delivery of the impacted head after prolonged obstructed labour can be associated with significant maternal and neonatal complication; to facilitate delivery of the head the surgeon may utilise either reverse breech extraction or head pushing. To compare the use of tocolysis (routine or selective use) with no use of tocolysis or placebo and to compare different extraction methods at the time of caesarean section for outcomes of infant birth trauma, maternal complications (particularly postpartum haemorrhage requiring blood transfusion), and long-term measures of infant and childhood morbidity. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. All published, unpublished, and ongoing randomised controlled trials comparing the use of tocolytic agents (routine or selective) at caesarean section versus no use of tocolytic or placebo at caesarean section to facilitate the birth of the baby. Use of instrument versus manual delivery to facilitate birth of the baby. Reverse breech extraction versus head pushing to facilitate delivery of the deeply impacted fetal head. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Seven randomised controlled trials, involving 582 women undergoing caesarean section were included in this review. The risk of bias of included trials was variable, with some trials not adequately describing allocation or randomisation.Three comparisons were included. 1. Tocolysis versus no tocolysisA single randomised trial involving 97 women was identified and included in the review. Birth trauma was not reported. There were no cases of any maternal side-effect reported in either the nitroglycerin or the placebo group. No other maternal and infant health outcomes were reported. 2. Reverse breech extraction versus head push for the deeply impacted head at full dilation at caesarean section Four randomised trials involving 357 women were identified and included in the review. The primary outcome of birth trauma was reported by three trials and there was no difference between reverse breech extraction and head push for this rare outcome (three studies, 239 women, risk ratio (RR) 1.55, 95% confidence interval (CI) 0.42 to 5.73). Secondary outcomes including endometritis rate (three studies, 285 women, average RR 0.52, 95% CI 0.26 to 1.05, Tau I² = 0.22, I² = 56%), extension of uterine incision (four studies, 357 women, average RR 0.23, 95% CI 0.13 to 0.40), mean blood loss (three studies, 298 women, mean difference (MD) -294.92, 95% CI -493.25 to -96.59; I² = 98%) and neonatal intensive care unit (NICU)/special care nursery (SCN) admission (two studies, 226 babies, average RR 0.53, 95% CI 0.23 to 1.22, Tau I² = 0.27, I² = 74%) were decreased with reverse breech extraction. No differences were observed between groups for many of the other secondary outcomes reported (blood loss > 500 mL; blood transfusion; wound infection; mean hospital stay; average Apgar score).There was significant heterogeneity between the trials for the outcomes mean blood loss, operative time and mean hospital stay, making comparison difficult. However the operation duration was significantly shorter for reverse breech extraction, which may correspond with ease of delivery and therefore, the amount of tissue trauma and therefore, significantly less blood loss. Given the heterogeneity, we cannot define the amount of difference in blood loss, operative time or hospital stay however. 3. Instrument (vacuum or forceps) versus manual extraction at elective caesarean section Two randomised trials involving 128 women were identified and included in the review. Only one trial reported maternal and infant health outcomes as prespecified in this review. This trial reported birth trauma as an outcome but there were no instances of birth trauma in either comparison group. There were no differences found in mean fall in haemoglobin (Hb) between groups (one study, 44 women, MD 0.03, 95% CI -0.53 to 0.59), or in uterine incision extension (one study, 44 women, RR 0.70, 95% CI 0.13 to 3.73). There is currently insufficient information available from randomised trials to support or refute the routine or selective use of tocolytic agents or instrument to facilitate infant birth at the time of difficult caesarean section. There is limited evidence that reverse breech extraction may improve maternal and fetal outcomes, though there was no difference in primary outcome of infant birth trauma. Further randomised controlled trials are needed to answer these questions.

Portrayal of caesarean section in Brazilian women's magazines: 20 year review.

PubMed

Torloni, Maria Regina; Daher, Silvia; Betrán, Ana Pilar; Widmer, Mariana; Montilla, Pilar; Souza, Joao Paulo; Merialdi, Mario

2011-01-25

To assess the quality and comprehensiveness of the information on caesarean section provided in Brazilian women's magazines. Review of articles published during 1988-2008 in top selling women's magazines. Brazil, one of the countries with the highest caesarean section rates in the world. Women's magazines with the largest distribution during the study period, identified through the official national media indexing organisations. Articles with objective scientific information or advice, comments, opinions, or the experience of ordinary women or celebrities on delivery by caesarean section. Sources of information mentioned by the author of the article, the accuracy and completeness of data presented on caesarean section, and alleged reasons why women would prefer to deliver though caesarean section. 118 articles were included. The main cited sources of information were health professionals (78% (n=92) of the articles). 71% (n=84) of the articles reported at least one benefit of caesarean section, and 82% (n=97) reported at least one short term maternal risk of caesarean section. The benefits most often attributed to delivery by caesarean section were reduction of pain and convenience for family or health professionals. The most frequently reported short term maternal risks of caesarean section were increased time to recover and that it is a less natural way of giving birth. Only one third of the articles mentioned any long term maternal risks or perinatal complications associated with caesarean section. Fear of pain was the main reported reason why women would prefer to deliver by caesarean section. Most of the articles published in Brazilian women's magazines do not use optimal sources of information. The portrayal of caesarean section is mostly balanced, not explicitly in favour of one or another route of delivery, but incomplete and may be leading women to underestimate the maternal/perinatal risks associated with this route of delivery.

Portrayal of caesarean section in Brazilian women’s magazines: 20 year review

PubMed Central

Daher, Silvia; Betrán, Ana Pilar; Widmer, Mariana; Montilla, Pilar; Souza, Joao Paulo; Merialdi, Mario

2011-01-01

Objective To assess the quality and comprehensiveness of the information on caesarean section provided in Brazilian women’s magazines. Design Review of articles published during 1988-2008 in top selling women’s magazines. Setting Brazil, one of the countries with the highest caesarean section rates in the world. Data sources Women’s magazines with the largest distribution during the study period, identified through the official national media indexing organisations. Selection criteria Articles with objective scientific information or advice, comments, opinions, or the experience of ordinary women or celebrities on delivery by caesarean section. Main outcome measures Sources of information mentioned by the author of the article, the accuracy and completeness of data presented on caesarean section, and alleged reasons why women would prefer to deliver though caesarean section. Results 118 articles were included. The main cited sources of information were health professionals (78% (n=92) of the articles). 71% (n=84) of the articles reported at least one benefit of caesarean section, and 82% (n=97) reported at least one short term maternal risk of caesarean section. The benefits most often attributed to delivery by caesarean section were reduction of pain and convenience for family or health professionals. The most frequently reported short term maternal risks of caesarean section were increased time to recover and that it is a less natural way of giving birth. Only one third of the articles mentioned any long term maternal risks or perinatal complications associated with caesarean section. Fear of pain was the main reported reason why women would prefer to deliver by caesarean section. Conclusions Most of the articles published in Brazilian women’s magazines do not use optimal sources of information. The portrayal of caesarean section is mostly balanced, not explicitly in favour of one or another route of delivery, but incomplete and may be leading women to underestimate the maternal/perinatal risks associated with this route of delivery. PMID:21266421

Outcomes of elective induction of labour compared with expectant management: population based study

PubMed Central

Ferguson, Evelyn; Duffy, Andrew; Ford, Ian; Chalmers, James; Norman, Jane E

2012-01-01

Objective To determine neonatal outcomes (perinatal mortality and special care unit admission) and maternal outcomes (mode of delivery, delivery complications) of elective induction of labour compared with expectant management. Design Retrospective cohort study using an unselected population database. Setting Consultant and midwife led obstetric units in Scotland 1981-2007. Participants 1 271 549 women with singleton pregnancies of 37 weeks or more gestation. Interventions Outcomes of elective induction of labour (induction of labour with no recognised medical indication) at 37, 38, 39, 40, and 41 weeks’ gestation compared with those of expectant management (continuation of pregnancy to either spontaneous labour, induction of labour or caesarean section at a later gestation). Main outcome measures Extended perinatal mortality, mode of delivery, postpartum haemorrhage, obstetric anal sphincter injury, and admission to a neonatal or special care baby unit. Outcomes were adjusted for age at delivery, parity, year of birth, birth weight, deprivation category, and, where appropriate, mode of delivery. Results At each gestation between 37 and 41 completed weeks, elective induction of labour was associated with a decreased odds of perinatal mortality compared with expectant management (at 40 weeks’ gestation 0.08% (37/44 764) in the induction of labour group versus 0.18% (627/350 643) in the expectant management group; adjusted odds ratio 0.39, 99% confidence interval 0.24 to 0.63), without a reduction in the odds of spontaneous vertex delivery (at 40 weeks’ gestation 79.9% (35 775/44 778) in the induction of labour group versus 73.7% (258 665/350 791) in the expectant management group; adjusted odds ratio 1.26, 1.22 to 1.31). Admission to a neonatal unit was, however, increased in association with elective induction of labour at all gestations before 41 weeks (at 40 weeks’ gestation 8.0% (3605/44 778) in the induction of labour group compared with 7.3% (25 572/350 791) in the expectant management group; adjusted odds ratio 1.14, 1.09 to 1.20). Conclusion Although residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery. PMID:22577197

'What about the mother?' Women's and caregivers' perspectives on caesarean birth in a low-resource setting with rising caesarean section rates.

PubMed

Litorp, Helena; Mgaya, Andrew; Kidanto, Hussein L; Johnsdotter, Sara; Essén, Birgitta

2015-07-01

in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section. qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis. a public university hospital in Dar es Salaam, Tanzania. we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives. both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to 'secure' a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision-makers. Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions. we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Traditional birth attendants issue: a menace in developing countries.

PubMed

Buowari, O Y

2012-01-01

A significant proportion of births in Nigeria still occur at homes of traditional birth attendant. Traditional birth attendants are popular in developing and low resource countries. They lack no formal education or medical training and their clients end up with obstetric complications which lead to severe morbidity and mortality. Two cases of pregnant women that engaged the services of traditional birth attendants (TBA) before presenting at a health facility are presented. They ended up with severe morbidity and mortalities. A 29 year old gravida 3 + para 2+0 woman with two previous caesarean section(C/S) was counselled for elective c/s but declined. She presented at the home of a TBA, had spontaneous vagina deliver, collapsed one hour after delivery and was dead by the time she was brought to the hospital. A 30 year old gravida 10 para 7 + 3 presented in hospital after being in labour at the home of a TBA for three days. On presentation in hospital there was absent foetal heart sound. At surgery there was ruptured uterus and subtotal hysterectomy was done. To improve the situation better access to optimal antenatal care and intrapartum care together with early referral of high-risk patients must be facilitated. Increased community awareness, promotion of appropriate technology for effective health care planning strategy from the grassroots level to tertiary centres is important in the reduction of obstructed labour. One of the most effective means of reducing maternal mortality is the provision of caesarean section for all women who need it.

Inter-hospital variations in caesarean sections. A risk adjusted comparison in the Valencia public hospitals

PubMed Central

Librero, J.; Peiro, S.; Calderon, S. M.

2000-01-01

BACKGROUND—The aim of this study was to describe the variability in caesarean rates in the public hospitals in the Valencia Region, Spain, and to analyse the association between caesarean sections and clinical and extra-clinical factors.
METHODS—Analysis of data contained in the Minimum Basic Data Set (MBDS) compiled for all births in 11 public hospitals in Valencia during 1994-1995 (n=36 819). Bivariate and multivariate analyses were used to evaluate the association between caesarean section rates and specific risk factors. The multivariate model was used to construct predictions about caesarean rates for each hospital, for comparison with rates observed.
RESULTS—Caesarean rates were 17.6% (inter-hospital range: 14.7% to 25.0%), with ample variability between hospitals in the diagnosis of maternal-fetal risk factors (particularly dystocia and fetal distress), and the indication for caesarean in the presence of these factors. Multivariate analysis showed that maternal-fetal risk factors correlated strongly with caesarean section, although extra-clinical factors, such as the day of the week, also correlated positively. After adjusting for the risk factors, the inter-hospital variation in caesarean rates persisted.
CONCLUSIONS—Although certain limitations (imprecision of some diagnoses and information biases in the MBDS) make it impossible to establish unequivocal conclusions, results show a high degree of variability among hospitals when opting for caesarean section. This variability cannot be justified by differences in obstetric risks.


Keywords: hospital utilisation; medical practice variation; caesarean section; administrative databases PMID:10890876

Fetal lacerations at caesarean section.

PubMed

Wiener, J J; Westwood, J

2002-01-01

Fetal lacerations occurred in 1.5% of caesarean sections carried out in our institution. The incidence was independent of type of caesarean section, fetal presentation, cervical dilatation, presence of intact membranes or operator grade. We advocate that this complication should be included in the preoperative counselling of all patients undergoing caesarean sections.

Safety of low dose heparin in elective coronary angioplasty.

PubMed Central

Koch, K. T.; Piek, J. J.; de Winter, R. J.; David, G. K.; Mulder, K.; Tijssen, J. G.; Lie, K. I.

1997-01-01

OBJECTIVES: To evaluate the safety of a low dose of heparin in consecutive stable patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA). DESIGN: Open prospective study in a single centre. PATIENTS: 1375 consecutive patients had elective PTCA (1952 lesions: type A 11%, B1 34%, B2 36%, and C 19%). There were no angiographic exclusion criteria. INTERVENTIONS: A bolus of 5000 IU heparin was used as the standard anticoagulation regimen during PTCA. The sheaths were removed immediately after successful completion of the procedure. Prolongation of heparin treatment was left to the operator's discretion. MAIN OUTCOME MEASURES: Procedural success was defined as < 50% residual stenosis without death from any cause, acute myocardial infarction, urgent coronary bypass surgery, or repeat angioplasty within 48 hours for acute recurrent ischaemia; the need for prolonged heparinisation; and the occurrence of puncture site complications. RESULTS: Procedural success without clinical events was achieved in 90% of patients. Mortality was 0.3%; coronary bypass surgery was performed in 1.7% of the procedures. The rate of myocardial infarction was 3.3%; repeat angioplasty within 48 hours was carried out in 0.7% of patients. A total of 89.1% of the patients were treated according to the protocol. Prolonged treatment with heparin was considered necessary in 123 patients (8.9%). Repeat angioplasty for abrupt closure was performed in two patients shortly after sheath removal and in two during prolonged heparinisation. Puncture site complications occurred in 2.1% of patients (low dose heparin 1.9% and prolonged heparinisation 4.9%). CONCLUSION: Elective PTCA can be safely performed using a low dose of heparin, with a negligible risk for subacute closure. Low dose heparin may reduce the incidence of puncture site complications, shorten hospitalisation, and enable out-patient angioplasty. PMID:9227294

Antibiotic prophylaxis in obstetric procedures.

PubMed

van Schalkwyk, Julie; Van Eyk, Nancy

2010-09-01

To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures. Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures. Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June 2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. SUMMARY STATEMENTS: 1. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following operative vaginal delivery. (II-1) 2. There is insufficient evidence to argue for or against the use of prophylactic antibiotics to reduce infectious morbidity for manual removal of the placenta. (III) 3. There is insufficient evidence to argue for or against the use of prophylactic antibiotics at the time of postpartum dilatation and curettage for retained products of conception. (III) 4. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following elective or emergency cerclage. (II-3) RECOMMENDATIONS: 1. All women undergoing elective or emergency Caesarean section should receive antibiotic prophylaxis. (I-A) 2. The choice of antibiotic for Caesarean section should be a single dose of a first-generation cephalosporin. If the patient has a penicillin allergy, clindamycin or erythromycin can be used. (I-A) 3. The timing of prophylactic antibiotics for Caesarean section should be 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 4. If an open abdominal procedure is lengthy (>3 hours) or estimated blood loss is greater than 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-L) 5. Prophylactic antibiotics may be considered for the reduction of infectious morbidity associated with repair of third and fourth degree perineal injury. (I-B) 6. In patients with morbid obesity (BMI>35), doubling the antibiotic dose may be considered. (III-B) 7. Antibiotics should not be administered solely to prevent endocarditis for patients who undergo an obstetrical procedure of any kind. (III-E).

Comparable risk of childhood asthma after vaginal delivery and emergency caesarean section.

PubMed

Brix, Nis; Stokholm, Lonny; Jonsdottir, Fjola; Kristensen, Kim; Secher, Niels Jørgen

2017-01-01

Caesarean section is thought to be a risk factor for childhood asthma, but this association may be caused by confounding from, for instance, familial factors. To address this problem, we used twin pairs to assess the risk of childhood asthma after emergency caesarean section. The study was a register-based nation-wide matched cohort study using twin pairs to minimise residual confounding. Included were twin pairs in which the first twin was delivered vaginally and the second by emergency caesarean section during the study period from January 1997 through December 2012. In total, 464 twin pairs (928 twins) were included. In 30 pairs, the first twin (vaginal delivery) was diagnosed with asthma, but the second twin (emergency caesarean section) was not. In 20 pairs, the second twin (emergency caesarean section) was diagnosed with asthma, but the first twin (vaginal delivery) was not. In 11 pairs, both twins developed asthma. In the unadjusted analysis, emergency caesarean section did not affect the risk of asthma (odds ratio = 0.67 (95% confidence interval: 0.38-1.17); p = 0.16). After adjusting for birth weight, gender, umbilical cord pH, Apgar score at 5 min. and neonatal respiratory morbidity, the risk of childhood asthma following emergency caesarean section remained unchanged. Emergency caesarean section was not associated with childhood asthma. none. not relevant.

The Free Caesareans Policy in Low-Income Settings: An Interrupted Time Series Analysis in Mali (2003–2012)

PubMed Central

Fournier, Pierre; Dumont, Alexandre; Tourigny, Caroline; Philibert, Aline; Coulibaly, Aliou; Traoré, Mamadou

2014-01-01

Introduction Several countries have instituted fee exemptions for caesareans to reduce maternal and newborn mortality. Objectives To evaluate the effect of fee exemptions for caesareans on population caesarean rates taking into account different levels of accessibility. Methods The observation period was from January 2003 to May 2012 in one Region and covered 11.7 million person-years. Exemption fees for caesareans were adopted on June 26, 2005. Data were obtained from a registration system implemented in 2003 that tracks all obstetrical emergencies and interventions including caesareans. The pre-intervention period was 30 months and the post-intervention period was 83 months. We used an interrupted time series to evaluate the trend before and after the policy adoption and the overall tendency. Findings During the study period, the caesarean rate increased from 0.25 to 1.5% for the entire population. For women living in cities with district hospitals that provided caesareans, the rate increased from 1.7% before the policy was enforced to 5.7% 83 months later. No significant change in trends was observed among women living in villages with a healthcare centre or those in villages with no healthcare facility. For the latter, the caesarean rate increased from 0.4 to 1%. Conclusions After nine years of implementation policy in Mali, the caesarean rate achieved in cities with a district hospital reached the full beneficial effect of this measure, whereas for women living elsewhere this policy did not increase the caesarean rate to a level that could contribute effectively to reduce their risk of maternal death. Only universal access to this essential intervention could reduce the inequities and increase the effectiveness of this policy. PMID:25137072

Mode of anaesthesia for preterm Caesarean delivery: secondary analysis from the Maternal–Fetal Medicine Units Network Caesarean Registry†‡

PubMed Central

Butwick, A. J.; El-Sayed, Y. Y.; Blumenfeld, Y. J.; Osmundson, S. S.; Weiniger, C. F.

2015-01-01

Background Preterm delivery is often performed by Caesarean section. We investigated modes of anaesthesia and risk factors for general anaesthesia among women undergoing preterm Caesarean delivery. Methods Women undergoing Caesarean delivery between 24+0 and 36+6 weeks' gestation were identified from a multicentre US registry. The mode of anaesthesia was classified as neuraxial anaesthesia (spinal, epidural, or combined spinal and epidural) or general anaesthesia. Logistic regression was used to identify patient characteristic, obstetric, and peripartum risk factors associated with general anaesthesia. Results Within the study cohort, 11 539 women had preterm Caesarean delivery; 9510 (82.4%) underwent neuraxial anaesthesia and 2029 (17.6%) general anaesthesia. In our multivariate model, African-American race [adjusted odds ratio (aOR)=1.9; 95% confidence interval (CI)=1.7–2.2], Hispanic ethnicity (aOR=1.5; 95% CI=1.2–1.8), other race (aOR=1.4; 95% CI=1.1–1.9), and haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or eclampsia (aOR=2.8; 95% CI=2.2–3.5) were independently associated with receiving general anaesthesia for preterm Caesarean delivery. Women with an emergency Caesarean delivery indication had the highest odds for general anaesthesia (aOR=3.5; 95% CI=3.1–3.9). For every 1 week decrease in gestational age at delivery, the adjusted odds of general anaesthesia increased by 13%. Conclusions In our study cohort, nearly one in five women received general anaesthesia for preterm Caesarean delivery. Although potential confounding by unmeasured factors cannot be excluded, our findings suggest that early gestational age at delivery, emergent Caesarean delivery indications, hypertensive disease, and non-Caucasian race or ethnicity are associated with general anaesthesia for preterm Caesarean delivery. PMID:25956901

Exploring full cervical dilatation caesarean sections-A retrospective cohort study.

PubMed

Corry, Edward M A; Ramphul, Meenakshi; Rowan, Ann M; Segurado, Ricardo; Mahony, Rhona M; Keane, Declan P

2018-05-01

The rate of caesarean sections at full cervical dilatation with their high risk of morbidity continues to rise mirroring the overall increase in caesarean section rates internationally. The objectives of this study were to determine the rate of full dilatation caesarean section in a tertiary referral unit and evaluate key labour, maternal and fetal factors potentially linked to those deliveries. We also assessed maternal and fetal morbidity at full dilatation sections. Where possible, these were compared with successful operative vaginal deliveries carried out in theatre to determine key differences. Retrospective cohort study. We reviewed the rate of full dilatation caesarean section over a 10-year period. We analysed deliveries (caesarean sections or operative vaginal deliveries) in single cephalic pregnancies ≥34 weeks with contemporaneously collected data from our unit's electronic database for 2015. The rate of full dilatation caesarean section increased by over a third in the ten-year period (56/6947 (0.80%) vs 92/7378 (1.24%), p = 0.01). Of 84 full dilatation caesarean sections who met the inclusion criteria, 63 (75%) were nulliparous and the mean maternal age was 33 (±5) years. Oxytocin was used in the second stage in less than half of second stage caesarean sections (22 out of a recorded 57, 38.6%). There were more fetal head malposition (occipito-posterior, or occipito-transverse) at full dilatation caesarean section compared to successful operative vaginal deliveries (41/46 (89.1%) vs 2/21 (9.5), p < 0.001). The rate of significant postpartum haemorrhage (defined as estimated blood loss ≥1000 ml) was similar in both full dilatation caesarean section and operative vaginal deliveries. There was no difference in the mean birthweight at full dilatation caesarean sections compared to operative vaginal delivery (3.88 kg (2.80-5.33 kg) vs 3.48 kg (1.53-4.40 kg)). There was no difference in neonatal morbidity. Fetal head malposition is associated with a higher risk of full dilatation caesarean section. Interestingly, maternal and fetal morbidity were similar between full dilatation caesarean sections and anticipated difficult operative vaginal deliveries carried out in theatre. The management of labour in terms of the decision to use oxytocin judiciously in hope of correcting inefficient uterine contractions and continuous labour ward training, particularly the diagnosis of malposition and its correction may be beneficial in reducing the rate of full dilation caesarean sections. Copyright © 2018 Elsevier B.V. All rights reserved.

Donations and dependence: Individual contributor strategies in house elections.

PubMed

Heerwig, Jennifer A

2016-11-01

Despite the importance of individual contributors to financing federal candidates, past work has largely neglected this crucial financial constituency in favor of research on corporate and trade political action committees (PACs). By contrast, in this study I offer the first analysis of aggregate contributions from the population of individual contributors to House candidates. Using an original big dataset constructed from over fifteen million Federal Election Commission (FEC) disclosure records, I identify individual contributors (rather than contributions) and trace the variation in their strategies across types of House candidates. I distinguish between frequent donors, who are theorized to have more contact with members of Congress, versus infrequent donors in these elections. I find evidence that the character of aggregate donations from repeat donors is more access-oriented even while controlling for other salient candidate characteristics. Funds from infrequent donors, in contrast, appear more ideologically motivated. By also examining the percentage of funds that House candidates receive from repeat donors, I show that the fundraising coalitions of candidates may reproduce reliance on more access-oriented, repeat donors despite the influx of dollars from infrequent donors. I suggest that my findings provide a persuasive case for re-evaluating the diversity of roles individual contributors play in the campaign finance system, and for systematically analyzing variation in contributor strategies. Copyright © 2016 Elsevier Inc. All rights reserved.

[Exchange amnioinfusion in conceptus with laparoschisis (first experience)].

PubMed

Turkota, L'; Hinst, J; Rusnák, I; Cunderlík, A; Slezák, I; Feitscher, P; Stencl, J; Horn, F; Babala, J; Siman, J

2004-05-01

During amnioinfusion exchange (AE) a certain amount of amniotic fluid is repeatedly extracted and the same amount of physiological solution is consequently instilled into the amniotic fetal cavity. The aim of this procedure is to dilute the amniotic fluid that surrounds the eviscerated organs of fetuses with laparoschisis so as to avoid the genesis of fibrous coating on these organs. Prospective study. Gynekologicko-pôrodnícka klinika SZU, FNsP akad. L. Dérera, Bratislava, Slovakia. We have executed AE in five fetuses with laparoschisis since June 2002. Two patients underwent the treatment 2 times during the 32nd and 36th weeks of gestation. Two other patients were treated once during the 32nd week and one patient once during the 36th week. Under ultrasound control we used a spinal needle to extract 120-180 ml of dense, cloudy amniotic fluid. Consequently, we instilled the same amount of physiological solution warmed up to the temperature of 37 degrees C into the amniotic cavity through antibacterial filter. The fetuses were monitored cardiotocographically and with the help of ultrasound flowmetry in umbilical vessels, before and after the treatment. The AE were successful and without complications in all five cases. All patients delivered via elective caesarean section during the 36th - 37th gestation week. One patient delivered 24 hours after second AE due to the danger of intrauterine fetal hypoxia that was verified cardiotocographically. The other patients delivered 1-4 weeks after AE. The significance of AE lies primarily in the reduction of the occurrence of fibrous coating on eviscerated organs. It enables postnatal primary surgical closure of the defect in the front abdominal wall, an earlier onset of intestine peristalsis, transition from parenteral to peroral nutrition and shorter hospitalization.

Targeted Next Generation Sequencing with ThyroSeq v2.1 for Indeterminate Thyroid Nodules in Clinical Practice.

PubMed

Witt, Robert L

2016-12-01

To determine if patients elect molecular testing over diagnostic surgery or repeat fine needle aspiration for indeterminate thyroid nodules. Can ThyroSeq v2.1 molecular testing reduce diagnostic thyroid surgery and rule out cancer? Retrospective review Setting: Single institution, single-practice surgeon. Fifteen month retrospective review of indeterminate thyroid nodules that went on to ThyroSeq v2.1 testing. 286 patients met American Thyroid Association guideline criteria for surgeon- performed, ultrasound-guided fine needle aspiration for a thyroid nodule with on-site cytopathology. The indeterminate (Bethesda III or IV) fine needle aspiration cytology rate was 9.1 percent. Prevalence of malignancy in indeterminate nodules was 19 percent. 26/26 (100 percent) patients with indeterminate thyroid nodules elected molecular testing. 16 patients had no mutation, 9 had one or more mutations, and I had no result. 16 of 25 (64 percent) patients with no mutation elected not to undergo diagnostic surgery for indeterminate thyroid nodules. Patients demonstrated a strong preference for molecular testing instead of diagnostic thyroid surgery for indeterminate thyroid nodules. All patients in this series, 25/25 (100 percent) with indeterminate thyroid nodules elected molecular testing instead of repeat biopsy or diagnostic thyroid surgery. 16 of 25 (64 percent) patients tested had no mutation. All 16/16 (100 percent) patients with no mutation on ThyroSeq "rule out" testing elected active surveillance rather than surgery or biopsy, reducing diagnostic surgery. The risk of malignancy among mutation negative patients was not definitively established. There are a number of factors currently that may mute the power of "rule in" testing.

Pre-operative assessment and post-operative care in elective shoulder surgery.

PubMed

Akhtar, Ahsan; Macfarlane, Robert J; Waseem, Mohammad

2013-01-01

Pre-operative assessment is required prior to the majority of elective surgical procedures, primarily to ensure that the patient is fit to undergo surgery, whilst identifying issues that may need to be dealt with by the surgical or anaesthetic teams. The post-operative management of elective surgical patients begins during the peri-operative period and involves several health professionals. Appropriate monitoring and repeated clinical assessments are required in order for the signs of surgical complications to be recognised swiftly and adequately. This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated, along with discussing thromboprophylaxis and post-operative analgesia following shoulder surgery.

International migration as a determinant of emergency caesarean.

PubMed

Merry, Lisa; Semenic, Sonia; Gyorkos, Theresa W; Fraser, William; Small, Rhonda; Gagnon, Anita J

2016-10-01

High caesarean rates are of concern given associated risks. International migrant women (women born abroad) represent a substantial proportion of women giving birth in high-income countries (HICs) and face social conditions that may exacerbate childbearing health risks. Among migrant women, emergency rather than planned caesareans, tend to be more prevalent. This method of delivery can be stressful, physically harmful and result in an overall negative birth experience. Research establishing evidence of risk factors for emergency caesareans in migrants is insufficient. (1) Describe potential pathways (with a focus on modifiable factors) by which migration, using internationally recommended migration indicators: country of birth, length of time in country, fluency in receiving-country language, migration classification and ethnicity, may lead to emergency caesarean; and (2) propose a framework to guide future research for understanding "potentially preventable" emergency caesareans in migrant women living in HICs. "Potentially preventable" emergency caesareans in migrant women are likely due to several modifiable, interrelated factors pre-pregnancy, during pregnancy and during labour. Migration itself is a determinant and also shapes other determinants. Complications and ineffective labour progress and/or foetal distress and ultimately the decision to perform an emergency caesarean may be the result of poor health (i.e., physiological effects), lack of support and disempowerment (i.e., psychological effects) and sub-optimal care. Understanding the direct and indirect effects of migration on emergency caesarean is crucial so that targeted strategies can be developed and implemented for reducing unnecessary caesareans in this vulnerable population. Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Spondylocostal dysostosis associated with right-sided polythelia, right-sided rib deformity and meningocoele: Case report with review of literature.

PubMed

Rai, Narendra; Thakur, Neha; Khan, Naheed Zin; Dwivedi, Akhilesh Dutt

2015-01-01

Spondylocostal dysostosis (SCD) is a rare anomaly of axial skeleton due to flawed embryological development. A newborn baby boy with right-sided polythelia, meningocoele, fan-like configuration of third and fourth rib, fused fifth and sixth rib and third thoracic hemivertebra was delivered to a second gravid mother by elective caesarean section. Baby was active, cried immediately after birth, had normal muscle tone and reflexes. He passed urine and meconium within 24 h of birth. Based on clinical examination and radiological picture, a diagnosis of SCD with meningocele with right-sided polythelia was made. Our case is the first SCD with polythelia and meningocele in newborn. SCD with right-sided polythelia and rib deformity with neural tube defect (NTD) may be due to a genetic defect with the culprit genes missing. Further genetic and embryological studies might find a link between right-sided rib defects, polythelia and NTD.

Difficulties in prenatal diagnosis of tumour in the fetal sacrococcygeal area

PubMed Central

Krekora, Michał; Blitek, Marek; Kęsiak, Marcin; Piaseczna-Piotrowska, Anna; Łukaszek, Stanisław; Krasomski, Grzegorz; Słodki, Maciej; Szaflik, Krzysztof; Respondek-Liberska, Maria

2016-01-01

Prenatal ultrasound at the 20th week of gestation revealed a 3-cm tumour in the sacrococcygeal area. Initially, a sacrococcygeal teratoma was suspected on the basis of fetal ultrasonography, which revealed normal heart anatomy and an increasing tumour mass. The diagnosis was then changed to fetus in fetu or teratoma. Prenatal magnetic resonance imaging at the 34th week of pregnancy confirmed the ultrasound diagnosis. No other anomalies were found. Elective caesarean section was performed at term. The care team included a paediatric surgeon, obstetricians, neonatologists, midwives, and an anesthesiologist. A female newborn was delivered in good condition. The tumour was resected in the operating room and mature teratoma was established by histopathological evaluation. Surprisingly, agenesis of the right forearm was revealed which had not been detected prenatally, despite many examinations (both in our hospital and earlier at a primary care obstetrician office). PMID:27482281

Mode of Delivery among HIV-Infected Pregnant Women in Philadelphia, 2005-2013.

PubMed

Thompson, Dana R; Momplaisir, Florence M; Adams, Joëlla W; Yehia, Baligh R; Anderson, Emily A; Alleyne, Gregg; Brady, Kathleen A

2015-01-01

Current guidelines call for HIV-infected women to deliver via scheduled Caesarean when the maternal HIV viral load (VL) is >1,000 copies/ml. We describe the mode of delivery among HIV-infected women and evaluate adherence to relevant recommendations. We performed a population-based surveillance analysis of HIV-infected pregnant women in Philadelphia from 2005 to 2013, comparing mode of delivery (vaginal, scheduled Caesarean, or emergent Caesarean) by VL during pregnancy, closest to the time of delivery (≤1,000 copies/ml versus an unknown VL or VL >1,000 copies/ml) and associated factors in multivariable analysis. Our cohort included 824 deliveries from 648 HIV-infected women, of whom 69.4% had a VL ≤1,000 copies/ml and 30.6% lacked a VL or had a VL >1,000 copies/ml during pregnancy, closest to the time of delivery. Mode of delivery varied by VL: 56.6% of births were vaginal, 30.1% scheduled Caesarean, and 13.3% emergent Caesarean when the VL was ≤1,000 copies/ml; when the VL was unknown or >1,000 copies/ml, 32.9% of births were vaginal, 49.9% scheduled Caesarean and 17.5% emergent Caesarean. In multivariable analyses, Hispanic women (adjusted odds ratio (AOR) 0.17, 95% Confidence Interval (CI) 0.04-0.76) and non-Hispanic black women (AOR 0.27, 95% CI 0.10-0.77) were less to likely to deliver via scheduled Caesarean compared to non-Hispanic white women. Women who delivered prior to 38 weeks' gestation (AOR 0.37, 95% CI 0.18-0.76) were also less likely to deliver via scheduled Caesarean compared to women who delivered after 38 weeks' gestation. An interaction term for race and gestational age at delivery was significant in multivariable analysis. Non-Hispanic black (AOR 0.06, 95% CI 0.01-0.36) and Hispanic women (AOR 0.03, 95% CI 0.00-0.59) were more likely to deliver prematurely and less likely to deliver via scheduled C-section compared to non-Hispanic white women. Having a previous Caesarean (AOR 27.77, 95% CI 8.94-86.18) increased the odds of scheduled Caesarean delivery. Only half of deliveries for women with an unknown VL or VL >1,000 copies/ml occurred via scheduled Caesarean. Delivery prior to 38 weeks, particularly among minority women, resulted in a missed opportunity to receive a scheduled Caesarean. However, even when delivering at or after 38 weeks' gestation, a significant proportion of women did not get a scheduled Caesarean when indicated, suggesting a need for focused public health interventions to increase the proportion of women achieving viral suppression during pregnancy and delivering via scheduled Caesarean when indicated.

Going public: do risk and choice explain differences in caesarean birth rates between public and private places of birth in Australia?

PubMed

Miller, Yvette D; Prosser, Samantha J; Thompson, Rachel

2012-10-01

women who birth in private facilities in Australia are more likely to have a caesarean birth than women who birth in public facilities and these differences remain after accounting for sector differences in the demographic and health risk profiles of women. However, the extent to which women's preferences and/or freedom to choose their mode of birth further account for differences in the likelihood of caesarean birth between the sectors remains untested. women who birthed in Queensland, Australia during a two-week period in 2009 were mailed a self-report survey approximately 3 months after birth. Seven hundred and fifty-seven women provided cross-sectional retrospective data on where they birthed (public or private facility), mode of birth (vaginal or caesarean) and risk factors, along with their preferences and freedom to choose their mode of birth. A hierarchical logistic regression was conducted to determine the extent to which maternal risk and freedom to choose one's mode of birth explain sector differences in the likelihood of having a caesarean birth. while there was no sector difference in women's preference for mode of birth, women who birthed in private facilities had higher odds of feeling able to choose either a vaginal or caesarean birth, and feeling able to choose only a caesarean birth. Women had higher odds of having caesarean birth if they birthed in private facilities, even after accounting for significant risk factors such as age, body mass index, previous caesarean and use of assisted reproductive technology. However, there was no association between place of birth and odds of having a caesarean birth after also accounting for freedom to choose one's mode of birth. these findings call into question suggestions that the higher caesarean birth rate in the private sector in Australia is attributable to increased levels of obstetric risk among women birthing in the private sector or maternal preferences alone. Instead, the determinants of sector differences in the likelihood of caesarean births are complex and are linked to differences in the perceived choices for mode of birth between women birthing in the private and public systems. Copyright © 2012 Elsevier Ltd. All rights reserved.

Maternal obesity, caesarean delivery and caesarean delivery on maternal request: a cohort analysis from China.

PubMed

Zhou, Yubo; Blustein, Jan; Li, Hongtian; Ye, Rongwei; Zhu, Liping; Liu, Jianmeng

2015-05-01

To quantify the association between maternal obesity and caesarean delivery, particularly caesarean delivery on maternal request (CDMR), a fast-growing component of caesarean delivery in many nations. We followed 1,019,576 nulliparous women registered in the Perinatal Healthcare Surveillance System during 1993-2010. Maternal body mass index (BMI, kg/m(2) ), before pregnancy or during early pregnancy, was classified as underweight (<18.5), normal (18.5 to <23; reference), overweight (23 to <27.5), or obese (≥27.5), consistent with World Health Organization guidelines for Asian people. The association between maternal obesity and overall caesarean and its subtypes was modelled using log-binomial regression. During the 18-year period, 404,971 (39.7%) caesareans and 93,927 (9.2%) CDMRs were identified. Maternal obesity was positively associated with overall caesarean and CDMR. Adjusted risk ratios for overall caesarean in the four ascending BMI categories were 0.96 [95% confidence interval (CI) 0.94, 0.97], 1.00 (Reference), 1.16 [95% CI 1.14, 1.18], 1.39 [95% CI 1.43, 1.54], and for CDMR were 0.95 [95% CI 0.94, 0.96], 1.00 (Reference), 1.20 [95% CI 1.18, 1.22], 1.48 [95% CI 1.433, 1.54]. Positive associations were consistently found in women residing in southern and northern provinces and in subgroups stratified by year of delivery, urban or rural residence, maternal age, education, level of delivering hospital, and birthweight. In a large Chinese cohort study, maternal obesity was associated with an increased risk of caesarean delivery and its subtypes, including CDMR. Given the rising global prevalence of obesity, and in view of the growth of CDMR, it seems likely that caesarean births will increase, unless there are changes in obstetrical practice. © 2015 John Wiley & Sons Ltd.

Mode of anaesthesia for preterm Caesarean delivery: secondary analysis from the Maternal-Fetal Medicine Units Network Caesarean Registry.

PubMed

Butwick, A J; El-Sayed, Y Y; Blumenfeld, Y J; Osmundson, S S; Weiniger, C F

2015-08-01

Preterm delivery is often performed by Caesarean section. We investigated modes of anaesthesia and risk factors for general anaesthesia among women undergoing preterm Caesarean delivery. Women undergoing Caesarean delivery between 24(+0) and 36(+6) weeks' gestation were identified from a multicentre US registry. The mode of anaesthesia was classified as neuraxial anaesthesia (spinal, epidural, or combined spinal and epidural) or general anaesthesia. Logistic regression was used to identify patient characteristic, obstetric, and peripartum risk factors associated with general anaesthesia. Within the study cohort, 11 539 women had preterm Caesarean delivery; 9510 (82.4%) underwent neuraxial anaesthesia and 2029 (17.6%) general anaesthesia. In our multivariate model, African-American race [adjusted odds ratio (aOR)=1.9; 95% confidence interval (CI)=1.7-2.2], Hispanic ethnicity (aOR=1.5; 95% CI=1.2-1.8), other race (aOR=1.4; 95% CI=1.1-1.9), and haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or eclampsia (aOR=2.8; 95% CI=2.2-3.5) were independently associated with receiving general anaesthesia for preterm Caesarean delivery. Women with an emergency Caesarean delivery indication had the highest odds for general anaesthesia (aOR=3.5; 95% CI=3.1-3.9). For every 1 week decrease in gestational age at delivery, the adjusted odds of general anaesthesia increased by 13%. In our study cohort, nearly one in five women received general anaesthesia for preterm Caesarean delivery. Although potential confounding by unmeasured factors cannot be excluded, our findings suggest that early gestational age at delivery, emergent Caesarean delivery indications, hypertensive disease, and non-Caucasian race or ethnicity are associated with general anaesthesia for preterm Caesarean delivery. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Inter-institutional Variation in Use of Caesarean Delivery for Labour Dystocia.

PubMed

Riddell, Corinne A; Hutcheon, Jennifer A; Strumpf, Erin C; Abenhaim, Haim A; Kaufman, Jay S

2017-11-01

To establish the degree of variation across hospitals in the use of Caesarean delivery for the indication of labour dystocia before and after accounting for maternal, fetal, and hospital characteristics. This study was a retrospective, population-based cohort study of nulliparous women delivering term singletons in cephalic position following labour. Delivery visits were extracted from three provincial perinatal registries in the Canadian provinces of Ontario, Alberta, and British Columbia, from 2008-2012. Crude hospital-specific rates of Caesarean delivery for labour dystocia were reported, and these rates were then stabilized to account for hospitals with low delivery volumes. Rates were then adjusted for maternal, fetal, and hospital characteristics using hierarchical logistic regression. Among 403 205 women delivering at 170 hospitals, the overall Caesarean delivery rate was 21.0%, and the rate of Caesarean delivery for labour dystocia was 12.7%, indicating that 60% of all Caesarean deliveries were performed in part for this indication. The middle 95% of hospitals had Caesarean delivery rates for labour dystocia ranging from 4.5% to 24.7%. Differences in maternal case mix and hospital characteristics explained only a small proportion of this variation (95% central range 6.3%-21.7%). Considerable inter-hospital variation in rates of Caesarean delivery for labour dystocia remained after accounting for differences in maternal and hospital factors. Reporting systems that monitor variation in inter-institutional rates should incorporate stabilization and adjustment for case-mix differences and consider indication-specific rates of Caesarean delivery to more fairly compare hospital performance and better target interventions to reduce Caesarean delivery for specific indications. Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.

Incidence of post-operative adhesions following Misgav Ladach caesarean section--a comparative study.

PubMed

Fatusić, Zlatan; Hudić, Igor

2009-02-01

To evaluate the incidence of peritoneal adhesions as a post-operative complication after caesarean section following the Misgav Ladach method and compare it with peritoneal adhesions following traditional caesarean section methods (Pfannenstiel-Dörffler, low midline laparotomy-Dörffler). The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina (data from 1 January 2001 to 31 December 2005). We analysed previous caesarean section dependent on caesarean section method (200 by Misgav Ladach method, 100 by Pfannenstiel-Dörffler method and 100 caesarean section by low midline laparotomy-Dörffler). Adhesion scores were assigned using a previously validated scoring system. We found statistically significant difference (p < 0.05) in incidence of peritoneal adhesions in second and third caesarean section between Misgav Ladach method and the Pfannestiel-Dörffler and low midline laparotomy-Dörffler method. Difference in incidence of peritoneal adhesions between low midline laparotomy-Dörffler and Pfannenstiel-Dörffler method was not statistically different (p > 0.05). The mean pelvic adhesion score was statistically lower in Misgav Ladach group (0.43 +/- 0.79) than the mean score in the Pfannestiel-Dörffler (0.71 +/- 1.27) and low midline laparotomy-Dörffler groups (0.99 +/- 1.49) (p < 0.05). Our study showed that Misgav Ladach method of caesarean section makes possible lower incidence of peritoneal adhesions as post-operative complication of previous caesarean section.

[An analysis of caesarean sections in Uruguay by type of hospital].

PubMed

Aguirre, Rafael; Antón, José-Ignacio; Triunfo, Patricia

2018-04-20

To analyse on a comparative basis the incidence of caesarean sections among the different health care systems in Uruguay and with respect to the World Health Organization's (WHO) standards, taking into account the medical-obstetric characteristics of the births, particularly, the Robson classification. We examine 190,847 births registered by the Perinatal Information System in Uruguay between 2009 and 2014 by type of health care system. Using logit models, we analyse the probability of caesarean section taking into account the Robson classification, other risk factors and the mothers' characteristics. We compared the caesarean rates predicted by the different subsystems for a common population. Furthermore, we contrast the caesarean rates observed in each subsystem with the rates that resulted if the Uruguayan hospitals followed the guidelines of the sample of WHO reference hospitals. Private health systems in Uruguay exhibit a much higher incidence of caesarean sections than public ones, even after considering the medical-obstetric characteristics of the births. Caesarean rates are more than 75% higher than those observed if the WHO standards are applied. Uruguay has a very high incidence of caesarean sections with respect to WHO standards, particularly, in the private sector. This fact is unrelated to the clinical characteristics of the births. Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

[Pregnancy in HIV-positive women: 6 years of activity of the Regional Reference Center].

PubMed

Bernardon, M; De Seta, F; Maso, G P; Cescutti, V; Olivuzzi, M; Redaelli, I; Alberico, S

2005-08-01

With this study, we wanted to evaluate HIV-positive pregnant mothers followed at the HIV Reference Center of Friuli Venezia Giulia and to describe obstetric treatment aimed at identifying vertical transmission factors and at undertaking a correct diagnostic-therapeutic approach to this patient group. The data include a large case series from the European Collaborative Study on HIV in Pregnancy, in which our facility is a collaborating center. The protocol includes the administration of personalized antiretroviral therapy to seropositive patients at the first visit. An elective caesarean section is performed at 38 weeks gestation. Antiretroviral therapy is continued in the neonate. Breastfeeding is prohibited. From 1998 to 2002, 28 pregnant mothers with HIV infection were followed. Most patients came from out of region and had acquired the infection through heterosexual intercourse with a serodiscordant partner. In 1 in 3 patients, a diagnosis of seropositivity was made during pregnancy. One case of vertical transmission was observed. When appropriate prevention measures are instituted, the percentage of vertical transmission of infection can be reduced to less than 1% in Europe today. An important part of this effort is early screening for HIV infection in pregnancy. Other fundamental measures are the institution of antiretroviral therapy starting from the first weeks of pregnancy, monitoring of pregnancy at a tertiary reference center, intravenous administration of therapies before caesarean section, possibly not during labor and with the membrane intact. Equally important factors are neonatal therapy, adequate pediatric monitoring after the infant is born and discontinuation of breastfeeding.

Proportion of litters of purebred dogs born by caesarean section.

PubMed

Evans, Katy M; Adams, Vicki J

2010-02-01

To describe the frequency of caesarean sections in a large sample of pedigree dogs in the UK. Data on the numbers of litters born in the previous 10 years were available from a cross-sectional study of dogs belonging to breed club members (2004 Kennel Club/BSAVA Scientific Committee Purebred Dog Health Survey). In this survey 151 breeds were represented with data for households that had reported on at least 10 litters (range 10-14,15): this represented 13,141 bitches which had whelped 22,005 litters. The frequency of caesarean sections was estimated as the percentage of litters that were reported to be born by caesarean section (caesarean rates) and are reported by breed. The dogs were categorised into brachycephalic, mesocephalic and dolicocephalic breeds. The 10 breeds with the highest caesarean rates were the Boston terrier, bulldog, French bulldog, mastiff, Scottish terrier, miniature bull terrier, German wirehaired pointer, Clumber spaniel, Pekingese and Dandie Dinmont terrier. In the Boston terrier, bulldog and French bulldog, the rate was > 80%. These data provide evidence for the need to monitor caesarean rates in certain breeds of dog.

Elections Have Consequences for Student Mental Health: An Accidental Daily Diary Study.

PubMed

Roche, Michael J; Jacobson, Nicholas C

2018-01-01

Polling suggested that the 2016 United States presidential election affected citizens' mood and stress levels. Yet, polling often fails to employ repeated measurement designs that can capture pre- and post-levels of change within the same person. In this study, undergraduate students ( N = 85) completed a 14-day daily diary where mood, stress, and mental health outcomes were assessed before and after the election. Multilevel modeling revealed an immediate upsurge in anxiety, stress, and poor sleep quality the day after the election, followed by a recovery period indicating these effects were short-lived. Other reactions (anger, fear, marginalization, and experiencing discrimination) evidenced a significant upsurge without a significant recovery. We consider how daily diary research designs like this one could be integrated into college settings to inform counseling center resource allocation, and we also comment on the promise of the daily diary methodology for political research.

Mode of Delivery among HIV-Infected Pregnant Women in Philadelphia, 2005-2013

PubMed Central

Adams, Joëlla W.; Anderson, Emily A.

2015-01-01

Objective Current guidelines call for HIV-infected women to deliver via scheduled Caesarean when the maternal HIV viral load (VL) is >1,000 copies/ml. We describe the mode of delivery among HIV-infected women and evaluate adherence to relevant recommendations. Study Design We performed a population-based surveillance analysis of HIV-infected pregnant women in Philadelphia from 2005 to 2013, comparing mode of delivery (vaginal, scheduled Caesarean, or emergent Caesarean) by VL during pregnancy, closest to the time of delivery (≤1,000 copies/ml versus an unknown VL or VL >1,000 copies/ml) and associated factors in multivariable analysis. Results Our cohort included 824 deliveries from 648 HIV-infected women, of whom 69.4% had a VL ≤1,000 copies/ml and 30.6% lacked a VL or had a VL >1,000 copies/ml during pregnancy, closest to the time of delivery. Mode of delivery varied by VL: 56.6% of births were vaginal, 30.1% scheduled Caesarean, and 13.3% emergent Caesarean when the VL was ≤1,000 copies/ml; when the VL was unknown or >1,000 copies/ml, 32.9% of births were vaginal, 49.9% scheduled Caesarean and 17.5% emergent Caesarean. In multivariable analyses, Hispanic women (adjusted odds ratio (AOR) 0.17, 95% Confidence Interval (CI) 0.04–0.76) and non-Hispanic black women (AOR 0.27, 95% CI 0.10–0.77) were less to likely to deliver via scheduled Caesarean compared to non-Hispanic white women. Women who delivered prior to 38 weeks’ gestation (AOR 0.37, 95% CI 0.18–0.76) were also less likely to deliver via scheduled Caesarean compared to women who delivered after 38 weeks’ gestation. An interaction term for race and gestational age at delivery was significant in multivariable analysis. Non-Hispanic black (AOR 0.06, 95% CI 0.01–0.36) and Hispanic women (AOR 0.03, 95% CI 0.00–0.59) were more likely to deliver prematurely and less likely to deliver via scheduled C-section compared to non-Hispanic white women. Having a previous Caesarean (AOR 27.77, 95% CI 8.94–86.18) increased the odds of scheduled Caesarean delivery. Conclusions Only half of deliveries for women with an unknown VL or VL >1,000 copies/ml occurred via scheduled Caesarean. Delivery prior to 38 weeks, particularly among minority women, resulted in a missed opportunity to receive a scheduled Caesarean. However, even when delivering at or after 38 weeks’ gestation, a significant proportion of women did not get a scheduled Caesarean when indicated, suggesting a need for focused public health interventions to increase the proportion of women achieving viral suppression during pregnancy and delivering via scheduled Caesarean when indicated. PMID:26657902

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study.

PubMed

Bagust, A; Grayson, A D; Palmer, N D; Perry, R A; Walley, T

2006-01-01

To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. Cost-utility analysis of audit based patient subgroups by means of a simple economic model. Tertiary care. 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be 112 pound sterling (212 USD, 162 pound sterling) (sirolimus stents) or 89 pound sterling (167 USD, 130 pound sterling) (paclitaxel stents). At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

[Unusual leukoencephalopathy of post-partum].

PubMed

Hsaini, Y; Karouache, A; Bourazza, A

2011-08-01

Neurologic complications of post-partum are serious and usually secondary to eclampsia or stroke. We here report a 26-year-old female who presented with severe headaches, blurred vision, and repeated generalized seizures secondary to posterior reversible encephalopathy that occurred after a caesarean section for fetal death in utero. Outcome was favourable. Although uncommon, this neurologic complication of the post-partum should be discussed in the presence of any sign of encephalopathy occurring in the context of acute hypertension. Copyright © 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.

Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes

PubMed Central

Bamigboye, Anthony A; Hofmeyr, G Justus

2014-01-01

Background Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed. Objectives The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intraoperative and immediate- and long-term postoperative outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (1 November 2013). Selection criteria Randomised controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked it for accuracy. Main results A total of 29 trials were included in this review and 21 trials (17,276 women) provided data that could be included in an analysis. The quality of the trials was variable. 1. Non-closure of visceral and parietal peritoneum versus closure of both parietal layers Sixteen trials involving 15,480 women, were included and analysed, when both parietal peritoneum was left unclosed versus when both peritoneal surfaces were closed. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found between groups (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.76 to 1.29). There was significant reduction in the operative time (mean difference (MD) -5.81 minutes, 95% CI -7.68 to -3.93). The duration of hospital stay in a total of 13 trials involving 14,906 women, was also reduced (MD -0.26, 95% CI -0.47 to -0.05) days. In a trial involving 112 women, reduced chronic pelvic pain was found in the peritoneal non-closure group. 2. Non-closure of visceral peritoneum only versus closure of both peritoneal surfaces Three trials involving 889 women were analysed. There was an increase in adhesion formation (two trials involving 157 women, RR 2.49, 95% CI 1.49 to 4.16) which was limited to one trial with high risk of bias.There was reduction in operative time, postoperative days in hospital and wound infection. There was no significant reduction in postoperative pyrexia. 3. Non-closure of parietal peritoneum only versus closure of both peritoneal layers The two identified trials involved 573 women. Neither study reported on postoperative adhesion formation. There was reduction in operative time and postoperative pain with no difference in the incidence of postoperative pyrexia, endometritis, postoperative duration of hospital stay and wound infection. In only one study, postoperative day one wound pain assessed by the numerical rating scale, (MD -1.60, 95% CI -1.97 to -1.23) and chronic abdominal pain d by the visual analogue score (MD -1.10, 95% CI -1.39 to -0.81) was reduced in the non-closure group. 4. Non-closure versus closure of visceral peritoneum when parietal peritoneum is closed There was reduction in all the major urinary symptoms of frequency, urgency and stress incontinence when the visceral peritoneum is left unsutured. Authors’ conclusions There was a reduction in operative time across all the subgroups. There was also a reduction in the period of hospitalisation postcaesarean section except in the subgroup where parietal peritoneum only was not sutured where there was no difference in the period of hospitalisation. The evidence on adhesion formation was limited and inconsistent. There is currently insufficient evidence of benefit to justify the additional time and use of suture material necessary for peritoneal closure. More robust evidence on long-term pain, adhesion formation and infertility is needed. Plain Language Summary Closure versus non-closure of the peritoneum at caesarean section: long- and short-term outcome Not stitching the peritoneum after caesarean section takes less theatre time and therefore has less cost, but information on possible long-term disadvantages are limited. There are many ways of performing a caesarean section and the techniques used depend on a number factors including the clinical situation and the preference of the operator. The peritoneum is a thin membrane of cells supported by a thin layer of connective tissue, and during caesarean section these peritoneal surfaces have to be cut through in order to reach the uterus and for the baby to be born. Following a caesarean section, it has been standard practice to close the peritoneum by stitching (suturing) the two layers of tissue that line the abdomen and cover the internal organs, to restore the anatomy. It has however been suggested that peritoneal adhesions may be more likely rather than less likely when the peritoneum is sutured, possibly as a result of a tissue reaction to the suture material. This review of trials sought to address whether to routinely suture these thin layers of tissue or not after delivering a baby by caesarean section. Twenty-nine randomised controlled trials were identified, with differences in their methodological quality; 21 trials involving over 17,000 women contributing data to the review. Several minutes were saved when the peritoneum was not stitched, and with a shorter period of hospital stay in most of the women. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found when leaving both layers of peritoneumunclosed was compared with closure of both. Longer-term outcomes were not adequately assessed, particularly adhesion formation, subfertility and ease of other surgeries in later life. Although the methodological quality of trials was variable, the results were in general consistent between the trials of better and poorer quality. Further studies are needed to further assess all these outcomes. PMID:25110856

Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods

PubMed Central

Béhague, Dominique P; Victora, Cesar G; Barros, Fernando C

2002-01-01

Objectives To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment. Design Population based birth cohort study, using ethnographic and epidemiological methods. Setting Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed. Participants 5304 women who gave birth in any of the city's hospitals in 1993. Main outcome measures Birth by caesarean section or vaginal delivery. Results In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education. Conclusions Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed. What is already known on this topicWomen's preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveriesWhat this study addsIn Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient PMID:11964338

'My pain was stronger than my happiness': experiences of caesarean births from Lebanon.

PubMed

Kabakian-Khasholian, Tamar

2013-11-01

the rising trends in caesarean section have been partially attributed to women's requests. Many studies in developed and very few in developing countries have attempted to understand this phenomenon. This qualitative study explores experiences of women having caesarean section on demand in a middle-income country with a private health-care system. an inductive qualitative design, using face-to-face semi-structured interviews. women were identified and recruited through a perinatal database and selected obstetricians' clinics in the Greater Beirut area in Lebanon. a purposive sample of women who had a caesarean childbirth within the four months preceding the interview, were visited for an interview at home using a semi-structured interview guide. Thematic content analysis was conducted on a sub-sample of 22 women who requested a caesarean birth. lack of information about caesarean sections fosters women's fear from labour pain and acts as the main impetus for women to consider caesareans as the pain free alternative. Findings reveal health-care providers' role in reinforcing beliefs about caesarean sections being the way for pain free deliveries by overestimating the safety of the procedure and disregarding postpartum health issues. caesarean birth is presented to women as a safe option for 'pain free' childbirth. This needs to be considered within the cultural context of understanding safety and pain as well as the dynamics of power in maternity care. Health-care professionals need to explore these dimensions and promote women's informed choice as well as encouraging the normality of birth. Copyright © 2012 Elsevier Ltd. All rights reserved.

The incidence of caesarean sections in the university clinical center of kosovo.

PubMed

Elshani, Brikene; Daci, Armond; Gashi, Sanije; Lulaj, Shefqet

2012-12-01

As in most countries of the world also at Kosovo the rate of Cesarean section from year to year is increasing. The main purpose of this paper was to present the incidence of births completed by Caesarean section at the Clinic of Gynecology and Obstetrics of University Clinical Center of Kosovo in Prishtinë. This study is retrospective, namely its made by collecting epidemiological data from patients' histories that completed birth by Caesarean section for the period 2000-2006 in this clinic. During this period, 14 maternal deaths were recorded during or after Caesarean section. Besides this, 14 lethal outcomes, the object of our study was 84 mothers which completed birth by Caesarean section and which are best used as a control group. The average age of mothers who died during or after Caesarean section was 32.1 years (SD ± 4.9). Youngest in this group was 24 years old and oldest 42 years. While the average age of mothers from the control group was 30.6 years (SD ± 5.9). Youngest was 19 and oldest 43 years, without significant difference. Most mothers included in the survey had more than one indication for Caesarean section. The most frequent indication was PIH syndrome with 33.7% and previous Caesarean section in 32.7%. Then with the participation of 12.2% were abruption of the placenta and disproportio feto pelvinea, 11.2% pelvinea and placenta praevia presentation, 10.2% parturiens while other indications were much rarer with less than 10% participation. Based on this we can conclude that the risk of the Caesarean section is high.

Maternal accounts of their breast-feeding intent and early challenges after caesarean childbirth.

PubMed

Tully, Kristin P; Ball, Helen L

2014-06-01

breast-feeding outcomes are often worse after caesarean section compared to vaginal childbirth. this study characterises mothers' breast-feeding intentions and their infant feeding experiences after caesarean childbirth. data are from 115 mothers on a postnatal unit in Northeast England during February 2006-March 2009. Interviews were conducted an average of 1.5 days (range 1-6 days) after the women underwent unscheduled or scheduled caesarean. thematic analysis of the data suggested was mostly considered the 'right thing to do,' preferable, natural, and 'supposedly healthier,' but tiring and painful. Advantages of supplementation involved more satiated infants, feeding ease, and longer sleep bouts. The need for 'thinking about yourself' was part of caesarean recovery. Infrequent feeding was concerning but also enabled maternal rest. Other breast-feeding obstacles were maternal mobility limitations, positioning difficulties, and frustration at the need for assistance. Participants were confused about nocturnal infant wakings, leading many to determine that they had insufficient milk. Mothers were surprised that sub-clinically poor infant condition was common following caesarean section. Some breast-feeding difficulty stemmed from 'mucus' expulsion that had to occur before the infants could be 'interested' in feeding. Women who cited motivations for breast feeding that included benefit to themselves were more likely to exclusively breast feed on the postnatal unit after their caesareans than those who reported infant-only motivations. for the majority of mothers, breast feeding after a caesarean is affected by interrelated and compounding difficulties. Provision of more relational breast-feeding information may enable families to better anticipate early feeding experiences after caesarean section childbirth. © 2013 Elsevier Ltd. All rights reserved.

[Caesarean sections in Mexico: tendencies, levels and associated factors].

PubMed

Puentes-Rosas, Esteban; Gómez-Dantés, Octavio; Garrido-Latorre, Francisco

2004-01-01

To describe the rate of caesarean sections in Mexico in the last 10 years and evaluate its relationship with several socioeconomic variables, type of health care services, and specialists' availability. The Ministry of Health's register of births was used as source of information. The dependent variable was the type of delivery (vaginal or caesarean). The independent variables were: gross domestic product, human development index, illiteracy percentage among women, social exclusion index and, gynecology and obstetrics specialists supply. Correlations between variables were evaluated using Pearson's parametric test and Spearman range test. A lineal multiple regression was used to model the national caesarean data of 1999. National caesarean percentage increased in the last 10 years at an annual rate of 1%. It was considerably higher in social security institutions and the private sector. Caesareans percentages in 1999 were slightly above 35%. The highest values were those of the private sector with 53%, followed by social security institutions, with 38.2%. The variables more strongly associated with C sections were GDP, specialists' availability and human development index. It seems reasonable to advocate for a widespread descent in caesarean sections in Mexico. Important declines in certain contexts have been witnessed by implementing measures such as a second opinion before any C-section, a precise definition of the reasons for using it, and the monitoring of individual caesarean percentage among hospital obstetricians.

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal

PubMed Central

Neuman, Melissa; Alcock, Glyn; Azad, Kishwar; Kuddus, Abdul; Osrin, David; More, Neena Shah; Nair, Nirmala; Tripathy, Prasanta; Sikorski, Catherine; Saville, Naomi; Sen, Aman; Colbourn, Tim; Houweling, Tanja A J; Seward, Nadine; Manandhar, Dharma S; Shrestha, Bhim P; Costello, Anthony; Prost, Audrey

2014-01-01

Objectives To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia. Design Cross-sectional study. Setting 81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban). Participants 45 327 births occurring in the study areas between 2005 and 2012. Outcome measures Proportion of caesarean section deliveries by location and type of facility; determinants of caesarean section delivery by location. Results Institutional delivery rates varied widely between settings, from 21% in rural India to 90% in urban India. The proportion of private and charitable facility births delivered by caesarean section was 73% in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India. The odds of caesarean section were greater in private and charitable health facilities than in public facilities in three of four study locations, even when adjusted for pregnancy and delivery characteristics, maternal characteristics and year of delivery (Bangladesh: adjusted OR (AOR) 5.91, 95% CI 5.15 to 6.78; Nepal: AOR 2.37, 95% CI 1.62 to 3.44; urban India: AOR 1.22, 95% CI 1.09 to 1.38). We found that highly educated women were particularly likely to deliver by caesarean in private facilities in urban India (AOR 2.10; 95% CI 1.61 to 2.75) and also in rural Bangladesh (AOR 11.09, 95% CI 6.28 to 19.57). Conclusions Our results lend support to the hypothesis that increased caesarean section rates in these South Asian countries may be driven in part by the private sector. They also suggest that preferences for caesarean delivery may be higher among highly educated women, and that individual-level and provider-level factors interact in driving caesarean rates higher. Rates of caesarean section in the private sector, and their maternal and neonatal health outcomes, require close monitoring. PMID:25550293

Obstetrical providers' preferred mode of delivery and attitude towards non-medically indicated caesarean sections: a cross-sectional study.

PubMed

Rivo, J C; Amyx, M; Pingray, V; Casale, R A; Fiorillo, A E; Krupitzki, H B; Malamud, J D; Mendilaharzu, M; Medina, M L; Del Pino, A B; Ribola, L; Schvartzman, J A; Tartalo, G M; Trasmonte, M; Varela, S; Althabe, F; Belizán, J M

2018-01-11

To describe obstetrical providers' delivery preferences and attitudes towards caesarean section without medical indication, including on maternal request, and to examine the association between provider characteristics and preferences/attitudes. Cross-sectional study. Two public and two private hospitals in Argentina. Obstetrician-gynaecologists and midwives who provide prenatal care and/or labour/delivery services. Providers in hospitals with at least 1000 births per year completed a self-administered, anonymous survey. Provider delivery preference for low-risk women, perception of women's preferred delivery method, support for a woman's right to choose her delivery method and willingness to perform caesarean section on maternal request. 168 providers participated (89.8% coverage rate). Providers (93.2%) preferred a vaginal delivery for their patients in the absence of a medical indication for caesarean section. Whereas 74.4% of providers supported their patient's right to choose a delivery method in the absence of a medical indication for caesarean section and 66.7% would perform a caesarean section upon maternal request, only 30.4% would consider a non-medically indicated caesarean section for their own personal delivery or that of their partner. In multivariate adjusted analysis, providers in the private sector [odds ratio (OR) 4.70, 95% CI 1.19-18.62] and obstetrician-gynaecologists (OR 4.37, 95% CI 1.58-12.09) were more willing than either providers working in the public/both settings or midwives to perform a caesarean section on maternal request. Despite the ethical debate surrounding non-medically indicated caesarean sections, we observe very high levels of support, especially by providers in the private sector and obstetrician-gynaecologists, as aligned with the high caesarean section rates in Argentina. Non-medically indicated c-section? 74% of sampled Argentine OB providers support women's right to choose. © 2018 Royal College of Obstetricians and Gynaecologists.

[Thinking about the evolution of caesarean section rate at University Teaching Hospital of Dakar between 1992 and 2001].

PubMed

Cissé, C-T; Ngom, P-M; Guissé, A; Faye, E-O; Moreau, J-C

2004-03-01

The objective of this study is to answer the question: have we not been doing a lot of caesarean sections at University Teaching Hospital of Dakar? This is an analytic study about caesarean section in 1992, 1996 and 2001; it was a prospective and longitudinal data collection from the epidemiological survey program carried through in Senegal about its obstetrical and surgical cover. For each year concerned, we have analysed caesarean section rate, maternal mortality rate and perinatal mortality rate. To eliminate the random part in observed variation, we used the comparison of proportions observed as a statistical test with a significant threshold less or equal to 5%. Caesarean section has gone from 12% in 1992 to 17.5 in 1996 and 25.2% in 2001. Operative indications are dominated by foeto-pelvic disproportion with an average of 31% and foetal suffering with an average of 25%. The increasing trend has been statistically significant for information's such as foeto-pelvic disproportion and maternal pathologies. The falling trend was statistically significant for indications in relation on relation to foetal suffering and scarred uterus. Gathering information has shown a stabilisation of "obligatory" caesarean rate around 41%, a decrease in "caution" caesarean rate from 50 to 37.2% and an increase in caesarean by "necessity" from 8.6 to 22.4%. The maternal mortality rate among women delivered has fallen from 1.4% to 0.8%, but postoperative surgery morbidity rate was still high around 10%, essentially due to infections. Reading of caesarean section rate has not a significant impact in perinatal prognosis. Today there is an inflation of caesarean section at University Teaching Hospital of Dakar, without any significant loss of the maternal and perinatal mortality rate. The high level of complications due to surgery incite to reverse trends in order to get reasonable rate around 10 to 15% of childbirths.

Myasthenia gravis and pregnancy: anaesthetic management--a series of cases.

PubMed

Almeida, Carlos; Coutinho, Ester; Moreira, Daniela; Santos, Ernestina; Aguiar, José

2010-11-01

Myasthenia gravis is an autoimmune neuromuscular disease, usually affecting women in the second and third decades. The course is unpredictable during pregnancy and puerperium. Myasthenia gravis can cause major interference in labour and partum and exacerbations of the disease frequently occur. The aim of this series of cases is to analyse retrospectively the anaesthetic management of myasthenia gravis patients and complications during the peripartum period. Retrospective, single centre study from clinical files of female myasthenia gravis patients who delivered between 1985 and 2007 at Hospital de Santo António, Porto, Portugal. Seventeen myasthenia gravis patients delivered between 1985 and 2007 in Hospital Santo António. Two women were not included in the study as they had a spontaneous abortion in the first trimester. Four patients presented exacerbations of the disease during pregnancy, no exacerbation occurred in eight patients and three patients presented their first symptoms of myasthenia gravis during pregnancy (without diagnosis at time of delivery). Concerning the eight patients without exacerbations of the disease during pregnancy, pregnancy was brought to term in 87.5% of the cases; five women were submitted to nonurgent caesarean section (62.5%); and epidural block was performed in six patients (75%). No complications related to anaesthesia occurred in the peripartum period. Concerning the four patients with exacerbations of the disease, pregnancy was brought to term in three cases (75%); three women were submitted to nonurgent caesarean section (75%); and epidural block was performed in three patients (75%). One patient underwent an uncomplicated thymectomy under general anaesthesia during pregnancy and, in the postpartum period, there was a myasthenic crisis in another patient. Concerning the three patients without a myasthenia gravis diagnosis at partum, one woman already being followed for presenting muscular weakness had a vaginal delivery under epidural block, without complications; another patient, presenting discrete supine dyspnoea, was submitted to elective caesarean section under spinal block and developed severe dyspnoea that required mechanical ventilation and ICU admission; and in the remaining case, a woman presenting mild blurred vision was submitted to general anaesthesia, which resulted in delayed emergence, muscular weakness and respiratory failure. Pregnancy went full term in all cases (100%). No newborn had a myasthenic crisis. Myasthenia gravis can interfere slightly with pregnancy and partum, although exacerbations of the disease occur frequently. Strict surveillance and therapeutic optimisation are crucial. In women with controlled disease, caesarean section should be carried out only if there are obstetric reasons. Locoregional anaesthesia is preferred, mainly epidural block. A good multidisciplinary cooperation, specific precautions and surveillance can certainly contribute to an improved outcome in myasthenia gravis patients during the peripartum period.

Comparison of results of Bakri balloon tamponade and caesarean hysterectomy in management of placenta accreta and increta: a retrospective study.

PubMed

Pala, Şehmus; Atilgan, Remzi; Başpınar, Melike; Kavak, Ebru Çelik; Yavuzkır, Şeyda; Akyol, Alparslan; Kavak, Burçin

2018-02-01

The aim of this study was to compare the postoperative results of the patients who were treated with Bakri balloon tamponade or hysterectomy for placenta accreta and increta. Patients who were diagnosed with placenta accreta or increta preoperatively and intraoperatively and treated with Bakri balloon tamponade (Group 1) or caesarean hysterectomy (Group 2) were compared in regards to the postoperative results. Among the 36 patients diagnosed with placenta accreta or increta, 19 patients were treated with Bakri balloon tamponade while 17 cases were treated with hysterectomy. Intraoperative blood loss amount was 1794 ± 725 ml in G1, which was lower than that in G2 (2694 ± 893 ml). Blood transfusion amount was 2.7 ± 2.6 units in G1, lower than that in G2 (5.7 ± 2.4 units), too. Operation time was 64.5 ± 29 min and 140 ± 51 min in G1 and G2, respectively, showing significant differences between two groups. The success rate of Bakri balloon was determined as 84.21%. In conclusion, cases with placenta accreta/increta, with predicted placental detachment who are willing to preserve fertility, application of uterine balloon tamponade devices before the hysterectomy is encouraging with its advantages compared with the hysterectomy. Impact statement What is already known on this subject: Invasive placental anomalies are the most common indication of postpartum hysterectomy. Recently, uterine balloon tamponade was also included in the treatment modalities of postpartum haemorrhage.This study aimed to compare the postoperative results of UBT or hysterectomy for patients with placenta accreta and increta. What the results of this study add: In this study, the total amount of blood loss was higher in the caesarean hysterectomy group when compared with the Bakri balloon tamponade group. The mean transfusion requirement, mean operation time and hospitalisation period was significantly longer in the caesarean hysterectomy group. The success rate of the Bakri balloon was determined as 84.21%. Two patients who were treated with balloon application had a successful pregnancy and delivery later. Maternal mortality was reported in neither balloon nor hysterectomy groups. What the implications are of these findings for clinical practice and/or further research: In conclusion, patients diagnosed with placenta accreta/increta with ultrasound should be taken into the operation in elective conditions, if possible, on lithotomy position. In cases with predicted placental detachment that are willing to preserve fertility, application of uterine balloon tamponade devices before the hysterectomy has advantages compared with the hysterectomy.

Epidural analgesia in labour and risk of caesarean delivery.

PubMed

Bannister-Tyrrell, Melanie; Ford, Jane B; Morris, Jonathan M; Roberts, Christine L

2014-09-01

A Cochrane Systematic Review of randomised controlled trials of epidural analgesia compared with other or no analgesia in labour reported no overall increased risk of caesarean delivery. However, many trials were affected by substantial non-compliance, and there are concerns about the external validity of some trials for contemporary maternity populations. We aimed to explore the association between epidural analgesia in labour and caesarean delivery in clinical practice and compare with findings from randomised controlled trials. Population-based cohort of pregnant women (n = 210 708) without major obstetrical complications who delivered a singleton live infant in hospitals in New South Wales, Australia, 2007-10. Data were obtained from linked, validated population-based data collections. Propensity score matching was used to examine the association between epidural analgesia in labour and caesarean delivery. Epidural analgesia in labour was used by a third (31.5%, n = 66 317) of the women, and 9.8% (n = 20 531) had a caesarean delivery. Epidural analgesia in labour was associated with increased risk of caesarean delivery {risk ratio [RR] 2.5, [95% confidence interval (CI) 2.5, 2.6]}. The association with epidural analgesia in labour was higher for caesarean delivery for failure to progress {RR 3.0, [95% CI 2.9, 3.0]} than for caesarean delivery for fetal distress {RR 1.9, [95% CI 1.8, 2.0]}. Epidural analgesia in labour is associated with caesarean delivery in a large maternity population. Population-based studies contribute important data about obstetrical care, when research settings and participants may not represent the clinical settings or broader population in which obstetrical interventions in labour are applied. © 2014 John Wiley & Sons Ltd.

Caesarean delivery before 39 weeks associated with selecting an auspicious time for birth in Taiwan.

PubMed

Chu, Kuei-Hui; Lee, Yu-Hsiang; Tai, Chen-Jei; Lin, Yu-Hung; Huang, Chiu-Mieh; Chien, Li-Yin

2015-09-01

Caesarean delivery before 39 weeks of gestation increases the risk of morbidity among infants. Taiwan has one of the highest caesarean rates in the world, but little attention has been paid to this issue. This study aimed to describe the rate of caesarean delivery before 39 weeks gestation among women who did not have labour signs and had a non-emergency caesarean delivery in Taiwan and to examine whether the phenomenon was associated with the Chinese cultural practice of selecting an auspicious time for birth. We recruited women at 15-28 weeks of pregnancy at 5 hospitals in northern Taiwan and followed them at 4 or 5 weeks after delivery using structured questionnaires. This analysis included 150 primiparous mothers with a singleton pregnancy who had a non-emergency caesarean delivery without the presence of labour signs. Ninety-three of these women (62.0%) had caesarean deliveries before 39 weeks of gestation. Logistic regression analysis showed that women who had selected an auspicious time for delivery (OR=2.82, 95% CI: 1.15-6.95) and delivered in medical centres (OR=5.26, 95% CI: 2.25-12.26) were more likely to deliver before 39 weeks of gestation. Non-emergency caesarean delivery before 39 weeks of gestation was common among the study women, and was related to the Chinese cultural practice of selecting an auspicious time for birth. Further studies are needed to examine the risks and benefits associated with timing of caesarean delivery in Taiwan in order to generate a consensus among obstetricians and give pregnant women appropriate information. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Successful external cephalic version is an independent factor for caesarean section during trial of labor - a matched controlled study.

PubMed

Boujenah, J; Fleury, C; Bonneau, C; Pharisien, I; Tigaizin, A; Carbillon, L

2017-12-01

To assess the mode of delivery and Caesarean Section (CS) rate after successful External Cephalic Version (ECV). A matched case-control study. Data were gathered from a tertiary care university hospital register from 1996-2015. All pregnant women who delivered after successful External Cephalic Version (ECV). Among 643 women who attempted ECV, we identified 198 with successful ECVs and compared them with the next two women who presented for labor management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index, and delivery history using univariate and stepwise logistic regression. The main outcome measure was the risk of caesarean. The caesarean section rate was higher after successful ECV (respectively 20.7% versus 7.07%, P<0.05). Caesarean section for abnormal fetal head position (forehead, bregma, face) was higher after successful ECV (28.6% versus 0%). After adjustment for matching and confounding variables (variation of the caesarean section rate over the study period, gestational maternal complications, antepartum fetal complications, term of delivery, induction of labor, oxytocin use for dystocia, neonatal cephalic perimeter), a successful ECV increased the risk of caesarean section (adjusted OR 3.17, 95% CI 1.86-5.46). By stratifying on week, a trend for increased risk for caesarean section was observed at the week after ECV and at post term (28.6% before 37+6, 14.8% at 38+0-38+6, 13.8% at 39+0-39+6, 14.2% at 40+0-40+6 and 33.3% beyond 41+0 weeks' gestation, P=0.06). Women who have a successful ECV are at increased risk of caesarean section compared with women who experience spontaneous cephalic presentation. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Joint effect of education and age at childbirth on the risk of caesarean delivery: findings from Germany 2008-2015.

PubMed

Castiglioni, L; Schmiedeberg, C

2018-02-01

This article aims at assessing the joint effect of maternal age and education on the risk of having a caesarean delivery. As high maternal education is often associated with lower caesarean-birth rates, but high-educated women tend to postpone motherhood, these effects may offset each other in traditional analyses. Secondary analysis of the data from the German Family Panel pairfam. The interview-based data refer to 1020 births between 2008 and 2015. We analyse only reports from mothers and calculate logistic regression models. The caesarean delivery rate differs strongly between education levels, and low-educated women are at higher risk of having a caesarean delivery when controlling for parity and age. A positive age gradient is found, indicating a higher risk of caesarean section for older mothers. Without controlling for age, the association of education and caesarean section risk is weaker, i.e., effects of age and education partially level each other out. A model including an interaction term between age and education confirms this result. The risk of having a caesarean delivery does not differ between levels of education when maternal age is not taken into account. Lower maternal education and higher age are both positively associated with the risk of experiencing a caesarean section in Germany. However, as higher educated women tend to have their children later, effects of education and age weigh each other out. Preventive campaigns should target women with lower education and raise women's awareness on the risks associated with late motherhood. Copyright © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

THE INCIDENCE OF CAESAREAN SECTIONS IN THE UNIVERSITY CLINICAL CENTER OF KOSOVO

PubMed Central

Elshani, Brikene; Daci, Armond; Gashi, Sanije; Lulaj, Shefqet

2012-01-01

Introduction: As in most countries of the world also at Kosovo the rate of Cesarean section from year to year is increasing. Aim: The main purpose of this paper was to present the incidence of births completed by Caesarean section at the Clinic of Gynecology and Obstetrics of University Clinical Center of Kosovo in Prishtinë. Material and methods: This study is retrospective, namely its made by collecting epidemiological data from patients’ histories that completed birth by Caesarean section for the period 2000-2006 in this clinic. Results and discussion: During this period, 14 maternal deaths were recorded during or after Caesarean section. Besides this, 14 lethal outcomes, the object of our study was 84 mothers which completed birth by Caesarean section and which are best used as a control group. The average age of mothers who died during or after Caesarean section was 32.1 years (SD ± 4.9). Youngest in this group was 24 years old and oldest 42 years. While the average age of mothers from the control group was 30.6 years (SD ± 5.9). Youngest was 19 and oldest 43 years, without significant difference. Most mothers included in the survey had more than one indication for Caesarean section. The most frequent indication was PIH syndrome with 33.7% and previous Caesarean section in 32.7%. Then with the participation of 12.2% were abruption of the placenta and disproportio feto pelvinea, 11.2% pelvinea and placenta praevia presentation, 10.2% parturiens while other indications were much rarer with less than 10% participation. Conclusion: Based on this we can conclude that the risk of the Caesarean section is high. PMID:23378692

External cephalic version for breech presentation at term: predictors of success, and impact on the rate of caesarean section.

PubMed

Hussin, O A; Mahmoud, M A; Abdel-Fattah, M M

2013-02-01

The incidence of caesarean section for breech presentation has increased markedly in the last 20 years. A prospective, interventional cohort study was carried out of the success rate of external cephalic version (ECV) and its predictors of as well as its impact on the rate of caesarean section for vaginal breech delivery. All 128 women admitted during the study period to the obstetrics department of a tertiary care military hospital in Taif, Saudi Arabia with breech presentation at term, regardless of age and parity, who accepted ECV were recruited. ECV was successful in 53.9% of the women. Most of the women with successful ECV delivered normally (84.1%) and only 14.5% of them delivered by caesarean section. Conversely, normal vaginal delivery was reported among 8.5% of those who had spontaneous version with failed ECV and approximately two-thirds of them delivered by caesarean section (62.7%). Successful ECV reduced the breech and caesarean section rate.

Atelectasis observed by computerized tomography after Caesarean section.

PubMed

Meira, M N C; Carvalho, C R R; Galizia, M S; Borges, J B; Kondo, M M; Zugaib, M; Vieira, J E

2010-06-01

Atelectasis after either vaginal or Caesarean delivery has not been adequately quantified. This study addresses the hypothesis that atelectasis may be worse in women who undergo Caesarean section when compared with vaginal delivery under regional anaesthesia. Twenty healthy non-smoking women submitted to a chest computed tomography (CT) 2 h after delivery in a University Hospital, who had experienced vaginal delivery (n=10) under combined spinal-epidural analgesia or a Caesarean section (n=10) under spinal anaesthesia, were evaluated. The percentage cross-sectional area of atelectasis in dependent lung regions were measured from the CT images obtained at cross-section of the xiphoid process and the top of the diaphragm. The percentage cross-sectional area of atelectasis was 3.95% in the vaginal delivery group and 14.1% in the Caesarean group (P<0.001, Mann-Whitney rank sum test). These results suggested that pulmonary atelectasis is greater after Caesarean section delivery under spinal anaesthesia than after vaginal delivery with combined spinal-epidural analgesia.

Patterns and Associated Factors of Caesarean Delivery Intention among Expectant Mothers in China: Implications from the Implementation of China’s New National Two-Child Policy

PubMed Central

Wang, Lianlian; Xu, Xianglong; Baker, Philip; Tong, Chao; Zhang, Lei; Qi, Hongbo; Zhao, Yong

2016-01-01

Objective: This study explores the basic demographic characteristics of expectant mothers in the context of their intentions regarding mode of delivery, in particular, the preference for caesarean delivery, and analyzes the social and psychological factors that influence delivery preference. Method: A cross-sectional survey of pregnant women was conducted during June to August in 2015. This study adopted a stratified sampling method, and 16 representative hospitals in five provinces of China were included. Results: 1755 and 590 of expectant mothers in their first and second pregnancies, respectively, were enrolled in this study. 354 (15.10%) intended to deliver by caesarean section and 585 (24.95%) participants were uncertain prior to delivery. 156 (8.89%) of expectant mothers in their first pregnancy and 198 (33.56%) expectant mothers in their second pregnancy intended to deliver by caesarean section. Ordinal logistic regression analysis found that nationality, parity, trimester of pregnancy, and advanced maternal age were factors associated with intention to deliver by caesarean (ordered logistic regression/three-level caesarean delivery intention criterion; odds ratios p < 0.05). Conclusions: 8.89% of first pregnancy expectant mothers and 33.56% of second pregnancy expectant mothers intended to deliver by caesarean section. Any intervention program to reduce the rate of Caesarean delivery should focus on the Han population, older pregnant women, and expectant mothers in their second pregnancy, at an early gestation. PMID:27399752

Caesarean Section in Peru: Analysis of Trends Using the Robson Classification System

PubMed Central

2016-01-01

Introduction Cesarean section rates continue to increase worldwide while the reasons appear to be multiple, complex and, in many cases, country specific. Over the last decades, several classification systems for caesarean section have been created and proposed to monitor and compare caesarean section rates in a standardized, reliable, consistent and action-oriented manner with the aim to understand the drivers and contributors of this trend. The aims of the present study were to conduct an analysis in the three Peruvian geographical regions to assess levels and trends of delivery by caesarean section using the Robson classification for caesarean section, identify the groups of women with highest caesarean section rates and assess variation of maternal and perinatal outcomes according to caesarean section levels in each group over time. Material and Methods Data from 549,681 pregnant women included in the Peruvian Perinatal Information System database from 43 maternal facilities in three Peruvian geographical regions from 2000 and 2010 were studied. The data were analyzed using the Robson classification and women were studied in the ten groups in the classification. Cochran-Armitage test was used to evaluate time trends in the rates of caesarean section rates and; logistic regression was used to evaluate risk for each classification. Results The caesarean section rate was 27% and a yearly increase in the overall caesarean section rates from 2000 to 2010 from 23.5% to 30% (time trend p<0.001) was observed. Robson groups 1, 3 (nulliparous and multiparas, respectively, with a single cephalic term pregnancy in spontaneous labour), 5 (multiparas with a previous uterine scar with a single, cephalic, term pregnancy) and 7 (multiparas with a single breech pregnancy with or without previous scars) showed an increase in the caesarean section rates over time. Robson groups 1 and 3 were significantly associated with stillbirths (OR 1.43, CI95% 1.17–1.72; OR 3.53, CI95% 2.95–4.2) and maternal mortality (OR 3.39, CI95% 1.59–7.22; OR 8.05, CI95% 3.34–19.41). Discussion The caesarean section rates increased in the last years as result of increased CS in groups with spontaneous labor and in-group of multiparas with a scarred uterus. Women included in groups 1 y 3 were associated to maternal perinatal complications. Women with previous cesarean section constitute the most important determinant of overall cesarean section rates. The use of Robson classification becomes an useful tool for monitoring cesarean section in low human development index countries. PMID:26840693

[Introducing a daily obstetric audit: A solution to reduce the cesarean section rate?].

PubMed

Lasnet, A; Jelen, A-F; Douysset, X; Pons, J-C; Sergent, F

2015-06-01

To evaluate the impact of a medical audit assessing the accuracy of caesarean indications on the final caesarean section rate of an obstetrics department. Comparative observational study conducted in a regional university teaching hospital on the two first quadrimester periods of 2013. During the first quadrimester, there was no cesarean section audit introduced for the daily reports meetings, while an audit was introduced during the second quadrimester. The caesarean rate and the instrumental delivery rate on both quadrimesters were compared. In the first quadrimester period, there were 248 caesarean sections for 947 deliveries (26.2%), while in the second quadrimester period, there were 246 for 1033 deliveries (23.8%), P=0.014. The emergency caesarean rate decreased from 19.6 to 16.7%, P=0.02 in the second quadrimester period while the instrumental delivery rate increased from 14.4 to 17.2%, P=0.0004. Mothers and children's health was not modified between the two periods. In our experience, the introduction of a daily obstetric audit of the caesarean indications is effective to decrease the emergency caesarean section rate and it encourages us to be active in the first like in the second part of the labor. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Oxytocin for labour and caesarean delivery: implications for the anaesthesiologist.

PubMed

Dyer, Robert A; Butwick, Alexander J; Carvalho, Brendan

2011-06-01

The implications of the obstetric use of oxytocin for obstetric anaesthesia practice are summarised. The review focuses on recent research on the uterotonic effects of oxytocin for prophylaxis and management of uterine atony during caesarean delivery. Oxytocin remains the first-line agent in the prevention and management of uterine atony. In-vitro and in-vivo studies show that prior exposure to oxytocin induces uterine muscle oxytocin receptor desensitization. This may influence oxytocin dosing for adequate uterine tone following delivery. Oxytocin has important cardiovascular side-effects (hypotension, tachycardia and myocardial ischaemia). Recent studies suggest that the effective dose of oxytocin for prophylaxis against uterine atony during caesarean delivery is significantly lower than the 5-10 IU historically used by anaesthesiologists. Slow administration of small bolus doses of oxytocin minimises maternal haemodynamic disturbance. Continuous oxytocin infusions are recommended for maintaining uterine tone after bolus administration, although ideal infusion rates are still to be established. The efficacy of the long-acting oxytocin analogue carbetocin requires further investigation. Recommendations are presented for oxytocin dosing during caesarean delivery. Oxytocin remains the first-line uterotonic after vaginal and caesarean delivery. Recent research elucidates the therapeutic range of oxytocin during caesarean delivery, as well as receptor desensitization. Evidenced-based protocols for the prevention and treatment of uterine atony during caesarean delivery are recommended.

Variations in first-time caesarean birth between Eastern African immigrants and Australian-born women in public care: A population-based investigation in Victoria.

PubMed

Belihu, Fetene B; Small, Rhonda; Davey, Mary-Ann

2017-06-01

Caesarean section (CS) rates are known to vary by country, migration status and social group. However, little population-based, confounder adjusted evidence exists on caesarean rate for African immigrants in Australia. To investigate disparities in first-time caesarean, mainly unplanned caesarean in labour for women born in Eritrea, Ethiopia, Somalia and Sudan relative to Australian-born women in public care. A population-based study of 237 943 Australian and 4057 Eastern African singleton births between 1999 and 2007, was conducted using Victorian Perinatal Data Collection. Descriptive and multivariable logistic regression analysis by parity, adjusting for confounders selected a priori, was performed for first-time unplanned caesarean in labour and overall caesarean. Primiparae born in each of the Eastern African countries had elevated odds of unplanned caesarean in labour: Eritrea adjusted odds ratio (OR adj ) 2.04 95% CI (1.41, 2.97), Ethiopia OR adj 2.08 95% CI (1.62, 2.68), Somalia OR adj 1.62 95% CI (1.25, 2.10) and Sudan OR adj 1.39 95% CI (1.03, 1.87). Similarly, multiparae from Eastern African countries had elevated odds of unplanned caesarean in labour: Eritrea OR adj 2.13 95%CI(1.15, 3.97), Ethiopia OR adj 2.05 95% CI (1.38, 3.03), Somalia OR adj 2.16 95% CI (1.69, 2.77) and Sudan OR adj 1.81 95% CI (1.32, 2.49). The odds of any first-time caesarean (planned or unplanned) were elevated for primiparae born in all countries except Sudan and for multiparae born in Ethiopia and Somalia. We observed substantial variations in a first-time CS between Eastern African and Australian-born women in Victoria, Australia. However, these disparities were unexplained by socio-demographic and clinical risks, suggesting the potential importance of other factors such as communication difficulties, support systems for immigrant pregnant women and possible differences in care. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Evaluating the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme': A mixed method study in England.

PubMed

Marshall, Joyce L; Spiby, Helen; McCormick, Felicia

2015-02-01

caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England. to evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units. a mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews. twenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation. collection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts. there was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline. it is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors. Copyright © 2014 Elsevier Ltd. All rights reserved.

Intrapartum care could be improved according to Swedish fathers: mode of birth matters for satisfaction.

PubMed

Johansson, Margareta; Hildingsson, Ingegerd

2013-09-01

Intrapartum care is expected to be shaped by parents' need and preferences. The aim was to explore Swedish fathers' intrapartum care quality experiences, with a specific focus on care deficiencies in relation to birth mode. A secondary aim was to explore which issues of quality that contributed most to dissatisfaction with the overall assessment of the care. Cross-sectional design, part of a prospective longitudinal survey in Sweden. A quality of care index was developed, based on perceived reality and subjective importance of given intrapartum care. Two months after birth 827 fathers answered nine questions related to quality of care. Descriptive statistics and logistic regression analysis were used. Dissatisfaction with overall intrapartum care was related to deficiencies in partner's medical care (OR 5.6; 2.7-11.2), involvement in decision-making during childbirth (OR 2.6; 1.3-4.9), midwives presence in the labour room (OR 2.4; 1.2-4.7), and ability to discuss the birth afterwards (OR 2.0; 1.1-3.8). After emergency caesarean section 46% judged the partner's medical intrapartum care as most deficient (OR 1.73; 1.05-2.86), and after elective caesarean section 40% of the fathers judged involvement in decision-making as deficient (OR 4.07; 1.95-8.50). When the fathers had participated in a spontaneous vaginal birth they were dissatisfied with the presence of the midwife in the labour room (OR 1.72; 1.03-2.87). Deficiencies existed in the intrapartum care and were judged differently depending on mode of birth. The fathers needed to feel secure about the women's medical care, and wanted to be involved and supported. Copyright © 2013 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Influence of lateral decubitus positioning after combined use of hyperbaric and hypobaric ropivacaine on hemodynamic characteristics in spinal anesthesia for caesarean section.

PubMed

Quan, Zhe-Feng; He, Hai-Li; Tian, Ming; Chi, Ping; Li, Xin

2014-01-01

Positioning of the patient during and after surgery can have significant implications on recovery. Therefore, the purpose of the present study was to determine the influence of placing patients in a lateral decubitus position for 15 min after combined use of hyperbaric and hypobaric ropivacaine and assess hemodynamic characteristics during spinal anesthesia for caesarean section. One hundred-forty patients undergoing elective cesarean delivery with combined use of hyperbaric and hypobaric ropivacaine were included in the present study. Patients meeting inclusion criteria (134) were randomly allocated into Group A: immediately turned to the supine position after induction of spinal anesthesia (n = 67) or Group B: maintained in a lateral decubitus position for 15 min before being turned to the supine position (n = 67). Primary endpoints of the study were to compare hemodynamic characteristics and sensory blockade levels in the two groups, while a secondary endpoint was to observe the incidence of complications. Both groups showed similar effects of the combined anesthetic treatment. Incidence of hypotension (43% vs 18%, P = 0.001), systolic AP < 90 mmHg (36% vs. 16%, P = 0.011), usage of ephedrine (43% vs. 18%, P = 0.001) and the total dose of ephedrine [0 (0-24) vs 0 (0-18), P = 0.001] were significantly higher in Group A compared to Group B. Group A had a higher incidence of nausea compared to Group B (25% vs 7%, P = 0.005). Combined use of hyperbaric and hypobaric ropivacaine had satisfactory anesthetic effects and a more stable hemodynamic characteristic than either drug used alone. Maintaining the patient in a lateral decubitus position for 15 min can significantly decrease the incidence of hypotension.

Influence of lateral decubitus positioning after combined use of hyperbaric and hypobaric ropivacaine on hemodynamic characteristics in spinal anesthesia for caesarean section

PubMed Central

Quan, Zhe-Feng; He, Hai-Li; Tian, Ming; Chi, Ping; Li, Xin

2014-01-01

Purpose: Positioning of the patient during and after surgery can have significant implications on recovery. Therefore, the purpose of the present study was to determine the influence of placing patients in a lateral decubitus position for 15 min after combined use of hyperbaric and hypobaric ropivacaine and assess hemodynamic characteristics during spinal anesthesia for caesarean section. Methods: One hundred-forty patients undergoing elective cesarean delivery with combined use of hyperbaric and hypobaric ropivacaine were included in the present study. Patients meeting inclusion criteria (134) were randomly allocated into Group A: immediately turned to the supine position after induction of spinal anesthesia (n = 67) or Group B: maintained in a lateral decubitus position for 15 min before being turned to the supine position (n = 67). Primary endpoints of the study were to compare hemodynamic characteristics and sensory blockade levels in the two groups, while a secondary endpoint was to observe the incidence of complications. Results: Both groups showed similar effects of the combined anesthetic treatment. Incidence of hypotension (43% vs 18%, P = 0.001), systolic AP < 90 mmHg (36% vs. 16%, P = 0.011), usage of ephedrine (43% vs. 18%, P = 0.001) and the total dose of ephedrine [0 (0-24) vs 0 (0-18), P = 0.001] were significantly higher in Group A compared to Group B. Group A had a higher incidence of nausea compared to Group B (25% vs 7%, P = 0.005). Conclusions: Combined use of hyperbaric and hypobaric ropivacaine had satisfactory anesthetic effects and a more stable hemodynamic characteristic than either drug used alone. Maintaining the patient in a lateral decubitus position for 15 min can significantly decrease the incidence of hypotension. PMID:25664088

External cephalic version for breech presentation at term.

PubMed

Rauf, Bushra; Nisa, Mehrun-; Hassan, Lubna

2007-09-01

To assess the success rate of External Cephalic Version (ECV) at term and its effects on measures of pregnancy outcome. A quasi-experimental study. The study was conducted at Hayatabad Medical Complex, Peshawar, from December 2003 to January 2005. A total of 40 patients were offered ECV over a period of fourteen months. All singleton breech presentations with an otherwise normal antenatal course between 36-41 weeks of gestation were included in the study. Exclusion criteria included contraindications to ECV i.e. multiple pregnancy, oligohydramnios, growth retardation, antepartum hemorrhage, rupture of membranes toxemias of pregnancy, non-reassuring fetal monitoring pattern, previous uterine scar, bad obstetric history, any contraindication to vaginal delivery, labour and patient wishes after thorough counseling. Overall success rate of the procedure and its effect on maternal and fetal outcome was determined. Significance of results was determined using Chi-square test. A total of 40 patients were recruited for the trial. Overall success rate was 67.5% with only 30% being primi-gravida (p < 0.05). Multi-gravida showed higher success rate of 80%. Following successful ECV, spontaneous vaginal delivery was attained in 77.7% (n=21), while caesarean section was performed due to various indications in about 6 cases (p < 0.05). Following failed version, 61.5% (n=8) had elective C/S and only 5 delivered vaginally. Route of delivery did not affect the perinatal outcome except for congenital abnormalities. Following successful ECV, there was only one stillbirth. Overall live births associated with successful version was 96.2% (p < 0.05), while in failed version, there were no fetal deaths. ECV at term appears to be a useful procedure to reduce the number and associated complications of term breech presentation. It is safe for the mother and the fetus and helps to avoid a significant number of caesarean sections.

Does surgical site infection after Caesarean section in Polish hospitals reflect high-quality patient care or poor postdischarge surveillance? Results from a 3-year multicenter study.

PubMed

Różańska, Anna; Jarynowski, Andrzej; Kopeć-Godlewska, Katarzyna; Wójkowska-Mach, Jadwiga; Misiewska-Kaczur, Agnieszka; Lech, Marzena; Rozwadowska, Małgorzata; Karwacka, Marlena; Liberda, Joanna; Domańska, Joanna

2018-01-01

Caesarean sections (CSs) are associated with a high infection risk. Surgical site infection (SSI) incidence is among the markers of effectiveness of infection prevention efforts. The aim of this study was to analyze risk factors for SSI, incidence, and microbiology in patients who underwent CS. The study was conducted during 2013-2015 using active infection surveillance in 5 Polish hospitals according to the European Centre for Disease Prevention and Control surveillance network known as HAI-Net. For each procedure, the following data were registered: age, American Society of Anesthesiologists score, procedure time, elective or emergency procedure, use of perioperative antibiotic prophylaxis, microbiology, the treatment used, and other information. SSI incidence was 0.5% and significant differences were noted among hospitals (between 0.1% and 1.8%), for different American Society of Anesthesiologists scales (between 0.2% and 4.8%) and different values of standardized SSI risk index (between 0.0% and 0.8%). In 3.1% of procedures, with no antibiotic prophylaxis, SSI risk was significantly higher. Deep infections dominated: 61.5% with superficial infections in only approximately 30% of cases and 2.6% of infections were detected postdischarge without readmissions. Results showed high incidence of SSI in Poland without perioperative antibiotic prophylaxis, and secondly, ineffective surveillance according to CS status, considering outpatient obstetric care. Without postdischarge surveillance, it is not possible to recognize the epidemiologic situation, and further, to set priorities and needs when it comes to infection prophylaxis, especially because such low incidence may indicate no need for improvement in infection control. Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Impact of maternal intrapartum antibiotics, method of birth and breastfeeding on gut microbiota during the first year of life: a prospective cohort study.

PubMed

Azad, M B; Konya, T; Persaud, R R; Guttman, D S; Chari, R S; Field, C J; Sears, M R; Mandhane, P J; Turvey, S E; Subbarao, P; Becker, A B; Scott, J A; Kozyrskyj, A L

2016-05-01

Dysbiosis of the infant gut microbiota may have long-term health consequences. This study aimed to determine the impact of maternal intrapartum antibiotic prophylaxis (IAP) on infant gut microbiota, and to explore whether breastfeeding modifies these effects. Prospective pregnancy cohort of Canadian infants born in 2010-2012: the Canadian Healthy Infant Longitudinal Development (CHILD) Study. General community. Representative sub-sample of 198 healthy term infants from the CHILD Study. Maternal IAP exposures and birth method were documented from hospital records and breastfeeding was reported by mothers. Infant gut microbiota was characterised by Illumina 16S rRNA sequencing of faecal samples at 3 and 12 months. Infant gut microbiota profiles. In this cohort, 21% of mothers received IAP for Group B Streptococcus prophylaxis or pre-labour rupture of membranes; another 23% received IAP for elective or emergency caesarean section (CS). Infant gut microbiota community structures at 3 months differed significantly with all IAP exposures, and differences persisted to 12 months for infants delivered by emergency CS. Taxon-specific composition also differed, with the genera Bacteroides and Parabacteroides under-represented, and Enterococcus and Clostridium over-represented at 3 months following maternal IAP. Microbiota differences were especially evident following IAP with emergency CS, with some changes (increased Clostridiales and decreased Bacteroidaceae) persisting to 12 months, particularly among non-breastfed infants. Intrapartum antibiotics in caesarean and vaginal delivery are associated with infant gut microbiota dysbiosis, and breastfeeding modifies some of these effects. Further research is warranted to explore the health consequences of these associations. Maternal #antibiotics during childbirth alter the infant gut #microbiome. © 2015 Royal College of Obstetricians and Gynaecologists.

Transversus abdominis plane block vs. wound infiltration in Caesarean section: a randomised controlled trial.

PubMed

Telnes, A; Skogvoll, E; Lonnée, H

2015-04-01

Multiple studies suggest that transversus abdominis plane (TAP) block (without intrathecal morphine) after Caesarean section (CS) reduces post-operative morphine consumption. In our study, we wanted to compare the analgesic effect of TAP block with infiltration of the wound after CS. We included 60 pregnant women scheduled for elective CS under spinal anaesthesia in a randomised, single-centre, double-blind study. Thirty patients received ultrasound-guided TAP block using 20 ml bupivacaine 0.25% with adrenaline 5 μg/ml bilaterally and 20 ml normal saline as wound infiltration (TAP group). The other 30 patients (the control group) received normal saline 20 ml bilaterally in the TAP, and 20 ml bupivacaine 0.25% with adrenaline 5 μg/ml as wound infiltration. The main outcome was cumulative morphine consumption at 48 h after surgery. In addition, continuous morphine consumption, pain scores and side effects were registered. Fifty-seven patients completed the study. Cumulative morphine consumption at 48 h (mean±standard deviation) was 41±34 mg in the TAP group and 38±27 mg in the control group (P=0.7); a difference of 3 mg (95% confidence interval -13 to 19 mg). Morphine consumption at any time up to 48 h was virtually identical in both groups. Side effects were similar, except for a higher degree of sedation in the TAP group (P=0.04). Compared with wound infiltration with local anaesthetics, TAP block did not reduce cumulative morphine consumption following CS. The TAP block was associated with more pronounced sedation. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Exercise during pregnancy and gestational diabetes-related adverse effects: a randomised controlled trial.

PubMed

Barakat, Ruben; Pelaez, Mireia; Lopez, Carmina; Lucia, Alejandro; Ruiz, Jonatan R

2013-07-01

To examine the effect of regular moderate-intensity exercise (three training sessions/week) on the incidence of gestational diabetes mellitus (GDM, primary outcome). We also examined if the exercise intervention modifies the association between GDM and birth weight and risk of macrosomia, gestational age, risk of caesarean delivery and maternal weight gain (secondary outcomes). We randomly assigned 510 healthy gravida to either an exercise intervention or a usual care (control) group (n=255 each). The exercise programme focused on moderate-intensity resistance and aerobic exercises (three times/week, 50-55 min/session). GDM diabetes was diagnosed according to the WHO criteria and the International Association for Diabetes in Pregnancy Study Group (IADPSG). The intervention did not reduce the risk of developing GDM (OR 0.84, 95% CI 0.50 to 1.40) when using the WHO criteria. We observed that the intervention reduced by 58% the GDM-related risk (WHO criteria) of having a newborn with macrosomia (OR 1.76, 95% CI 0.04 to 78.90 vs 4.22, 95% CI 1.35 to 13.19) in exercise and control groups, respectively), and by 34% the GDM-related risk of having acute and elective caesarean delivery (OR 1.30, 95% CI 0.44 to 3.84 vs 1.99, 95% CI 0.98 to 4.06 in exercise and control groups, respectively). Gestational age was similar across the treatment groups (control, exercise) and GDM category (GDM or non-GDM), and maternal weight gain was ∼12% lower in the exercise group independent of whether women developed GDM. The results were similar when the IADPSG criteria were used instead. Regular moderate-intensity exercise performed over the second-third trimesters of pregnancy can be used to attenuate important GDM-related adverse outcomes.

Repeat cesarean delivery: what indications are recorded in the medical chart?

PubMed

Lydon-Rochelle, Mona T; Gardella, Carolyn; Cárdenas, Vicky; Easterling, Thomas R

2006-03-01

National surveillance estimates reported a troubling 63 percent decline in the rate of vaginal birth after cesarean delivery (VBAC) from 1996 (28.3%) to 2003 (10.6%), with subsequent rising rates of repeat cesarean delivery. The study objective was to examine patterns of documented indications for repeat cesarean delivery in women with and without labor. We conducted a population-based validation study of 19 nonfederal short-stay hospitals in Washington state. Of the 4,541 women who had live births in 2000, 11 percent (n = 493) had repeat cesarean without labor and 3 percent (n = 138) had repeat cesarean with labor. Incidence of medical conditions and pregnancy complications, patterns of documented indications for repeat cesarean delivery, and perioperative complications in relation to repeat cesarean delivery with and without labor were calculated. Of the 493 women who underwent a repeat cesarean delivery without labor, "elective"(36%) and "maternal request"(18%) were the most common indications. Indications for maternal medical conditions (3.0%) were uncommon. Among the 138 women with repeat cesarean delivery with labor, 60.1 percent had failure to progress, 24.6 percent a non-reassuring fetal heart rate, 8.0 percent cephalopelvic disproportion, and 7.2 percent maternal request during labor. Fetal indications were less common (5.8%). Breech, failed vacuum, abruptio placentae, maternal complications, and failed forceps were all indicated less than 5.0 percent. Women's perioperative complications did not vary significantly between women without and with labor. Regardless of a woman's labor status, nearly 10 percent of women with repeat cesarean delivery had no documented indication as to why a cesarean delivery was performed. "Elective" and "maternal request" were common indications among women undergoing repeat cesarean delivery without labor, and nearly 10 percent of women had undocumented indications for repeat cesarean delivery in their medical record. Improvements in standardization of indication nomenclature and documentation of indication are especially important for understanding falling VBAC rates. Future research should examine how clinicians and women anticipate, discuss, and make decisions about childbirth after a previous cesarean delivery within the context of actual antepartum care.

Is the caesarean section rate a performance indicator of an obstetric unit?

PubMed

Singh, Ruchi; Nath Trivedi, Amarendra

2011-02-01

The indications of caesarean section are increasing. The need to respect maternal desire in the decision making has been supported by law and ethics. Some of the other contributors to the increasing caesarean section rate are breech with failed external cephalic version, decreasing rate of trial of scar, increasing induction rate and electronic fetal heart rate monitoring and changing demography. Despite the adverse effects of caesarean section, the incidence of severe morbidity and mortality is low. The strategies put forward to reduce the caesarean section rate (CSR) have not been effective and in no country or province, the CSR has come down. CSR should not be looked at in isolation or as high or low. It is the product of changing obstetric practice and societal norms and demographics. CSR not reflect the performance of a maternity unit.

Determinants and trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh.

PubMed

Shahabuddin, A S M; Delvaux, Thérèse; Utz, Bettina; Bardají, Azucena; De Brouwere, Vincent

2016-09-15

To identify the determinants and measure the trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh. In order to measure the trends in health facility-based deliveries and caesarean sections, Bangladesh Demographic Health Survey (BDHS) data sets were analysed (BDHS; 1993-1994, 1996-1997, 1999-2000, 2004, 2007, 2011). The BDHS 2011 data sets were analysed to identify the determinants of health facility-based deliveries and caesarean sections. A total of 2813 adolescent girls (aged 10-19 years) were included for analysis. Bivariate and multivariate analyses were performed. Health facility-based deliveries have continuously increased among adolescents in Bangladesh over the past two decades from 3% in 1993-1994 to 24.5% in 2011. Rates of population-based and facility-based caesarean sections have increased linearly among all age groups of women including adolescents. Although the country's overall (population-based) caesarean section rate among adolescents was within acceptable range (11.6%), a rate of nearly 50% health facility level caesarean sections among adolescent girls is alarming. Among adolescent girls, use of antenatal care (ANC) appeared to be the most important predictor of health facility-based delivery (OR: 4.04; 95% CI 2.73 to 5.99), whereas the wealth index appeared as the most important predictor of caesarean sections (OR: 5.7; 95% CI 2.74 to 12.1). Maternal health-related interventions should be more targeted towards adolescent girls in order to encourage them to access ANC and promote health facility-based delivery. Rising trends of caesarean sections require further investigation on indication and provider-client-related determinants of these interventions among adolescent girls in Bangladesh. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

PubMed

Morisaki, N; Ganchimeg, T; Ota, E; Vogel, J P; Souza, J P; Mori, R; Gülmezoglu, A M

2014-03-01

To illustrate the variability in the use of antibiotic prophylaxis for caesarean section, and its effect on the prevention of postoperative infections. Secondary analysis of a cross-sectional study. Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. Three hundred and fifty-nine health facilities with the capacity to perform caesarean section. Descriptive analysis and effect estimates using multilevel logistic regression. Coverage of antibiotic prophylaxis for caesarean section. A total of 89 121 caesarean sections were performed in 332 of the 359 facilities included in the survey; 87% under prophylactic antibiotic coverage. Thirty five facilities provided 0-49% coverage and 77 facilities provided 50-89% coverage. Institutional coverage of prophylactic antibiotics varied greatly within most countries, and was related to guideline use and the practice of clinical audits, but not to the size, location of the institution or development index of the country. Mothers with complications, such as HIV infection, anaemia, or pre-eclampsia/eclampsia, were more likely to receive antibiotic prophylaxis. At the same time, mothers undergoing caesarean birth prior to labour and those with indication for scheduled deliveries were also more likely to receive antibiotic prophylaxis, despite their lower risk of infection, compared with mothers undergoing emergency caesarean section. Coverage of antibiotic prophylaxis for caesarean birth may be related to the perception of the importance of guidelines and clinical audits in the facility. There may also be a tendency to use antibiotics when caesarean section has been scheduled and antibiotic prophylaxis is already included in the routine clinical protocol. This study may act as a signal to re-evaluate institutional practices as a way to identify areas where improvement is possible. © 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Interventions for supporting pregnant women's decision-making about mode of birth after a caesarean.

PubMed

Horey, Dell; Kealy, Michelle; Davey, Mary-Ann; Small, Rhonda; Crowther, Caroline A

2013-07-30

Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth. To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth.Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies. All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted. Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors. Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters.We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%).There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women).More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women).Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met.Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload. Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.

Does attendance at a specialist antenatal clinic improve clinical outcomes in women with class III obesity compared with standard care? A retrospective case-note analysis.

PubMed

Denison, Fiona C; MacGregor, Heather; Stirrat, Laura I; Stevenson, Kerrie; Norman, Jane E; Reynolds, Rebecca M

2017-06-21

To determine whether attendance at a specialised multidisciplinary antenatal clinic for women with class III obesity (BMI >40 kg/m 2 ) is associated with improved clinical outcomes compared with standard antenatal care. Retrospective cohort study using routinely collected data from electronic patient record. Community and hospital based antenatal care. Women with a singleton pregnancy with class III obesity booked for antenatal care and delivered in one of two hospitals in NHS Lothian, Scotland, UK between 2008 and 2014. Maternal and offspring outcomes were compared in women who attended a specialised obesity clinic (n=511) compared with standard antenatal care (n=502). Included stillbirth, low birth weight, gestational diabetes, induction of labour and caesarean section. Compared with standard care, women receiving specialist care were less likely to have a stillbirth (OR 0.12, 95% CI 0.06 to 0.97) and a low birthweight baby (OR 0.57, 95% CI 0.33 to 0.99) and more likely to be screened for (100% vs 73.6%; p<0.001) and diagnosed with (26.0% vs 12.5%; p<0.001) gestational diabetes, to require induction of labour (38.4% vs 29.9%; p=0.009), an elective (20.3% vs 17.7%; p<0.001) and emergency (23.9% vs 20.3%; p<0.001) caesarean section and attend antenatal triage one or more times during pregnancy (77.7% vs 53.1%; p<0.001). Women attending the specialist clinic had a higher BMI (44.5 kg/m 2 (4.3) vs 43.2 kg/m 2 (3.1); p<0.001) and were more likely to be nulliparous (46.0% vs 24.9%; p<0.001). There were no other differences in maternal demographic or maternal and offspring outcomes between groups. Attendance at a specialised antenatal clinic for obesity is associated with reduced rates of stillbirth and low birth weight and improved detection of gestational diabetes. The improvement in clinical outcomes is associated with an increase in healthcare attendance to obstetric triage and clinical interventions including induction of labour and caesarean section. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Enterobius vermicularis infection with tuboovarian abscess and peritonitis occurring during pregnancy.

PubMed

Craggs, Barbara; De Waele, Elisabeth; De Vogelaere, Kristel; Wybo, Ingrid; Laubach, Monika; Hoorens, Anne; De Waele, Boudewijn

2009-12-01

Extraintestinal Enterobius vermicularis infections are rare but may occasionally affect the female genital tract. Although mostly asymptomatic or causing minor clinical problems, they may lead to severe infectious complications. Case report and review of the pertinent English language literature. A 31-year-old, 30-week-pregnant female was admitted with a clinical suspicion of appendicitis. At surgery, the appendix appeared normal, but generalized peritonitis of unclear origin was present. Eggs of Enterobius vermicularis were found upon microbiological and pathological examination. Because of persisting infectious disease, the patient underwent an elective caesarean section, and at that time the diagnosis of a right tuboovarian abscess was made, and salpingo-oophorectomy was performed. The pathology report confirmed the diagnosis of an E. vermicularis salpingo-oophoritis. This case was extraordinary because of a combination of tuboovarian abscess and generalized peritonitis with E. vermicularis infection occurring during late pregnancy. Ectopic enterobiasis should be considered in the differential diagnosis of pelvic infections of gynecological origin.

Spondylocostal dysostosis associated with right-sided polythelia, right-sided rib deformity and meningocoele: Case report with review of literature

PubMed Central

Rai, Narendra; Thakur, Neha; Khan, Naheed Zin; Dwivedi, Akhilesh Dutt

2015-01-01

Spondylocostal dysostosis (SCD) is a rare anomaly of axial skeleton due to flawed embryological development. A newborn baby boy with right-sided polythelia, meningocoele, fan-like configuration of third and fourth rib, fused fifth and sixth rib and third thoracic hemivertebra was delivered to a second gravid mother by elective caesarean section. Baby was active, cried immediately after birth, had normal muscle tone and reflexes. He passed urine and meconium within 24 h of birth. Based on clinical examination and radiological picture, a diagnosis of SCD with meningocele with right-sided polythelia was made. Our case is the first SCD with polythelia and meningocele in newborn. SCD with right-sided polythelia and rib deformity with neural tube defect (NTD) may be due to a genetic defect with the culprit genes missing. Further genetic and embryological studies might find a link between right-sided rib defects, polythelia and NTD. PMID:26962344

Human immunodeficiency virus type 1 mother-to-child transmission and prevention: successes and controversies.

PubMed

Cavarelli, M; Scarlatti, G

2011-12-01

The World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) estimated that an additional 370 000 new human immunodeficiency virus type 1 (HIV-1) infections occurred in children in 2009, mainly through mother-to-child transmission (MTCT). Intrapartum transmission contributes to approximately 20-25% of infections, in utero transmission to 5-10% and postnatal transmission to an additional 10-15% of cases. MTCT accounts for only a few hundred infected newborns in those countries in which services are established for voluntary counselling and testing of pregnant women, and a supply of antiretroviral drugs is available throughout pregnancy with recommendations for elective Caesarean section and avoidance of breastfeeding. The single-dose nevirapine regimen has provided the momentum to initiate MTCT programmes in many resource-limited countries; however, regimens using a combination of antiretroviral drugs are needed also to effectively reduce transmission via breastfeeding. 2011 The Association for the Publication of the Journal of Internal Medicine.

Orocervical foetus-in-foetu with prenatal sonographic diagnosis: a case report.

PubMed

Braimoh, Kolawole T; Abdulkadir, Adekunle Y; Balogun, Rabiu O

2008-12-04

Foetus-in-foetu is a very rare congenital abnormality where a malformed foetus is included within the body of another foetus. Less than 200 cases have been reported with over 80% occurring in the abdomen. Only three cases of cervical foetus in foetu have been reported. The present case of giant orocervical foetus-in-foetu appears to be an index case. This is a report of an extremely rare orocervical foetus-in-foetu with grotesque oddity diagnosed on prenatal ultrasonography at 35 weeks gestational age in a 28-year-old, G2P1+0, Nigerian woman who was unsure of her last menstrual date or month. The included foetus had two eyes, cranium, nose, long bones and a spine. The mother's attempts at vaginal delivery rather than the elective Caesarean delivery she was offered resulted in obstructed labour and intrauterine foetal demise. Giant cervical foetus-in-foetu is extremely rare. It could result in obstructed labour if vaginal delivery is attempted.

Orocervical foetus-in-foetu with prenatal sonographic diagnosis: a case report

PubMed Central

Braimoh, Kolawole T; Abdulkadir, Adekunle Y; Balogun, Rabiu O

2008-01-01

Introduction Foetus-in-foetu is a very rare congenital abnormality where a malformed foetus is included within the body of another foetus. Less than 200 cases have been reported with over 80% occurring in the abdomen. Only three cases of cervical foetus in foetu have been reported. The present case of giant orocervical foetus-in-foetu appears to be an index case. Case presentation This is a report of an extremely rare orocervical foetus-in-foetu with grotesque oddity diagnosed on prenatal ultrasonography at 35 weeks gestational age in a 28-year-old, G2P1+0, Nigerian woman who was unsure of her last menstrual date or month. The included foetus had two eyes, cranium, nose, long bones and a spine. The mother's attempts at vaginal delivery rather than the elective Caesarean delivery she was offered resulted in obstructed labour and intrauterine foetal demise. Conclusion Giant cervical foetus-in-foetu is extremely rare. It could result in obstructed labour if vaginal delivery is attempted. PMID:19055795

Hypothesis: proposals for the management of a neonate at risk of hyperammonaemia due to a urea cycle disorder.

PubMed

Leonard, James Vivian; Ward Platt, Martin Peter; Morris, Andrew Alan Myles

2008-03-01

It is difficult to prevent hyperammonaemia in patients with urea cycle disorders that present in the newborn period. This is true, even if treatment is started prospectively because of an affected relative. We propose several additional measures that could be used in conjunction with conventional therapy to improve the metabolic control. Catabolism could be reduced by delivering the babies by elective caesarean section, by starting intravenous glucose immediately after delivery and, possibly, by using beta-blockers or octreotide and insulin. The effectiveness of sodium benzoate and sodium phenylbutyrate might be increased by giving phenobarbital to the mother before delivery and subsequently to the baby to induce the enzymes for conjugation. We would expect the proposed measures to reduce the risk of hyperammonaemia and to improve the outcome for these patients. They have not, however, previously been used in this context, so families would need to be counselled carefully and controlled studies should be undertaken.

Support from a prenatal instructor during childbirth is associated with reduced rates of caesarean section in a Mexican study.

PubMed

Campero, Lourdes; Hernández, Bernardo; Osborne, Jomo; Morales, Sara; Ludlow, Teresa; Muñoz, Christian

2004-12-01

to assess the association between non-clinical factors and the incidence of caesarean section (CS); to estimate the effect of a prenatal instructor's presence during childbirth on birth outcome (vaginal or CS). cross-sectional study from a register of women who attended prenatal classes. Multivariate logistic regression was used to measure the effects of each variable on whether the birth was vaginal or CS. Mexico City, Mexico. 992 births to 847 women from the register of the Birth Education Centre (CEPAPAR) between 1987 and 2000. the incidence of CS was 33%. The most commonly reported (by the women) reason for performing a CS was dystocia (53%). Most women were middle or upper-middle class professionals, and 85% of the women gave birth in private institutions. Odds of having a CS were higher among women who gave birth in a large hospital, women who were over 25 years of age, primigravidae, and women who were not supported by a prenatal instructor during childbirth. non-clinical factors considerably affect the type of birth outcome (vaginal vs. CS). A system in which a prenatal instructor provided support to the woman during childbirth could contribute significantly to reducing initial and repeat CS.

Individual or group antenatal education for childbirth or parenthood, or both.

PubMed

Gagnon, A J; Sandall, J

2007-07-18

Structured antenatal education programs for childbirth or parenthood, or both, are commonly recommended for pregnant women and their partners by healthcare professionals in many parts of the world. Such programs are usually offered to groups but may be offered to individuals. To assess the effects of this education on knowledge acquisition, anxiety, sense of control, pain, labour and birth support, breastfeeding, infant-care abilities, and psychological and social adjustment. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2006), CINAHL (1982 to April 2006), ERIC (1984 to April 2006), EMBASE (1980 to April 2006) and PsycINFO (1988 to April 2006). We handsearched the Journal of Psychosomatic Research from 1956 to April 2006 and reviewed the reference lists of retrieved studies. Randomized controlled trials of any structured educational program provided during pregnancy by an educator to either parent that included information related to pregnancy, birth or parenthood. The educational interventions could have been provided on an individual or group basis. Educational interventions directed exclusively to either increasing breastfeeding success, knowledge of and coping skills concerning postpartum depression, improving maternal psycho-social health including anxiety, depression and self-esteem or reducing smoking were excluded. Both authors assessed trial quality and extracted data from published reports. Nine trials, involving 2284 women, were included. Thirty-seven studies were excluded. Educational interventions were the focus of eight of the studies (combined n = 1009). Details of the randomization procedure, allocation concealment, and/or participant accrual or loss for these trials were not reported. No consistent results were found. Sample sizes were very small to moderate, ranging from 10 to 318. No data were reported concerning anxiety, breastfeeding success, or general social support. Knowledge acquisition, sense of control, factors related to infant-care competencies, and some labour and birth outcomes were measured. The largest of the included studies (n = 1275) examined an educational and social support intervention to increase vaginal birth after caesarean section. This high-quality study showed similar rates of vaginal birth after caesarean section in 'verbal' and 'document' groups (relative risk 1.08, 95% confidence interval 0.97 to 1.21). The effects of general antenatal education for childbirth or parenthood, or both, remain largely unknown. Individualized prenatal education directed toward avoidance of a repeat caesarean birth does not increase the rate of vaginal birth after caesarean section.

Women's decision-making processes and the influences on their mode of birth following a previous caesarean section in Taiwan: a qualitative study.

PubMed

Chen, Shu-Wen; Hutchinson, Alison M; Nagle, Cate; Bucknall, Tracey K

2018-01-17

Vaginal birth after caesarean (VBAC) is an alternative option for women who have had a previous caesarean section (CS); however, uptake is limited because of concern about the risks of uterine rupture. The aim of this study was to explore women's decision-making processes and the influences on their mode of birth following a previous CS. A qualitative approach was used. The research comprised three stages. Stage I consisted of naturalistic observation at 33-34 weeks' gestation. Stage II involved interviews with pregnant women at 35-37 weeks' gestation. Stage III consisted of interviews with the same women who were interviewed postnatally, 1 month after birth. The research was conducted in a private medical centre in northern Taiwan. Using a purposive sampling, 21 women and 9 obstetricians were recruited. Data collection involved in-depth interviews, observation and field notes. Constant comparative analysis was employed for data analysis. Ensuring the safety of mother and baby was the focus of women's decisions. Women's decisions-making influences included previous birth experience, concern about the risks of vaginal birth, evaluation of mode of birth, current pregnancy situation, information resources and health insurance. In communicating with obstetricians, some women complied with obstetricians' recommendations for repeat caesarean section (RCS) without being informed of alternatives. Others used four step decision-making processes that included searching for information, listening to obstetricians' professional judgement, evaluating alternatives, and making a decision regarding mode of birth. After birth, women reflected on their decisions in three aspects: reflection on birth choices; reflection on factors influencing decisions; and reflection on outcomes of decisions. The health and wellbeing of mother and baby were the major concerns for women. In response to the decision-making influences, women's interactions with obstetricians regarding birth choices varied from passive decision-making to shared decision-making. All women have the right to be informed of alternative birthing options. Routine provision of explanations by obstetricians regarding risks associated with alternative birth options, in addition to financial coverage for RCS from National Health Insurance, would assist women's decision-making. Establishment of a website to provide women with reliable information about birthing options may also assist women's decision-making.

Does counsellor's attitude influence change in a request for a caesarean in women with fear of birth?

PubMed

Halvorsen, Lotta; Nerum, Hilde; Sørlie, Tore; Oian, Pål

2010-02-01

the attitudes of two counsellors towards women requesting a caesarean section due to fear of birth were identified. One emphasised the ability to overcome any emotional obstacle to vaginal birth ('coping attitude'), and the other emphasised that the ultimate choice of mode of birth was the womans' ('autonomy attitude'). Two research questions were asked: (1) What are the predictors of change in a wish for a caesarean and of vaginal birth in women with fear of birth? (2) Does a change from an 'autonomy attitude' to a 'coping attitude' increase the number of women who change their request for a caesarean and who give birth vaginally? the study population consisted of two samples of pregnant women with fear of birth and concurrent request for a caesarean, referred for crisis-oriented counselling at the antenatal clinic, University Hospital of North Norway between 2000-2002 (n=86) and 2004-2006 (n=107). Data were gathered from referral letters, counseling and antenatal, intra- and postpartum records. a coping attitude of the counsellor was positively associated with change in the request for a caesarean and with vaginal birth. A change from an autonomy attitude to a coping attitude was associated with a significant increase in the percentage of women who changed their desire for a caesarean from 77 to 93, and who had a vaginal birth from 42 to 81. a coping attitude was strongly associated with change in the desire for a caesarean and giving birth vaginally. A coping attitude can be learned through critical reflection and awareness of the counsellor's attitude, with measurable clinical results. Copyright 2008 Elsevier Ltd. All rights reserved.

International migration and caesarean birth: a systematic review and meta-analysis.

PubMed

Merry, Lisa; Small, Rhonda; Blondel, Béatrice; Gagnon, Anita J

2013-01-30

Perinatal health disparities including disparities in caesarean births have been observed between migrant and non-migrant women and some literature suggests that non-medical factors may be implicated. A systematic review was conducted to determine if migrants in Western industrialized countries consistently have different rates of caesarean than receiving-country-born women and to identify the reasons that explain these differences. Reports were identified by searching 12 literature databases (from inception to January 2012; no language limits) and the web, by bibliographic citation hand-searches and through key informants. Studies that compared caesarean rates between international migrants and non-migrants living in industrialized countries and that did not have a 'fatal flaw' according to the US Preventative Services Task Force criteria were included. Studies were summarized, analyzed descriptively and where possible, meta-analyzed. Seventy-six studies met inclusion criteria. Caesarean rates between migrants and non-migrants differed in 69% of studies. Meta-analyses revealed consistently higher overall caesarean rates for Sub-Saharan African, Somali and South Asian women; higher emergency rates for North African/West Asian and Latin American women; and lower overall rates for Eastern European and Vietnamese women. Evidence to explain the consistently different rates was limited. Frequently postulated risk factors for caesarean included: language/communication barriers, low SES, poor maternal health, GDM/high BMI, feto-pelvic disproportion, and inadequate prenatal care. Suggested protective factors included: a healthy immigrant effect, preference for a vaginal birth, a healthier lifestyle, younger mothers and the use of fewer interventions during childbirth. Certain groups of international migrants consistently have different caesarean rates than receiving-country-born women. There is insufficient evidence to explain the observed differences.

Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention

PubMed Central

Burns, Christy Turlington; Metzler, Ian S.; Farmer, Paul E.; Meara, John G.

2012-01-01

Background Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand. Methods and Findings Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to $3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL. Conclusions Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered “highly cost-effective” for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study. PMID:22558089

International migration and caesarean birth: a systematic review and meta-analysis

PubMed Central

2013-01-01

Background Perinatal health disparities including disparities in caesarean births have been observed between migrant and non-migrant women and some literature suggests that non-medical factors may be implicated. A systematic review was conducted to determine if migrants in Western industrialized countries consistently have different rates of caesarean than receiving-country-born women and to identify the reasons that explain these differences. Methods Reports were identified by searching 12 literature databases (from inception to January 2012; no language limits) and the web, by bibliographic citation hand-searches and through key informants. Studies that compared caesarean rates between international migrants and non-migrants living in industrialized countries and that did not have a ‘fatal flaw’ according to the US Preventative Services Task Force criteria were included. Studies were summarized, analyzed descriptively and where possible, meta-analyzed. Results Seventy-six studies met inclusion criteria. Caesarean rates between migrants and non-migrants differed in 69% of studies. Meta-analyses revealed consistently higher overall caesarean rates for Sub-Saharan African, Somali and South Asian women; higher emergency rates for North African/West Asian and Latin American women; and lower overall rates for Eastern European and Vietnamese women. Evidence to explain the consistently different rates was limited. Frequently postulated risk factors for caesarean included: language/communication barriers, low SES, poor maternal health, GDM/high BMI, feto-pelvic disproportion, and inadequate prenatal care. Suggested protective factors included: a healthy immigrant effect, preference for a vaginal birth, a healthier lifestyle, younger mothers and the use of fewer interventions during childbirth. Conclusion Certain groups of international migrants consistently have different caesarean rates than receiving-country-born women. There is insufficient evidence to explain the observed differences. PMID:23360183

Short hospitalization after caesarean delivery: effects on maternal pain and stress at discharge.

PubMed

Zanardo, Vincenzo; Giliberti, Lara; Volpe, Francesca; Simbi, Alphonse; Guerrini, Pietro; Parotto, Matteo; Straface, Gianluca

2018-09-01

To characterize predischarge maternal pain and stress after caesarean delivery and short hospitalization. This is a descriptive study with 60 women in the postoperative period of caesarean section and 60 control women after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Stress Measure (Psychological Stress Measure (PSM)), respectively, at mother-infant dyad discharge, scheduled at 36 hours after delivery. Caesarean section was the delivery modality with the highest MGPQ pain and sensorial, evaluative and mixed pain descriptive categories scores. The pain location involved lower abdomen, with associated localizations at back, breast and shoulders. Conversely, vaginal delivery was the delivery modality with the highest stress scores. This study provides important information on the quality of care implications of early discharge practices in puerperae after caesarean delivery, a critical time characterized by qualitatively and quantitatively high pain and stress.

Maternal mortality following caesarean sections.

PubMed

Sikdar, K; Kundu, S; Mandal, G S

1979-08-01

A study of 26 maternal deaths following 3647 caesarean sections was conducted in Eden Hospital from 1974-1977. During the time period there were 35,544 births and 308 total maternal deaths (8.74/1000). Indications for Caesarean sections included: 1) abnormal presentation; 2) cephalopelvic disproportion; 3) toxemia; 4) prolonged labor; 5) fetal distress; and 6) post-caesarean pregnancies. Highest mortality rates were among cephalopelvic disproportion, toxemia, and prolonged labor patients. 38.4% of the patients died due to septicaemia and peritonitis, but other deaths were due to preclampsia, shock, and hemorrhage. Proper antenatal care may have prevented anemia and preclampsia and treated other pre-existing or superimposed diseases.

Caesarean section: an historical riddle.

PubMed

Majumdar, S K

2001-01-01

Etymologically, the word 'Caesar' originates from the Latin word 'Caedaere' meaning - 'to cut'. So cutting remains the core point, but little is known about the real origin of the history of Caesarean Section. There is evidence that, the ancient Hindus excelled in surgery and many operations were performed, including caesarean section. This operation was mentioned several times in the Mishnah of Rabbi Judah, the first large commentary on the Hebrew Bible. There are also several mythological anecdotes in Hindu, Buddhist and Greek mythologies. The myth of caesarean section did not even escape the keen eyes of William Skakespeare. The landmarks, treatises and the advancement in this operative procedure are presented in this article.

Developments in caesarean section techniques: a review.

PubMed

Uzoigwe, S A; Jeremiah, I

2006-01-01

Caesarean section is the most common surgical procedure performed on women world-wide. It is recommended when vaginal delivery might pose a risk to the mother or baby. This review examines the history and developments in caesarean section techniques over the years as well as the difficulties that may be encountered in each stage in our environment. A review of relevant literature was conducted using Pubmed and e-medicine websites for computer search. The following keywords were used: history, development, techniques and caesarean section. Relevant review articles, Cochrane database and chapters in text books were also used to extract information. Though practiced since ancient times, the history of caesarean section remains shrouded in myths as no document describing its indication and techniques is still available. Ancient medical writers like Galen, Hippocrates and Soranus made no mention of the procedure. However, the evidence that it was performed arose from legal texts. The development in its technique was gradual over many years. The development of caesarean section technique occurred with the withdrawal of surgeries from the stronghold of religion in Renaissance time. Operative techniques vary and this has continued to improve through many years of trial and error.

Chewing gum for intestinal function recovery after caesarean section: a systematic review and meta-analysis.

PubMed

Wen, Zunjia; Shen, Meifen; Wu, Chao; Ding, Jianping; Mei, Binbin

2017-04-18

Gum chewing has been reported to enhance the intestinal function recovery after caesarean section, current perspectives and practice guidelines vary widely on the use of gum chewing, more studies on the role of gum chewing after caesarean section are needed. We performed a comprehensive, systematic meta-analysis of randomized controlled trials (RCTs) on the efficacy of gum chewing after caesarean section. Studies were identified by searching EMBASE et al database (until June 30, 2016). Summary odd ratios or weighted mean differences with 95% confidence intervals were calculated for each outcome with fixed- or random-effects model. Ten RCTs with a total of 1659 women were included in our meta-analysis. Gum chewing provided significant benefits in reducing the time to first passage of flatus, first defecation, first bowel sound, first bowel movement and the length of hospital stay, but not in the time to first feeling of hunger. Gun chewing hastens the intestinal function recovery after caesarean section and offers a safe and inexpensive option. High-quality and larger-scale RCTs are still warranted to clarify the role of gum chewing in intestinal function recovery after caesarean section.

Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

PubMed Central

Boatin, Adeline Adwoa; Schlotheuber, Anne; Betran, Ana Pilar; Moller, Ann-Beth; Barros, Aluisio J D; Boerma, Ties; Torloni, Maria Regina; Victora, Cesar G

2018-01-01

Abstract Objective To provide an update on economic related inequalities in caesarean section rates within countries. Design Secondary analysis of demographic and health surveys and multiple indicator cluster surveys. Setting 72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time. Participants Women aged 15-49 years with a live birth during the two or three years preceding the survey. Main outcome measures Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change. Results National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries. Conclusions Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health. PMID:29367432

Caesarean birth rates in public and privately funded hospitals: a cross-sectional study.

PubMed

Alonso, Bruna Dias; Silva, Flora Maria Barbosa da; Latorre, Maria do Rosário Dias de Oliveira; Diniz, Carmen Simone Grilo; Bick, Debra

2017-01-01

To examine maternal and obstetric factors influencing births by cesarean section according to health care funding. A cross-sectional study with data from Southeastern Brazil. Caesarean section births from February 2011 to July 2012 were included. Data were obtained from interviews with women whose care was publicly or privately funded, and from their obstetric and neonatal records. Univariate and multivariate analyses were conducted to generate crude and adjusted odds ratios (OR) with 95% confidence intervals (95%CI) for caesarean section births. The overall caesarean section rate was 53% among 9,828 women for whom data were available, with the highest rates among women whose maternity care was privately funded. Reasons for performing a c-section were infrequently documented in women's maternity records. The variables that increased the likelihood of c-section regardless of health care funding were the following: paid employment, previous c-section, primiparity, antenatal and labor complications. Older maternal age, university education, and higher socioeconomic status were only associated with c-section in the public system. Higher maternal socioeconomic status was associated with greater likelihood of a caesarean section birth in publicly funded settings, but not in the private sector, where funding source alone determined the mode of birth rather than maternal or obstetric characteristics. Maternal socioeconomic status and private healthcare funding continue to drive high rates of caesarean section births in Brazil, with women who have a higher socioeconomic status more likely to have a caesarean section birth in all birth settings.

[Caesarean section with vacuum extraction of the head].

PubMed

Dimitrov, A; Pavlova, E; Krŭsteva, K; Nikolov, A

2008-01-01

The aim of the study is to investigate the benefits and the limits in using the soft cup vacuum extractor on the fetal scalp during the caesarean section. The prospective study includes 19 cases of caesarean sections (group A), with vacuum assisted delivery using the soft cup vacuum extractor on the fetal scalp (diameter 6 cm) and 25 cases (group B) of caesarean sections with usual, manual extraction of the head assisted by fundal compression. All of the patients had undergone a planned caesarean section on term in absence of uterine activity and preserved amniotic membranes. Our results doesn't show differences in the Apgar score on the first and 5-th minute in the newborns of the two groups. The duration of the scalp traction was significantly shorter (30 +/- 4 sec) in comparison to the classical manual extraction (53 +/- 21 sec). The mean duration for applying the vacuum cup was 10 sec and 25 sec for tractions. The total blood loose and total duration of the caesarean sections were shorter than in the control group. The applied traction with the vacuum cup was sufficient for head extraction and there was no need for additional fundal compression. In conclusion we consider that the extraction of the fetal head in high position in caesarean section with vacuum extractor is an easy, non traumatic and rapid method which can put away the need of rough and prolonged fundal compression and its consequences.

Trends of Various Techniques of Tubectomy: A Five Year Study in a Tertiary Institute

PubMed Central

Prasanna, Naveen; Channabasappa, Ramalingappa Antartani

2016-01-01

Introduction Female sterilization is one of the best and effective methods of contraception for women who have completed their family. Tubectomy during caesarean operation and minilaparotomy are popular methods in developing countries whereas laparoscopic sterilization and hysteroscopic tubal occlusion are the preferred methods in developed countries. Aim To know the trends, incidence and immediate complications of methods of female sterilizations performed at our institute. Materials and Methods This is a retrospective analytical study conducted at our tertiary care centre from January 2010 to December 2014 in Karnataka Institute of Medical Sciences, Hubli, Karnataka. The case files of all the patients who underwent sterilization were taken from the medical records section and reviewed in detail. The cases were grouped as caesarean tubectomy, minilaparotomy and laparoscopic sterilization, based on the abdominal entry. For minilaparotomy and during caesarean tubectomy, modified pomeroy’s technique was used. For laparoscopic sterilization, falope rings were used. Data was analysed by Karl Pearson’s correlation co-efficient method and Chi-Square test. The p-value < 0.05 was considered significant. Results Out of 5442 cases of female sterilization, 2872 underwent caesarean tubectomy, remaining half underwent minilaparotomy (1306) and laparoscopic sterilization (1264). Sterilizations were significantly more during puerperal period (caesarean tubectomy + post abortal + postpartum) compared to interval period. There was an increasing trend in caesarean tubectomy and laparoscopic sterilization. There were 11 procedure related complications in the laparoscopic sterilization, one in caesarean tubectomy and none in minilaparotomy. Two deaths were reported in minilaparotomy, one in laparoscopic sterilization and four in the caesarean tubectomy, which were due to septicaemia. Conclusion An increasing trend in caesarean tubectomy and laparoscopic sterilization is seen in this study. Female sterilization should be individualized based on the timing, place and surgeons experience. Sepsis is a major cause of death and asepsis could be compromised when female sterilization is done in large numbers in camps. Hence target related approach towards female sterilization should be avoided. Laparoscopic sterilization has more procedure related complications, which can be better handled in tertiary care centres. PMID:26894125

Rate of caesarean sections according to the Robson classification: Analysis in a French perinatal network - Interest and limitations of the French medico-administrative data (PMSI).

PubMed

Lafitte, A-S; Dolley, P; Le Coutour, X; Benoist, G; Prime, L; Thibon, P; Dreyfus, M

2018-02-01

The objective of our study was to determine, in accordance with WHO recommendations, the rates of Caesarean sections in a French perinatal network according to the Robson classification and determine the benefit of the medico-administrative data (PMSI) to collect this indicator. This study aimed to identify the main groups contributing to local variations in the rates of Caesarean sections. A descriptive multicentric study was conducted in 13 maternity units of a French perinatal network. The rates of Caesarean sections and the contribution of each group of the Robson classification were calculated for all Caesarean sections performed in 2014. The agreement of the classification of Caesarean sections according to Robson using medico-administrative data and data collected in the patient records was measured by the Kappa index. We also analysed a 6 groups simplified Robson classification only using data from PMSI, which do not inform about parity and onset of labour. The rate of Caesarean sections was 19% (14.5-33.2) in 2014 (2924 out of 15413 deliveries). The most important contributors to the total rates were groups 1, 2 and 5, representing respectively 14.3%, 16.7% and 32.1% of the Caesarean sections. The rates were significantly different in level 1, 2b and 3 maternity units in groups 1 to 4, level 2a maternity units in group 5, and level 3 maternity units in groups 6 and 7. The agreement between the simplified Robson classification produced using the medical records and the medico-administrative data was excellent, with a Kappa index of 0.985 (0.980-0.990). To reduce the rates of Caesarean sections, audits should be conducted on groups 1, 2 and 5 and local protocols developed. Simply by collecting the parity data, the excellent metrological quality of the medico-administrative data would allow systematisation of the Robson classification for each hospital. Copyright © 2017. Published by Elsevier Masson SAS.

Residual Angina After Elective Percutaneous Coronary Intervention in Patients With Diabetes Mellitus.

PubMed

Grodzinsky, Anna; Kosiborod, Mikhail; Tang, Fengming; Jones, Philip G; McGuire, Darren K; Spertus, John A; Beltrame, John F; Jang, Jae-Sik; Goyal, Abhinav; Butala, Neel M; Yeh, Robert W; Arnold, Suzanne V

2017-09-01

Previous studies suggest that among patients with stable coronary artery disease, patients with diabetes mellitus (DM) have less angina and more silent ischemia when compared with those without DM. However, the burden of angina in diabetic versus nondiabetic patients after elective percutaneous coronary intervention (PCI) has not been recently examined. In a 10-site US PCI registry, we assessed angina before and at 1, 6, and 12 months after elective PCI with the Seattle Angina Questionnaire angina frequency score (range, 0-100, higher=better). We also examined the rates of antianginal medication prescriptions at discharge. A multivariable, repeated-measures Poisson model was used to examine the independent association of DM with angina over the year after treatment. Among 1080 elective PCI patients (mean age, 65 years; 74.7% men), 34.0% had DM. At baseline and at each follow-up, patients with DM had similar angina prevalence and severity as those without DM. Patients with DM were more commonly prescribed calcium channel blockers and long-acting nitrates at discharge (DM versus not: 27.9% versus 20.9% [ P =0.01] and 32.8% versus 25.5% [ P =0.01], respectively), whereas β-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated-measures model, the risk of angina was similar over the year after PCI in patients with versus without DM (relative risk, 1.04; range, 0.80-1.36). Patients with stable coronary artery disease and DM exhibit a burden of angina that is at least as high as those without DM despite more antianginal prescriptions at discharge. These findings contradict the conventional teachings that patients with DM experience less angina because of silent ischemia. © 2017 American Heart Association, Inc.

Comparison effect of oral propranolol and oxytocin versus oxytocin only on induction of labour in nulliparous women (a double blind randomized trial).

PubMed

Moghadam, Ashraf Direkvand; Jaafarpour, Molouk; Khani, Ali

2013-11-01

Today, research on new methods for preventing caesarean sections owing to labour induction, have been requested in obstetric practice, because of the increased morbidity related to caesarean section. Therefore, the aim of this study was to compare the effect of Oral Propranolol and Oxytocin versus Oxytocin only on induction of labour in nulliparous women. A double blind randomized controlled trial was performed at the Ilam Mostafa Hospital, Ilam, Iran, from March 2010 to March 2011 on 146 nulliparous pregnant women who had gestational age of 40-42 weeks of pregnancy and a Bishop score of ≤5. Participants were divided in two groups (with 73 participants in each group). In the first group (placebo plus Oxytocin group = 73), Oxytocin was used for the induction of labour. In the second group (Propranolol plus Oxytocin group = 73 cases), before the use of Oxytocin, 20 mg Propranolol was administrated orally and then the Oxytocin was initiated. Twenty mg Propranolol was repeated after 8 hours if good contraction was not obtained. The mean duration for obtaining good contractions was significantly shorter in the Propranolol group than in the placebo group, on both the first and second day of induction (p<.05). The mean duration of latent phase was shorter in the first in Propranolol group (p<.05). In Propranolol plus Oxytocine group, frequency of cesarean deliveries significantly decreased than in the placebo plus Oxytocin group (21% versus 39.7%). No significant differences in neonate outcome, such as Apgar scores of minutes 1 and 5 and need of admissions to NICU, were found between the groups (p>.05) DISCUSSION AND CONCLUSION: Our study showed that oral Propranolol was effective for labour induction and that it could decrease the frequency of caesarean deliveries without producing any adverse effects on mothers or neonates.

[What type of delivery for twins?].

PubMed

Vendittelli, F; Accoceberry, M; Savary, D; Laurichesse-Delmas, H; Gallot, D; Jacquetin, B; Lémery, D

2009-12-01

To determine if perinatal and neonatal morbidity and mortality is improved by a planned caesarean section for twins before and at term. A systematic search was conducted in Medline between May 2001 and December 2008. Randomised controlled studies and meta-analysis were researched at first. There is no evidence to support a policy of planned caesarean section or vaginal delivery for twins before term or at term whatever the presentation of the first twin. There is also no evidence to support a policy of caesarean section or vaginal delivery for a patient with a history of prior caesarean section. Vaginal delivery must be made in the presence of an obstetrician, an anaesthesiologist, and a paediatrician in a level maternity adapted to the risks of the future newborn. Otherwise, there is no evidence to support a policy of planned caesarean delivery for twins but the type of delivery has to be decided with the informed patient. Copyright © 2009 Elsevier Masson SAS. All rights reserved.

Characteristics in the first vaginal birth and their association with mode of delivery in the subsequent birth.

PubMed

Chen, Jian Sheng; Ford, Jane B; Ampt, Amanda; Simpson, Judy M; Roberts, Christine L

2013-03-01

The extent to which complications or adverse outcomes in a first vaginal birth may contribute to mode of delivery in the next birth remains unclear. This study examines the impact of the first birth on subsequent mode of delivery. The study population included women with a first vaginal birth and a consecutive second birth. Data were obtained from linked birth and hospital records for the state of New South Wales, Australia 2000-09. The primary outcome was the mode of delivery for the second birth. Planned caesarean was modelled using logistic regression; intrapartum caesarean and instrumental delivery were modelled using multinomial logistic regression. Of the 114 287 second births, 4.2% were planned caesarean, 3.0% were intrapartum caesarean and 4.8% were instrumental deliveries. Adjusted risk factors from the first birth for a planned second birth caesarean were third to fourth degree tear [odds ratio (OR) = 5.0 [95% confidence interval (CI) 4.6, 5.4

The efficacy and safety of external cephalic version after a previous caesarean delivery.

PubMed

Weill, Yishay; Pollack, Raphael N

2017-06-01

External cephalic version (ECV) in the presence of a uterine scar is still considered a relative contraindication despite encouraging studies of the efficacy and safety of this procedure. We present our experience with this patient population, which is the largest cohort published to date. To evaluate the efficacy and safety of ECV in the setting of a prior caesarean delivery. A total of 158 patients with a fetus presenting as breech, who had an unscarred uterus, had an ECV performed. Similarly, 158 patients with a fetus presenting as breech, and who had undergone a prior caesarean delivery also underwent an ECV. Outcomes were compared. ECV was successfully performed in 136/158 (86.1%) patients in the control group. Of these patients, 6/136 (4.4%) delivered by caesarean delivery. In the study group, 117/158 (74.1%) patients had a successful ECV performed. Of these patients, 12/117 (10.3%) delivered by caesarean delivery. There were no significant complications in either of the groups. ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

An anthropological analysis of the perspectives of Somali women in the West and their obstetric care providers on caesarean birth.

PubMed

Essén, Birgitta; Binder, Pauline; Johnsdotter, Sara

2011-03-01

We explored the perceptions of 39 Somali women and 62 obstetric care providers in London in relation to caesarean birth, as borne out of a paradox we recognised from evidence-based information about the Somali group. Socio-cultural factors potentially leading to adverse obstetric outcome were identified using in-depth and focus group interviews with semi-structured, open-ended questions. A cultural anthropology model, the emic/etic model, was used for analysis. Somali women expressed fear and anxiety throughout the pregnancy and identified strategies to avoid caesarean section (CS). There was widespread, yet anecdotal, awareness among obstetric care providers about negative Somali attitudes. Caesarean avoidance and refusal were expressed as being highly stressful among providers, but also as being the responsibility of the women and families. For women, avoiding or refusing caesarean was based on a rational choice to avoid death and coping with adverse outcome relied on fatalistic attitudes. Motivation for the development of preventive actions among both groups was not described, which lends weight to the vast distinction and lack of correspondence in identified perspectives between Somali women and UK obstetric providers. Early booking and identification of women likely to avoid caesarean is proposed, as is the development of preventive strategies to address CS avoidance.

Caesarean section deliveries: Experiences of mothers of midwifery care at a public hospital in Nelson Mandela Bay.

PubMed

Jikijela, Thobeka P; James, Sindiwe; Sonti, Balandeli S I

2018-01-30

The rate of caesarean section deliveries has increased globally and mothers are faced with challenges of postoperative recovery and caring thereof. Midwives have a duty to assist these mothers to self-care. The objective was to explore and describe experiences of post-caesarean section delivered mothers of midwifery care at a public hospital in Nelson Mandela Bay. A qualitative, descriptive and explorative research design was used in the study. Data were collected from 11 purposively criterion-selected mothers who had a caesarean section delivery. One-on-one semi-structured interviews were conducted in the post-natal wards. Research ethics, namely autonomy, beneficence, justice and informed consent, were adopted in the study. All participants were informed of their right to withdraw from the study at any stage without penalties. Interviews were analysed using Tesch's method of data analysis. Three main themes were identified as experiences of: diverse pain, physical limitation and frustration and health care services as different. Experiences of mothers following a caesarean section delivery with midwifery services at a public hospital in Nelson Mandela Bay were explored and described as diverse. A need for adequate pain management as well as assistance and breastfeeding support to mothers following caesarean delivery was identified as crucial to promote a good mother-to-child relationship.

Factors influencing rising caesarean section rates in China between 1988 and 2008.

PubMed

Feng, Xing Lin; Xu, Ling; Guo, Yan; Ronsmans, Carine

2012-01-01

To identify factors driving the rapid increase in caesarean section in China between 1988 and 2008. Data from four national cross-sectional surveys (1993, 1998, 2003 and 2008) and modified Poisson regression were used to determine whether changes in household income, access to health insurance or women's education accounted for the rise in caesarean sections in urban and rural areas. In 2008, 64.1% of urban women and 11.3% of women in the poorest rural region reported giving birth by caesarean section. A fast rise was occurring in all socioeconomic groups. Between 1993 and 2008, the risk of caesarean section had increased more than threefold in urban areas (relative risk, RR: 3.63; 95% confidence interval, CI: 2.61-5.04) and more than 15-fold in rural areas (RR: 15.46; 95% CI: 10.46-22.86). After adjustment for improvements in income, education and access to health insurance over the study period, the RR dropped minimally in urban areas (RR: 3.07; 95% CI: 2.32-4.07), which suggests that these factors do not explain the rise; in rural areas, the adjusted RR dropped to 7.18 (95% CI: 4.82-10.69), which shows that socioeconomic change is only partly responsible for the rise. Socioeconomic region of residence was a more important driver of the caesarean section rate than individual socioeconomic status. The large variation in caesarean section rate by socioeconomic region--independent of individual income, health insurance or education--suggests that structural factors related to service supply have influenced the increasing rate more than a woman's ability to pay.

Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study.

PubMed

Belachew, J; Cnattingius, S; Mulic-Lutvica, A; Eurenius, K; Axelsson, O; Wikström, A K

2014-01-01

To evaluate whether women with a caesarean section at their first delivery have an increased risk of retained placenta at their second delivery. Population-based cohort study. Sweden. All women with their first and second singleton deliveries in Sweden during the years 1994-2006 (n = 258,608). Women with caesarean section or placental abruption in their second pregnancy were not included in the study population. The risk of retained placenta at second delivery was estimated for women with a first delivery by caesarean section (n = 19,458), using women with a first vaginal delivery as reference (n = 239,150). Risks were calculated as odds ratios by unconditional logistic regression analysis with 95% confidence intervals (95%) after adjustments for maternal, delivery, and infant characteristics. Retained placenta with normal (≤1000 ml) and heavy (>1000 ml) bleeding. The overall rate of retained placenta was 2.07%. In women with a previous caesarean section and in women with previous vaginal delivery, the corresponding rates were 3.44% and 1.96%, respectively. Compared with women with a previous vaginal delivery, women with a previous caesarean section had an increased risk of retained placenta (adjusted OR 1.45; 95% CI 1.32-1.59), and the association was more pronounced for retained placenta with heavy bleeding (adjusted OR 1.61; 95% CI 1.44-1.79). Our report shows an increased risk for retained placenta in women previously delivered by caesarean section, a finding that should be considered in discussions of mode of delivery. © 2013 Royal College of Obstetricians and Gynaecologists.

Caesarean section and asthma in Malaysian children: a case-control study.

PubMed

Nathan, Anna Marie; de Bruyne, Jessie; Khalid, Farah; Arumugam, Kulantheran

2012-09-01

Birth cohort studies in some countries have shown a link between caesarean section and asthma. To determine if there is an association between asthma and delivery via caesarean section in Malaysian children. This is a case-control study involving 156 children aged 3-15 years old, in a tertiary hospital in Kuala Lumpur, Malaysia. Seventy-eight children with a confirmed diagnosis of asthma and seventy-eight age-matched controls (no history of asthma or wheezing) were enrolled. Demographic data including mode of delivery and family history of allergic disorders was obtained. Total serum immunoglobulin E (IgE) was measured and skin prick tests (SPT) to 6 common aeroallergens were performed. The median age of the patients was 8 years old. One hundred and three (66%) children were delivered via normal vaginal delivery, 8 (5.1%) via assisted vaginal delivery and 45 children (28.9%) via caesarean section. Delivery via caesarean section was not significantly associated with asthma (OR = 1.21 [95% CI 0.60-2.41], p = 0.596). Children delivered via caesarean section did not have higher IgE levels nor were they more sensitized to aeroallergens. Multiple logistic regression showed that asthma was significantly associated with a positive family history of atopy (OR = 13.8 [95% CI 5.96, 32.1], p < 0.001). Introduction of semi-solid food after 6 months old had a protective effect against asthma (OR = 0.97 [95% CI 0.94, 0.99], p = 0.034). Childhood asthma in Malaysian children was not associated with delivery by caesarean section.

The Collision of Athletics & Consolidation

ERIC Educational Resources Information Center

Graves, Bill

2010-01-01

For decades, people questioned the sense of having two school districts, each with its own superintendent, central office and high school, operating in the same small town of The Dalles on the banks of the Columbia River in north-central Oregon. But election campaigns to consolidate repeatedly failed because each community had strong emotional…

Music during caesarean section under regional anaesthesia for improving maternal and infant outcomes.

PubMed

Laopaiboon, Malinee; Lumbiganon, Pisake; Martis, Ruth; Vatanasapt, Patravoot; Somjaivong, Busaba

2009-04-15

Evidence on the benefits of music during caesarean section under regional anaesthesia to improve clinical and psychological outcomes for mothers and infants has not been established. To evaluate the effectiveness of music during caesarean section under regional anaesthesia for improving clinical and psychological outcomes for mothers and infants. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2008). We included randomised controlled trials comparing music added to standard care during caesarean section under regional anaesthesia to standard care alone. Two review authors, Malinee Laopaiboon and Ruth Martis, independently assessed eligibility, risk of bias in included trials and extracted data. We analysed continuous outcomes using a mean difference (MD) with a 95% confidence interval (CI). One trial involving 76 women who planned to have their babies delivered by caesarean section met the inclusion criteria, but data were available for only 64 women. This trial was of low quality with unclear allocation concealment and only a few main clinical outcomes reported for the women. The trial did not report any infant outcomes. It appears that music added to standard care during caesarean section under regional anaesthesia had some impact on pulse rate at the end of maternal contact with the neonate in the intra-operative period (MD -7.50 fewer beats per minute, 95% CI -14.08 to -0.92) and after completion of skin suture for the caesarean section (MD -7.37 fewer beats per minute, 95% CI -13.37 to -1.37). There was also an improvement in the birth satisfaction score (maximum possible score of 35) (MD of 3.38, 95%CI 1.59 to 5.17). Effects on other outcomes were either not significant or not reported in the one included trial. The findings indicate that music during planned caesarean section under regional anaesthesia may improve pulse rate and birth satisfaction score. However, the magnitude of these benefits is small and the methodological quality of the one included trial is questionable. Therefore, the clinical significance of music is unclear. More research is needed to investigate the effects of music during caesarean section under regional anaesthesia on both maternal and infant outcomes, in various ethnic pregnant women, and with adequate sample sizes.

Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia.

PubMed

Shaw, Jonathan G; Asch, Steven M; Katon, Jodie G; Shaw, Kate A; Kimerling, Rachel; Frayne, Susan M; Phibbs, Ciaran S

2017-05-01

Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy. This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery). Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery. The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health. © 2017 John Wiley & Sons Ltd.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study.

PubMed

Hsia, Renee Y; Akosa Antwi, Yaa; Weber, Ellerie

2014-01-15

To examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Hospital charges and discounted prices adjusted for each patient's clinical and demographic characteristics. We analysed 76 766 vaginal deliveries and 32 660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3296 or as much as US$37 227 for a vaginal delivery, and US$8312-US$70 908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35-36% of the between-hospital variation in charges. These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups-uncomplicated vaginal delivery and caesarean section-vary widely between hospitals and are not well explained by observable patient or hospital characteristics.

Is place of birth associated with mode of birth? The effect of hospital on caesarean section rates in a public metropolitan health service.

PubMed

Biro, Mary A; Knight, Michelle; Wallace, Euan; Papacostas, Kerrie; East, Christine

2014-02-01

The effects of place of birth on birth outcomes have been examined in several studies both locally and internationally. However, none has examined the impact on caesarean section rates of different level maternity hospitals operating within the one health service. This study aimed to examine the impact of place of (Hospital level 6; 4-5 or 4) on birth outcomes in a large metropolitan health service in Victoria. A cross-sectional study utilising data on births to low-risk first-time mothers during 2010-2011. Data were obtained from the Birthing Outcome System (BOS) database of Monash Health. Unadjusted and adjusted analyses were undertaken using logistic regression to examine the association between place of birth and caesarean section. In this group of low-risk nulliparae, there was evidence of a significant association between place of birth and caesarean section. The lower the acuity of the hospital, the higher the odds for the caesarean section. Compared with the level 6 hospital, the AdjOR for caesarean section at the level 4 hospital was 1.81 (95% CI: 1.37-2.41) and at the level 4-5 hospital, 1.30 (95% CI: 1.0-1.7). Low-risk nulliparae in spontaneous labour giving birth at the level 4 hospital in this health service are at significantly increased risk of caesarean section. This may have implications for the organisation and resource management of other level 4 public maternity units. Care in a tertiary (level 6) service may not necessarily equate to the higher rates of intervention reported by others. © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Introduction of the Misgav Ladach caesarean section at an African tertiary centre: a randomised controlled trial.

PubMed

Björklund, K; Kimaro, M; Urassa, E; Lindmark, G

2000-02-01

To determine whether the Misgav Ladach caesarean section technique can offer benefits compared with conventional caesarean section technique in the prevailing conditions of a busy African tertiary centre. A randomised controlled trial. A tertiary African obstetric unit with 18,000 deliveries annually. Three hundred and thirty-nine women undergoing caesarean section. Eight residents and registrars were instructed in the Misgav Ladach technique for caesarean section during one week, after which the study commenced. The course participants instructed their colleagues; in total, 16 doctors participated. Women requiring caesarean section were randomised to Misgav Ladach or to the conventional lower midline incision procedure, excluding those with a previous scar. During 11 weeks 339 randomised procedures (328 of which were emergency procedures) were carried out. Mean operating time was 25 x 3 minutes for Misgav Ladach and 32 x 6 minutes for the lower midline incision procedure (95% CI -8 x 3; -6 x 3). Mean blood loss was 354 mL and 447 mL (-133; -53), and the number of sutures 3 x 1 and 6 x 1 (-3 x 1; -2 x 9), respectively. No significant difference was found in Apgar scores. Mobilisation was earlier with the Misgav Ladach procedure. No difference was found in overall post-operative infection rates i.e. wound infection or febrile illness, but the combination of wound infection and fever was more common in the Misgav Ladach group. The Misgav Ladach caesarean section confers benefits such as reduced blood loss, conservation of time and suture material, and rapid mobilisation, but more studies are needed to explore modifications aimed at reducing post-operative infections in settings with limited resources.

Caesarean Birth is Associated with Both Maternal and Paternal Origin in Immigrants in Sweden: a Population-Based Study.

PubMed

Juárez, Sol P; Small, Rhonda; Hjern, Anders; Schytt, Erica

2017-11-01

To investigate the association between maternal country of birth and father's origin and unplanned and planned caesarean birth in Sweden. Population-based register study including all singleton births in Sweden between 1999 and 2012 (n = 1 311 885). Multinomial regression was conducted to estimate odds ratios (OR) for unplanned and planned caesarean with 95% confidence intervals for migrant compared with Swedish-born women. Analyses were stratified by parity. Women from Ethiopia, India, South Korea, Chile, Thailand, Iran, and Finland had statistically significantly higher odds of experiencing unplanned (primiparous OR 1.10-2.19; multiparous OR 1.13-2.02) and planned caesarean (primiparous OR 1.18-2.25; multiparous OR 1.13-2.46). Only women from Syria, the former Yugoslavia and Germany had consistently lower risk than Swedish-born mothers (unplanned: primiparous OR 0.76-0.86; multiparous OR 0.74-0.86. Planned; primiparous OR 0.75-0.82; multiparous OR 0.60-0.94). Women from Iraq and Turkey had higher odds of an unplanned caesarean but lower odds of a planned one (among multiparous). In most cases, these results remained after adjustment for available social characteristics, maternal health factors, and pregnancy complications. Both parents being foreign-born increased the odds of unplanned and planned caesarean in primiparous and multiparous women. Unplanned and planned caesarean birth varied by women's country of birth, with both higher and lower rates compared with Swedish-born women, and the father's origin was also of importance. These variations were not explained by a wide range of social, health, or pregnancy factors. © 2017 John Wiley & Sons Ltd.

Improving the organisation of maternal health service delivery and optimising childbirth by increasing vaginal birth after caesarean section through enhanced women-centred care (OptiBIRTH trial): study protocol for a randomised controlled trial (ISRCTN10612254).

PubMed

Clarke, Mike; Savage, Gerard; Smith, Valerie; Daly, Deirdre; Devane, Declan; Gross, Mechthild M; Grylka-Baeschlin, Susanne; Healy, Patricia; Morano, Sandra; Nicoletti, Jane; Begley, Cecily

2015-11-30

The proportion of pregnant women who have a caesarean section shows a wide variation across Europe, and concern exists that these proportions are increasing. Much of the increase in caesarean sections in recent years is due to a cascade effect in which a woman who has had one caesarean section is much more likely to have one again if she has another baby. In some places, it has become common practice for a woman who has had a caesarean section to have this procedure again as a matter of routine. The alternative, vaginal birth after caesarean (VBAC), which has been widely recommended, results in fewer undesired results or complications and is the preferred option for most women. However, VBAC rates in some countries are much lower than in other countries. The OptiBIRTH trial uses a cluster randomised design to test a specially developed approach to try to improve the VBAC rate. It will attempt to increase VBAC rates from 25 % to 40 % through increased women-centred care and women's involvement in their care. Sixteen hospitals in Germany, Ireland and Italy agreed to join the study, and each hospital was randomly allocated to be either an intervention or a control site. If the OptiBIRTH intervention succeeds in increasing VBAC rates, its application across Europe might avoid the 160,000 unnecessary caesarean sections that occur every year at an extra direct annual cost of more than €150 million. Current Controlled Trials ISRCTN10612254 , registered 3 April 2013.

Placenta previa with early opening of the uterine isthmus is associated with high risk of bleeding during pregnancy, and massive haemorrhage during caesarean delivery.

PubMed

Goto, M; Hasegawa, J; Arakaki, T; Takita, H; Oba, T; Nakamura, M; Sekizawa, A

2016-06-01

To demonstrate the relationship between the timing of opening of the uterine isthmus and bleeding during pregnancy and caesarean section in patients with placenta previa. A prospective observational study was conducted at a single perinatal centre. All patients with placenta previa, diagnosed between 20 and 22 weeks of gestation, who were followed up at the study hospital and underwent caesarean section were enrolled. The condition of the uterine isthmus was examined every 2 weeks. The timing (in gestational weeks) of complete opening of the uterine isthmus was determined. Patients were divided into two groups: patients in whom the uterine isthmus opened before 25 weeks of gestation (EO-previa), and patients in whom the uterine isthmus opened after 25 weeks of gestation (LO-previa). The frequency of bleeding during pregnancy and the amount of intra-operative bleeding were compared between the two groups. Forty-four cases of EO-previa and 55 cases of LO-previa were analysed. Complete placenta previa at delivery was observed more frequently in the EO-previa group than in the LO-previa group (88.6% vs 47.3%, p<0.001). An emergency caesarean section due to active bleeding was performed more frequently in the EO-previa group (48%) than in the LO-previa group (25%) (p=0.021). The frequency of massive haemorrage (>2500ml) during caesarean section was higher in the EO-previa group than in the LO-previa group (25% vs 9%, p=0.033). Placenta previa was associated with a high risk of bleeding leading to emergency caesarean section during pregnancy, and massive haemorrhage during caesarean section in patients in whom the uterine isthmus opened before 25 weeks of gestation. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Double balloon catheter for induction of labour in Chinese women with previous caesarean section: one-year experience and literature review.

PubMed

Cheuk, Queenie K Y; Lo, T K; Lee, C P; Yeung, Anita P C

2015-06-01

To evaluate the efficacy and safety of double balloon catheter for induction of labour in Chinese women with one previous caesarean section and unfavourable cervix at term. Retrospective cohort study. A regional hospital in Hong Kong. Women with previous caesarean delivery requiring induction of labour at term and with an unfavourable cervix from May 2013 to April 2014. Primary outcome was to assess rate of successful vaginal delivery (spontaneous or instrument-assisted) using double balloon catheter. Secondary outcomes were double balloon catheter induction-to-delivery and removal-to-delivery interval; cervical score improvement; oxytocin augmentation; maternal or fetal complications during cervical ripening, intrapartum and postpartum period; and risk factors associated with unsuccessful induction. All 24 Chinese women tolerated double balloon catheter well. After double balloon catheter expulsion or removal, the cervix successfully ripened in 18 (75%) cases. The improvement in Bishop score 3 (interquartile range, 2-4) was statistically significant (P<0.001). Overall, 18 (75%) cases were delivered vaginally. The median insertion-to-delivery and removal-to-delivery intervals were 19 (interquartile range, 13.4-23.0) hours and 6.9 (interquartile range, 4.1-10.8) hours, respectively. Compared with cases without, the interval to delivery was statistically significantly shorter in those with spontaneous balloon expulsion or spontaneous membrane rupture during ripening (7.8 vs 3.0 hours; P=0.025). There were no major maternal or neonatal complications. The only factor significantly associated with failed vaginal birth after caesarean was previous caesarean section for failure to progress (P<0.001). This is the first study using double balloon catheter for induction of labour in Asian Chinese women with previous caesarean section. Using double balloon catheter, we achieved a vaginal birth after caesarean rate of 75% without major complications.

Differences in rates and odds for emergency caesarean section in six Palestinian hospitals: a population-based birth cohort study

PubMed Central

Laine, Katariina; Hassan, Sahar; Fosse, Erik; Lieng, Marit; Zimmo, Kaled; Anti, Marit; Sørum Falk, Ragnhild; Vikanes, Åse

2018-01-01

Objective To assess the differences in rates and odds for emergency caesarean section among singleton pregnancies in six governmental Palestinian hospitals. Design A prospective population-based birth cohort study. Setting Obstetric departments in six governmental Palestinian hospitals. Participants 32 321 women scheduled to deliver vaginally from 1 March 2015 until 29 February 2016. Methods To assess differences in sociodemographic and antenatal obstetric characteristics by hospital, χ2 test, analysis of variance and Kruskal-Wallis test were applied. Logistic regression was used to estimate differences in odds for emergency caesarean section, and ORs with 95% CIs were assessed. Main outcome measures The primary outcome was the adjusted ORs of emergency caesarean section among singleton pregnancies for five Palestinian hospitals as compared with the reference (Hospital 1). Results The prevalence of emergency caesarean section varied across hospitals, ranging from 5.8% to 22.6% among primiparous women and between 4.8% and 13.1% among parous women. Compared with the reference hospital, the ORs for emergency caesarean section were increased in all other hospitals, crude ORs ranging from 1.95 (95% CI 1.42 to 2.67) to 4.75 (95% CI 3.49 to 6.46) among primiparous women. For parous women, these differences were less pronounced, crude ORs ranging from 1.37 (95% CI 1.13 to 1.67) to 2.99 (95% CI 2.44 to 3.65). After adjustment for potential confounders, the ORs were reduced but still statistically significant, except for one hospital among parous women. Conclusion Substantial differences in odds for emergency caesarean section between the six Palestinian governmental hospitals were observed. These could not be explained by the studied sociodemographic or antenatal obstetric characteristics. PMID:29500211

Neurological outcomes by mode of delivery for fetuses with open neural tube defects: A systematic review and meta-analysis.

PubMed

Tolcher, Mary C; Shazly, Sherif A; Shamshirsaz, Alireza A; Whitehead, William E; Espinoza, Jimmy; Vidaeff, Alex C; Belfort, Michael A; Nassr, Ahmed A

2018-06-20

Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects. To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared to caesarean delivery. Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials. gov were searched from inception to November 2017. Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair. Two reviewers independently reviewed abstracts and full text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus labour. The primary outcome was motor-anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% confidence interval calculated. Of 201 abstracts identified in the primary search, 9 studies (672 women) met eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor-anatomic level difference (mean difference -0.10, 95% CI -0.58-0.38; I 2 =57%). The vaginal delivery group was less likely to require a shunt or have sac disruption (OR 0.37, 95% CI 0.14-0.95 and OR 0.46, 95% CI 0.23-0.90, respectively). Comparisons by prelabour caesarean versus labour showed no significant difference in motor-anatomic level difference (OR 1.29, 95% CI -0.63-3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35-13.12). Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Mode of delivery and neonatal death in 17,587 infants presenting by the breech.

PubMed

Kiely, J L

1991-09-01

To study the effects of caesarean section on neonatal mortality in infants presenting by the breech. Population-based non-experimental comparison of infants presenting by the breech born vaginally with those born by caesarean section. Neonatal mortality rates were calculated for 250 g birthweight intervals. Weight-specific relative risks (RRs) were further adjusted for birthweight in 50 g categories. New York City, 1978-1983. Data came from the Department of Health's computerized vital records on livebirths and infant deaths. 17,587 singleton breech livebirths greater than or equal to 500 g birthweight, with congenital anomaly deaths excluded. 6178 were born vaginally and 11409 were born by caesarean section. Birthweight-specific and birthweight-adjusted neonatal mortality. At birthweights of 501 to 1750 g, the risk of neonatal death for breech infants born vaginally was significantly higher than the risk for those born by caesarean section (weight-adjusted RR = 1.7). For breech infants with birthweights over 3000 g, the weight-adjusted risk was 5.6 times greater for a vaginal birth compared with caesarean section. The addition of 16 additional control variables in multiple logistic regression analyses did not change these RRs. Population-based studies indicate that an increase in the caesarean section rate among breech singletons may be associated with increased neonatal survival, but a large multicentre randomized trial of management of breech presentation would answer the question much more definitively.

Life saving or money wasting? Perceptions of caesarean sections among users of services in rural Bangladesh.

PubMed

Parkhurst, Justin Oliver; Rahman, Syed Azizur

2007-03-01

Bangladesh has a high level of maternal mortality, corresponding to one of the world's lowest rates of use of skilled birth attendance (12.1%), and a similarly low rate of caesarean births (2.4%). While increasing the proportion of women who deliver with professional medical care is essential to prevent maternal deaths, past work has identified distrust of caesarean procedures in Bangladesh. The reasons behind this distrust can manifest itself in health seeking behaviour around maternal care. This paper presents findings from a qualitative study of 30 women in a rural district of Bangladesh who recently delivered in a health facility. It finds that the distrust in doctor's recommendations for surgery stemmed from high costs incurred and a belief that it was used when not medically justified. This could lead to women avoiding or leaving medical facilities in extreme cases. Some women's experiences further illustrated disagreement among medical staff as to whether or not a caesarean procedure should be done, with conflicting financial incentives for doctors to perform caesarean deliveries, and for nurses and midwives to conduct normal deliveries. Policy makers must recognise that the fears women hold of caesarean deliveries may not simply be rooted in ignorance and may, in fact, reflect legitimate concerns with medical practice. Ultimately, it will be essential to address problems in the health systems environment, which may promote improper service provision.

The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized control trial.

PubMed

Hussein, Ahmed M; Dakhly, Dina Mohamed Refaat; Raslan, Ayman N; Kamel, Ahmed; Abdel Hafeez, Ali; Moussa, Manal; Hosny, Ahmed Samir; Momtaz, Mohamed

2018-04-25

To identify the role of bilateral internal iliac artery (IIA) ligation on reducing blood loss in abnormally invasive placenta (AIP) undergoing caesarean hysterectomy. In this parallel-randomized control trial, 57 pregnant females with ultrasound features suggestive of AIP were enrolled. They were randomized into two groups; IIA group (n = 29 cases) performed bilateral IIA ligation followed by caesarean hysterectomies, while Control group (n = 28 cases) underwent caesarean hysterectomy only. The main outcome was the difference in the estimated intraoperative blood loss between the two groups. There was no significant difference between the two groups regarding the intraoperative estimated blood loss (1632 ± 804 versus 1698 ± 1251, p value .83). The operative procedure duration (minutes) (223 ± 66 versus 171 ± 41.4, p value .001) varied significantly between the two groups. Bilateral internal iliac artery ligation, in cases of AIP undergoing caesarean hysterectomy, is not recommended for routine practice to minimize blood loss intraoperatively.

Does advanced operative obstetrics still have a place in contemporary practice?

PubMed

Tempest, Nicola; Navaratnam, Kate; Hapangama, Dharani Kosala

2015-04-01

This article reviews recent significant contributions to the literature concerning advanced operative obstetric procedures used for rotational vaginal deliveries and their alternative, primary caesarean section. Rising caesarean section rates are a global concern. Caesarean section in the second stage of labour is associated with high rates of maternal and fetal morbidity. Rotational vaginal deliveries may reduce the caesarean section rate without additional adverse effects on maternal and fetal outcomes. A recent national trainees' survey highlighted that training in the management of operative birth in the second stage of labour, especially when there is malposition of the fetal head, is a priority. There is a need for evidence-based guidelines, including standardized documentation of these advanced procedures. Training strategies for junior practitioners to acquire these skills and for experienced practitioners to maintain and disseminate their skills should be prioritized. The safety of rotational delivery methods versus primary caesarean section is likely to prove difficult to assess directly, in the context of a randomized controlled trial, but may be approximated via a national prospective audit.

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births

PubMed Central

Liang, Juan; Mu, Yi; Li, Xiaohong; Tang, Wen; Wang, Yanping; Liu, Zheng; Huang, Xiaona; Scherpbier, Robert W; Guo, Sufang; Li, Mingrong; Dai, Li; Deng, Kui; Deng, Changfei; Li, Qi; Kang, Leni; Zhu, Jun

2018-01-01

Abstract Objective To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. Design Observational study. Setting China’s National Maternal Near Miss Surveillance System (NMNMSS). Participants 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. Main outcome measures Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. Results Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government’s policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. Conclusions China is the only country that has succeeded in reverting the rising trends in caesarean sections. China’s success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China’s experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter. PMID:29506980

Protocol for a randomised controlled trial of fetal scalp blood lactate measurement to reduce caesarean sections during labour: the Flamingo trial [ACTRN12611000172909].

PubMed

East, Christine E; Kane, Stefan C; Davey, Mary-Ann; Kamlin, C Omar; Brennecke, Shaun P

2015-11-03

The rate of caesarean sections around the world is rising each year, reaching epidemic proportions. Although many caesarean sections are performed for concerns about fetal welfare on the basis of abnormal cardiotocography, the majority of babies are shown to be well at birth, meaning that the operation, with its inherent short and long term risks, could have been avoided without compromising the baby's health. Previously, fetal scalp blood sampling for pH estimation was performed in the context of an abnormal cardiotocograph, to improve the identification of babies in need of expedited delivery. This test has largely been replaced by lactate measurement, although its validity is yet to be established through a randomised controlled trial. This study aims to test the hypothesis that the performance of fetal scalp blood lactate measurement for women in labour with an abnormal cardiotocograph will reduce the rate of birth by caesarean section from 38 % to 25 % (a 35 % relative reduction). Prospective unblinded randomised controlled trial conducted at a single tertiary perinatal centre. Women labouring with a singleton fetus in cephalic presentation at 37 or more weeks' gestation with ruptured membranes and with an abnormal cardiotocograph will be eligible. Participants will be randomised to one of two groups: fetal monitoring by cardiotocography alone, or cardiotocography augmented by fetal scalp blood lactate analysis. Decisions regarding the timing and mode of delivery will be made by the treating team, in accordance with hospital protocols. The primary study endpoint is caesarean section with secondary outcomes collected from maternal, fetal and neonatal clinical course and morbidities. A cost effectiveness analysis will also be performed. A sample size of 600 will provide 90 % power to detect the hypothesised difference in the proportion of women who give birth by caesarean section. This world-first trial is adequately powered to determine the impact of fetal scalp blood lactate measurement on rates of caesarean section. Preventing unnecessary caesarean sections will reduce the health and financial burdens associated with this operation, both in the index and any future pregnancies. Australian New Zealand Clinical Trials Registry ACTRN12611000172909.

The impact of curve severity on obstetric complications and regional anesthesia utilization in pregnant patients with adolescent idiopathic scoliosis: a preliminary analysis.

PubMed

Chan, Emily W; Gannon, Stephen R; Shannon, Chevis N; Martus, Jeffrey E; Mencio, Gregory A; Bonfield, Christopher M

2017-10-01

OBJECTIVE Adolescent idiopathic scoliosis (AIS), the most common type of scoliosis, often presents immediately prior to a woman's childbearing years; however, research investigating the impact of AIS on women's health, particularly pregnancy delivery outcomes, is sparse, with existing literature reporting mixed findings. Similarly limited are studies examining the change in scoliotic curve during or after pregnancy. Therefore, this study aims to determine 1) the impact of scoliotic curvature on obstetric complications (preterm births, induction of labor, and urgent/emergency caesarean section delivery), 2) regional anesthetic decision making and success during delivery for these patients, and 3) the effect of pregnancy on curve progression. METHODS Records of all pregnant patients diagnosed with AIS at the authors' institution who delivered between January 2002 and September 2016 were retrospectively reviewed. Demographic information, pre- and postpartum radiographic Cobb angles, and clinical data for each pregnancy and delivery were recorded and analyzed. The Wilcoxon rank-sum test and the Wilcoxon signed-rank test were used for statistical analyses. RESULTS Fifty-nine patients (84 deliveries) were included; 14 patients had undergone prior posterior spinal fusion. The median age at AIS diagnosis was 15.2 years, and the median age at delivery was 21.8 years. Overall, the median major Cobb angle prior to the first pregnancy was 25° (IQR 15°-40°). Most births were by spontaneous vaginal delivery (n = 45; 54%); elective caesarean section was performed in 17 deliveries (20%). Obstetric complications included preterm birth (n = 18; 21.4%), induction of labor (n = 20; 23.8%), and urgent/emergency caesarean section (n = 12; 14.0%); none were associated with severity of scoliosis curve or prior spinal fusion. Attempts at spinal anesthesia were successful 99% of the time (70/71 deliveries), even among the patients who had undergone prior spinal fusion (n = 13). There were only 3 instances of provider refusal to administer spinal anesthesia. In the subset of 11 patients who underwent postpartum scoliosis radiography, there was no statistically significant change in curve magnitude either during or immediately after pregnancy. CONCLUSIONS The results of this study suggest that there was no effect of the severity of scoliosis on delivery complications or regional anesthetic decision making in pregnant patients with AIS. Moreover, scoliosis was not observed to progress significantly during or immediately after pregnancy. Larger prospective studies are needed to further investigate these outcomes, the findings of which can guide the prenatal education and counseling of pregnant patients with AIS.

[Pelvic floor and pregnancy].

PubMed

Fritel, X

2010-05-01

Congenital factor, obesity, aging, pregnancy and childbirth are the main risk factors for female pelvic floor disorders (urinary incontinence, anal incontinence, pelvic organ prolapse, dyspareunia). Vaginal delivery may cause injury to the pudendal nerve, the anal sphincter, or the anal sphincter. However the link between these injuries and pelvic floor symptoms is not always determined and we still ignore what might be the ways of prevention. Of the many obstetrical methods proposed to prevent postpartum symptoms, episiotomy, delivery in vertical position, delayed pushing, perineal massage, warm pack, pelvic floor rehabilitation, results are disappointing or limited. Caesarean section is followed by less postnatal urinary incontinence than vaginal childbirth. However this difference tends to disappear with time and following childbirth. Limit the number of instrumental extractions and prefer the vacuum to forceps could reduce pelvic floor disorders after childbirth. Ultrasound examination of the anal sphincter after a second-degree perineal tear is useful to detect and repair infra-clinic anal sphincter lesions. Scientific data is insufficient to justify an elective cesarean section in order to avoid pelvic floor symptoms in a woman without previous disorders. Copyright 2010 Elsevier Masson SAS. All rights reserved.

Paraesthesia during the needle-through-needle and the double segment technique for combined spinal epidural anaesthesia.

PubMed

Ahn, H J; Choi, D H; Kim, C S

2006-07-01

Paraesthesia during regional anaesthesia is an unpleasant sensation for patients and, more importantly, in some cases it is related to neurological injury. Relatively few studies have been conducted on the frequency of paraesthesia during combined spinal epidural anaesthesia. We compared two combined spinal epidural anaesthesia techniques: the needle-through-needle technique and the double segment technique in this respect. We randomly allocated 116 parturients undergoing elective Caesarean section to receive anaesthesia using one of these techniques. Both techniques were performed using a 27G pencil point needle, an 18G Tuohy needle, and a 20G multiport epidural catheter from the same manufacturer. The overall frequency of paraesthesia was higher in the needle-through-needle technique group (56.9% vs. 31.6%, p = 0.011). The frequency of paraesthesia at spinal needle insertion was 20.7% in the needle-through-needle technique group and 8.8% in the double segment technique group; whereas the frequency of paraesthesia at epidural catheter insertion was 46.6% in the needle-through-needle technique group and 24.6% in the double segment technique group.

Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section

PubMed Central

Griffiths, James D; Gyte, Gillian ML; Paranjothy, Shantini; Brown, Heather C; Broughton, Hannah K; Thomas, Jane

2014-01-01

Background Nausea and vomiting are distressing symptoms which are experienced commonly during caesarean section under regional anaesthesia and can also occur in the period following the procedure. Objectives To assess the efficacy of pharmacological and non-pharmacological interventions given prophylactically to prevent nausea and vomiting in women undergoing regional anaesthesia for caesarean section. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (27 February 2012) and reference lists of identified studies. Selection criteria We included randomised controlled trials (RCTs) and excluded quasi-RCTs and cross-over studies. Data collection and analysis Review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. Main results Fifty-two studies met the inclusion criteria but only 41 studies, involving 5046 women, provided useable data for the review involving women having caesareans under regional anaesthesia. The majority of the studies involved women undergoing elective caesarean section. Only two studies included emergency surgery, however, they did not stratify data according to type of surgery. The studies covered numerous comparisons, but the majority of studies involved 5-HT3 receptor antagonists, dopamine receptor antagonists, corticosteroids or acupressure. Studies were mainly small and of unclear quality. Three classes of intervention were found to be effective in at least three out of four of our primary outcomes (intraoperative nausea, intraoperative vomiting, postoperative nausea and postoperative vomiting). These interventions were 5-HT3 antagonists, dopamine antagonists and sedatives. Other classes of intervention were effective for fewer than three of our primary outcomes. With 5-HT antagonists, we found a reduction in intraoperative nausea (average risk ratio (RR) 0.64, 95% confidence interval (CI) 0.46 to 0.88, eight studies, 720 women). There were also reductions in postoperative nausea (average RR 0.40, 95% CI 0.25 to 0.64, four studies, 405 women) and vomiting (average RR 0.50, 95% CI 0.32 to 0.77, five studies, 565 women). We did not detect a significant reduction in intraoperative vomiting (average RR 0.56, 95% CI 0.31 to 1.00, seven studies, 668 women). Dopamine antagonists demonstrated a reduction in intraoperative nausea (average RR 0.38, 95% CI 0.25 to 0.57, nine studies, 636 women) and intraoperative vomiting (average 0.39, 95% CI 0.24 to 0.64, eight studies, 536 women), with similar reductions in postoperative nausea (average RR 0.60, 95% CI 0.40 to 0.91, five studies, 412 women) and vomiting (average RR 0.57, 95% CI 0.36 to 0.91, six studies, 472 women). These differences were observed with both metoclopramide and droperidol. Sedatives (most commonly propofol) demonstrated a reduction in intraoperative nausea (average RR 0.71, 95% CI 0.52 to 0.96, four studies, 285 women) and intraoperative vomiting (average RR 0.42, 95% CI 0.26 to 0.68, four studies, 285 women), also with a reduction in postoperative nausea (average RR 0.25, 95% CI 0.09 to 0.71, two studies 145 women) and vomiting (average RR 0.09, 95% CI 0.03 to 0.28, two studies, 145 women). Acupressure was found to be effective for intraoperative nausea (average RR 0.59, 95% CI 0.38 to 0.90, six studies, 649 women) but not postoperative nausea (average RR 0.83, 95% CI 0.68 to 1.00, three studies, 429 women). Acupressure was not effective at reducing vomiting either intraoperatively (average RR 0.74, 95% CI 0.46 to 1.18, six studies, 649 women) or postoperatively (average RR 0.69, 95% CI 0.45 to 1.06, three studies, 429 women). Other effective intervention classes included corticosteroids, antihistamines, and anticholinergics. There were insufficient data to demonstrate any class of intervention was superior to another. There were no significant differences observed in the comparison of combined versus single interventions. Few studies assessed our secondary outcomes or the incidence of adverse effects. However, one study showed an increase in respiratory depression with sedation (midazolam) compared with dopamine antagonists. Authors’ conclusions This review indicates that many different interventions have efficacy in preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. There is little evidence that combinations of treatment are better than single agents. PMID:22972112

Factors associated to Caesarean delivery in public and private health care systems.

PubMed

Oliveira, Rosana Rosseto de; Melo, Emiliana Cristina; Novaes, Elisiane Soares; Ferracioli, Patrícia Louise Rodrigues Varela; Mathias, Thais Aidar de Freitas

2016-01-01

Identifying factors associated to Caesarean sections among the residents of Maringá-PR, according to the financing source for delivery. A cross-sectional study with data from 920 postpartum women interviewed between October 2013 and February 2014. Association analysis was performed by logistic regression. Caesarean section rates were 55.5% in the Unified Healthcare System (SUS) and 93.8% in the private system. Factors associated with Caesarean section in the SUS were: previous Caesarean section (OR=8.9; CI=4.6-16.9), desire for Caesarean section early in pregnancy (OR=2.0; CI=1.1-3.6), pregestational overweight/obesity (OR=1.8; CI=1.1-2.8), and per capita family income higher than one minimum wage (OR=2.1; CI=1.3-3.4). In the private system, desire for Caesarean section early in pregnancy (OR=25.3) and a previous Caesarean section (OR=11.3) were strongly associated to its performance. It is necessary to properly orientate all pregnant women who desire a Caesarean delivery, from both the SUS and the private system, about the inherent risks of the surgical procedure without indication. In the public health sector, guidelines should be focused on pregnant women with previous Caesarean delivery, with a per capita income higher than one minimum wage and those who are overweight or obese, as these women are more likely to have a Caesarean section. Identificar fatores associados à cesárea entre residentes de Maringá-PR, segundo a fonte de financiamento do parto. Estudo transversal com dados de 920 puérperas entrevistadas entre outubro de 2013 e fevereiro de 2014. A análise de associação foi feita por regressão logística. A taxa de cesariana foi de 55,5% e 93,8% no Sistema Único de Saúde (SUS) e no sistema privado, respectivamente. Associou-se à cesárea no SUS: realização de cesárea anterior (OR=8,9; IC=4,6-16,9), desejo pela cesárea no início da gestação (OR=2,0; IC=1,1-3,6), sobrepeso/obesidade pré-gestacional (OR=1,8; IC=1,1-2,8), e renda familiar per capita maior que um salário mínimo (OR=2,1; IC=1,3-3,4). No sistema privado, o desejo pela cesárea no início da gestação (OR=25,3) e uma cesárea anterior (OR=11,3) estiveram fortemente associados à sua realização. É necessário orientar adequadamente todas as gestantes que desejam o parto cesárea, no SUS e no sistema privado, sobre os riscos inerentes ao procedimento cirúrgico sem indicação. No setor público de saúde, devem ser foco das orientações as gestantes com parto cesárea anterior, as com renda familiar per capita maior que um salário mínimo e com sobrepeso ou obesidade, as quais têm mais chances de realizar cesárea.

Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals.

PubMed

Maaløe, N; Sorensen, B L; Onesmo, R; Secher, N J; Bygbjerg, I C

2012-04-01

To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour. A quality assurance analysis of a retrospective criterion-based audit supplemented by in-depth interviews with hospital staff. Two Tanzanian rural mission hospitals. Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed. Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings. Prevalence of suboptimal management and themes emerging from an analysis of the transcripts. Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions. The lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature.

PubMed

Stevens, Jeni; Schmied, Virginia; Burns, Elaine; Dahlen, Hannah

2014-10-01

The World Health Organization and the United Nations International Children's Emergency Fund recommends that mothers and newborns have skin-to-skin contact immediately after a vaginal birth, and as soon as the mother is alert and responsive after a Caesarean section. Skin-to-skin contact can be defined as placing a naked infant onto the bare chest of the mother. Caesarean birth is known to reduce initiation of breastfeeding, increase the length of time before the first breastfeed, reduce the incidence of exclusive breastfeeding, significantly delay the onset of lactation and increase the likelihood of supplementation. The aim of this review is to evaluate evidence on the facilitation of immediate (within minutes) or early (within 1 h) skin-to-skin contact following Caesarean section for healthy mothers and their healthy term newborns, and identify facilitators, barriers and associated maternal and newborn outcomes. A range of electronic databases were searched for papers reporting research findings published in English between January 2003 and October 2013. Seven papers met the criteria. This review has provided some evidence that with appropriate collaboration skin-to-skin contact during Caesarean surgery can be implemented. Further evidence was provided, albeit limited, that immediate or early skin-to-skin contact after a Caesarean section may increase breastfeeding initiation, decrease time to the first breastfeed, reduce formula supplementation in hospital, increase bonding and maternal satisfaction, maintain the temperature of newborns and reduce newborn stress. © 2014 John Wiley & Sons Ltd.

Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study.

PubMed

Macfarlane, A J; Blondel, B; Mohangoo, A D; Cuttini, M; Nijhuis, J; Novak, Z; Ólafsdóttir, H S; Zeitlin, J

2016-03-01

To use data from routine sources to compare rates of obstetric intervention in Europe both overall and for subgroups at higher risk of intervention. Retrospective analysis of aggregated routine data. Thirty-one European countries or regions contributing data on mode of delivery to the Euro-Peristat project. Births in participating countries in 2010. Countries provided aggregated data about overall rates of obstetric intervention and about caesarean section rates for specified subgroups. Mode of delivery. Rates of caesarean section ranged from 14.8% to 52.2% of all births and rates of instrumental vaginal delivery ranged from 0.5% to 16.4%. Overall, there was no association between rates of instrumental vaginal delivery and rates of caesarean section, but similarities were observed between some countries that are geographically close and may share common traditions of practice. Associations were observed between caesarean section rates for women with breech and vertex births and with singleton and multiple births but patterns of association for women who had and had not had previous caesarean sections were more complex. The persisting wide variations in caesarean section and instrumental vaginal delivery rates point to a lack of consensus about practice and raise questions for further investigation. Further research is needed to explore the impact of differences in clinical guidelines, healthcare systems and their financing and parents' and professionals' attitudes to care at delivery. © 2015 Royal College of Obstetricians and Gynaecologists.

The Misgav Ladach method: a step forward in the operative technique of caesarean section.

PubMed

Poonam; Banerjee, B; Singh, S N; Raina, A

2006-01-01

Caesarean delivery remains the most common intraperitoneal surgical procedure in obstetric and gynaecologic practice. Since time immemorial there have been countless efforts to improve the technique of caesarean section. One such innovative breakthrough technique is the Misgav Ladach method of caesarean of section. The objective of this trial was to compare the intraoperative and short-term postoperative outcomes between the conventional and the Misgav-Ladach technique for caesarean section. The randomized prospective comparative study was carried out in the department of Obstetrics and Gynaecology, B.P Koirala Institute of Health Sciences, Dharan Nepal. Four hundred patients were randomized to either Misgav Ladach or the Conventional method of caesarean section. Only term pregnancies with singleton foetuses' were included whereas pregnancies with previous caesarean section were excluded from the study. The study period was from September 2001 to September 2004. There was not much difference in the demographic variables between the two groups. The age of the patients ranged between 18-40 years. The mean age of patients in Misgav Ladach and conventional group was 24.5 and 23.6 years respectively. Foetal distress was the commonest indication for caesarean section followed by non progress of labour. The mean incision to delivery interval, operating time and blood loss in the Misgav Ladach group was 1 minute 30 seconds, 16 minutes and 35 0ml as compared to 3 minutes, 28 minutes and 600 ml in the conventional group respectively. 3.5%of patients in the Misgav Ladach group showed febrile morbidity as compared to 7% in the conventional group. 19% from conventional group and only 4%from Misgav Ladach group required added analgesia. Almost equal number of patients (10-12) in each group experienced significant headache.).0.1%in the Misgav group and 5% in the Conventional group required post operative blood transfusion. Four patients from the conventional group had their wound gaped. The number of neonates requiring intensive care was sixteen (8% ) in the conventional group and 3 (1.5%) in the Misgav group.6.5% from conventional group and 2% from Misgav Ladach group required maternal intensive care admissions. Misgav-Ladach technique has been be associated with shorter operative time, quicker recovery, and lesser need for postoperative medications, when compared with traditional caesarean section. It has also been shown to be more cost-effective. A further advantage of the technique may be the shorter time taken for the delivery of the child.

Appendectomy for asymptomatic appendicitis during caesarean section - an interesting case report.

PubMed

Panteleris, N; Daniilidis, A; Stamkopoulou, A; Kogeorgos, S; Chatzis, P; Assimakopoulos, E

2016-01-01

The authors present an interesting case report of an appendectomy during caesarean section in an asymptomatic pregnant woman, which highlights the need of peritoneal cavity check during every caesarean section. A 32-year-old para 0 woman at 34 weeks of gestation attended to the present clinic because of a feeling of reduced fetal movements in the last 24 hours. She underwent a non-stress test (NST), that was non-reassuring and no contractions were recorded. The woman underwent a caesarean section, which revealed a large phlegmonic appendix. Appendectomy was decided after the closure of the uterine cavity. The woman was treated with appendectomy. Histology came back as an appendicitis three days later. Acute appendicitis during pregnancy may be associated with serious maternal and fetal complications. It is also associated with a high risk of premature delivery. In the absence of lower abdominal pain and inflammatory changes, the incidence of acute appendicitis is low, but exists. In every caesarean section at any week of gestation, we should check the peritoneal cavity and especially the appendix, as appendicitis is the most pregnant woman who mentions preterm contractions or/and reduced fetal movements.

Maternal obesity, obstetric interventions and post-partum anaemia increase the risk of post-partum sepsis: a population-based cohort study based on Swedish medical health registers.

PubMed

Axelsson, Daniel; Blomberg, Marie

2017-10-01

The objective was to estimate whether maternal obesity and/or obstetric interventions are associated with diagnosed maternal post-partum sepsis. A retrospective observational cohort study including all deliveries in Sweden between 1997 and 2012 (N = 1,558,752). Cases of sepsis (n = 376) were identified by International Classification of Diseases, (ICD-10) codes A40, A41 and O 85 in the Medical Birth Register and the National Patient Register. The reference population was non-infected, and therefore, women with any other infection diagnosis and/or with dispensed antibiotics within eight weeks post-partum were excluded. Information on dispensed drugs was available in the prescribed drug Register. Women with sepsis were compared with non-infected women concerning maternal characteristics and obstetric interventions. Adjusted odds ratios (aOR) were determined using the Mantel-Haenszel technique. Adjustments were made for maternal age, parity and smoking. Obese women (body mass index ≥30) had a doubled risk of sepsis (3.6/10,000) compared with normal weight women (2.0/10,000) (aOR 1.85 (95%CI: 1.37-2.48)). Induction of labour (aOR 1.44 (95%CI: 1.09-1.91)), caesarean section overall (aOR 3.06 (95%CI: 2.49-3.77)) and elective caesarean section (aOR 2.41 (95%CI: 1.68-3.45)) increased the risk of sepsis compared with normal vaginal delivery. Post-partum anaemia due to acute blood loss was associated with maternal sepsis (aOR 3.40 (95%CI: 2.59-4.47)). Maternal obesity, obstetric interventions and post-partum anaemia due to acute blood loss increased the risk of diagnosed post-partum sepsis indicating that interventions in obstetric care should be considered carefully and anaemia should be treated if resources are available.

Elective Caesarean section on maternal request in Germany: factors affecting decision making concerning mode of delivery.

PubMed

Stützer, Paul Philipp; Berlit, Sebastian; Lis, Stefanie; Schmahl, Christian; Sütterlin, Marc; Tuschy, Benjamin

2017-05-01

To investigate sociopsychological factors of women undergoing a caesarean section on maternal request (CSMR). Twenty-eight women who underwent CSMR and 29 women with vaginal delivery (VD) filled in standardized questionnaires concerning psychological burden (SCL-R 90), fear of childbirth (W-DEQ, STAI), personality structure (HEXACO-Pi-R) and social support (F-SozU) as well as one questionnaire assessing potential factors influencing their mode of delivery. Women with CSMR were older (36.5 ± 5.4 vs. 30.6 ± 5.2 years; p < 0.001) and suffered more from fear of childbirth (W-DEQ 4.3 ± 0.8 vs. 3.7 ± 1.2; p = 0.041), concerns for their child (W-DEQ 2.0 ± 1.5 vs. 1.3 ± 0.7; p = 0.026) and appraised the birth less negative (W-DEQ 2.0 ± 0.7 vs. 2.7 ± 1.1; p = 0.008). The majority of parturients had chosen their preferred mode of delivery before pregnancy (CS 61% vs. VD 82%, p = 0.328). In the decision-making process for the mode of delivery, the advice of the partner (85 and 90%) played an important role. 82% of the women who delivered via CSMR did not regret the decision for this mode of delivery. Women who underwent CS had higher fear of childbirth and appraised the birth less negative. The majority did not regret the decision for the CS and would even choose this mode of delivery for their next pregnancy. Although the partner and the physician seem to be important in the decision process for of the mode of delivery, reasons for the choice for CSMR appear to be multifactorial.

Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

PubMed

Wickramasinghe, Dakshitha Praneeth; Senaratne, Supun; Senanayake, Hemantha; Samarasekera, Dharmabandhu Nandadeva

2016-09-01

The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births.

PubMed

Liang, Juan; Mu, Yi; Li, Xiaohong; Tang, Wen; Wang, Yanping; Liu, Zheng; Huang, Xiaona; Scherpbier, Robert W; Guo, Sufang; Li, Mingrong; Dai, Li; Deng, Kui; Deng, Changfei; Li, Qi; Kang, Leni; Zhu, Jun; Ronsmans, Carine

2018-03-05

To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. Observational study. China's National Maternal Near Miss Surveillance System (NMNMSS). 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. China is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study

PubMed Central

Hsia, Renee Y; Akosa Antwi, Yaa; Weber, Ellerie

2014-01-01

Objective To examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Design, setting and participants Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Outcome measures Hospital charges and discounted prices adjusted for each patient's clinical and demographic characteristics. Results We analysed 76 766 vaginal deliveries and 32 660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3296 or as much as US$37 227 for a vaginal delivery, and US$8312–US$70 908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35–36% of the between-hospital variation in charges. Conclusions These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups—uncomplicated vaginal delivery and caesarean section—vary widely between hospitals and are not well explained by observable patient or hospital characteristics. PMID:24435892

Delivery by caesarean section and risk of childhood obesity: analysis of a Peruvian prospective cohort.

PubMed

Carrillo-Larco, Rodrigo M; Miranda, J Jaime; Bernabé-Ortiz, Antonio

2015-01-01

Objectives. We aimed to assess if Caesarean section is a risk factor for overnutrition in early- and late-childhood, and to assess the magnitude of the effect of child- versus family-related variables in these risk estimates. Methods. Longitudinal data from Peruvian children from the Young Lives Study was used. Outcomes assessed were overweight, obesity, overnutrition (overweight plus obesity), and central obesity (waist circumference) at the age 5 (first follow-up) and 7 (second follow-up) years. The exposure of interests was delivery by Caesarean section. Relative risks (RR) and 95% confidence intervals (95% CI) were calculated using multivariable models adjusted for child-related (e.g., birth weight) and family-related (e.g., maternal nutritional status) variables. Results. At baseline, mean age was 11.7 (± 3.5) months and 50.1% were boys. Children born by Caesarean section were 15.6%. The 10.5% of the children were overweight and 2.4% were obese. For the obesity outcome, data from 6,038 and 9,625 children-years was included from baseline to the first and second follow-up, respectively. Compared to those who did not experience Caesarean delivery, the risk of having obesity was higher in the group born by Caesarean: RRs were higher at early-childhood (first follow-up: 2.25; 95% CI [1.36-3.74]) than later in life (second follow-up: 1.57; 95% CI [1.02-2.41]). Family-related variables had a greater effect in attenuating the risk estimates for obesity at the first, than at the second follow-up. Conclusion. Our results suggest a higher probability of developing obesity, but not overweight, among children born by Caesarean section delivery. The magnitude of risk estimates decreased over time, and family-related variables had a stronger effect on the risk estimates at early-childhood.

Differences in rates and odds for emergency caesarean section in six Palestinian hospitals: a population-based birth cohort study.

PubMed

Zimmo, Mohammed; Laine, Katariina; Hassan, Sahar; Fosse, Erik; Lieng, Marit; Ali-Masri, Hadil; Zimmo, Kaled; Anti, Marit; Bottcher, Bettina; Sørum Falk, Ragnhild; Vikanes, Åse

2018-03-02

To assess the differences in rates and odds for emergency caesarean section among singleton pregnancies in six governmental Palestinian hospitals. A prospective population-based birth cohort study. Obstetric departments in six governmental Palestinian hospitals. 32 321 women scheduled to deliver vaginally from 1 March 2015 until 29 February 2016. To assess differences in sociodemographic and antenatal obstetric characteristics by hospital, χ 2 test, analysis of variance and Kruskal-Wallis test were applied. Logistic regression was used to estimate differences in odds for emergency caesarean section, and ORs with 95% CIs were assessed. The primary outcome was the adjusted ORs of emergency caesarean section among singleton pregnancies for five Palestinian hospitals as compared with the reference (Hospital 1). The prevalence of emergency caesarean section varied across hospitals, ranging from 5.8% to 22.6% among primiparous women and between 4.8% and 13.1% among parous women. Compared with the reference hospital, the ORs for emergency caesarean section were increased in all other hospitals, crude ORs ranging from 1.95 (95% CI 1.42 to 2.67) to 4.75 (95% CI 3.49 to 6.46) among primiparous women. For parous women, these differences were less pronounced, crude ORs ranging from 1.37 (95% CI 1.13 to 1.67) to 2.99 (95% CI 2.44 to 3.65). After adjustment for potential confounders, the ORs were reduced but still statistically significant, except for one hospital among parous women. Substantial differences in odds for emergency caesarean section between the six Palestinian governmental hospitals were observed. These could not be explained by the studied sociodemographic or antenatal obstetric characteristics. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Predictors of obstetric intervention rates: case-mix, staffing levels and organisational factors of hospital of birth.

PubMed

Joyce, Rachel; Webb, R; Peacock, Janet

2002-11-01

We performed a cross-sectional study of all Thames maternity units, 1994-96, including 540,834 live and stillbirths. In contrast to recent media speculation, no association of caesarean section rates with midwifery staffing levels was found after adjustment for confounders. The only association with staffing was with levels of junior obstetric staffing, which could be a reflection of less experienced management of labour. Caesarean section rates were also associated positively with the levels of delivery beds, which could be a reflection of the closer monitoring of labour that may result from increased bed availability. Both caesarean section and instrumental vaginal delivery rates were associated with epidural rates, which was expected from the literature. Variations in epidural rates were mainly associated with variations in demographic case-mix, due possibly to patient demand. Demographic case-mix was also associated with instrumental vaginal deliveries but not the caesarean section rate.

Antenatal Corticosteroids for Reducing Adverse Maternal and Child Outcomes in Special Populations of Women at Risk of Imminent Preterm Birth: A Systematic Review and Meta-Analysis

PubMed Central

Amiya, Rachel M.; Mlunde, Linda B.; Ota, Erika; Swa, Toshiyuki

2016-01-01

Background This study synthesizes available evidence on antenatal corticosteroids (ACS) use among special subgroups of women at risk of imminent preterm birth, including those (1) with pregestational and gestational diabetes mellitus, (2) undergoing elective caesarean section (CS) in late preterm (34 to<37 weeks), (3) with chorioamnionitis, and (4) with growth-restricted fetuses. Methods A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, POPLINE, and World Health Organization Regional Databases was conducted for all comparative studies. Two reviewers independently determined study eligibility, extracted data, and assessed study quality. Pooled mean differences and odds ratios with 95% confidence intervals were estimated from available data, based on fixed- and random-effects models, as appropriate. Results No eligible studies were identified for ACS use in diabetic pregnant women or those undergoing elective CS at late preterm. Nine studies each on ACS use in women with chorioamnionitis and in women with fetal growth restriction met inclusion criteria; eight studies were separately included in the meta-analyses for the two subpopulations. For ACS administration in women with chorioamnionitis, pooled analyses showed reductions in neonatal mortality (OR: 0.49, 95% CI: 0.34–0.73), respiratory distress syndrome (OR: 0.58, 95% CI: 0.44–0.76), intraventricular haemorrhage (OR: 0.41, 95% CI: 0.24–0.69), and severe intraventricular haemorrhage (OR: 0.40, 95% CI: 0.24–0.69). Maternal and long-term newborn outcomes were not reported. Effects of ACS use were inconclusive for cases with fetal growth restriction. Conclusion Direct evidence on the effectiveness and safety of ACS is lacking for diabetic pregnant women at risk of preterm birth and those undergoing elective late-preterm CS, though this does not necessarily recommend against their use in diabetic women. While evidence remains inconclusive for women with growth-restricted preterm neonates, ACS appears to benefit preterm neonates delivered by women with chorioamnionitis. High-quality studies on maternal and long-term child outcomes in more diverse settings are needed to establish the balance of potential harms versus benefits in using ACS for these understudied subgroups. PMID:26841022

[The Misgav-Ladach method for cesarean section compared to the Pfannenstiel technique].

PubMed

Studziński, Zbigniew

2002-08-01

The aim of the study was to evaluate the outcome of two different methods of cesarean section. To determine whether the Misgav-Ladach caesarean technique can offer benefits when compared with conventional Pfannenstiel caesarean section technique. This study describes operative details and the postoperative course of 110 patients who underwent caesarean section in May 2000 to December 2000 in Department of Gynecology and Obstetrics in Regional Hospital in Slupsk, Poland. One group (50 women) was operated with the Misgav-Ladach method for caesarean section and the other group (60 women) with Pfannenstiel method. Operating time was significantly different between the two methods, with an average of 20.2 minutes with the Misgav-Ladach method and 47.3 minutes with the Pfannenstiel method (p < 0.001). Time of child delivery was with average 1.1 minutes with the Misgav-Ladach method and 3.8 minutes with the Pfannenstiel method (p < 0.001). The amount of blood loss different significantly, with 336 ml and 483 ml respectively (p < 0.001). No significant difference was found in Apgar scores. No difference was found in overall postoperative complications, wound infection, febrile illness, febrile morbidity, wound dehiscence affected by the new technique. Significantly less suture material was used during Misgav-Ladach caesarean section compared to Pfannenstiel technique (p < 0.001). The Misgav-Ladach method of caesarean section has advantages over the Pfannenstiel technique by being significantly quicker to perform, with the reduced amounts of bleeding and suture material. The women were satisfied with the appearance of their scars. In this study no negative effects of the new operation technique were discovered.

Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor.

PubMed

Barber, Sarah L

2010-08-01

Caesarean section rates are increasing in Mexico and Latin America. This study evaluates the impact of a large-scale, conditional cash transfer programme in Mexico on caesarean section rates. The programme provides cash transfers to participating low income, rural households in Mexico conditional on accepting health care and nutrition supplements. The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states. Using multivariate and instrumental variable analyses, we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting. Programme participation is measured by beneficiary status, programme months and cash transfers. More than two-thirds of poor rural women delivered in a health facility. Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for >or=6 months before delivery. Beneficiaries had significantly higher caesarean delivery rates in social security facilities (24.0 compared with 5.6% among non-beneficiaries) and in other government facilities (19.3 compared with 9.5%). The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities. This effect appears to be driven by the increases in disposable income from the cash transfer. These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements.

Uncomplicated Caesarean section: is prolonged hospital stay necessary?

PubMed

Fasubaa, O B; Ogunniyi, S O; Dare, F O; Isawumi, A I; Ezechi, O C; Orji, E O

2000-08-01

Caesarean section among the Yoruba of western Nigerian is surrounded by a lot of fears, miseries, aversion, guilt and misconceptions for reasons varying from the desire by women to have a natural vaginal birth, fear of surgery, morbidity and deaths from the operation and prolonged hospital stay. To examine issues of reduced hospital stay following Caesarean section with a view of making the operation more acceptable and proffering solution to some of the problems faced by women when Caesarean section is indicated. A prospective case control study. Wesley Guild Hospital, Ilesha, Nigeria from 1st July, 1997 to 30th June, 1998. One hundred consecutive patients who had uncomplicated Caesarean section, randomised into two groups of short (three days) and prolonged (seven to eight days) hospital stay respectively. Observations of patients in both groups were made by an independent observer on day seven post-operation and the main outcomes measured included: wound infection rates, ability to maintain erect posture, mood changes, neonatal sepsis rate, immunisation rate of the neonates and average hospital bills. The findings revealed that wound infection rates of six per cent and ten per cent among the short and prolonged hospitalised patients respectively are not significantly different. Patients with short stay have better erect posture, lower incidence of depressive mood, lower neonatal sepsis rate, lower hospital bill and are more satisfied with early home discharge. Embracing the concept of early home discharge after Caesarean section in uncomplicated cases may remove some of the psychological upsets and economical impediments associated with the operation and make the operation more acceptable.

Comparative Evaluation of Remifentanil and Dexmedetomidine in General Anesthesia for Cesarean Delivery

PubMed Central

Li, Chengwen; Li, Yandong; Wang, Kun; Kong, Xiangang

2015-01-01

Background Use of remifentanil and dexmedetomidine in general anesthesia for cesarean section have been described. This study was designed to evaluate the effects of remifentanil and dexmedetomidine on maternal hemodynamics and bispectral index, and neonatal outcomes in elective caesarean delivery. Material/Methods Forty-four women undergoing elective cesarean delivery with ASA I or II and term or near-term singleton pregnancies were randomly assigned to receive remifentanil at a loading dose of 2 μg/kg over 10 min followed by a continuous infusion of 2 μg/kg/h until about 6 min before fetal delivery (Group REM), or dexmedetomidine at a loading dose of 0.4 μg/kg over 10 min followed by a continuous infusion of 0.4 μg/kg/h until about 6 min before fetal delivery (Group DEX). Maternal hemodynamics and BIS values were recorded. Neonatal effects were assessed using Apgar scores and umbilical cord blood gas analysis. Results Mean arterial pressure (MAP) increased after intubation in both groups, and the change magnitude of the MAP was higher in Group DEX (P<0.05). Patients in Group DEX had a lower BIS value at recovery and consumed less propofol during surgery (P<0.05). The incidences of neonatal resuscitation at 1 min were 81.8% in Group REM and 54.5% in Group DEX (P=0.052). There was no significant difference in either group in Apgar scores at 1 and 5 min and umbilical cord blood gas values. Conclusions Both remifentanil and dexmedetomidine are effective to blunt hemodynamic responses to intubation and also seem safe for neonates at the administrated doses, but remifentanil still has the potential to cause neonatal transient respiratory depression. PMID:26638888

Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008.

PubMed

Pradhan, A; Tincello, D G; Kearney, R

2013-01-01

To report the numbers of patients having childbirth after pelvic floor surgery in England. Retrospective analysis of Hospital Episode Statistics data. Hospital Episode Statistics database. Women, aged 20-44 years, undergoing childbirth after pelvic floor surgery between the years 2002 and 2008. Analysis of the Hospital Episode Statistics database using Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code at the four-character level for pelvic floor surgery and delivery, in women aged 20-44 years, between the years 2002 and 2008. Numbers of women having delivery episodes after previous pelvic floor surgery, and numbers having further pelvic floor surgery after delivery. Six hundred and three women had a delivery episode after previous pelvic floor surgery in the time period 2002-2008. In this group of 603 women, 42 had a further pelvic floor surgery episode following delivery in the same time period. The incidence of repeat surgery episode following delivery was higher in the group delivered vaginally than in those delivered by caesarean (13.6 versus 4.4%; odds ratio, 3.38; 95% confidence interval, 1.87-6.10). There were 603 women having childbirth after pelvic floor surgery in the time period 2002-2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.

PubMed

Lundgren, Ingela; Smith, Valerie; Nilsson, Christina; Vehvilainen-Julkunen, Katri; Nicoletti, Jane; Devane, Declan; Bernloehr, Annette; van Limbeek, Evelien; Lalor, Joan; Begley, Cecily

2015-02-05

The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, 'Effective Public Health Practice Project'. The primary outcome measure was VBAC rates. 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.

21 CFR 522.775 - Doxapram.

Code of Federal Regulations, 2010 CFR

2010-04-01

... horses to stimulate respiration during and after general anesthesia; or to speed awakening and return of reflexes after anesthesia. Administer to neonate dogs and cats to initiate respiration following dystocia or caesarean section; or to stimulate respiration following dystocia or caesarean section. (3...

[Results of the Misgav Ladach caesarean section].

PubMed

Heidenreich, W; Borgmann, U

2001-11-01

At the Department of Obstetrics and Gynecology, Allgemeines Krankenhaus Celle, 224 caesarean sections according to the Misgav Ladach technique were performed from 01. 05. 1998 to 30. 04. 1999. Anamnestic findings, intraoperative conditions, and postoperative course were compared to 125 conventionel caesarean deliveries. The Misgav Ladach technique resulted in notably shorter operative time, fewer complications of wound healing and reduced hospital stay. No further significant differences were observed in both groups. - The question of postoperative adhesions still remains to be answered. According to our experience the Misgav Ladach operation shows some advantages as compared to the usual method.

Caesarean Section--A Density-Equalizing Mapping Study to Depict Its Global Research Architecture.

PubMed

Brüggmann, Dörthe; Löhlein, Lena-Katharina; Louwen, Frank; Quarcoo, David; Jaque, Jenny; Klingelhöfer, Doris; Groneberg, David A

2015-11-17

Caesarean section (CS) is a common surgical procedure. Although it has been performed in a modern context for about 100 years, there is no concise analysis of the international architecture of caesarean section research output available so far. Therefore, the present study characterizes the global pattern of the related publications by using the NewQIS (New Quality and Quantity Indices in Science) platform, which combines scientometric methods with density equalizing mapping algorithms. The Web of Science was used as a database. 12,608 publications were identified that originated from 131 countries. The leading nations concerning research activity, overall citations and country-specific h-Index were the USA and the United Kingdom. Relation of the research activity to epidemiologic data indicated that Scandinavian countries including Sweden and Finland were leading the field, whereas, in relation to economic data, countries such as Israel and Ireland led. Semi-qualitative indices such as country-specific citation rates ranked Sweden, Norway and Finland in the top positions. International caesarean section research output continues to grow annually in an era where caesarean section rates increased dramatically over the past decades. With regard to increasing employment of scientometric indicators in performance assessment, these findings should provide useful information for those tasked with the improvement of scientific achievements.

Foetal electrocardiograph (ST-analyser or STAN) for intrapartum foetal heart rate monitoring: a friend or a foe?

PubMed

Chandraharan, Edwin

2018-01-01

Cardiotocograph (CTG) is associated with a high false positive rate of up to 60% which may increase the risk of unnecessary intrapartum interventions (emergency caesarean sections or operative vaginal deliveries) without any significant benefits. A recent study on variation of caesarean section rates in England has concluded that there was a very wide variation even in the adjusted rates of caesarean section from 14.9% to 32.1%. Cochrane Systematic Reviews have concluded that the use of FBS does not reduce caesarean section rate or any pre-specified neonatal outcomes. Fetal ECG (ST-Analyser or STAN) has been used in the clinical practice for more than 20 years. Although, initial randomised controlled trials (RCTs) showed great promise regarding the role of STAN in reducing operative delivery rates (instrumental vaginal births and emergency caesarean sections) and neonatal metabolic acidosis, subsequent studies have questioned the role of STAN in clinical practice. A recent meta-analysis which included six randomised controlled trials (a total of 26,446 women) has concluded that there was a 36% reduction in the rate of neonatal metabolic acidosis. Practising clinicians currently face a dilemma as to whether STAN has a place in contemporary obstetric practice or whether it?s use should be discouraged and discontinued.

Caesarean Section—A Density-Equalizing Mapping Study to Depict Its Global Research Architecture

PubMed Central

Brüggmann, Dörthe; Löhlein, Lena-Katharina; Louwen, Frank; Quarcoo, David; Jaque, Jenny; Klingelhöfer, Doris; Groneberg, David A.

2015-01-01

Caesarean section (CS) is a common surgical procedure. Although it has been performed in a modern context for about 100 years, there is no concise analysis of the international architecture of caesarean section research output available so far. Therefore, the present study characterizes the global pattern of the related publications by using the NewQIS (New Quality and Quantity Indices in Science) platform, which combines scientometric methods with density equalizing mapping algorithms. The Web of Science was used as a database. 12,608 publications were identified that originated from 131 countries. The leading nations concerning research activity, overall citations and country-specific h-Index were the USA and the United Kingdom. Relation of the research activity to epidemiologic data indicated that Scandinavian countries including Sweden and Finland were leading the field, whereas, in relation to economic data, countries such as Israel and Ireland led. Semi-qualitative indices such as country-specific citation rates ranked Sweden, Norway and Finland in the top positions. International caesarean section research output continues to grow annually in an era where caesarean section rates increased dramatically over the past decades. With regard to increasing employment of scientometric indicators in performance assessment, these findings should provide useful information for those tasked with the improvement of scientific achievements. PMID:26593932

Maternal obesity and Caesarean delivery in sub-Saharan Africa.

PubMed

Cresswell, Jenny A; Campbell, Oona M R; De Silva, Mary J; Slaymaker, Emma; Filippi, Veronique

2016-07-01

To quantify maternal obesity as a risk factor for Caesarean delivery in sub-Saharan Africa. Multivariable logistic regression analysis using 31 nationally representative cross-sectional data sets from the Demographic and Health Surveys (DHS). Maternal obesity was a risk factor for Caesarean delivery in sub-Saharan Africa; a clear dose-response relationship (where the magnitude of the association increased with increasing BMI) was observable. Compared to women of optimal weight, overweight women (BMI 25-29 kg/m(2) ) were significantly more likely to deliver by Caesarean (OR: 1.54; 95% CI: 1.33, 1.78), as were obese women (30-34.9 kg/m(2) (OR: 2.39; 95%CI: 1.96-2.90); 35-39.9 kg/m(2) (OR: 2.47 95%CI: 1.78-3.43)) and morbidly obese women (BMI ≥40 kg/m(2) OR: 3.85; 95% CI: 2.46-6.00). BMI is projected to rise substantially in sub-Saharan Africa over the next few decades and demand for Caesarean sections already exceeds available capacity. Overweight women should be advised to lose weight prior to pregnancy. Furthermore, culturally appropriate prevention strategies to discourage further population-level rises in BMI need to be designed and implemented. © 2016 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.

Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in South Africa.

PubMed

Maswime, T S; Buchmann, E

2017-10-31

A rising caesarean section rate and substandard peri-operative care are believed to be the main reasons for recent increases in maternal deaths from bleeding during and after caesarean section (BDACS) in South Africa (SA). The Donabedian model assumes that clinical outcomes are influenced by healthcare workers and the healthcare system. To evaluate near-miss cases from BDACS with regard to health system structure (resources and facilities) and process (patient care). A cross-sectional prospective study was conducted in greater Johannesburg, SA. Data of women who had near-miss-related BDACS were collected by means of ongoing surveillance at 13 public hospitals. The World Health Organization intervention criteria were used to identify near-miss cases. A comparison of structure and process between the healthcare facilities was conducted. Of 20 527 caesarean sections , there were 93 near misses and 7 maternal deaths from BDACS. Dominant risk factors for near misses were previous caesarean section (43.9%), anaemia (25.3%) and pregnancy-induced hypertension (28.6%). Eighteen women were transferred to higher levels of care, and 8 (44.4%) experienced transport delays of >1 hour. The caesarean section decision-to-incision interval (DII) was ≥60 minutes in 77 of 86 women, with an average interval of 4 hours. Structural deficiencies were frequently present in district hospitals, and there were serious delays in ambulance transfer and DIIs at all levels of care. The majority of the women had risk factors for BDACS. There were major ambulance delays and lack of facilities, mostly in district hospitals. All women required life-saving interventions, but could not access appropriate care timeously. Prevention and management of BDACS require a fully functional health system.

The Hidden Costs of a Free Caesarean Section Policy in West Africa (Kayes Region, Mali).

PubMed

Ravit, Marion; Philibert, Aline; Tourigny, Caroline; Traore, Mamadou; Coulibaly, Aliou; Dumont, Alexandre; Fournier, Pierre

2015-08-01

The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.

Quality of obstetric care in the sparsely populated sub-arctic area of Norway 2009–2011

PubMed Central

2013-01-01

Background It is challenging to obtain high quality obstetric care in a sparsely populated area. In the subarctic region of Norway, significant distances, weather conditions and seasonable darkness have called for a decentralized care model. We aimed to explore the quality of this care. Methods A retrospective study employing data (2009–11) from the Medical Birth Registry of Norway was initiated. Northern Norwegian and Norwegian figures were compared. Midwife administered maternity units, departments at local and regional specialist hospitals were compared. National registry data on post-caesarean wound infection (2009–2010) was added. Quality of care was measured as rate of multiple pregnancies, caesarean section, post-caesarean wound infection, Apgar score <7, birth weight <2.5 kilos, perineal rupture, stillbirth, eclampsia, pregnancy induced diabetes and vacuum or forceps assisted delivery. There were 15,586 births in 15 delivery units. Results Multiple pregnancies were less common in northern Norway (1.3 vs. 1.7%) (P = 0.02). Less use of vacuum (6.6% vs. 8.3%) (P = 0.01) and forceps (0.9% vs 1.7%) (P < 0.01) assisted delivery was observed. There was no difference with regard to pregnancy induced diabetes, caesarean section, stillbirth, Apgar score < 7 and eclampsia. A significant difference in birth weight < 2.5 kilos (4.7% vs. 5.0%) (P < 0.04) and perineal rupture grade 3 and 4 (1.5% vs. 2.3%) (P < 0.02) were revealed. The post-caesarean wound infection rate was higher (10.5% vs. 7.4%) (P < 0.01). Conclusion Northern Norway had an obstetric care of good quality. Birth weight, multiple pregnancies and post-caesarean wound infection rates should be further elucidated. PMID:24034451

Involving women in personalised decision-making on mode of delivery after caesarean section: the development and pilot testing of a patient decision aid.

PubMed

Schoorel, E N C; Vankan, E; Scheepers, H C J; Augustijn, B C C; Dirksen, C D; de Koning, M; van Kuijk, S M J; Kwee, A; Melman, S; Nijhuis, J G; Aardenburg, R; de Boer, K; Hasaart, T H M; Mol, B W J; Nieuwenhuijze, M; van Pampus, M G; van Roosmalen, J; Roumen, F J M E; de Vries, R; Wouters, M G A J; van der Weijden, T; Hermens, R P M G

2014-01-01

To develop a patient decision aid (PtDA) for mode of delivery after caesarean section that integrates personalised prediction of vaginal birth after caesarean (VBAC) with the elicitation of patient preferences and evidence-based information. A PtDA was developed and pilot tested using the International Patients Decision Aid Standards (IPDAS) criteria. Obstetric health care in the Netherlands. A multidisciplinary steering group, an expert panel, and 25 future users of the PtDA, i.e. women with a previous caesarean section. The development consisted of a construction phase (definition of scope and purpose, and selection of content, framework, and format) and a pilot testing phase by interview. The process was supervised by a multidisciplinary steering group. Usability, clarity, and relevance. The construction phase resulted in a booklet including unbiased balanced information on mode of birth after caesarean section, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. During pilot testing, visualisation of risks and clarity formed the main basis for revisions. Pilot testing showed the availability of tailored structured information to be the main factor involving women in decision-making. The PtDA meets 39 out of 50 IPDAS criteria (78%): 23 out of 23 criteria for content (100%) and 16 out of 20 criteria for the development process (80%). Criteria for effectiveness (n = 7) were not evaluated. An evidence-based PtDA was developed, with the probability of successful VBAC and the availability of structured information as key items. It is likely that the PtDA enhances the quality of decision-making on mode of birth after caesarean section. © 2013 Royal College of Obstetricians and Gynaecologists.

The utility of caesarean myomectomy as a safe procedure: a retrospective analysis of 21 cases with review of literature.

PubMed

Kumar R, Ramesh; Patil, Manjula; Sa, Shruthi

2014-09-01

Myomectomy at the time of caesarean delivery has been discouraged because of the risk of intractable haemorrhage and increased postoperative morbidity. The aim of this study is to determine the safety and feasibility of caesarean myomectomy. A retrospective case control study done between June 2012 to May 2013 in a tertiary care teaching hospital in Karnataka, India which included 21 pregnant women with uterine fibroids who underwent myomectomy during caesarean section and were compared with 42 matched controls without uterine fibroids who had caesarean section alone during the same period. Primary outcome measures studied were incidence of haemorrhage and need for blood transfusion. Secondary outcome measures were duration of operation, length of hospital stay, postpartum fever and wound infection. Statistical analysis is done using IBMSPSS 20.0 software and students t-test. For calculation of incidence of haemorrhage Fisher's exact test is used. Mean age of the 21 cases was 31.81yrs and 47.62% were primigravida. Total 37 fibroids were removed. Subserosal were 30 cases(81.08%) while 1(2.07%) was submucous. 21(56.76%)fibroids were situated in fundal region and 3(8.11%) were in lower segment. Mean change in the haemoglobin from preoperative to postoperative period in the cases was 1.3gm/dl(±1.155mg/dl) and control was 1.05% (±.854mg/dl). Two of the cases(9.52%) required blood transfusion compared to none in control. None in either group required hysterectomy. Mean duration of surgery was 68.57min (±15.012min)and 51.55min (±9.595min) for controls which is statistically significant. This study shows that myomectomy during caesarean section is a safe procedure and is not associated with major intraoperative and postoperative complications.

Effects of gum chewing on postoperative bowel motility after caesarean section: a meta-analysis of randomised controlled trials.

PubMed

Zhu, Y-P; Wang, W-J; Zhang, S-L; Dai, B; Ye, D-W

2014-06-01

Gum chewing has been reported to enhance bowel motility and reduce postoperative ileus (POI). However, the efficacy remains imprecise for women following caesarean section. To summarise and evaluate the current evidence for postoperative gum chewing on the recovery of bowel function following caesarean section. We searched studies from the following electronic databases: PubMed, EMBASE, SCOPUS and Cochrane Library from inception to 30 May 2013. We included randomised controlled trials (RCTs) of women after caesarean section; these RCTs should compared gum chewing with no gum chewing and reported on at least one of the outcomes: time to flatus, time to bowel sound, time to passing stool and length of hospital stay (LOS). Study outcomes were presented as mean differences (for continuous data) with 95% confidence interval (95% CI). The risk of bias in the study results was assessed using the assessment tool from the Cochrane Handbook. Six RCTs including 939 women were included in our meta-analysis. The pooled results demonstrated that gum chewing is superior to no gum chewing with a reduction of 6.42 hours (95% CI -7.55 to -5.29) for time to first flatus, 3.62 hours (95% CI -6.41 to -0.83) for time to first bowel sound, 6.58 hours (95% CI -10.10 to -3.07) for time to first stool and 5.94 hours (95% CI -9.39 to -2.49) for LOS. In addition, no evidence emerged for any side effects caused by gum chewing. The current evidence suggests that gum chewing is associated with early recovery of bowel motility and shorter LOS for women after caesarean section. This safe and inexpensive intervention should be included in routine postoperative care following a caesarean section. © 2014 Royal College of Obstetricians and Gynaecologists.

Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012.

PubMed

Cresswell, Jenny A; Assarag, Bouchra; Meski, Fatima-Zahra; Filippi, Veronique; Ronsmans, Carine

2015-05-01

To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care. Using data from nationally representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events. Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades, particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95% CI: 1.02-1.02). A similar pattern was observed for caesareans (annual increase among poorest RR: 1.13; 95% CI: 1.07-1.19 vs. annual increase among richest RR: 1.08; 95% CI: 1.06-1.10). We found no significant acceleration in trend coinciding with any of the events investigated. Morocco's success in improving uptake of facility deliveries and caesareans is likely to be the result of the synergistic effects of comprehensive demand and supply-side strategies, including a major investment in human resources and free delivery care. Equity still needs to be improved; however, the overall trend is positive. © 2015 John Wiley & Sons Ltd.

Planned caesarean section for term breech delivery.

PubMed

Hofmeyr, G Justus; Hannah, Mary; Lawrie, Theresa A

2015-07-21

Poor outcomes after breech birth might be the result of underlying conditions causing breech presentation or due to factors associated with the delivery. To assess the effects of planned caesarean section for singleton breech presentation at term on measures of pregnancy outcome. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015). Randomised trials comparing planned caesarean section for singleton breech presentation at term with planned vaginal birth. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Three trials (2396 participants) were included in the review. Caesarean delivery occurred in 550/1227 (45%) of those women allocated to a vaginal delivery protocol and 1060/1169 (91%) of those women allocated to planned caesarean section (average risk ratio (RR) random-effects, 1.88, 95% confidence interval (CI) 1.60 to 2.20; three studies, 2396 women, evidence graded low quality). Perinatal or neonatal death (excluding fatal anomalies) or severe neonatal morbidity was reduced with a policy of planned caesarean section in settings with a low national perinatal mortality rate (RR 0.07, 95% CI 0.02 to 0.29, one study, 1025 women, evidence graded moderate quality), but not in settings with a high national perinatal mortality rate (RR 0.66, 95% CI 0.35 to 1.24, one study, 1053 women, evidence graded low quality). The difference between subgroups was significant (Test for subgroup differences: Chi² = 8.01, df = 1 (P = 0.005), I² = 87.5%). Due to this significant heterogeneity, a random-effects analysis was performed. The average overall effect was not statistically significant (RR 0.23, 95% CI 0.02 to 2.44, one study, 2078 infants). Perinatal or neonatal death (excluding fatal anomalies) was reduced with planned caesarean section (RR 0.29, 95% CI 0.10 to 0.86, three studies, 2388 women). The proportional reductions were similar for countries with low and high national perinatal mortality rates.The numbers studied were too small to satisfactorily address reductions in birth trauma and brachial plexus injury with planned caesarean section. Neither of these outcomes reached statistical significance (birth trauma: RR 0.42, 95% CI 0.16 to 1.10, one study, 2062 infants (20 events),evidence graded low quality; brachial plexus injury: RR 0.35, 95% CI 0.08 to 1.47, three studies, 2375 infants (nine events)).Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61, three studies, 2396 women,low quality evidence). At three months after delivery, women allocated to the planned caesarean section group reported less urinary incontinence (RR 0.62, 95% CI 0.41 to 0.93, one study, 1595 women); no difference in 'any pain' (RR 1.09, 95% CI 0.93 to 1.29, one study, 1593 women,low quality evidence); more abdominal pain (RR 1.89, 95% CI 1.29 to 2.79, one study, 1593 women); and less perineal pain (RR 0.32, 95% CI 0.18 to 0.58, one study, 1593 women).At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay' (RR 1.09, 95% CI 0.52 to 2.30, one study, 920 children,evidence graded low quality); more infants who had been allocated to planned caesarean delivery had medical problems at two years (RR 1.41, 95% CI 1.05 to 1.89, one study, 843 children). Maternal outcomes at two years were also similar. In countries with low perinatal mortality rates, the protocol of planned caesarean section was associated with lower healthcare costs, expressed in 2002 Canadian dollars (mean difference -$877.00, 95% CI -894.89 to -859.11, one study, 1027 women).All of the trials included in this review had design limitations, and the GRADE level of evidence was mostly low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in two studies. Two of the three trials had serious design limitations, however these studies contributed to fewer outcomes than the large multi-centre trial with lower risk of bias. Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death as well as the composite outcome death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity. In a subset with 2-year follow up, infant medical problems were increased following planned caesarean section and no difference in long-term neurodevelopmental delay or the outcome "death or neurodevelopmental delay" was found, though the numbers were too small to exclude the possibility of an important difference in either direction.The benefits need to be weighed against factors such as the mother's preference for vaginal birth and risks such as future pregnancy complications in the woman's specific healthcare setting. The option of external cephalic version is dealt with in separate reviews. The data from this review cannot be generalised to settings where caesarean section is not readily available, or to methods of breech delivery that differ materially from the clinical delivery protocols used in the trials reviewed. The review will help to inform individualised decision-making regarding breech delivery. Research on strategies to improve the safety of breech delivery and to further investigate the possible association of caesarean section with infant medical problems is needed.

Enhancing Student International Awareness and Global Competency through Compact International Experience Courses

NASA Astrophysics Data System (ADS)

Jacobitz, Frank; Schubert, Thomas

2013-11-01

Short-term, study-abroad, elective engineering courses were developed in order to raise the international awareness and global competency of engineering students. These Compact International Experience (CIE) courses were taught in response to a strong student desire for engineering study abroad courses and an effort by the home institution to internationalize its curriculum. An assessment of repeat offerings of two three-semester-unit courses on Topics in Fluid Mechanics and Advanced Electronic Circuit Design in a three-week time frame in France and Australia was performed. The goals of the two CIE courses are an effective teaching of their respective technical content as well as a student understanding of the cultural environment and the impact of engineering solutions from a global and societal viewpoint. In the repeat offerings, increased interaction with local industry was an additional goal. The CIE courses were assessed through surveys completed at the beginning and end of the courses, weekly student reflection papers, course evaluations, and formalized instructor observations. Based on the assessment performed, the two CIE courses have been found to be a valuable approach in the delivery of engineering technical electives combined with an international experience.

[Comparative analysis of modification of Misgav-Ladach and Pfannenstiel methods for cesarean section in the material of Fetal-Maternal Clinical Department PMMH-RI between 1994-1999].

PubMed

Pawłowicz, P; Wilczyński, J; Stachowiak, G

2000-04-01

Comparative analysis of own modification of Misgav-Ladach (mML) and Pfannenstiel methods for caesarean section in the material of Fetal-Maternal Medicine Clinical Department PMMH-RI between 1994-99. Study group consists of 242 patients. In all women from this group we performed caesarean section using Misgav-Ladach method. Among all patients from control group counting 285 women we performed caesarean section applying Pfannenstiel method. To analyse clinical postoperative course in both groups we took account several parameters. Statistical analysis revealed that most of clinical postoperative course parameters was significantly better values in the study group we performed caesarean section using Misgav-Ladach method. The benefits of Misgav-Ladach method, with less pain post-operatively and quicker recovery, are all a by-product of doing the least harm during surgery and removing every unnecessary step. This method is appealing for its simplicity, ease of execution and its time-saving advantage.

Caesarean section greatly increases risk of scar endometriosis.

PubMed

Nominato, Nilo Sérgio; Prates, Luis Felipe Victor Spyer; Lauar, Isabela; Morais, Jaqueline; Maia, Laura; Geber, Selmo

2010-09-01

To estimate the incidence of scar endometriosis after different surgical procedures. A retrospective study of 72 patients diagnosed with scar endometriosis between 1978 and 2003 was performed. Patient age, site of endometriosis, previous operations, time-gap between last surgery and onset of symptoms, nodule characteristics, and recurrence were evaluated. Age ranged from 16 to 48 years. Location varied according to the previous surgery: 46 caesarean section, one hysterectomy, one in abdominal surgery, 19 episiotomy, one was a relapse and two pelvic floor procedures, two women with no previous surgery. The incidence of scar endometriosis after caesarean section was significantly higher than after episiotomy (0.2 and 0.06%, respectively: p<0.00001) with a relative risk of 3.3. Pain was the most frequent symptom. The mean time between surgery and onset of symptoms was 3.7 years. Our findings confirm that scar endometriosis is a rare condition and indicate, probably for the first time, that caesarean section greatly increases the risk of developing scar endometriosis. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

Antioxidative defence mechanisms against reactive oxygen species in bovine retained and not-retained placenta: activity of glutathione peroxidase, glutathione transferase, catalase and superoxide dismutase.

PubMed

Kankofer, M

2001-05-01

Glutathione peroxidase (GSH-Px), glutathione transferase (GSH-Tr), catalase (CAT) and superoxide dismutase (SOD)-the members of enzymatic antioxidative defence mechanisms against reactive oxygen species-may play an important role in proper or improper release of bovine fetal membranes. The aim of the following study was the determination of GSH-Px, GSH-Tr, CAT and SOD activity in order to define antioxidative status of bovine placenta during retention of fetal membranes (RFM) in cows. Placental samples were collected immediately after spontaneous parturition or during caesarean section before term and at term and divided into six groups as follows: A: caesarean section before term without RFM; B: caesarean section before term with RFM; C: caesarean section at term without RFM; D: caesarean section at term with RFM; E: spontaneous delivery at term without RFM; F: spontaneous delivery at term with RFM. The enzyme activities in placental homogenates were measured spectrophotometrically. GSH-Px activity was statistically significantly higher in fetal than in maternal placenta in all examined groups, increased towards parturition and was higher in caesarean section groups than spontaneous delivery groups. Statistically significantly higher activities were noticed in retained than not-retained placentae. GSH-Tr activity was significantly lower in fetal than in maternal placenta. In preterm groups, the activity was statistically significantly higher in retained than not retained placenta. In term groups, the opposite relationship was observed, higher values in caesarean section groups than spontaneous delivery were noticed. CAT activity was statistically significantly higher in fetal than in maternal part of placenta in all groups examined. The highest values in C and D groups and the differences between retained and not-retained placenta were observed. SOD exhibited the highest values in preterm placenta and alterations between retained and not-retained fetal membranes. In conclusion, the activities of GSH-Px, GSH-Tr, CAT and SOD are altered in cases of retained fetal membranes which may suggest the activation of antioxidative mechanisms caused by the imbalance between production and neutralization of reactive oxygen species. Copyright 2001 Harcourt Publishers Ltd.

An Examination of Women Experiencing Obstetric Complications Requiring Emergency Care: Perceptions and Sociocultural Consequences of Caesarean Sections in Bangladesh

PubMed Central

Khan, Rasheda; Sultana, Marzia; Bilkis, Sayeda; Koblinsky, Marge

2012-01-01

Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008–August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health systems need to be strengthened to ensure that all women in clinical need of lifesaving obstetric surgery access quality EmOC services rapidly and, once in a facility, can obtain a caesarean section promptly, if needed. While greater access to surgical interventions may be lifesaving, policy-makers need to institute mechanisms to discourage the over-medicalization of childbirth in a context where the use of caesarean section is rapidly rising. PMID:22838158

Perinatal outcomes of singleton term breech deliveries in Basra.

PubMed

Alshaheen, H; Abd Al-Karim, A

2010-01-01

This study aimed to assess the perinatal morbidity and mortality in breech deliveries, to study the correlation of parity and birth weight with perinatal mortality by mode of delivery. Of 210 women in labour in Basra maternity and child hospital, 97 underwent vaginal breech deliveries and 113 delivered by caesarean section. Birth trauma was restricted to vaginal deliveries. The perinatal mortality was significantly higher in vaginal deliveries (8.2%) compared with caesarean deliveries (0.9%). A higher perinatal mortality was recorded among infants > 3500-4000 g birth weight in vaginal deliveries. Caesarean section reduced the perinatal mortality in both nulliparous and parous women in term breech infants.

Effects of Recruiting Midwives into a Family Physician Program on Women's Awareness and Preference for Mode of Delivery and Caesarean Section Rates in Rural Areas of Kurdistan.

PubMed

Hajizadeh, Shayesteh; Tehrani, Fahimeh Ramezani; Simbar, Masoumeh; Farzadfar, Farshad

2016-01-01

The accepted rate rate of caesarean section is 15%. It is expected that an increase in the density of midwives in the family physician program lead to a decrease in this indicator. This study aimed to compare the rates of caesarean section and women's awareness and preference for mode of delivery before and after the implementation of the family physician program in health centres with and without an increase in midwives density. In this cross-sectional study, using multistage cluster sampling method a total of 668 mothers with two-month-old children were selected from among all mothers with two-month-old children who were living in rural areas of Kurdistan province. Using the difference-in-differences model and Matchit statistical model, the factors associated with caesarean section rates and women's awareness and preference for mode of delivery were compared in centres with and without an increase in midwives density after the implementation of the family physician program. To compare the changes before and after the program, we used the data collected from the same number of women in 2005 as the baseline. After adjusting for baseline data collected in 2005, the resutls showed no significant change in caesarean section rates and women's awareness and preference for mode of delivery in the centres with and without an increase in midwives density after the implementation of the family physician program. The Matchit model showed a significant mean increase 14%(0.03-0.25) in women's awareness of the benefits of natural childbirth between 2005 and 2013 in health centres where the density of midwives increased compared with health centres where it did not. The difference-in-differences model showed that the odds ratio of women's preference for caesarean section decreased by 41% among participants who were aware of the benefits of natural childbirth, (OR = 0.59, 95% CI: (0.22-0.85); P>0.001). The results of this study showed that an increase in the density of midwives in the family physician program led to an increase in women's awareness of the benefits of natural childbirth. An increase in women's awareness of the benefits of natural childbirth was associated with a decreased preference for caesarean section, however this reduction did not have a significant impact on caesarean section rates; possibly, this finding might be attributed to the complexity of this problem that needs a mixed strategy involving various stockholders.

New Technique for Caesarean Section.

PubMed

Vejnović, T R; Costa, S D; Ignatov, A

2012-09-01

Caesarean section is one of the most common operations worldwide and more than 30 % of procedures in perinatal centres in Germany are caesarean sections. In the last few years the technique used for caesarean sections has been simplified, resulting in a lower postoperative morbidity. But persistent problems associated with all caesarean section techniques include high intraoperative loss of blood, the risk of injury to the child during uterotomy and postoperative wound dehiscence of the uterine scar. We present here a modification of the most common Misgav-Ladach method. The initial skin incision is done along the natural skin folds and is extended intraoperatively depending on the circumference of the baby's head. After blunt expansion of the uterine incision using an anatomical forceps, the distal uterine wall is pushed behind the baby's head. The baby's head is rotated into the occipito-anterior or posterior position and delivery occurs through the application of gentle pressure on the uterine fundus. Closure of the uterotomy is done using 2 continuous sutures, which are then knotted together resulting in a short double-layer closure. The two ends of the skin suture are left open to allow for natural drainage. Our experience at the University Gynaecological Hospitals in Novi Sad and Magdeburg has shown that this modification is associated with shorter operating times, minimal blood loss and shorter in-hospital stay of patients as well as high rates of patient satisfaction.

The Impact of Caesarean Delivery on Paracetamol and Ketorolac Pharmacokinetics: A Paired Analysis

PubMed Central

Kulo, Aida; van Calsteren, Kristel; Verbesselt, Rene; Smits, Anne; Devlieger, Roland; de Hoon, Jan; Allegaert, Karel

2012-01-01

Pharmacokinetics is a first, but essential step to improve population-tailored postoperative analgesia, also after Caesarean delivery. We therefore aimed to quantify the impact of caesarean delivery on the pharmacokinetics of intravenous (iv) paracetamol (2 g, single dose) and iv ketorolac tromethamine (30 mg, single dose) in 2 cohorts eachof 8 women at caesarean delivery and to compare these findings with postpartum to quantify intrapatient changes. We documented a higher median paracetamol clearance at delivery when compared to 10–15 weeks postpartum (11.7 to 6.4 L/h·m2, P < 0.01), even after correction for weight-related changes. Similar conclusions were drawn for ketorolac: median clearance was higher at delivery with a subsequent decrease (2.03 to 1.43 L/h·m2, P < 0.05) in postpartum (17–23 weeks). These differences likely reflect pregnancy- and caesarean-delivery-related changes in drug disposition. Moreover, postpartum paracetamol clearance was significantly lower when compared to estimates published in healthy young volunteers (6.4  versus  9.6 L/h·m2), while this was not the case for ketorolac (1.43  versus  1.48 L/h·m2). This suggests that postpartum is another specific status in young women that merits focused, compound-specific pharmacokinetic evaluation. PMID:22675252

The immediate effect of vaginal and caesarean delivery on anal sphincter measurements.

PubMed

Karcaaltincaba, Deniz; Erkaya, Salim; Isik, Hatice; Haberal, Ali

2016-08-01

This study evaluated the effects of vaginal and caesarean delivery on internal and external anal sphincter muscle thickness using translabial ultrasonography (TL-US). This prospective cohort study enrolled nulliparous women who either had vaginal or caesarean deliveries. The thickness of the hypoechoic internal anal sphincter (IAS) and hyperechoic external anal sphincter (EAS) at the 12, 3, 6, and 9 o'clock positions at the distal level were measured before delivery and within 24-48 h after delivery. A total 105 consecutive women were enrolled in the study: 60 in the vaginal delivery group and 45 in the caesarean delivery group. The IAS muscle thickness at the 12 o'clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.31 ± 0.74 mm versus 1.81 ± 0.64 mm, respectively). The EAS muscle thickness at the 12 o'clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.42 ± 0.64 mm versus 1.97 ± 0.85, respectively). There was significant muscle thinning of both the IAS and EAS at the 12 o'clock position after vaginal delivery, but not after caesarean delivery. © The Author(s) 2016.

Japan's 2014 General Election: Political Bots, Right-Wing Internet Activism, and Prime Minister Shinzō Abe's Hidden Nationalist Agenda.

PubMed

Schäfer, Fabian; Evert, Stefan; Heinrich, Philipp

2017-12-01

In this article, we present results on the identification and behavioral analysis of social bots in a sample of 542,584 Tweets, collected before and after Japan's 2014 general election. Typical forms of bot activity include massive Retweeting and repeated posting of (nearly) the same message, sometimes used in combination. We focus on the second method and present (1) a case study on several patterns of bot activity, (2) methodological considerations on the automatic identification of such patterns and the prerequisite near-duplicate detection, and (3) we give qualitative insights into the purposes behind the usage of social/political bots. We argue that it was in the latency of the semi-public sphere of social media-and not in the visible or manifest public sphere (official campaign platform, mass media)-where Shinzō Abe's hidden nationalist agenda interlocked and overlapped with the one propagated by organizations such as Nippon Kaigi and Internet right-wingers (netto uyo) during the election campaign, the latter potentially forming an enormous online support army of Abe's agenda.

Japan's 2014 General Election: Political Bots, Right-Wing Internet Activism, and Prime Minister Shinzō Abe's Hidden Nationalist Agenda

PubMed Central

Schäfer, Fabian; Evert, Stefan; Heinrich, Philipp

2017-01-01

Abstract In this article, we present results on the identification and behavioral analysis of social bots in a sample of 542,584 Tweets, collected before and after Japan's 2014 general election. Typical forms of bot activity include massive Retweeting and repeated posting of (nearly) the same message, sometimes used in combination. We focus on the second method and present (1) a case study on several patterns of bot activity, (2) methodological considerations on the automatic identification of such patterns and the prerequisite near-duplicate detection, and (3) we give qualitative insights into the purposes behind the usage of social/political bots. We argue that it was in the latency of the semi-public sphere of social media—and not in the visible or manifest public sphere (official campaign platform, mass media)—where Shinzō Abe's hidden nationalist agenda interlocked and overlapped with the one propagated by organizations such as Nippon Kaigi and Internet right-wingers (netto uyo) during the election campaign, the latter potentially forming an enormous online support army of Abe's agenda. PMID:29182493

Recurrence of phaeochromocytoma in pregnancy in a patient with multiple endocrine neoplasia 2A: a case report and review of literature.

PubMed

Tingi, Efterpi; Kyriacou, Angelos; Verghese, Lynda

2016-11-01

Multiple endocrine neoplasia type 2A (MEN 2A) is an autosomal dominant inherited condition with a prevalence of one in 40 000 individuals. It causes the development of tumours in endocrine glands, such as medullary thyroid cancer, pheochromocytomas, as well as primary hyperparathyroidism. MEN 2A in pregnancy is very rare with only 29 cases reported in the literature. The presence of pheochromocytoma is a rare cause of hypertension during pregnancy with an incidence of 0.007% of all pregnancies. This has severe implications on both mother and the foetus. This case report describes a 22-year-old nulliparous Caucasian woman with known MEN2A syndrome, who underwent thyroidectomy for medullary thyroid carcinoma in childhood and excision of left sided pheochromocytoma at the age of 19. She was found to have a recurrence of pheochromocytoma in the right adrenal gland during pregnancy at 16 weeks of gestation and was oddly normotensive. Catecholamine effects were blocked with phenoxybenzamine and she delivered by an uneventful elective caesarean section at 36 weeks gestation. She underwent a laparoscopic right adrenalectomy six weeks postpartum, followed by lifelong corticosteroid replacement.

Success of elective cholecystectomy treatment plans after emergency department visit.

PubMed

Bingener, Juliane; Thomsen, Kristine M; McConico, Andrea; Hess, Erik P; Habermann, Elizabeth B

2015-01-01

Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive. Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate. From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group. One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways. Copyright © 2015 Elsevier Inc. All rights reserved.

Maternal and neonatal copeptin levels at cesarean section and vaginal delivery.

PubMed

Foda, Ashraf A; Abdel Aal, Ibrahim A

2012-12-01

The objective of the study was to measure the copeptin levels in maternal serum and umbilical cord serum at cesarean section and vaginal delivery in normotensive pregnancy and pre-eclamptic women. This was a prospective study at Mansoura University Hospital, Egypt. Ninety cases were included. They were divided into six groups: (1) normal pregnancy near term, as a control group, (2) primiparas who had vaginal delivery, (3) primiparas who had vaginal delivery and mild preeclampsia, (4) elective repeat cesarean section, (5) intrapartum cesarean section for indications other than fetal distress, and (6) intrapartum cesarean section for fetal distress. Serum copeptin concentrations were quantified with an enzyme-linked immunosorbent assay (ELISA). Mean, standard deviation, and paired t-test were used to test for significant change in quantitative data. The vaginal delivery groups had higher levels of maternal serum copeptin than the elective cesarean section group (P<0.01). Higher maternal serum copeptin levels were found in cases with pre-eclampsia as compared with the normotensive cases. The maternal copeptin levels during intrapartum cesarean section were higher than that during elective repeat cesarean section. There was a significant correlation between maternal copeptin levels and the duration of the first stage. In the presence of fetal distress, umbilical cord serum copeptin levels were significantly higher than other groups. Vaginal delivery can be very painful and stressful, and is accompanied by a marked increase of maternal serum copeptin. Increased maternal levels of serum copeptin were found in cases with pre-eclampsia as compared with the normotensive cases, and it may be helpful in assessing the disease. Intrauterine fetal distress is a strong stimulus to the release of copeptin into the fetal circulation. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

On becoming a first-time mother after an emergency Caesarean section: a journey from alienation to symbolic adoption.

PubMed

Herishanu-Gilutz, Shirley; Shahar, Golan; Schattner, Emanuel; Kofman, Ora; Holcberg, Gershon

2009-10-01

This qualitative research focused on the significance of subjective experience of mothers who gave birth in an emergency Caesarean section. Ten first-time mothers experiencing emergency Caesarean section were interviewed, and their narrative accounts were analyzed using Giorgi's phenomenological method. Mothers described alienation from the infant on encountering her/him; primal difficulties in holding; a 'mechanistic' pattern of childcare at home; over-apprehension and fear of a cradle-death. A few of the women seemed to cope with these experiences by performing 'a symbolic adoption' of their infants. In the context of object-relations theory, the findings, will potentially inform psychological care in obstetrics and gynaecology.

Anaesthetic management of severe hypertrophic obstructive cardiomyopathy with bronchial asthma for emergency caesarean section.

PubMed

Rajesh, M C; Varma, Ravi; Lima, P; Ramdas, E K

2012-10-01

A 39-year-old primi and a known case of hypertrophic obstructive cardiomyopathy presented for emergency lower segment caesarean section. She was also an asthmatic with a recent exacerbation. She underwent uneventful lower segment caesarean section under general anaesthesia with lumbar epidural analgesia for postoperative pain relief. Anaesthetic agents and techniques were selected to suit the haemodynamic profile of severe hypertrophic obstructive cardiomyopathy in pregnancy. The case has been reported because of successful outcome in an emergency scenario with such high intraventricular gradients and omissions in the case so that it will be of benefit to readers who may happen to land up in similar situations.

Facial laceration at caesarean section: experience with tissue adhesive.

PubMed

Saraf, Sanjay

2009-01-01

The fetal laceration is one of the most commonly identified injuries at the caesarean delivery. The incidence in the literature has been reported to be as high as 3%. The management of such injuries has remained a perplexing problem for both the physician and the parents. We present a case of a newborn who accidentally sustained laceration over the face during a caesarean delivery. A review of the literature and management of lacerations with tissue adhesives has been presented. The laceration was successfully managed with tissue adhesive alone with good aesthetic outcome. Topical 2-octylcyanoacrylate tissue adhesives can be an effective alternative therapy for traditional devices for closing simple low-tension lacerations.

[External cephalic version of breech presentation at term].

PubMed

Albrechtsen, Susanne; Berge, Lillian N; Børdahl, Per E; Egeland, Thore; Henriksen, Tore; Håheim, Lise Lund; Øian, Pål

2005-03-03

External cephalic version could be an alternative to either vaginal delivery or caesarean section in breech presentation at term. A systematic literature review about external cephalic version in breech presentation. The numbers of breech presentation delivered by caesarean section could probably be reduced in Norway by offering version, but this would not affect perinatal mortality.

Transverse uterine fundal incision for placenta praevia with accreta, involving the entire anterior uterine wall: a case series.

PubMed

Kotsuji, F; Nishijima, K; Kurokawa, T; Yoshida, Y; Sekiya, T; Banzai, M; Minakami, H; Udagawa, Y

2013-08-01

To determine the feasibility and safety of transverse fundal incision with manual placental removal in women with placenta praevia and possible placenta accreta. Case series. Four level-three Japanese obstetric centres. Thirty-four women with prior caesarean section and placenta praevia that widely covers the anterior uterine wall, in whom placenta accreta cannot be ruled out. A transverse fundal incision was performed at the time of caesarean section and manual placental removal was attempted under direct observation. Operative fluid loss. The total volume of fluid lost during our operative procedure compares favourably with the volume lost during our routine transverse lower-segment caesarean sections performed in patients without placenta praevia or accreta. The average fluid loss was 1370 g. No patients required transfer to intensive care, and there were no cases of fetal anaemia. This procedure has the potential to reduce the heavy bleeding that arises from caesarean deliveries in women with placenta praevia and placenta accreta. © 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.

Successful vaginal birth after caesarean section in patient with Ehler-Danlos syndrome type 2.

PubMed

Maraj, Hemant; Mohajer, Michelle; Bhattacharjee, Deepannita

2011-12-01

We present the case of a 31-year-old woman with Ehler-Danlos syndrome (EDS) type 2. She had a previous caesarean section and went on to have an uncomplicated vaginal birth in her last pregnancy. To our knowledge, this is the first case of a successful vaginal birth after caesarean section in a patient with EDS. EDS is a multisystem disorder involving a genetic defect in collagen and connective-tissue synthesis and structure. It is a heterogeneous group of 11 different inherited disorders. Obstetric complications in these patients include miscarriages, stillbirths, premature rupture of the membranes, preterm labour, uterine prolapse, uterine rupture and severe postpartum haemorrhage. There has been much controversy over the appropriate mode of delivery. Abdominal deliveries are complicated by delayed wound healing and increased perioperative blood loss. Vaginal deliveries may be complicated by tissue friability causing extensive perineal tears, pelvic floor and bladder lesions. Our case highlights that in specific, controlled situations it is possible to have a vaginal delivery even after previous caesarean section in patients with EDS.

Successful vaginal birth after caesarean section in patient with Ehler-Danlos syndrome type 2

PubMed Central

Maraj, Hemant; Mohajer, Michelle; Bhattacharjee, Deepannita

2011-01-01

We present the case of a 31-year-old woman with Ehler-Danlos syndrome (EDS) type 2. She had a previous caesarean section and went on to have an uncomplicated vaginal birth in her last pregnancy. To our knowledge, this is the first case of a successful vaginal birth after caesarean section in a patient with EDS. EDS is a multisystem disorder involving a genetic defect in collagen and connective-tissue synthesis and structure. It is a heterogeneous group of 11 different inherited disorders. Obstetric complications in these patients include miscarriages, stillbirths, premature rupture of the membranes, preterm labour, uterine prolapse, uterine rupture and severe postpartum haemorrhage. There has been much controversy over the appropriate mode of delivery. Abdominal deliveries are complicated by delayed wound healing and increased perioperative blood loss. Vaginal deliveries may be complicated by tissue friability causing extensive perineal tears, pelvic floor and bladder lesions. Our case highlights that in specific, controlled situations it is possible to have a vaginal delivery even after previous caesarean section in patients with EDS. PMID:27579117

[Ethics of medical management of inability to give birth. Johannes Stahelin and his plea for embryotomy].

PubMed

Sahmland, I

2001-01-01

Confronted with the inability to give birth to a child, delivery could be achieved by embryotomy--that was only permitted, when the foetus was dead--or by Caesarean section--where the chance to save mother and child as well was merely theoretical until the end of the 19th century. In two statements of the Theological Faculty of the Sorbonne in Paris embryotomy was absolutely rejected (1648), in nearly all cases of impossible delivery the Caesarean section was required (1733). In 1749 Johannes Stähelin starts a daring attempt to justify embryotomy by application of natural law to the situation of critical childbirth. Keywords of the theological statements are confronted with categories of the natural law in a sophisticated way, nevertheless the basis of Christian confession is maintained. This argumentation in order to justify embryotomy as a lawful method to deliver a woman seemed to be more adequate to the medical sphere than claiming the Caesarean section. The ethical debate continued until the problem was solved by mastering Caesarean section.

Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success.

PubMed

Knight, H E; Gurol-Urganci, I; van der Meulen, J H; Mahmood, T A; Richmond, D H; Dougall, A; Cromwell, D A

2014-01-01

To investigate the demographic and obstetric factors associated with the uptake and success rate of vaginal birth after caesarean section (VBAC). Cohort study using data from Hospital Episode Statistics. English National Health Service. Women whose first birth resulted in a live singleton delivery by caesarean section between 1 April 2004 and 31 March 2011, and who had a second birth before 31 March 2012. Logistic regression to estimate adjusted odds ratios (OR). Attempted and successful VBAC. Among the 143,970 women in the cohort, 75,086 (52.2%) attempted a VBAC for their second birth. Younger women, those of non-white ethnicity and those living in a more deprived area had higher rates of attempted VBAC. Overall, 47,602 women (63.4%) who attempted a VBAC had a successful vaginal birth. Younger women and women of white ethnicity had higher success rates. Black women had a particularly low success rate (OR, 0.54; 95% confidence interval [CI], 0.50-0.57). Women who had an emergency caesarean section in their first birth also had a lower VBAC success rate, particularly those with a history of failed induction of labour (OR, 0.59; 95% CI, 0.53-0.67). In this national cohort, just over one-half of women with a primary caesarean section who were eligible for a trial of labour attempted a VBAC for their second birth. Of these, almost two-thirds successfully achieved a vaginal delivery. © 2013 Royal College of Obstetricians and Gynaecologists.

Estimation of blood haemoglobin concentration using the HemoCue during caesarean section: the effect of sampling site.

PubMed

Richards, N A; Boyce, H; Yentis, S M

2010-01-01

Haemoglobin concentration measured using the HemoCue is accurate for capillary and venous/arterial blood, provided the recommended sampling method is strictly observed. Analysis of blood, particularly of capillary samples, using the HemoCue is useful during caesarean section. The toe might be preferred to the thumb since it is numb during neuraxial anaesthesia, but whether sampling at either site is accurate in this situation, given the cardiovascular effects of anaesthesia and pregnancy, is not known. We aimed to compare haemoglobin values measured in venous and capillary samples (toe and thumb) during caesarean section under neuraxial anaesthesia. Fifty healthy women having caesarean section under spinal or combined spinal-epidural anaesthesia were included. At the end of surgery, the great toe and thumb (non-i.v. fluid side) were lanced as recommended for a HemoCue reading. A venous blood sample (non-i.v. fluid side) was also taken and sent for formal laboratory measurement and tested with the HemoCue. Bland-Altman analysis was applied to the haemoglobin values. Bias (mean difference) and precision +/- 2 SD were respectively 0.2 +/-1.6 for laboratory vs. toe, 0.1 +/-1.8 for laboratory vs. thumb, and 0.2 +/-1.6 laboratory vs. venous. Our results suggest that in terms of accuracy, the two sites are equally suitable for use during caesarean section under neuraxial anaesthesia. Copyright 2009 Elsevier Ltd. All rights reserved.

New Technique for Caesarean Section

PubMed Central

Vejnović, T. R.; Costa, S. D.; Ignatov, A.

2012-01-01

Caesarean section is one of the most common operations worldwide and more than 30 % of procedures in perinatal centres in Germany are caesarean sections. In the last few years the technique used for caesarean sections has been simplified, resulting in a lower postoperative morbidity. But persistent problems associated with all caesarean section techniques include high intraoperative loss of blood, the risk of injury to the child during uterotomy and postoperative wound dehiscence of the uterine scar. We present here a modification of the most common Misgav-Ladach method. The initial skin incision is done along the natural skin folds and is extended intraoperatively depending on the circumference of the babyʼs head. After blunt expansion of the uterine incision using an anatomical forceps, the distal uterine wall is pushed behind the babyʼs head. The babyʼs head is rotated into the occipito-anterior or posterior position and delivery occurs through the application of gentle pressure on the uterine fundus. Closure of the uterotomy is done using 2 continuous sutures, which are then knotted together resulting in a short double-layer closure. The two ends of the skin suture are left open to allow for natural drainage. Our experience at the University Gynaecological Hospitals in Novi Sad and Magdeburg has shown that this modification is associated with shorter operating times, minimal blood loss and shorter in-hospital stay of patients as well as high rates of patient satisfaction. PMID:25328165

Midwifery provision and uptake of maternity care in Indonesia.

PubMed

Achadi, Endang; Scott, Susana; Pambudi, Eko S; Makowiecka, Krystyna; Marshall, Tom; Adisasmita, Asri; Deviany, Poppy E; Ronsmans, Carine

2007-12-01

To examine the association between midwife density, other characteristics of midwifery provision and village contextual factors, and the percentage of births attended by a health professional and deliveries via caesarean section in two districts in West Java, Indonesia. Analysis of: (i) a census of midwives; (ii) a population-based survey of women who had delivered over a 2-year period; (iii) a census of all caesareans in the four hospitals serving the two districts; and (iv) data from National Statistical Office. At an average density of 2.2 midwives per 10 000 population, 33% of births are with a health professional, and 1% by caesarean section. Having at least six midwives per 10 000 population was associated with a fourfold increase in caesareans [adjusted risk ratio (RR) 4.3: 95% confidence interval (CI): 3.3-5.5] and a threefold increase in the odds of having a health professional attend the delivery [adjusted odds ratio (OR) 2.88: 95% CI: 0.96-8.70]. The assigned midwife's professional status and the duration of her service in the village were also associated with higher rates of health professionals' attendance of delivery and caesareans. Regardless of the provision of services, women's education and wealth were strong predictors of delivery with a health professional. Promoting a stable workforce of midwives, better financial access for the poor and expanding female education are important for the achievement of the fifth Millennium Development Goal (MDG-5).

Association between Caesarean Delivery and Childhood Asthma in India and Vietnam.

PubMed

Lavin, Tina; Franklin, Peter; Preen, David B

2017-01-01

While there is evidence of an association between caesarean birth and increased asthma in children in high-income countries, it is unknown whether this association exists in low-to-middle-income countries (LMICs). We investigated whether children born through caesarean in India and Vietnam are at increased risk of caregiver-reported asthma by 8 years of age. Data from an ongoing multi-national longitudinal cohort study (the Young Lives Study) in two LMICs (India n = 2026; Vietnam n = 2000) were used. Caregiver questionnaires captured information on caregiver-reported long-term respiratory problems such as asthma or wheeze at age 8 years, birth mode and a range of sociodemographic factors. Multivariable logistic regression models using propensity score adjustment were used to explore birth mode and asthma at age 8 years adjusted for a range of known confounders. Children delivered by caesarean in India (odds ratio (OR) 2.6, 95% confidence interval (CI) 1.3, 5.4) and Vietnam (OR 2.0, 95% CI 1.2, 3.3) had greater odds of asthma at age 8 years, after adjustment for other risk factors including wealth, liveborn parity, low birthweight, geographic location, cooking fuel used, livestock ownership, household size, housing quality and parental smoking. The study suggests that caesarean birth may be associated with an increased risk of childhood asthma in India and Vietnam. The underlying mechanisms of this finding need to be further elucidated. © 2016 John Wiley & Sons Ltd.

Health care financing and utilization of maternal health services in developing countries.

PubMed

Kruk, Margaret E; Galea, Sandro; Prescott, Marta; Freedman, Lynn P

2007-09-01

The Millennium Development Goals call for a 75% reduction in maternal mortality between 1990 and 2015. Skilled birth attendance and emergency obstetric care, including Caesarean section, are two of the most important interventions to reduce maternal mortality. Although international pressure is rising to increase donor assistance for essential health services in developing countries, we know less about whether government or the private sector is more effective at financing these essential services in developing countries. We conducted a cross-national analysis to determine the association between government versus private financing of health services and utilization of antenatal care, skilled birth attendants and Caesarean section in 42 low-income and lower-middle-income countries. We controlled for possible confounding effects of total per capita health spending and female literacy. In multivariable analysis, adjusting for confounders, government health expenditure as a percentage of total health expenditure is significantly associated with utilization of skilled birth attendants (P = 0.05) and Caesarean section (P = 0.01) but not antenatal care. Total health expenditure is also significantly associated with utilization of skilled birth attendants (P < 0.01) and Caesarean section (P < 0.01). Greater government participation in health financing and higher levels of health spending are associated with increased utilization of two maternal health services: skilled birth attendants and Caesarean section. While government financing is associated with better access to some essential maternal health services, greater absolute levels of health spending will be required if developing countries are to achieve the Millennium Development Goal on maternal mortality.

Postpartum urinary tract infection by mode of delivery: a Danish nationwide cohort study.

PubMed

Gundersen, Tina Djernis; Krebs, Lone; Loekkegaard, Ellen Christine Leth; Rasmussen, Steen Christian; Glavind, Julie; Clausen, Tine Dalsgaard

2018-03-14

To examine the association between postpartum urinary tract infection and intended mode of delivery as well as actual mode of delivery. Retrospective cohort study. All live births in Denmark between 2004 and 2010 (n=450 856). Births were classified by intended caesarean delivery (n=45 053) or intended vaginal delivery (n=405 803), and by actual mode of delivery: spontaneous vaginal delivery, operative vaginal delivery, emergency or planned caesarean delivery in labour or prelabour. The primary outcome measure was postpartum urinary tract infection (n=16 295) within 30 days post partum, defined as either a diagnosis of urinary tract infection in the National Patient Registry or redemption of urinary tract infection-specific antibiotics recorded in the Register of Medicinal Product Statistics. We found that 4.6% of women with intended caesarean delivery and 3.5% of women with intended vaginal delivery were treated for postpartum urinary tract infection.Women with intended caesarean delivery had a significantly increased risk of postpartum urinary tract infection compared with women with intended vaginal delivery (OR 1.33, 95% CI 1.27 to 1.40), after adjustment for age at delivery, smoking, body mass index, educational level, gestational diabetes mellitus, infection during pregnancy, birth weight, preterm delivery, preterm prelabour rupture of membranes, pre-eclampsia, parity and previous caesarean delivery (adjusted OR 1.24, 95% CI 1.17 to 1.46).Using actual mode of delivery as exposure, all types of operative delivery had an equally increased risk of postpartum urinary tract infection compared with spontaneous vaginal delivery. Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. Future studies should focus on reducing routine catheterisation prior to operative vaginal delivery as well as improving procedures related to catheterisation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Postpartum urinary tract infection by mode of delivery: a Danish nationwide cohort study

PubMed Central

Krebs, Lone; Loekkegaard, Ellen Christine Leth; Rasmussen, Steen Christian; Glavind, Julie; Clausen, Tine Dalsgaard

2018-01-01

Objectives To examine the association between postpartum urinary tract infection and intended mode of delivery as well as actual mode of delivery. Design Retrospective cohort study. Setting and participants All live births in Denmark between 2004 and 2010 (n=450 856). Births were classified by intended caesarean delivery (n=45 053) or intended vaginal delivery (n=405 803), and by actual mode of delivery: spontaneous vaginal delivery, operative vaginal delivery, emergency or planned caesarean delivery in labour or prelabour. Primary and secondary outcome measures The primary outcome measure was postpartum urinary tract infection (n=16 295) within 30 days post partum, defined as either a diagnosis of urinary tract infection in the National Patient Registry or redemption of urinary tract infection-specific antibiotics recorded in the Register of Medicinal Product Statistics. Results We found that 4.6% of women with intended caesarean delivery and 3.5% of women with intended vaginal delivery were treated for postpartum urinary tract infection. Women with intended caesarean delivery had a significantly increased risk of postpartum urinary tract infection compared with women with intended vaginal delivery (OR 1.33, 95% CI 1.27 to 1.40), after adjustment for age at delivery, smoking, body mass index, educational level, gestational diabetes mellitus, infection during pregnancy, birth weight, preterm delivery, preterm prelabour rupture of membranes, pre-eclampsia, parity and previous caesarean delivery (adjusted OR 1.24, 95% CI 1.17 to 1.46). Using actual mode of delivery as exposure, all types of operative delivery had an equally increased risk of postpartum urinary tract infection compared with spontaneous vaginal delivery. Conclusions Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. Future studies should focus on reducing routine catheterisation prior to operative vaginal delivery as well as improving procedures related to catheterisation. PMID:29540408

Association of caesarean delivery with child adiposity from age 6 weeks to 15 years.

PubMed

Blustein, J; Attina, T; Liu, M; Ryan, A M; Cox, L M; Blaser, M J; Trasande, L

2013-07-01

o assess associations of caesarean section with body mass from birth through adolescence. ongitudinal birth cohort study, following subjects up to 15 years of age. Children born in 1991-1992 in Avon, UK who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) (n=10 219). standardized measures of body mass (weight-for length z-scores at 6 weeks, 10 and 20 months; and body mass index (BMI) z-scores at 38 months, 7, 9, 11 and 15 years). Secondary outcome: categorical overweight or obese (BMI: 85th percentile) for age and gender, at 38 months, 7, 9, 11 and 15 years. Of the 10 219 children, 926 (9.06%) were delivered by caesarean section. Those born by caesarean had lower-birth weights than those born vaginally (-46.1 g, 95% confidence interval(CI): 14.6-77.6 g; P=0.004). In mixed multivariable models adjusting for birth weight, gender, parental body mass, family sociodemographics, gestational factors and infant feeding patterns, caesarean delivery was consistently associated with increased adiposity, starting at 6 weeks (+0.11 s.d. units, 95% CI: 0.03-0.18; P=0.005), through age 15 (BMI z-score increment+0.10 s.d. units, 95% CI: 0.001-0.198; P=0.042). By age 11 caesarean-delivered children had 1.83 times the odds of overweight or obesity (95% CI: 1.24-2.70; P=0.002). When the sample was stratified by maternal pre-pregnancy weight, the association among children born of overweight/obese mothers was strong and long-lasting. In contrast, evidence of an association among children born of normal-weight mothers was weak. Cesarean delivery is associated with increased body mass in childhood and adolescence. Research is needed to further characterize the association in children of normal weight women. Additional work is also needed to understand the mechanism underlying the association, which may involve relatively enduring changes in the intestinal microbiome.

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.

PubMed

McLachlan, H L; Forster, D A; Davey, M A; Farrell, T; Gold, L; Biro, M A; Albers, L; Flood, M; Oats, J; Waldenström, U

2012-11-01

To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. Randomised controlled trial. Tertiary-care women's hospital in Melbourne, Australia. A total of 2314 low-risk pregnant women. Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care. In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

Change in primary midwife-led care in the Netherlands in 2000–2008: A descriptive study of caesarean sections and other interventions among 807,437 low-risk births.

PubMed

Offerhaus, Pien M; de Jonge, Ank; van der Pal-de-Bruin, Karin M; Hukkelhoven, Chantal W P M; Scheepers, Peer L H; Lagro-Janssen, Antoine L M

2015-06-01

to study whether an increase in intrapartum referrals in primary midwife-led care births in the Netherlands is accompanied by an increase in caesarean sections. nationwide descriptive study. The Netherlands Perinatal Registry. 807,437 births of nine year cohorts of women with low risk pregnancies in primary midwife-led care at the onset of labour between 2000 and 2008. primary outcome is the caesarean section rate. Vaginal instrumental childbirth, augmentation with oxytocin, and pharmacological pain relief are secondary outcomes. Trends in outcomes are described. We used logistic regression to explore whether changes in the planned place of birth and other maternal characteristics were associated with the caesarean section rate. the caesarean section rate increased from 6.2 to 8.3 per cent for nulliparous and from 0.8 to 1.1 per cent for multiparous women. After controlling for maternal characteristics the year by year increase in the caesarean section rate was still significant for nulliparous women (adj OR 1.03; 95% CI 1.02–1.03). The vaginal instrumental birth declined from 18.2 to 17.4 per cent for nulliparous women (multiparous women: 1.7–1.5 per cent). Augmentation of labour and/or pharmacological pain relief increased from 23.1 to 38.1 per cent for nulliparous women and from 5.4 to 9.6 per cent for multiparous women. the rise in augmentation of labour, pharmacological pain relief and electronic fetal monitoring in the period 2000–2008 among women in primary midwife-led care was accompanied by an increase in caesarean section rate for nulliparous women. The vaginal instrumental deliveries declined for both nulliparous and multiparous women. primary care midwives should evaluate whether they can strengthen the opportunities for nulliparous women to achieve a physiological birth, without augmentation or pharmacological pain relief. If such interventions are considered necessary to achieve a spontaneous vaginal birth, the current disadvantage of discontinuity of care should be reduced. In a more integrated care system, women could receive continuous care and support from their own primary care midwife, as long as only supportive interventions are needed.

Caesarean of Lion (Panthera leo) at Dulahajra Safari Park, Bangladesh

PubMed Central

Khan, S.A.; Hassan, M.M.; Uddin, M.B.; Rahman, Z.M.M.; Yasin, G.; Epstein, J.H.

2011-01-01

A six years eight months pregnant lioness at the Dulahajara Safari Park, Chakoria, Cox’s Bazar, Bangladesh, was presented with dystocia. This paper described the pre-, intra- and postoperative procedures including anesthetic protocol carried out and performing a caesarean section to remove dead fetuses and the successful recovery of the lioness without complications. PMID:26623273

Anaesthesia for Caesarean section in a patient with diastrophic dwarfism.

PubMed

Porter, M; Mendonca, C

2007-04-01

Diastrophic dwarfism is a rare disease in which pregnancy is uncommon. In this report we present a woman with diastrophic dwarfism who underwent caesarean section under epidural anaesthesia. Her care was successfully managed with multidisciplinary team planning. The total dose of local anaesthetic needed for epidural block was greater than the doses reported for achondroplastic dwarfism.

Learning from the Law. A review of 21 years of litigation for pain during caesarean section.

PubMed

McCombe, K; Bogod, D G

2018-02-01

The large majority of caesarean sections in the UK are now carried out under neuraxial anaesthesia. Although this technique is widely accepted as being the safest option in most circumstances, the use of regional anaesthesia increases the risk of patients experiencing intra-operative discomfort or pain. Pain during operative obstetric delivery is the commonest successful negligence claim relating to regional anaesthesia against obstetric anaesthetists in the UK. In the following article, using a database of over 360 cases spanning 21 years, we break down and examine the recurrent components of medicolegal claims concerning pain during caesarean section and consider how anaesthetists might avoid litigation. © 2017 The Association of Anaesthetists of Great Britain and Ireland.

Facial Laceration at Caesarean Section: Experience With Tissue Adhesive

PubMed Central

Saraf, Sanjay

2009-01-01

Background: The fetal laceration is one of the most commonly identified injuries at the caesarean delivery. The incidence in the literature has been reported to be as high as 3%. The management of such injuries has remained a perplexing problem for both the physician and the parents. Materials and Methods: We present a case of a newborn who accidentally sustained laceration over the face during a caesarean delivery. A review of the literature and management of lacerations with tissue adhesives has been presented. Results: The laceration was successfully managed with tissue adhesive alone with good aesthetic outcome. Conclusion: Topical 2-octylcyanoacrylate tissue adhesives can be an effective alternative therapy for traditional devices for closing simple low-tension lacerations. PMID:19198643

A comparison of 25 gauge Quincke spinal needle with 26 gauge Eldor spinal needle for the elective Caesarian sections: insertion characteristics and complications.

PubMed

Tabedar, S; Maharjan, S K; Shrestha, B R; Shrestha, B M

2003-01-01

The study was designed to compare the insertion characteristics and incidence of PDPH between 25 gauge Quincke needle and 26 gauge Eldor needle for spinal anaesthesia in elective c/s. 60 pregnant women (aged 19-35 yrs and weighing 58 -67 kg) undergoing elective caesarean section were randomized into group A (Quincke spinal needle group) or group B (Eldor spinal needle group). Spinal anaesthesia was performed with 2.9 ml 0.5% heavy bupivacaine using 25 gauge Quincke spinal needle in group A and 26 Gauge Eldor spinal needle in group B. Onset, time of first identification of backflow of CSF, number of attempts, level of sensory and motor blockade, failure of anaesthesia, inadequate anaesthesia and incidence of PDPH were recorded. Quincke spinal needle was found easy at insertion, first attempt was successful in 90% of cases, whereas Eldor spinal needle was successful at first attempt in only 60% of cases. Early identification of CSF was seen in Eldor spinal needle group in 3.5 seconds vs. 5.2 seconds in Quincke spinal needle group. Blood mixed CSF was seen in 8 Quincke spinal needle group vs. none in Eldor spinal needle group. Onset was similar between both groups i.e. in 6 minutes. Failure of anaesthesia was none in Eldor spinal needle group vs. 2 in quincke spinal needle group. Height of sensory block achieved was T4 level in 26 parturients,T6 in 1 ,T8 in 1 and no anaesthesia at all in another 2 parturient as compared to T4 level in 29 and T3 in 1 parturient in Eldor spinal needle group. The degree of motor block with the use of Bromage criteria showed a motor score of 1 or 2 in 26 parturients in Quincke spinal needle group vs. same in all cases in Eldor spinal needle group. The total incidence of PDPH was 8.3 % (5 out of 60 parturient) which occurred all in Quincke spinal needle group. 2 parturient who developed severe PDPH required epidural blood patch. 26 gauge Eldor spinal needle was found to be better than 25 gauge Quincke spinal needle for caesarian sections to decrease the incidence of PDPH, though not all insertion characteristics were in favour of the Eldor needle.

External cephalic version for breech presentation before term.

PubMed

Hutton, E K; Hofmeyr, G J

2006-01-25

External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This review examines studies initiating ECV prior to term (before 37 weeks' gestation). To assess the effectiveness of a policy of beginning ECV before term (before 37 weeks' gestation) for breech presentation on fetal presentation at birth, method of delivery, and the rate of preterm birth, perinatal morbidity, stillbirth or neonatal mortality. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (April 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2005), MEDLINE (1965 to April 2005), EMBASE (1988 to April 2005), and Controlled Clinical Trials randomised controlled trials registry (April 2005). Randomised trials of ECV beginning before term (before 37 weeks' gestation) compared with a control group in women with breech presentation before term. Two review authors independently assessed eligibility and trial quality and extracted data. Three studies are included. One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared to no ECV. No difference was found in the rate of non-cephalic presentation at birth. One study reported on a policy of ECV that was initiated before term (33 weeks) and up until 40 weeks' gestation and which could be repeated up until delivery compared to no ECV. This study showed a decrease in the rate of non-cephalic presentation at birth (relative risk 0.59, 95% confidence interval 0.45 to 0.77). One study reported on ECV started at between 34 to 35 weeks' gestation compared to beginning at 37 to 38 weeks' gestation. Although findings were not statistically significant, a 9.5% decrease in the rate of non-cephalic presentation at birth and a 7% decrease in the caesarean section rate were reported when ECV was started early. Compared with no ECV attempt, ECV commenced before term reduces non-cephalic births. Compared with ECV at term, beginning ECV at between 34 to 35 weeks may have some benefit in terms of decreasing the rate of non-cephalic presentation, and caesarean section. Further trials are needed to confirm this finding and to rule out increased rates of preterm birth, or other adverse perinatal outcomes. A large pragmatic trial is ongoing (www.utoronto.ca/miru/eecv2).

Determinants of caesarean section in Lebanon: geographical differences.

PubMed

Carayol, Marion; Zein, Ali; Ghosn, Nada; Du Mazaubrun, Christiane; Breart, Gérard

2008-03-01

This study, based on the Lebanese National Perinatal Survey which included 5231 women, examined the relations between the caesarean section (CS) rate and the characteristics of mothers, children, antenatal care and maternity units in two geographical zones of Lebanon (Beirut-Mount Lebanon and the rest of the country) and then looked at geographical variations. This analysis concerned 3846 women with singleton pregnancies and livebirths at low risk of CS, after exclusion of women with a previous CS, non-cephalic fetal presentations, or delivery before 37 weeks' gestation. The principal end point was caesarean delivery. The relations between the factors studied and CS were estimated by odds ratios (OR), both crude and adjusted, using logistic regression. The rate of CS was higher in the Beirut-Mount Lebanon zone than elsewhere (13.4% vs. 7.6%). After adjustment, several factors remained associated with caesarean delivery in each zone. Common factors were primiparity, gestational age > or = 41 weeks and antenatal hospitalisation. Factors identified only in the Beirut-Mount Lebanon zone were obstetric history and insurance coverage, whereas for the other zones we only found major risk factors for obstetric disease: maternal age > or = 35 years, number of antenatal consultations > or = 4 and birthweight < or = 2500 g. The multivariable analysis of the overall population, adjusting for zone of delivery and other variables, shows that zone was one of the principal factors associated with the risk of caesarean delivery in Lebanon (OR = 1.80 [95% CI 1.09, 2.95]). In conclusion, the CS rates in Lebanon were high, with geographical differences that were associated with access to care and with obstetric practices.

Outcome of Pregnancies After Balloon Occlusion of the Infrarenal Abdominal Aorta During Caesarean in 230 Patients With Placenta Praevia Accreta

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wu, Qinghua, E-mail: qh-wu77@163.com; Liu, Zhuan, E-mail: liuchuan2015ck@163.com; Zhao, Xianlan, E-mail: zxl121292014@163.com

PurposeTo explore the efficacy and safety of prophylactic temporary balloon occlusion of the infrarenal abdominal aorta during caesarean for the management of patients with placenta praevia accreta.MethodsTwo hundred and sixty-eight cases of placenta praevia accreta from January 2012 to June 2015 were retrospectively reviewed. Group A included two hundred and thirty patients who underwent prophylactic temporary balloon occlusion of infrarenal abdominal aorta followed by caesarean section. Group B included thirty-eight patients who underwent caesarean without endovascular intervention. The parameters including operating room time, estimated blood loss, blood transfusion volume, PT (prothrombin time) during operation, days in the intensive care unit,more » and total hospital days were compared between the two groups.ResultsThe operating room time, estimated blood loss, PT, the incidence of hysterectomy, blood transfusion volume, postpartum haemorrhage, and days in intensive care unit were lower in group A than in group B, with statistical significance (P < 0.05). There was no significant difference in the Apgar scores of the neonates and the incidences of thrombosis in lower limbs between the two groups (P > 0.05). No patient in the group with prophylactic temporary balloon occlusion of the infrarenal abdominal aorta was performed hysterectomy, while three patients in group B were performed hysterectomy because of uncontrollable haemorrhage.ConclusionsThe results indicate that prophylactic temporary balloon occlusion of infrarenal abdominal aorta followed by caesarean section is safe and effective to control intraoperative blood loss and greatly decreases the risk of hysterectomy in patients with placenta praevia accreta.« less

Obstetricians' attitudes, subjective norms, perceived controls, and intentions on antibiotic prophylaxis in caesarean section.

PubMed

Liabsuetrakul, Tippawan; Chongsuvivatwong, Virasakdi; Lumbiganon, Pisake; Lindmark, Gunilla

2003-11-01

Over 10% of current births in all countries of the world are delivered by caesarean section. Single-dose ampicillin or cefazolin administered after cord clamping has been proven to be effective for the prevention of post-caesarean infections as indicated in many randomised trials and reviews in the Cochrane Library. This study aimed to determine three determinants of behavioural intention using the theory of planned behaviour: attitudes, subjective norms, and perceived controls. Intentions were examined for five aspects of the use of antibiotic prophylaxis, namely whether or not antibiotics were used, used in all caesarean sections, after rather than before cord clamping, whether ampicillin/cefazolin or broader-spectrum antibiotics were used, and whether single or multiple doses were given. Fifty obstetricians selected from university, regional, and general hospitals in southern Thailand, were surveyed using a questionnaire and in-depth interview. Their intentions to use a single dose and to use in all cases were low, and this was related to negative attitudes and reference groups who did not approve of the single dose. The negative attitude was based on scepticism concerning the applicability of well-equipped trials from the developed world and fear of consequences of post-caesarean infections. Norms carried over from residency training had more long-term influence in their practice than newer information from books or journals. Perceived external controls on their practice were less predictive of intentions. Intentions were only partly predictive of behaviour. Changing attitudes, introducing evidence-based information into residency training and strengthening control systems in the hospital are essential to improve intentions.

Effect of pumping pressure on onset of lactation after caesarean section: A randomized controlled study.

PubMed

Zhang, Feng; Yang, Yahui; Bai, Ting; Sun, Lele; Sun, Mingzhu; Shi, Xueling; Zhu, Meng; Ge, Meijuan; Xia, Haiou

2018-01-01

Caesarean section is associated with weaker newborn suction pressure. This nonblinded, randomized trial explored the effect of suction pressures generating by a breast pump on mothers' onset of lactation and milk supply after caesarean section. A high pressure group (-150 mmHg), a low pressure group (-100 mmHg), and a control group (none) were generated under computer random assignment with concealed allocation in 2 tertiary hospitals. The breast pumping began within 2 hr after caesarean operation (6 times a day and 30 min per time) until onset of lactation. The primary outcomes were the timing of onset of lactation, milk supply, and mother's satisfaction in lactation, using both intention-to-treat and per-protocol analyses. The secondary endpoints were the pumping-related pain, nipple injury, and maternal fatigue. All 164 women randomized were included in analysis. The breast pumping at -150 mmHg optimally advanced the timing of the onset of lactation and increased daytime milk supply. The pumping also appeared to boost mothers' confidence in lactation. The results in the per-protocol population (n = 148) were consistent with those of intention-to-treat population (n = 164). However, the pumping aggravated maternal nipple pain and fatigue, though there was no statistical significance. The findings suggest that a higher pumping pressure within the range of normal vaginally born infant suction could promote onset of lactation and milk supply among mothers giving birth by caesarean section. The pumping could also enhance mothers' confidence in breastfeeding. © 2017 John Wiley & Sons Ltd.

Quality of anaesthesia for Caesarean sections: a cross-sectional study of a university hospital in a low-income country.

PubMed

Eriksson, Jesper; Baker, Tim; Jörnvall, Henrik; Irestedt, Lars; Mulungu, Moses; Larsson, Emma

2015-10-01

To evaluate the quality of anaesthesia for Caesarean sections at Muhimbili National Hospital, Dar es Salaam, Tanzania. We developed an instrument consisting of 40 quality indicators using an expert group process based on the existing literature. Using the instrument, we observed 50 Caesarean sections. Twenty-eight of the indicators were structural indicators, such as essential drugs, oxygen supply and anaesthetic equipment. Twelve were process indicators such as evaluation of airway, blood pressure assessment or insertion of an intravenous line. The median patient age was 28.5 years. A total of 75% (range 61-82%) of the structural indicators were present in the operating theatres, and 55% (range 33-83%) of the process indicators were performed. The neonates' median Apgar score was 9 (range 3-10). Seven babies required ventilation, four babies were stillborn, and all others were alive at follow-up 2 days after partus. All mothers were alive 2 days post-surgery. The low process score suggests that quality improvement initiatives should focus on the processes of anaesthesia for Caesarean sections rather than new drugs and equipment. © 2015 John Wiley & Sons Ltd.

Impending thyroid storm in a pregnant woman with undiagnosed hyperthyroidism

PubMed Central

Ma, Yushan; Li, Hao; Liu, Jin; Lin, Xuemei; Liu, Hui

2018-01-01

Abstract Rationale: Thyroid storm is a rare complication during caesarean section of patients with hyperthyroidism. It occurs abruptly, with a high mortality rate if not recognized immediately and aggressively treated. Herein, we reported a case of impending thyroid storm during a caesarean section. Patient concerns: A healthy 23-year-old woman with undiagnosed hyperthyroidism underwent an emergency caesarean section under general anesthesia. After tracheal extubation, the patient exhibited abnormal tachycardia, agitation, sweating, and hyperpyrexia. Diagnoses: The clinical manifestation and the following thyroid function test indicate a high index of suspicion for impending thyroid storm. Interventions: Hydrocortisone and esmolol were intravenously administered immediately. Propylthiouracil and propranolol were orally administered after the patient regained complete consciousness. Outcomes: Due to our immediate recognition and aggressive treatment, more serious manifestations of thyroid storm were avoided. Lessons: Good antenatal care is very important for pregnant women, and they should be generally screened for thyroid disorders, especially if the resting heart rate is >100 beats/min and weight increases are inconsistent with gestational age. When hyperthyroidism is suspected, drugs that excite the sympathetic nerves or promote the release of histamine should not be used during caesarean section. PMID:29504986

Impending thyroid storm in a pregnant woman with undiagnosed hyperthyroidism: A case report and literature review.

PubMed

Ma, Yushan; Li, Hao; Liu, Jin; Lin, Xuemei; Liu, Hui

2018-01-01

Thyroid storm is a rare complication during caesarean section of patients with hyperthyroidism. It occurs abruptly, with a high mortality rate if not recognized immediately and aggressively treated. Herein, we reported a case of impending thyroid storm during a caesarean section. A healthy 23-year-old woman with undiagnosed hyperthyroidism underwent an emergency caesarean section under general anesthesia. After tracheal extubation, the patient exhibited abnormal tachycardia, agitation, sweating, and hyperpyrexia. The clinical manifestation and the following thyroid function test indicate a high index of suspicion for impending thyroid storm. Hydrocortisone and esmolol were intravenously administered immediately. Propylthiouracil and propranolol were orally administered after the patient regained complete consciousness. Due to our immediate recognition and aggressive treatment, more serious manifestations of thyroid storm were avoided. Good antenatal care is very important for pregnant women, and they should be generally screened for thyroid disorders, especially if the resting heart rate is >100 beats/min and weight increases are inconsistent with gestational age. When hyperthyroidism is suspected, drugs that excite the sympathetic nerves or promote the release of histamine should not be used during caesarean section. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

JPRS Report, Soviet Union, Political Affairs

DTIC Science & Technology

1989-07-27

and G.Z. Fedorov, shop chief of Donetsk Chemical and Metal Plant are continuing their campaigns, too. Lvov. Repeat elections took place in four...example, by this incident: when we—Cher- nanko and I—failed to get our report into the newspaper concerning the use of chemical agents, because we...broadcast. In it, a repre- sentative of the internal troops admitted the use of chemical agents—tear gas. Chiding him for his "belated acknowledgement" we

Sub-Saharan Africa Report. No. 2824.

DTIC Science & Technology

1983-07-25

certain amount of disappointment was felt within some of the political groups. This disappointment affected the MONIMA K movement first. This group hoped...to repeat its achievements of November 1982 at the time of the presidential elections. A similar feeling affects the AKFM which, in a striking...most seriously affected by drought. "In continuing this long term effort I can assure you that Mali does not stand alone and that it will continue to

Influence of timing of admission in labour and management of labour on method of birth: results from a randomised controlled trial of caseload midwifery (COSMOS trial).

PubMed

Davey, Mary-Ann; McLachlan, Helen L; Forster, Della; Flood, Margaret

2013-12-01

to explore the relationship between the degree to which labour is established on admission to hospital and method of birth. a recent randomised controlled trial found fewer caesarean sections (CS) in women allocated to caseload midwifery (19.4%) compared with standard care (24.9%). There is interest in exploring what specific aspects of the care might have resulted in this reduction. a large tertiary-level maternity service in Melbourne, Australia. English-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532). this secondary analysis included women admitted to hospital in spontaneous labour who were randomised to caseload midwifery compared with those randomised to standard care with regard to timing of admission in labour, augmentation of labour and use of epidural analgesia. In a further analysis randomised groups were pooled to examine predictors of caesarean section for first births only using multiple logistic regression. nulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p=0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth (p=0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p=0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4 cm compared with 5 cm in the caseload arm (p=0.012). Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively. these findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Comparison of pregnancy outcomes Caesarean techniques: modified Misgav-Ladach, Pfannenstiel-Kerr and Kerr-half infraumbilical].

PubMed

Cardona-Osuna, M E; Avila-Vergara, M A; Peraza-Garay, F; Meneses-Valderrama, V; Flores-Pompa, E; Corrales-López, A

2016-08-01

In Mexico, the prevalence of caesarean section is 40.9% in the health sector, the techniques used are the traditional Pfannenstiel-Kerr and Kerr-half infraumbilical and little experience with this new technique Misgav-Ladach modified. To compare pregnancy outcomes (surgical and fetal extraction time, bleeding, postoperative pain, surgical wound infection, maternal and fetal death) caesarean section techniques modified Misgav-Ladach, Pfannenstiel-Kerr and infraumbilical. Clinical trial in primiparous women with term pregnancy treated at the Medical Unit of High Specialty 23 of the Mexican Social Security Institute, Monterrey, Nuevo Leon, Mexico. Misgav-Ladach caesarean Caesarean modified and Kerr, the latter subdivided into two groups: infraumbilical Pfannenstiel incision and incision half-Kerr two groups patients were randomized. 137 gilts were studied, with term pregnancy and BMI between 19 and 24.9 kg / m2. Caesarean modified Misgav-Ladach 68 patients and 69 classical Kerr (35 Pfannenstiel-Kerr and 34 infraumbilical) was performed. The surgical time in minutes was lower with modified Misgav-Ladach: 27.8 ± 8.0, Pfannenstiel-Kerr recorded 51.7 ± 12.1 and 12.0 ± infraumbilical media48.3 (p = 0.000). The time in seconds fetal extraction was lower in modified Misgav-Ladach: 96.2 ± 68.3, 474.9 ± Pfannenstiel-Kerr 294.1 and 423.2 ± 398.6 infraumbilical (p = 0.000). The trasoperatory milliliters bleeding was lower with modified Misgav-Ladach: 298.5 ± 57.3, 354.3 ± Pfannenstiel-Kerr 98.0 and 355.9 ± 110.6 infraumbilical (p = 0.001). Postoperative pain assessed with the visual analog scale in the first 24 hours was lower with modified Misgav-Ladach: 4.4 ± 1.9, 5.7 ± Pfannenstiel-Kerr and IK 2.1 6.1 ± 2.0 (p = 0.000). The start of the oral route and ambulation Nwas soon comparing modified Misgav-Ladach against Pfannenstiel-Kerr and Kerr-infraumbilical (p = 0.000). The prevalence of fever was 5.9% with modified Misgav-Ladach, 5.9% Pfannenstiel-Kerr and 32.4% withinfraumbilical-Kerr (p = 001). The discharge in hours was modified Misgav-Ladach ± 45.8 to 12.1 h, Pfannenstiel-Kerr 49.3 ± 12.3 h and 58.5 infraumbilical-Kerr ± 21.5 h (p = .000). In this study no maternal or fetal deaths were observed. Surgical time, bleeding, postoperative pain, better postoperative recovery and shorter hospital stays and less infection were significantly lower than with conventional techniques of caesarean Nsection or infraumbilical-Kerr technique.

Postoperative pain and neuropathy after caesarean operation featuring blunt or sharp opening of the fascia: a randomised, parallel group, double-blind study.

PubMed

Yazici Yilmaz, Fatma; Aydogan Mathyk, Begum; Yildiz, Serhat; Yenigul, Nefise Nazli; Saglam, Ceren

2018-03-21

The purpose of this study was to compare postoperative pain and neuropathy after primary caesarean sections with either blunt or sharp fascial expansions. A total of 123 women undergoing primary caesarean sections were included in the study. The sharp group had 61 patients, and the blunt group had 62. In the sharp group, the fascia was incised sharply and extended using scissors. In blunt group, the fascia was bluntly opened by lateral finger-pulling. The primary outcome was postoperative pain. The long-term chronic pain scores were significantly lower in the blunt group during mobilisation (p = .012 and p = .022). Neuropathy was significantly more prevalent in the sharp group at both 1 and 3 months postoperatively (p = .043 and p = .016, respectively). The odds ratio (OR) and 95%CI for postoperative neuropathy at 1 and 3 months were as follows; OR 3.71, 95%CI 0.97-14.24 and OR 5.67, 95%CI 1.18-27.08, respectively. The OR for postoperative pain after 3 months was 3.26 (95%CI 1.09-9.73). The prevelance of postsurgical neuropathy and chronic pain at 3 months were significantly lower in the blunt group. Blunt fascial opening reduces the complication rate of postoperative pain and neuropathy after caesarean sections. Impact statement What is already known on this subject? The anatomic relationship of the abdominal fascia and the anterior abdominal wall nerves is a known fact. The fascia during caesarean sections can be opened by either a sharp or blunt extension. Data on the isolated impact of different fascial incisions on postoperative pain is limited. What do the results of this study add? The postoperative pain scores on the incision area are lower in the bluntly opened group compared to the sharp fascial incision group. By extending the fascia bluntly, a decrease in trauma and damage to nerves was observed. What are the implications of these findings for clinical practice and/or future research? The lateral extension of the fascia during caesarean sections must be done cautiously to prevent temporary damage to nerves and vessels. The blunt opening of the fascia by lateral finger pulling might be a preferred method over the sharp approach that uses scissors. We included only primary caesarean cases, however, comparisons of blunt and sharp fascial incisions in patients with more than one abdominal surgery should be explored in future studies.

Epidural anaesthesia for caesarean section in pituitary dwarfism.

PubMed

Li, Hongbo; Li, Ruihua; Lang, Bao

2017-04-01

We describe the anaesthetic management for caesarean section in a 32-year-old patient with pituitary dwarfism. In addition to supportive treatment, we offered a postoperative epidural analgesia pump. The patient recovered well without any complications. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Association of Maternal Vitamin D Status with Glucose Tolerance and Caesarean Section in a Multi-Ethnic Asian Cohort: The Growing Up in Singapore Towards Healthy Outcomes Study

PubMed Central

Loy, See Ling; Lek, Ngee; Yap, Fabian; Soh, Shu E.; Padmapriya, Natarajan; Tan, Kok Hian; Biswas, Arijit; Yeo, George Seow Heong; Kwek, Kenneth; Gluckman, Peter D.; Godfrey, Keith M.; Saw, Seang Mei; Müller-Riemenschneider, Falk; Chong, Yap-Seng; Chong, Mary Foong-Fong; Chan, Jerry Kok Yen

2015-01-01

Objective Epidemiological studies relating maternal 25-hydroxyvitamin D (25OHD) with gestational diabetes mellitus (GDM) and mode of delivery have shown controversial results. We examined if maternal 25OHD status was associated with plasma glucose concentrations, risks of GDM and caesarean section in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study. Methods Plasma 25OHD concentrations, fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations were measured in 940 women from a Singapore mother-offspring cohort study at 26–28 weeks’ gestation. 25OHD inadequacy and adequacy were defined based on concentrations of 25OHD ≤75nmol/l and >75nmol/l respectively. Mode of delivery was obtained from hospital records. Multiple linear regression was performed to examine the association between 25OHD status and glucose concentrations, while multiple logistic regression was performed to examine the association of 25OHD status with risks of GDM and caesarean section. Results In total, 388 (41.3%) women had 25OHD inadequacy. Of these, 131 (33.8%), 155 (39.9%) and 102 (26.3%) were Chinese, Malay and Indian respectively. After adjustment for confounders, maternal 25OHD inadequacy was associated with higher FG concentrations (β = 0.08mmol/l, 95% Confidence Interval (CI) = 0.01, 0.14), but not 2HPPG concentrations and risk of GDM. A trend between 25OHD inadequacy and higher likelihood of emergency caesarean section (Odds Ratio (OR) = 1.39, 95% CI = 0.95, 2.05) was observed. On stratification by ethnicity, the association with higher FG concentrations was significant in Malay women (β = 0.19mmol/l, 95% CI = 0.04, 0.33), while risk of emergency caesarean section was greater in Chinese (OR = 1.90, 95% CI = 1.06, 3.43) and Indian women (OR = 2.41, 95% CI = 1.01, 5.73). Conclusions 25OHD inadequacy is prevalent in pregnant Singaporean women, particularly among the Malay and Indian women. This is associated with higher FG concentrations in Malay women, and increased risk of emergency caesarean section in Chinese and Indian women. PMID:26571128

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study.

PubMed

Ampt, Amanda J; Roberts, Christine L; Morris, Jonathan M; Ford, Jane B

2015-02-13

With rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth. Using two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth. Of 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. Although the OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p < 0.01), this may not reflect a clinically significant increase. Following adjustment for first and second birth factors, first birth diabetes and second birthweight ≥3.5 kg were associated with increased likelihood of OASI recurrence, while first birthweight ≥4.0 kg and second gestation at 37-38 weeks were associated with decreased likelihood. A fourth degree tear at the first birth was the strongest factor associated with planned caesarean at the second birth, with other factors including epidural, spinal or general anaesthetic, birthweight, gestation, country of birth and maternal age. Compared with previous reports, the low OASI recurrence rate (approximately one in twenty) may reflect appropriate decision-making about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.

Association of Maternal Vitamin D Status with Glucose Tolerance and Caesarean Section in a Multi-Ethnic Asian Cohort: The Growing Up in Singapore Towards Healthy Outcomes Study.

PubMed

Loy, See Ling; Lek, Ngee; Yap, Fabian; Soh, Shu E; Padmapriya, Natarajan; Tan, Kok Hian; Biswas, Arijit; Yeo, George Seow Heong; Kwek, Kenneth; Gluckman, Peter D; Godfrey, Keith M; Saw, Seang Mei; Müller-Riemenschneider, Falk; Chong, Yap-Seng; Chong, Mary Foong-Fong; Chan, Jerry Kok Yen

2015-01-01

Epidemiological studies relating maternal 25-hydroxyvitamin D (25OHD) with gestational diabetes mellitus (GDM) and mode of delivery have shown controversial results. We examined if maternal 25OHD status was associated with plasma glucose concentrations, risks of GDM and caesarean section in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study. Plasma 25OHD concentrations, fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations were measured in 940 women from a Singapore mother-offspring cohort study at 26-28 weeks' gestation. 25OHD inadequacy and adequacy were defined based on concentrations of 25OHD ≤75nmol/l and >75nmol/l respectively. Mode of delivery was obtained from hospital records. Multiple linear regression was performed to examine the association between 25OHD status and glucose concentrations, while multiple logistic regression was performed to examine the association of 25OHD status with risks of GDM and caesarean section. In total, 388 (41.3%) women had 25OHD inadequacy. Of these, 131 (33.8%), 155 (39.9%) and 102 (26.3%) were Chinese, Malay and Indian respectively. After adjustment for confounders, maternal 25OHD inadequacy was associated with higher FG concentrations (β = 0.08mmol/l, 95% Confidence Interval (CI) = 0.01, 0.14), but not 2HPPG concentrations and risk of GDM. A trend between 25OHD inadequacy and higher likelihood of emergency caesarean section (Odds Ratio (OR) = 1.39, 95% CI = 0.95, 2.05) was observed. On stratification by ethnicity, the association with higher FG concentrations was significant in Malay women (β = 0.19mmol/l, 95% CI = 0.04, 0.33), while risk of emergency caesarean section was greater in Chinese (OR = 1.90, 95% CI = 1.06, 3.43) and Indian women (OR = 2.41, 95% CI = 1.01, 5.73). 25OHD inadequacy is prevalent in pregnant Singaporean women, particularly among the Malay and Indian women. This is associated with higher FG concentrations in Malay women, and increased risk of emergency caesarean section in Chinese and Indian women.

Obstetric mode of delivery and attention-deficit/hyperactivity disorder: a sibling-matched study.

PubMed

Curran, Eileen A; Khashan, Ali S; Dalman, Christina; Kenny, Louise C; Cryan, John F; Dinan, Timothy G; Kearney, Patricia M

2016-04-01

It has been suggested that birth by caesarean section (CS) may affect psychological development through changes in microbiota or stress response. We assessed the impact of mode of delivery, specifically CS, on the development of attention-deficit/hyperactivity disorder (ADHD), using a large, population-based cohort. The study cohort consisted of all singleton live births in Sweden from 1990 to 2008 using data from Swedish national registers. Mode of delivery included: unassisted vaginal delivery(VD), assisted VD, elective CS or emergency CS. ADHD was determined using International Classification of Diseases version 10 (F90 or F98.8), or prescription for ADHD medication. We used Cox regression to assess the association between birth by CS and ADHD in the total study population, adjusting for perinatal and sociodemographic factors, then stratified Cox regression analysis on maternal identification number to assess the association among siblings. Our cohort consisted of 1 722 548 children, and among these 47 778 cases of ADHD. The hazard ratio (HR) of the association between elective CS, compared with unassisted VD, and ADHD was 1.15 [95% confidence interval (CI): 1.11-1.20] in the cohort, and 1.05 (95% CI: 0.93-1.18) in the stratified analysis. The HR of the association between emergency CS and ADHD was 1.16 (95% CI: 1.12-1.20])in the cohort and 1.13 (95% CI: 1.01-1.26) in the stratified analysis. Birth by CS is associated with a small increased risk of ADHD. However among siblings the association only remained for emergency CS. If this were a causal effect by CS, the association would be expected to persist for both types of CS, suggesting the observed association is due to confounding. © The Author 2016; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.

Clinicians' Perspectives and Experiences Regarding Maternity Care in Women With Vulvodynia.

PubMed

Smith, Kelly B; Sadownik, Leslie A; Basson, Rosemary; Isaacson, Jordanna; Brotto, Lori A

2016-09-01

To assess clinicians' frequency of and comfort with provision of maternity care for women with vulvodynia, their beliefs and practices regarding delivery mode, and frequency of maternal requests for Caesarean section (CS). We invited physicians and midwives to complete a questionnaire assessing their frequency of contact with pregnant women with vulvodynia; their level of comfort providing antenatal, intrapartum, and postpartum care for these women; whether they believed that vulvodynia is an indication for elective CS and the frequency of making this recommendation; and the number of patients with vulvodynia who strongly requested CS. Of the 140 participating clinicians, 91 were physicians and 49 were midwives. Most physicians (n = 64; 70.4%) saw patients with vulvodynia at least once per month. Clinicians who saw women with vulvodynia were most likely to see pregnant women with vulvodynia rarely (n = 54; 40.3%) or every six to 12 months (n = 29; 21.6%). Almost one third (n = 44; 31.4%) were not comfortable providing maternity care for these women, and 16.4% (n = 23) agreed that vulvodynia was an indication for elective CS. Of respondents who provided maternity care for women with vulvodynia, 15.4% (n = 18) had recommended CS; the most common reason for doing so was potential worsening of vulvar symptoms. The majority of clinicians who provided maternity care for women with vulvodynia (n = 73; 62.4%) indicated that maternal requests for CS were rare. Almost one third of participating clinicians (31.4%) were not comfortable providing maternity care for women with vulvodynia. Despite infrequent maternal requests, a minority of clinicians believed that vulvodynia is an indication for CS and/or made that recommendation. Additional research and education are needed to provide optimal obstetric care for women with vulvodynia. Copyright © 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.

Caesarean Section: Could Different Transverse Abdominal Incision Techniques Influence Postpartum Pain and Subsequent Quality of Life? A Systematic Review

PubMed Central

Gizzo, Salvatore; Andrisani, Alessandra; Noventa, Marco; Di Gangi, Stefania; Quaranta, Michela; Cosmi, Erich; D’Antona, Donato; Nardelli, Giovanni Battista; Ambrosini, Guido

2015-01-01

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon’s experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: “acute pain”, “chronic pain”, “Pfannenstiel incision”, “Misgav-Ladach”, “Joel Cohen incision”, in combination with “Caesarean Section”, “abdominal incision”, “numbness”, “neuropathic pain” and “nerve entrapment”. Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required. PMID:25646621

Does amnioinfusion reduce caesarean section rate in meconium-stained amniotic fluid.

PubMed

Choudhary, Deepti; Bano, Imam; Ali, S M

2010-07-01

The purpose of our study was to evaluate the safety and efficacy of transcervical amnioinfusion during labour complicated by meconium-stained amniotic fluid, in a setting with limited peripartum facilities, to lower the incidence of caesarean section. A prospective study was conducted in a teaching hospital in north India, which enrolled 292 patients admitted in labour. Patients were randomly divided into two groups after taking their consent. One group received transcervical amnioinfusion, whilst in the other group amnioinfusion was not done. Caesarean sections were performed in either group if there were foetal heart rate abnormalities (bradycardia or irregularity for 10-20 min) or slow progress of labour. The outcomes studied were the incidence of caesarean sections, duration of maternal hospital stay, maternal febrile morbidity (temperature of >38 degrees C, 24 h after delivery), low Apgar score (at 1 and 5 min), respiratory death, MAS and perinatal mortality. There was a statistically significant reduction in the incidence of caesarean sections in the study group compared to the control group (31 vs. 61%). Amnioinfusion was associated with improved neonatal outcome as evidenced by statistically improved Apgar score at 1 min in newborns in the study group compared to the control group (10 vs. 37.2%). Amnioinfusion during labour was not associated with any significant maternal and neonatal complications. The mean hospital stay of the mother was decreased significantly in the study group patients compared to the control group. Transcervical amnioinfusion in labour for meconium-stained amniotic fluid is a simple, safe and easy-to-perform procedure. It can be performed safely in a setup with limited peripartum facilities, especially in developing countries, to decrease intrapartum operative intervention and reduce foetomaternal morbidity and mortality.

Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review.

PubMed

Gizzo, Salvatore; Andrisani, Alessandra; Noventa, Marco; Di Gangi, Stefania; Quaranta, Michela; Cosmi, Erich; D'Antona, Donato; Nardelli, Giovanni Battista; Ambrosini, Guido

2015-01-01

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon's experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: "acute pain", "chronic pain", "Pfannenstiel incision", "Misgav-Ladach", "Joel Cohen incision", in combination with "Caesarean Section", "abdominal incision", "numbness", "neuropathic pain" and "nerve entrapment". Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required.

Mode of childbirth and neonatal outcome after external cephalic version: A prospective cohort study.

PubMed

Rosman, A N; Vlemmix, F; Ensing, S; Opmeer, B C; Te Hoven, S; Velzel, J; de Hundt, M; van den Berg, S; Rota, H; van der Post, J A M; Mol, B W J; Kok, M

2016-08-01

to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. prospective matched cohort study. 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2-2.5)). women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. ECV is an important tool to reduce the caesarean section rates. Copyright © 2016. Published by Elsevier Ltd.

Magnesium sulphate has beneficial effects as an adjuvant during general anaesthesia for Caesarean section.

PubMed

Lee, D H; Kwon, I C

2009-12-01

The use of low concentrations of volatile anaesthetics with avoidance of opioids may induce intraoperative awareness and adverse haemodynamic responses during Caesarean section. Magnesium is well known to reduce anaesthetic requirements and to block noxious stimuli. We investigated whether i.v. magnesium sulphate modulates anaesthetic depth and analgesic efficacy during Caesarean section. Seventy-two patients undergoing Caesarean section were randomly assigned to receive i.v. saline (control group) or magnesium sulphate 30 mg kg(-1) bolus+10 mg kg(-1) h(-1) continuous infusion (Mg 30 group) or 45 mg kg(-1) bolus+15 mg kg(-1) h(-1) continuous infusion (Mg 45 group) after induction. Bispectral index (BIS) value, mean arterial pressure (MAP), and midazolam, fentanyl, and atracurium consumptions were recorded. BIS values [mean (sd)] at 7.5 and 10 min after surgery and before delivery in the control [64 (9), 66 (8), 67 (8), P<0.001] and the Mg 30 groups [62 (8), P<0.01; 64 (7), 63 (9), P<0.001] were higher than in the Mg 45 group [56 (8), 55 (8), 55 (7)]. MAP was greater in the control group (P<0.05) than in the Mg 30 and Mg 45 groups during the pre-delivery period. The magnesium groups required less midazolam (P<0.05), fentanyl (Mg 30, P<0.05; Mg 45, P<0.01), and atracurium (P<0.001) vs the control group. Preoperative i.v. magnesium sulphate attenuated BIS and arterial pressure increases during the pre-delivery period. Magnesium sulphate can be recommended as an adjuvant during general anaesthesia for Caesarean section to avoid perioperative awareness and pressor response resulting from inadequate anaesthesia, analgesia, or both.

A randomised controlled trial of the effect of a head-elevation pillow on intrathecal local anaesthetic spread in caesarean section.

PubMed

Elfil, H; Crowley, L; Segurado, R; Spring, A

2015-11-01

A head-elevation pillow places a patient in a ramped posture, which maximises the view of the larynx during laryngoscopy, particularly in obese parturients. In our institution an elevation pillow is used pre-emptively for neuraxial anaesthesia. We hypothesised that head-elevation may impair cephalad spread of local anaesthetic before caesarean section resulting in a lower block or longer time to achieve a T6 level. We aimed to investigate the effect of head-elevation on spread of intrathecal local anaesthetics during anaesthesia for caesarean section. One-hundred parturients presenting for caesarean section under combined spinal-epidural anaesthesia were randomised to either the standard supine position with lateral displacement or in the supine position with lateral displacement on an head-elevation pillow. Each patient received intrathecal hyperbaric bupivacaine 11 mg, morphine 100 μg and fentanyl 15 μg. Patients were assessed for adequacy of sensory block (T6 or higher) at 10 min. Sensory block to T6 was achieved within 10 min in 65.9% of parturients in the Elevation Pillow Group compared to 95.7% in the Control Group (P<0.05). Compared to the Control Group, patients in the Elevation Pillow Group had greater requirements for epidural supplementation (43.5% vs 2.1%, P<0.001) or conversion to general anaesthesia (9.3% vs 0%, P<0.04). Use of a ramped position with an head-elevation pillow following injection of the intrathecal component of a combined spinal-epidural anaesthetic for scheduled caesarean section was associated with a significantly lower block height at 10min. Copyright © 2015 Elsevier Ltd. All rights reserved.

A randomised trial of the analgesic efficacy of ultrasound-guided transversus abdominis plane block after caesarean delivery under general anaesthesia.

PubMed

Tan, Terry T; Teoh, Wendy H L; Woo, David C M; Ocampo, Cecilia E; Shah, Mukesh K; Sia, Alex T H

2012-02-01

Previous studies examining the efficacy of transversus abdominis plane block after caesarean section have mostly been in parturients under spinal anaesthesia. We postulated that the advantage of performing transversus abdominis plane block after caesarean section might be even more obvious after general anaesthesia, resulting in reduced 24-h consumption of morphine. DESIGN, SETTING, PATIENTS AND INTERVENTIONS: In this single centre, randomised double-blind controlled trial, 40 women who underwent caesarean delivery under general anaesthesia were allocated randomly to receive a transversus abdominis plane block or no block. In those who received the block, 20 ml of levobupivacaine 2.5 mg ml was deposited bilaterally into the transversus abdominis plane under ultrasound guidance using a Sonosite Titan (SonoSite, Bothell, Washington, USA) 7-13 MHz linear transducer at the end of surgery when the patient was still anaesthetised. We recorded patient-controlled intravenous morphine use for 24 h, pain scores at rest and activity, sedation, nausea and vomiting, use of antiemetic medication and overall maternal satisfaction. The primary outcome was 24-h morphine consumption. Patients who received the transversus abdominis plane block used significantly less morphine in 24 h than those in the control group [12.3 (2.6) vs. 31.4 mg (3.1), P<0.001) and had higher satisfaction scores [16 (80%) vs. 5 (25%), P = 0.012). There were no differences between groups in the visual analogue pain scores, sedation level, nausea and vomiting or the use of antiemetic medication. Ultrasound-guided transversus abdominis plane block reduced morphine consumption following caesarean section under general anaesthesia, with increased maternal satisfaction.

[Prophylaxis and treatment of arterial hypotension during caesarean with spinal anaesthesia].

PubMed

Arias, J; Lacassie, H J

2013-11-01

Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance. Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor. Copyright © 2012 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

Erector spinae plane block for analgesia after lower segment caesarean section: Case report.

PubMed

Yamak Altinpulluk, E; García Simón, D; Fajardo-Pérez, M

2018-05-01

Effective postoperative analgesia after emergency caesarean section is important because it provides early recovery, ambulation and breast-feeding. The ultrasound-guided erector spinae plane block has been orginally described for providing thoracic analgesia at the T5 transverse process by Forero et al. We performed post-operative bilateral erector spinae plane blocks with 20ml bupivacaine 0.25% at the level of the T9 transverse process in a pregnant woman after caesarean section. In this report, we described that bilateral erector spinae plane block at T9 level provides effective and long-lasting postoperative analgesia for lower abdominal surgery. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Caesarean section on demand: influence of personal birth experience and working environment on attitude of German gynaecologists.

PubMed

Faas-Fehervary, Patricia; Schwarz, Kai; Bauer, Lelia; Melchert, Frank

2005-10-01

We performed a survey among German obstetricians and gynecologists in order to evaluate the influence of biographic data, working environment and personal birth experience on the attitude towards Cesarean Section on demand. All 2106 board-certified gynecologists in Baden-Württemberg received an anonymous questionnaire in 2002-2003 concerning attitude towards C-section on demand, biographical data, personal birth experience and working environment. Seven hundred and nineteen questionnaires were returned and entered into statistical analysis. General approval of C-section was in 59% of all participants, with huge statistically significant variations according to age, personal birth experience and working field. When asked for their preferred way of delivery for themselves or their partner after a low-risk pregnancy, 90% of the responding gynecologists opted for vaginal delivery. The approval depended statistically significant on parenthood, personal birth experience and working environment. Biographical data, personal birth experience and working environment influence the attitude towards elective Cesaran section. Although 90% would chose vaginal delivery for themselves or their partner as best medical practice, 59% of the physicians approve of the general opportunity of C-section on demand. This shows, that not only best medical practice, but also patient autonomy and forensic aspects seem to play an important role.

Ethnicity and OPRM variant independently predict pain perception and patient-controlled analgesia usage for post-operative pain.

PubMed

Tan, Ene-choo; Lim, Eileen C P; Teo, Yik-ying; Lim, Yvonne; Law, Hai-yang; Sia, Alex T

2009-06-23

Morphine consumption can vary widely between individuals even for identical surgical procedures. As mu-opioid receptor (OPRM1) is known to modulate pain perception and mediate the analgesic effects of opioid compounds in the central nervous system, we examined the influence of two OPRM polymorphisms on acute post-operative pain and morphine usage in women undergoing elective caesarean delivery. Data on self-reported pain scores and amount of total morphine use according to patient-controlled analgesia were collected from 994 women from the three main ethnic groups in Singapore. We found statistically significant association of the OPRM 118A>G with self-administered morphine during the first 24-hour postoperative period both in terms of total morphine (p = 1.7 x 10(-5)) and weight-adjusted morphine (p = 6.6 x 10(-5)). There was also significant association of this OPRM variant and time-averaged self-rated pain scores (p = 0.024). OPRM 118G homozygotes used more morphine and reported higher pain scores than 118A carriers. Other factors which influenced pain score and morphine usage include ethnicity, age and paying class. Our results suggest that ethnicity and OPRM 118A>G genotype are independent and significant contributors to variation in pain perception and postoperative morphine use in patients undergoing cesarean delivery.

Gut microbiota in early life and its influence on health and disease: A position paper by the Malaysian Working Group on Gastrointestinal Health.

PubMed

Lee, Yeong Yeh; Hassan, Siti Asma; Ismail, Intan Hakimah; Chong, Sze Yee; Raja Ali, Raja Affendi; Amin Nordin, Syafinaz; Lee, Way Seah; Majid, Noorizan Abdul

2017-12-01

The role of gut microbiota in early life and its impact on gut health and subsequent diseases remain unclear. There is a lack of research and awareness in this area, especially in the Asia-Pacific region, including Malaysia. This paper reports the position of a Malaysian Working Group on some key issues surrounding gut microbiota in early life and its role in gut health and diseases, as well as experts' stand on probiotics and prebiotics. The group reached a consensus that certain factors, including elective caesarean; premature deliveries; complementary feeding; use of antibiotics, prebiotics and/or probiotics; and exposure to the external environmental, have an impact on gut microbiota in early life. However, as evidence is lacking, especially from the Asia-Pacific region, further studies are needed to understand how gut microbiota in early life affects subsequent diseases, including allergy, inflammatory bowel disease, obesity and infantile colic. Lastly, although beneficial in acute diarrhoeal disease and probably allergic eczema, probiotics (and/or prebiotics) should be used cautiously in other gut dysbiotic conditions until more data are available. © 2017 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Changes in myometrial expression of progesterone receptor membrane components 1 and 2 are associated with human parturition at term.

PubMed

Wang, Ray; Sheehan, Penelope M; Brennecke, Shaun P

2016-04-01

While the exact mechanism of human parturition remains unknown, functional progesterone withdrawal is believed to play a key regulatory role. Progesterone receptor membrane components 1 and 2 (PGRMC1, PGRMC2) are putative progesterone receptors and the aim of this project was to investigate their expression in human myometrium. Human term myometrium was obtained from the lower uterine segment incision in women undergoing elective (not-in-labour, NIL; n=11) and emergency Caesarean sections (in-labour, IL; n=10), following written consent. PGRMC1 and 2 expression was quantified using real-time reverse transcription polymerase chain reaction and western blot. Subcellular localisation was performed by immunohistochemistry and immunofluorescence. There was a significant decrease in PGRMC1 mRNA (P=0.0317) and protein expression (P=0.0151) in IL myometrium, compared with NIL myometrium. PGRMC2 mRNA expression (P=0.0151) was also decreased in IL myometrium, compared with NIL myometrium. Immunostaining studies confirmed the presence of PGRMC1 and 2 in smooth-muscle cells. Expression was perinuclear in NIL myometrium and more generalised and cytoplasmic in IL myometrium. The decrease in PGRMC1 expression and the translocation away from a perinuclear location for both PGRMC1 and 2 could contribute to a functional progesterone withdrawal that may ultimately initiate parturition.

Successful pregnancy outcome following maternal intravenous immunoglobulin treatment in a woman with recurrent perinatal haemochromatosis.

PubMed

Venkat-Raman, Narayanaswamy; Venkata-Krishnan, Radha V; Howarth, Edmund S

2006-12-01

We report a case of successful pregnancy outcome following maternal intravenous immunoglobulin treatment in a woman with previous history of recurrent fetal hydrops secondary to perinatal haemochromatosis. A 32-year old woman had two successive pregnancies complicated by fetal hydrops and perinatal deaths. Pathological examination of the fetus showed severe liver destruction with siderosis of hepatocytes at extrahepatic sites, but sparing of the reticulo-endothelial elements, consistent with the diagnosis of perinatal haemochromatosis. In the subsequent pregnancy, maternal intravenous immunoglobulin was administered weekly from the 18th week of gestation until delivery by elective caesarean section at 38 weeks. The infant was treated with desferrioxamine, N-acetylcysteine, vitamins K and E. The infant was born in good health, but had high serum ferritin levels, markedly elevated percent transferrin saturation, and mild transient derangement of liver and coagulation function. The infant made an excellent recovery and the treatment was stopped at 7 weeks of age. The liver and coagulation parameters and the serum ferritin levels returned to normal values. Haemochromatosis should be considered in the differential diagnosis of hydrops fetalis. The recurrence risk is high, and immunomodulation with intravenous immunoglobulin treatment appears to alter the course of the disease with better infant survival. Copyright (c) 2006 John Wiley & Sons, Ltd.

Management of CHAOS by intact cord resuscitation: case report and literature review.

PubMed

Kumar, Manisha; Gupta, Amit; Kumar, Vijay; Handa, Anu; Balliyan, Mayura; Meena, Jyoti; Roychoudhary, Shubhasis

2018-06-12

Congenital high airway obstruction syndrome (CHAOS) is a near fatal condition, except when the ex utero intrapartum treatment (EXIT) procedure is performed as rescue. After antenatal diagnosis of the condition, counseling regarding prognosis and outcome needs to be provided. We describe here a case with CHAOS due to isolated fetal laryngeal atresia, presented at our center at 33-week gestation. After counseling regarding the uncertain outcome, consent for elective caesarean was not given. Intact cord resuscitation (ICR) was done as a rescue by a well-coordinated team during delivery. Tracheostomy was performed successfully under local anesthesia within five minutes, while the cord was still attached to the placenta. The baby had supraglottic stenosis on CT scan. Reconstructive surgery is planned after 8 months. The literature review showed 24 reports of 28 cases with intrinsic airway obstruction managed by EXIT, laryngeal atresia was the most common cause (18/28). The outcome was poor in tracheal agenesis (1/4 survived) whereas those having laryngeal web or small communication (4/4 survived) had better outcome. Tracheal reconstruction was done in 3/28 cases only. The case emphasizes that ICR and tracheostomy during vaginal delivery can rescue the baby. The literature reviewed provided insight into the outcome of CHAOS cases in world literature.

[Comparative clinical analysis of cesarean section technique by Misgav Ladach method and Pfennenstiel method].

PubMed

Popiela, A; Pańszczyk, M; Korzeniewski, J; Baranowski, W

2000-04-01

Clinical and biochemical parameters were analysed in 55 patients who underwent a caesarean section performed using Misgav Ladach method compared to reference group of 41 patients who underwent caesarean section using Pfannenstiel method. Shortened operation time, shortened hospitalisation time and less postoperative morbidity were observed in the Misgav Ladach group. This kind of method seems to have advantages in comparison to Pfannenstiel method.

Caesarean section in Ancient Greek mythology.

PubMed

Lurie, Samuel

2015-01-01

The narrative of caesarean birth appears on several occasions in Greek mythology: in the birth of Dionysus is the God of the grape harvest and winemaking and wine; in the birth of Asclepius the God of medicine and healing; and in the birth of Adonis the God of beauty and desire. It is possible, however not obligatory, that it was not solely a fantasy but also reflected a contemporary medical practice.

[Cesarean birth: justifying indication or justified concern?].

PubMed

Muñoz-Enciso, José Manuel; Rosales-Aujang, Enrique; Domínguez-Ponce, Guillermo; Serrano-Díaz, César Leopoldo

2011-02-01

Caesarean section is the most common surgery performed in all hospitals of second level of care in the health sector and more frequently in private hospitals in Mexico. To determine the behavior that caesarean section in different hospitals in the health sector in the city of Aguascalientes and analyze the indications during the same period. A descriptive and cross in the top four secondary hospitals in the health sector of the state of Aguascalientes, which together account for 81% of obstetric care in the state, from 1 September to 31 October 2008. Were analyzed: indication of cesarean section and their classification, previous pregnancies, marital status, gestational age, weight and minute Apgar newborn and given birth control during the event. were recorded during the study period, 2.964 pregnancies after 29 weeks, of whom 1.195 were resolved by Caesarean section with an overall rate of 40.3%. We found 45 different indications, which undoubtedly reflect the great diversity of views on the institutional medical staff to schedule a cesarean section. Although each institution has different resources and a population with different characteristics, treatment protocols should be developed by staff of each hospital to have the test as a cornerstone of labor, also request a second opinion before a caesarean section, all try to reduce the frequency of cesarean section.

The free delivery and caesarean policy in Morocco: how much do households still pay?

PubMed

Boukhalfa, C; Abouchadi, S; Cunden, N; Witter, S

2016-02-01

The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliver free of charge within public hospitals. This study assesses the policy's effectiveness by analysing household expenditures related to childbirth, by delivery type and quintile. Structured exit survey of 973 women in six provinces at five provincial hospitals, two regional hospitals, two university hospitals and three primary health centres with maternity units. Households reported spending a median of US$ 59 in total for costs inside and outside of hospitals. Women requiring caesareans payed more than women with uncomplicated deliveries (P < 0.0001). The median cost was US$45 for a uncomplicated delivery, US$50 for a complicated delivery and US$65 for a caesarean section. The prescription given upon exiting the hospital comprised 62% of the total costs. Eighty-eight per cent of women from the poorest quintiles faced catastrophic expenditures. The women's perception of their hospital stay and the FDCP policy was overwhelmingly positive, but differences were noted at the various sites. The policy has been largely but not fully effective in removing financial barriers for delivery care in Morocco. More progress should also be made on increasing awareness of the policy and on easing the financial burden, which is still borne by households with lower incomes. © 2015 John Wiley & Sons Ltd.

Postoperative Foot Massage for Patients after Caesarean Delivery.

PubMed

Xue, M; Fan, L; Ge, L N; Zhang, Y; Ge, J L; Gu, J; Wang, Y; Chen, Y

2016-08-01

Little evidence is available on complementary therapies for anxiety and pain relief after caesarean delivery. The purpose of this study was to evaluate the effects of foot massage post-operatively in patients after caesarean delivery. 70 patients were divided to the study or control group after cesarean delivery. Patients in the study group had foot massages for 20 min after surgery. All patients underwent heart rate variability analysis (HRV) and scored their anxiety; pain intensity was evaluated using an 11-point numerical rating scale (NRS). In the study group the HRV, as measured by the low frequency power (LF) value and the LF-to-high frequency power (LF/HF) ratio during Holter assessment, was significantly less after foot massage intervention, but was not changed in the control group. Moreover, the HF value significantly increased and the anxiety score significantly decreased after foot massage intervention, but not in the control group. The pain intensity score obtained 60 min after the massage was significantly lower in the study group than the control group, as were the vital signs (respiratory rate, and systolic and diastolic blood pressure). Post-operative massage intervention can reduce anxiety and pain in patients after caesarean delivery. © Georg Thieme Verlag KG Stuttgart · New York.

Maternal and neonatal outcomes in labor and at delivery when long QT syndrome is present.

PubMed

Tanaka, Hiroaki; Katsuragi, Shinji; Tanaka, Kayo; Sawada, Masami; Iwanaga, Naoko; Yoshimatsu, Jun; Ikeda, Tomoaki

2016-01-01

Women during labor may be susceptible to torsades de pointes (TdP), which may cause the fetal condition to deteriorate. The aim of the present investigation was to analyze maternal and fetal outcomes during labor when long QT syndrome (LQTS) was present. We examined the maternal and neonatal outcomes of 25 pregnancies (18 women) with LQT between 1995 and 2012 at the Department of Perinatology, National Cardiovascular Center, Japan. Maternal and neonatal outcomes including cardiovascular events, cardiovascular events within a week after delivery, caesarean delivery rate, still births, preterm births, and non-reassuring fetal heart rate pattern (NRFHR) during labor were investigated. All the mothers survived, and no cardiovascular events occurred in labor or postpartum due to LQTS in either vaginal delivery or caesarean delivery. A total of 23 women (92%) had used beta blockers in this study. Caesarean delivery was performed due to NRFHR during labor in 5 pregnancies (20%). Delivery when LQTS is present has a low likelihood of cardiovascular events, but pregnancy with LQTS had a higher caesarean delivery rate due to NRFHR in labor. Most women used beta blockers in this study, and it is possible that beta blocker use prevents cardiovascular events during labor. NRFHR during labor may be related with inherited LQT through the mother.

Assessment of block height for satisfactory spinal anaesthesia for caesarean section.

PubMed

Ousley, R; Egan, C; Dowling, K; Cyna, A M

2012-12-01

We investigated block heights that anaesthetists considered adequate for caesarean section to proceed under spinal anaesthesia. During 3 months, 15 obstetric anaesthetists recorded block height to touch, pinprick or cold when spinal anaesthesia was considered satisfactory for caesarean section to proceed. Median (IQR [range]) block height for touch, pinprick, first cold and icy were: T10 (T7-T12 [T3-L1]); T5 (T4-T6 [C7-L1]); T5 (T4-T6 [C7-L1]); and T3 (T2-T4 [C7-L1]), respectively. Modalities were significantly correlated for: touch and cold, p = 0.0001; touch and icy, p = 0.0007; touch and pinprick, p = 0.0018; cold and icy, p < 0.0001; cold and pinprick, p = 0.0001; icy and pinprick, p < 0.0001. Pairwise comparisons showed differences between all modalities (p < 0.001) apart from pinprick and first cold (p = 0.94). All women had satisfactory anaesthesia despite 76 (81%) having a block to touch below T6. Single modality assessment of block height, particularly using touch, may erroneously indicate inadequate anaesthesia for caesarean section. Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.

Differential attentional responding in caesarean versus vaginally delivered infants.

PubMed

Adler, Scott A; Wong-Kee-You, Audrey M B

2015-11-01

Little is known about the role that the birth experience plays in brain and cognitive development. Recent research has suggested that birth experience influences the development of the somatosensory cortex, an area involved in spatial attention to sensory information. In this study, we explored whether differences in spatial attention would occur in infants who had different birth experiences, as occurs for caesarean versus vaginal delivery. Three-month-old infants performed either a spatial cueing task or a visual expectation task. We showed that caesarean-delivered infants' stimulus-driven, reflexive attention was slowed relative to vaginally delivered infants', whereas their cognitively driven, voluntary attention was unaffected. Thus, types of birth experience influence at least one form of infants' attention, and possibly any cognitive process that relies on spatial attention. This study also suggests that birth experience influences the initial state of brain functioning and, consequently, should be considered in our understanding of brain development.

[Caesarean section in conflict with the patient's right to self-determination?].

PubMed

Blondeau, Marie-José C E; Koorengevel, Kathelijne M; Schneider, A J Tom; van der Knijff-van Dortmont, A L M J Anouk; Dondorp, Wybo J

2015-01-01

Competent patients have the right to refuse treatment and healthcare workers should acknowledge their wishes. In the Netherlands there are conflicting (constitutional) rights of the foetus and of mentally ill patients. This paper describes the legal and ethical problems in the case of a mentally ill patient at 37 weeks of pregnancy who refused an obstetric examination. The patient refused to cooperate and have her physical condition and mental status examined. Her refusal endangered the life of the foetus. The obstetrician decided to perform a caesarean section, even if this would be in conflict with the patient's right to self-determination. In these cases no legal framework exists for providing the best medical care. New legislation should be drawn up to prevent similar cases occurring in the future. If a caesarean section is in conflict with a patient's right to self-determination, it should always be performed as a last resort.

The relation between height, foot length, pelvic adequacy and mode of delivery.

PubMed

Van Bogaert, L J

1999-02-01

To investigate the value of maternal height and foot length as predictors of pelvic adequacy and to evaluate the influence of body components' proportions on the mode of delivery. Retrospective study of the anthropometry of women having normal vertex deliveries (NVD), caesarean sections (CS) and vaginal birth after caesarean (VBAC). NVD patients were taller, had a longer vertebral column, longer lower limbs and longer feet than CS and than VBAC patients. The anthropometric measurements of VBAC patients yielded values intermediate between CS and NVD patients. The ratios of height to any of the other measured variables (vertebral column, lower limb and foot length) were similar in the three groups indicating that the body proportions were the same. Maternal height and foot length are of limited value as predictors of pelvic (in-)adequacy. The anthropometric features of women delivered by CS only are similar to those of women having a vaginal birth after Caesarean.

Quantitative evaluation of pregnant women delivery status' records in Akure, Nigeria.

PubMed

Adejumo, Adebowale O; Suleiman, Esivue A; Okagbue, Hilary I; Oguntunde, Pelumi E; Odetunmibi, Oluwole A

2018-02-01

In this data article, monthly records (datasets) of total delivery, normal delivery, delivery through Caesarean section and number of still births from pregnant women in Akure, the capital city of Ondo state Nigeria, for a period of ten years, between January 2007 and December 2016 were considered. Correlational and time series analyses were conducted on the monthly records of total delivery, normal delivery (delivery through woman virginal), delivery through Caesarean section, and number of still births, in order to observe the patterns each of these indicators follows and to recommend appropriate model for forecasting their future values. The data were obtained in raw form from State Specialist Hospital (SSH), Akure, Ondo state, Nigeria. A clear description and variation in each of these indicators (total delivery, normal delivery, caesarean section, and still births) were considered separately using descriptive statistics and box plots. Different models were also proposed for each of these indicators using time series models.

The cost of ignoring acute cholecystectomy.

PubMed

Garner, J P; Sood, S K; Robinson, J; Barber, W; Ravi, K

2009-01-01

Biliary symptoms whilst awaiting elective cholecystectomy are common, resulting in hospital admission, further investigation and increased hospital costs. Immediate cholecystectomy during the first admission is safe and effective, even when performed laparoscopically, but acute laparoscopic cholecystectomy has only recently become increasingly commonplace in the UK. This study was designed to quantify this problem in our hospital and its cost implications. The case notes of all patients undergoing laparoscopic cholecystectomy in our hospital between January 2004 and June 2005 were examined for details of hospital admissions with biliary symptoms or complications whilst waiting for elective cholecystectomy. Additional bed occupancy and radiological investigations were recorded and these costs to the trust calculated. We compared the potential tariff income to the hospital trust for the actual management of these patients and if a policy of acute laparoscopic cholecystectomy on first admission were in place. In the 18-month study period, 259 patients (202 females) underwent laparoscopic cholecystectomy. Of these, 147 presented as out-patients and only 11% required hospital admission because of biliary symptoms whilst waiting for elective surgery. There were 112 patients who initially presented acutely and were managed conservatively. Twenty-four patients were re-admitted 37 times, which utilised 231 hospital bed-days and repeat investigations costing over 40,000 pounds. There would have been a marginal increase in tariff income if a policy of acute laparoscopic cholecystectomy had been in place. Adoption of a policy of acute laparoscopic cholecystectomy on the index admission would result in substantial cost savings to the trust, reduce elective cholecystectomy waiting times and increase tariff income.

Design, dissemination, and evaluation of an advanced communication elective at seven U.S. medical schools.

PubMed

Mauksch, Larry; Farber, Stuart; Greer, H Thomas

2013-06-01

To test educational methods that continue communication training into the fourth year of medical school. The authors disseminated and evaluated an advanced communication elective in seven U.S. medical schools between 2007 and 2009; a total of 9 faculty and 22 fourth-year students participated. The elective emphasized peer learning, practice with real patients, direct observation, and applications of video technology. The authors used qualitative and quantitative survey methods and video review to evaluate the experience of students and faculty. Students reported that the elective was better than most medical school clerkships they had experienced. Their self-confidence in time management and in the use of nine communication skills improved significantly. The most valued course components were video review, repeated practice with real patients, and peer observation. Analysis of student videos with real patients and in role-plays showed that some skills (e.g., agenda setting, understanding the patient perspective) were more frequently demonstrated than others (e.g., exploring family and cultural values, communication while using the electronic health record). Faculty highly valued this learner-centered model and reported that their self-awareness and communication skills grew as teachers and as clinicians. Learner-centered methods such as peer observation and video review and editing may strengthen communication training and reinforce skills introduced earlier in medical education. The course design may counteract a "hidden curriculum" that devalues respectful interactions with trainees and patients. Future research should assess the impact of course elements on skill retention, attitudes for lifelong learning, and patients' health outcomes.

Effect of maternal height on caesarean section and neonatal mortality rates in sub-Saharan Africa: An analysis of 34 national datasets.

PubMed

Arendt, Esther; Singh, Neha S; Campbell, Oona M R

2018-01-01

The lifecycle perspective reminds us that the roots of adult ill-health may start in-utero or in early childhood. Nutritional and infectious disease insults in early life, the critical first 1000 days, are associated with stunting in childhood, and subsequent short adult stature. There is limited or no opportunity for stunted children above 2 years of age to experience catch-up growth. Some previous research has shown short maternal height to lead to adverse birth outcomes. In this paper, we document the association between maternal height and caesarean section, and between maternal height and neonatal mortality in 34 sub-Saharan African countries. We also explore the appropriate height cut-offs to use. Our paper contributes arguments to support a focus on preventing non-communicable risk factors, namely early childhood under-nutrition, as part of the fight to reduce caesarean section rates and other adverse maternal and newborn health outcomes, particularly neonatal mortality. We focus on the Sub-Saharan Africa region because it carries the highest burden of maternal and neonatal ill-health. We used the most recent Demographic and Health Survey for 34 sub-Saharan African countries. The distribution of heights of women who had given birth in the 5 years before the survey was explored. We adopted the following cut-offs: Very Short (<145.0cm), Short (145.0-149.9cm), Short-average (150.0-154.9cm), Average (155.0-159.9cm), Average-tall (160.0-169.9cm) and Tall (≥170.0cm). Multivariate logistic regression was used to assess the contribution of maternal stature to the odds ratio of caesarean section delivery, adjusting for other exposures, such as age at index birth, residence, maternal BMI, maternal education, wealth index quintile, previous caesarean section, multiple birth, birth order and country of survey. We also look at its contribution to neonatal mortality adjusting for age at index birth, residence, maternal BMI, maternal education, wealth index quintile, multiple birth, birth order and country of survey. There was a gradual increase in the rate of caesarean section with decreasing maternal height. Compared to women of Average height (155.0-159.9cm), taller women were protected. The adjusted odds ratio (aOR) for Tall women was 0.67 (95% CI:0.52-0.87) and for Average-tall women was 0.78 (95% CI:0.69-0.89). Compared to women of Average height, shorter women were at increased risk. The aOR for Short-average women was 1.19 (95% CI:1.03-1.37), for Short women was 2.06 (95% CI:1.71-2.48), and for Very Short women was 2.50 (95% CI:1.85-3.38). There was evidence that compared to Average height women, Very Short and Short women had increased odds of experiencing a neonatal death aOR = 1.95 (95% CI 1.17-3.25) and aOR = 1.66 (95% CI 1.20-2.28) respectively. When we focused on the period of highest risk, the day of delivery and first postnatal day, these aORs increased to 2.36 (95% CI 1.57-3.55) and 2.34 (95% CI 1.19-4.60) respectively. The aORs for the first week of life (early neonatal mortality) were 1.90 (95% CI 1.07-3.36) and 1.83 (95% CI 1.30-2.59) respectively. Short stature is associated with an increased prevalence of caesarean section and neonatal mortality, particularly on the newborn's first days. These results are even more striking because we know that caesarean section rates tend to be higher among wealthier and more educated women, who are often taller and that the same patterns may hold for neonatal survival; in such cases, adjusting for wealth, education and urban residence would attenuate these associations. Caesarean sections can be lifesaving operations; however, they cost the health system and families more, and are associated with worse health outcomes. We suggest that our findings be used to argue for policies targeting stunting in infant girls and potential catch-up growth in adolescence and early adulthood, aiming to increase their adult height and thus decrease their subsequent risk of experiencing caesarean section and adverse birth outcomes.

The CORONIS Trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial

PubMed Central

2007-01-01

Background Caesarean section is one of the most commonly performed operations on women throughout the world. Rates have increased in recent years – about 20–25% in many developed countries. Rates in other parts of the world vary widely. A variety of surgical techniques for all elements of the caesarean section operation are in use. Many have not yet been rigorously evaluated in randomised controlled trials, and it is not known whether any are associated with better outcomes for women and babies. Because huge numbers of women undergo caesarean section, even small differences in post-operative morbidity rates between techniques could translate into improved health for substantial numbers of women, and significant cost savings. Design CORONIS is a multicentre, fractional, factorial randomised controlled trial and will be conducted in centres in Argentina, Ghana, India, Kenya, Pakistan and Sudan. Women are eligible if they are undergoing their first or second caesarean section through a transverse abdominal incision. Five comparisons will be carried out in one trial, using a 2 × 2 × 2 × 2 × 2 fractional factorial design. This design has rarely been used, but is appropriate for the evaluation of several procedures which will be used together in clinical practice. The interventions are: • Blunt versus sharp abdominal entry • Exteriorisation of the uterus for repair versus intra-abdominal repair • Single versus double layer closure of the uterus • Closure versus non-closure of the peritoneum (pelvic and parietal) • Chromic catgut versus Polyglactin-910 for uterine repair The primary outcome is death or maternal infectious morbidity (one or more of the following: antibiotic use for maternal febrile morbidity during postnatal hospital stay, antibiotic use for endometritis, wound infection or peritonitis) or further operative procedures; or blood transfusion. The sample size required is 15,000 women in total; at least 7,586 women in each comparison. Discussion Improvements in health from optimising caesarean section techniques are likely to be more significant in developing countries, because the rates of postoperative morbidity in these countries tend to be higher. More women could therefore benefit from improvements in techniques. Trial registration The CORONIS Trial is registered in the Current Controlled Trials registry. ISCRTN31089967. PMID:18336721

[External cephalic version for breech presentation at term: an effective procedure to reduce the caesarean section rate].

PubMed

Lojacono, A; Donarini, G; Valcamonico, A; Soregaroli, M; Frusca, T

2003-12-01

Although term breech presentation is a relatively rare condition (3-5% of all births), it continues to be an important indication for caesarean section and has contributed to its increased use. Risk of complications may be increased for both mother and foetus in such a situation. Vaginal delivery of a breech presenting foetus is complex and may involve many difficulties, so today there is a general consensus that planned caesarean section is better than planned vaginal birth for the foetus in breech presentation at term. External cephalic version is one of the most effective procedures in modern obstetrics. It involves the external manipulation of the foetus from the breech into the cephalic presentation. A successful manoeuvre can decrease costs by avoiding operative deliveries and decreasing maternal morbidity. The aim of the present study is to evaluate the effectiveness of this obstetric manoeuvre to increase the proportion of vertex presentation among foetuses that were formerly in the breech position near term, so as to reduce the caesarean section rate. The safety of the version is also showed. From 1999 to 2002, 89 women with foetal breech presentation underwent external cephalic version at the Department of Obstetrics and Gynaecology of the Brescia University. The gestational age was 36.8+/-0.8 weeks. The following variables have been taken into consideration: breech variety, placental location, foetal back position, parity, amount of amniotic fluid and gestational age. Every attempt was performed with a prior use of an intravenous drip of Ritodrine, and foetal heart rate was monitored continuously with cardiotocogram. The success rate of the procedure was 42.7% (n=38). No maternal or foetal complication or side effects occurred, both during and after the manoeuvre, except a transient foetal bradycardia that resolved spontaneously. Only one spontaneous reversion of the foetus occurred before delivery. Of all the women that underwent a successful version, 84.2% (n=32) had a non complicated vaginal delivery. Five women (15.8%) had a caesarean section. There was no significant interaction between the variables assessed. The external cephalic version is a safe and effective manoeuvre reducing the risks of vaginal breech delivery and the rate of caesarean section.

An analysis of variations of indications and maternal-fetal prognosis for caesarean section in a tertiary hospital of Beijing: A population-based retrospective cohort study.

PubMed

Liu, Yajun; Wang, Xin; Zou, Liying; Ruan, Yan; Zhang, Weiyuan

2017-02-01

In recent decades, we have observed a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries, especially in China. According to the World Health Organization (WHO) systematic review, if the increase in CS rate was between 10% and 15%, the maternal and neonatal mortality was decreased. However, above this level, increasing the rate of CS is no longer associated with reduced mortality. To date, no consensus has been reached on the main factors driving the cesarean epidemic. To reduce the progressively increasing rate of CS, we should find indications for the increasing CS rate. The aim of our study was to estimate the change of CS rate of Beijing Obstetrics and Gynecology Hospital and to find the variation of the indications.From January 1995 to December 2014, the CS rate of Beijing Obstetrics and Gynecology Hospital was analyzed. For our analysis, we selected 14,642 and 16,335 deliveries respectively that occurred during the year 2011 and 2014, to analyze the difference of indications, excluding incomplete data and miscarriages or termination of pregnancy before 28 weeks of gestation because of fatal malformations, intrauterine death, or other reasons.The average CS rate during the past 20 years was 51.15%. The highest caesarean delivery rate was 60.69% in 2002; however, the caesarean delivery rate declined to 34.53% in 2014. The obviously different indications were caesarean delivery on maternal request and previous CS delivery. The rate of CS due to maternal request in 2014 was decreased by 8.16% compared with the year 2011. However, the percentage of pregnancy women with a previous CS delivery increased from 9.61% to 20.42% in 3 years. Along with the decline of CS rate, the perinatal mortality and the rate of neonatal asphyxia decreased in 2014 compared with that in 2011.After a series of measures, the CS rate declined indeed. Compared with 2011, the perinatal mortality and the rate of neonatal asphyxia decreased in 2014. Caesarean delivery on maternal request (CDMR) cannot improve the maternal-fetal prognosis compared with the spontaneous vaginal delivery. With the releasing of China's 2 children policy, more CS will be implemented due to previous CS. There is a need for further research that evaluates interventions for increasing VBAC rates that target clinicians.

Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study.

PubMed

Jadon, Ashok; Jain, Priyanka; Chakraborty, Swastika; Motaka, Mayur; Parida, Sudhansu Sekhar; Sinha, Neelam; Agrawal, Amit; Pati, Asit Kumar

2018-05-14

While opioids are the mainstay for post-operative analgesia after lower segment caesarean section, they are associated with various untoward effects. Ultrasound guided transversus abdominis plane (TAP) block has been postulated to provide effective analgesia for caesarean section. We evaluated the analgesic efficacy of this block for post caesarean analgesia in a randomised controlled trial. One hundred thirty-nine mothers undergoing caesarean delivery were randomised to receive TAP block with either 20 ml 0.375% ropivacaine or 20 ml saline after obtaining informed consent. All the subjects received a standard spinal anaesthetic and diclofenac was administered for post-operative pain. Breakthrough pain was treated with tramadol. Post-operatively, all the subjects were assessed at 0, 2, 4, 6, 8, 10, 12, 18 & 24 h. The primary outcome was the time to first analgesic request. The secondary measures of outcome were pain, nausea, sedation, number of doses of tramadol administered and satisfaction with the pain management. The median (interquartile range) time to first analgesic request was prolonged in the TAP group compared to the control group (p < 0.0001); 11 h (8,12) and 4 h (2.5,6) respectively. The median (interquartile range) number of doses of tramadol consumed in the TAP group was 0 (0,1) compared to 2 (1,2) in the control group (p < 0.0001). At all points in the study, pain scores both at rest and on movement were lower in the study group (p < 0.0001). Maternal satisfaction with pain relief was also higher in the study group (p 0.0002). One subject in the TAP group had convulsions following injection of local anaesthetic solution. She was managed conservatively with supportive treatment following which she recovered. TAP block reduces pain, prolongs the duration of analgesia and decreases supplemental opioid consumption when used for multimodal analgesia for pain relief after caesarean section. However, the risk of local anaesthetic systemic toxicity remains unknown with this block. Hence larger safety trials and measures to limit this complication need to be ascertained. The trial was registered with the Clinical Trial Registry of India ( CTRI/2017/03/008194 ) on 23/03/2017 (trial registered retrospectively).

[Caesarean section among seven public hospitals at Lima: trend analysis during 2001-2008 period].

PubMed

Quispe, Antonio M; Santivañez-Pimentel, Alvaro; Leyton-Valencia, Imelda; Pomasunco, Denis

2010-03-01

To analyze the trend of the monthly "caesarean section rate" (CSR) at the DISA V Lima-Ciudad Hospitals during the period 2001 - 2008. Ecological study that aim to analyze the monthly reports of all DISA V Lima-Ciudad Hospitals that attends childbirths, and by analyzing the trend of theirs monthly caesarean section ratio or monthly CSR (TCM = total caesarean births in a month * 100/total number of newborns in the same month ) to determine their characteristic patterns. Of the 7 hospitals studied, it was found that between 2001 and 2008, TCM average was 36.9% ± 9.1% (range: 16.5%-71.4%). From 2001 (33.5% ± 6.9%) to 2008 (39.7% ± 8.3%) years TCM increased 6.9% ± 7.0% on average, having registered a increase of 7.7% ± 6.4% at the year 2007 (43.5% ± 9.8%). Analyzing the TCM trend was found that most hospitals have a significant increase between 2004 and 2005 years. Analyzing the TCM trend was found that it tends to increase in April (37,9% ± 9,7%) and September (40.2% ± 8.9%), cycle that characterize most DISA V Lima-Ciudad Hospitals. TCM of the DISA V Lima-Ciudad Hospitals length exceeds the limit recommended by WHO and, during the period 2001-2008, has had a significant trend to increase.

Placenta accreta as a cause of peripartum hysterectomy.

PubMed

Palova, E; Redecha, M; Malova, A; Hammerova, L; Kosibova, Z

2016-01-01

Our objective was to identify the risk factors associated with placenta accreta. Cases of peripartum hysterectomy at University Hospital of Bratislava were identified in the period from January 1st 2008 to December 31th 2013. Included were only those cases which had a histological evidence of placenta accreta. Fifty patients, who underwent peripartum hysterectomy were included in the study. Between 2008 and 2013 eight cases of placenta accreta were identified. Five (62.5 %) of these were suspected before delivery. The overall incidence of PA was 0.19 per 1000 deliveries. Median gestational age at delivery was 37 weeks (range 25-41 weeks). Six of eight (75 %) women with placenta accreta had a previous caesarean delivery or curettage. In 5 patients both placenta praevia and prior Caesarean delivery were present. Among the 50 women who underwent peripartum hysterectomy, 8 (16 %) were patients with both prenatally diagnosed placenta praevia and previous caesarean delivery, placenta accreta was suspected in 4 of these (50 %) compared with 10 of 42 (24 %) without this combination of risk factors. Those in whom placenta accreta was suspected were delivered earlier than 37 weeks of gestation and were less likely to have emergency delivery. Placenta accreta is the second most common indication for an emergency peripartum hysterectomy. There is a high suspicion of placenta accreta in patients with placenta praevia and after previous Caesarean section (Tab. 3, Ref. 17).

Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy.

PubMed

Brogly, Nicolas; Schiraldi, Renato; Puertas, Laura; Maggi, Genaro; Yanci, Eduardo Alonso; Maldonado, Ever Hugo Martinez; Arévalo, Emilia Guasch; Rodríguez, Fernando Gilsanz

2016-01-01

The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality. To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy. We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus(®) monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs. This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

[Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy].

PubMed

Brogly, Nicolas; Schiraldi, Renato; Puertas, Laura; Maggi, Genaro; Yanci, Eduardo Alonso; Maldonado, Ever Hugo Martinez; Arévalo, Emilia Guasch; Rodríguez, Fernando Gilsanz

2016-01-01

The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality. To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy. We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus(®) monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs. This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Intravenous ketamine during spinal and general anaesthesia for caesarean section: systematic review and meta-analysis.

PubMed

Heesen, M; Böhmer, J; Brinck, E C V; Kontinen, V K; Klöhr, S; Rossaint, R; Straube, S

2015-04-01

Intravenous ketamine has been used during general and regional anaesthesia for caesarean section. No systematic review and meta-analysis on the desired effects and adverse effects of ketamine administration during caesarean section have yet been performed. After a systematic literature search a meta-analysis was conducted with the random effects model. Weighted mean difference (WMD) or risk ratio and 95% confidence intervals (CIs) were computed. Twelve randomised controlled double-blind trials comprising 953 patients were included: seven studies reported on spinal anaesthesia and five on general anaesthesia. Significant differences in the aforementioned outcome variables were found only in the spinal anaesthesia studies. In the spinal anaesthesia studies the time to the first analgesic request was significantly longer in ketamine-treated women, the WMD was 49.36 min (95% CI 43.31-55.41); visual analogue scale pain scores at rest 2 h after surgery were significantly lower. No differences were observed for maternal nausea, vomiting, pruritus, and psychomimetic effects. Only few data were found for neonatal outcomes. We conclude that ketamine enhances post-operative analgesia after caesarean section under spinal anaesthesia. There is a paucity of data for several maternal adverse effects as well as for neonatal well-being. Further studies are needed for general anaesthesia. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

High-dose, single-bolus eptifibatide: a safe and cost-effective alternative to conventional glycoprotein IIb/IIIa inhibitor use for elective coronary interventions.

PubMed

Fischell, Tim A; Attia, Tamer; Rane, Santosh; Salman, Waddah

2006-10-01

Adjunctive pharmacotherapy with eptifibatide, a glycoprotein (GP) IIb/IIIa inhibitor, as an intravenous bolus followed by infusion has been shown to improve outcomes in elective coronary interventions (PCI). However, bleeding complications and costs have limited the routine adoption of this regimen. The goal of this study was to examine the safety, efficacy and cost-effectiveness of high-dose, single-bolus eptifibatide, without post-intervention infusion, in "real-world" patients undergoing elective PCI. We studied 401 patients with stable and unstable angina who were treated with a high-dose (20 mg), single bolus of eptifibatide plus heparin prior to the start of elective PCI. Exclusion criteria included recent MI, stenting of bypass graft(s), rotational atherectomy and/or brachytherapy. The primary study endpoints were major adverse clinical events (MACE), defined as the in-hospital and 30-day incidence of death from any cause, Q-wave or non-Q-wave MI, repeat target vessel revascularization and/or major bleeding complications. Relevant demographic and procedural characteristics included mean age: 66.4 +/- 11.2; male gender: 242/401 (61%); number of vessels treated per patient: 1.46 +/- 0.42; and number of stents deployed per patient: 1.82 +/- 0.65. In-hospital non-Q-wave MI (CPK and/or CPK-MB > 3 times the upper limit of normal) occurred in 7/401 patients (1.75%) and MACE was 2.25%. Major bleeding complications were seen in 2/401 patients (0.49%). There were 4 additional MACE events at 30-day follow up (total MACE and bleeding = 3.25%). The average anticoagulation cost was 66 dollars/patient. Intravenous eptifibatide, administered as a high-dose (20 mg) single-vial bolus, is a safe, effective and highly cost-effective alternative to the conventional regimens of bolus plus prolonged intravenous GP IIb/IIIa inhibitor infusion for patients undergoing elective PCI.

Statewide Quality Improvement Initiative to Reduce Early Elective Deliveries and Improve Birth Registry Accuracy.

PubMed

Kaplan, Heather C; King, Eileen; White, Beth E; Ford, Susan E; Fuller, Sandra; Krew, Michael A; Marcotte, Michael P; Iams, Jay D; Bailit, Jennifer L; Bouchard, Jo M; Friar, Kelly; Lannon, Carole M

2018-04-01

To evaluate the success of a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data accuracy rapidly and at scale in Ohio. Between February 2013 and March 2014, participating hospitals were involved in a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data. This initiative was designed as a learning collaborative model (group webinars and a single face-to-face meeting) and included individual quality improvement coaching. It was implemented using a stepped wedge design with hospitals divided into three balanced groups (waves) participating in the initiative sequentially. Birth registry data were used to assess hospital rates of nonmedically indicated inductions at less than 39 weeks of gestation. Comparisons were made between groups participating and those not participating in the initiative at two time points. To measure birth registry accuracy, hospitals conducted monthly audits comparing birth registry data with the medical record. Associations were assessed using generalized linear repeated measures models accounting for time effects. Seventy of 72 (97%) eligible hospitals participated. Based on birth registry data, nonmedically indicated inductions at less than 39 weeks of gestation declined in all groups with implementation (wave 1: 6.2-3.2%, P<.001; wave 2: 4.2-2.5%, P=.04; wave 3: 6.8-3.7%, P=.002). When waves 1 and 2 were participating in the initiative, they saw significant decreases in rates of early elective deliveries as compared with wave 3 (control; P=.018). All waves had significant improvement in birth registry accuracy (wave 1: 80-90%, P=.017; wave 2: 80-100%, P=.002; wave 3: 75-100%, P<.001). A quality improvement initiative enabled statewide spread of change strategies to decrease early elective deliveries and improve birth registry accuracy over 14 months and could be used for rapid dissemination of other evidence-based obstetric care practices across states or hospital systems.

Effect of bed exercises and gum chewing on abdominal sounds, flatulence and early discharge in the early period after caesarean section.

PubMed

Çevik, Semra Akköz; Başer, Mürüvvet

2016-05-01

The purpose of this study was to determine the effects of bed exercises and gum chewing on abdominal sounds, flatulence and early discharge on women who have given birth at the Cengiz Gökçek Gynecology and Obstetrics Hospital surgery services in Gaziantep city centre. Caesarean operation is the most significant surgical intervention that affects central nervous system and decelerates bowel movements in the postoperative period. Conducted studies show that practices such as gum chewing ensure that bowel functions start in a short time through early feeding and mobilisation and shorten the duration of hospital stay. A randomised controlled experimental was used. A total of 120 women participated in the study in three groups of 40 for gum, exercise and control groups. Gum was given to the groups in the gum section two hours after the ceasarean, the women chewed gum for the first eight hours until flatulence for 15 minutes every two hours. However, the women in the exercise group started moving two hours after the caesarean for the first eight hours until flatulence for five minutes every two hours. The control group consisted of women under routine treatment and care of the hospital. All women were hourly evaluated in terms of abdominal sounds, flatulence and defaecation. It was determined that following caesarean, bowel functions started in three groups at the same time, there was no significant difference between three groups. It was determined that the gum group, exercise group and the control group were discharged earlier, there was no significant difference between three groups The study results show that spinal anaesthesia have positive effects on discharge time after caesarean section operation. This study provides useful information to clinician and researchers when determining practices such as postoperative standing up in early period, gum chewing and early liquid intake related to postoperative bowel functions after abdominal operations. © 2016 John Wiley & Sons Ltd.

Caesarean section audit to improve quality of care in a rural referral hospital in Tanzania.

PubMed

Dekker, Luuk; Houtzager, Tessa; Kilume, Omary; Horogo, John; van Roosmalen, Jos; Nyamtema, Angelo Sadock

2018-05-15

Caesarean section (CS) is often a life-saving procedure, but can also lead to serious complications, even more so in low-resource settings. Therefore unnecessary CS should be avoided and optimal circumstances for vaginal delivery should be created. In this study, we aim to audit indications for Caesarean sections and improve decision-making and obstetric management. Audit of all cases of CS performed from January to August 2013 was performed in a rural referral hospital in Tanzania. The study period was divided in three audit blocks; retrospective (before auditing), prospective 1 and prospective 2. A local audit panel (LP) and an external auditor (EA) judged if obstetric management was adequate and indications were appropriate or if CS could have been prevented and yet retain good pregnancy outcome. Furthermore, changes in modes of deliveries, overall pregnancy outcome and decision-to-delivery interval were monitored. During the study period there were 1868 deliveries. Of these, 403 (21.6%) were Caesarean sections. The proportions of unjustified CS prior to introduction of audit were as high as 34 and 75%, according to the respective judgments of LP and EA. Following introduction of audit, the proportions of unjustified CS decreased to 23% (p = 0.29) and 52% (p = 0.01) according to LP and EA respectively. However, CS rate did not change (20.2 to 21.7%), assisted vacuum delivery rate did not increase (3.9 to 1.8%) and median decision-to-delivery interval was 83 min (range 10 - 390 min). Although this is a single center study, these findings suggest that unnecessary Caesarean sections exist at an alarming rate even in referral hospitals and suggest that a vast number can be averted by introducing a focused CS audit system. Our findings indicate that CS audit is a useful tool and, if well implemented, can enhance rational use of resources, improve decision-making and harmonise practice among care providers.

A cost effectiveness analysis of midwife psycho-education for fearful pregnant women - a health system perspective for the antenatal period.

PubMed

Toohill, J; Callander, E; Gamble, J; Creedy, D K; Fenwick, J

2017-07-11

Psycho-education can reduce childbirth fear and caesarean section numbers. This study determines the cost-effectiveness of a midwife-led psycho-education intervention for women fearful of birth. One thousand four hundred ten pregnant women in south-east Queensland, Australia were screened for childbirth fear (W-DEQ A ≥ 66). Women with high scores (n = 339) were randomised to the BELIEF Study (Birth Emotions and Looking to Improve Expectant Fear) to receive psycho-education (n = 170) at 24 and 34 weeks of pregnancy or to the control group (n = 169). Women in both groups were surveyed 6 weeks postpartum with total cost for health service use during pregnancy calculated. Logistic regression models assessed the odds ratio of having vaginal birth or caesarean section in the study groups. Of 339 women randomised, 184 (54%) women returned data at 6 weeks postpartum (Intervention Group n = 91; Control Group n = 93). Women receiving psycho-education had a higher likelihood of vaginal birth compared to controls (n = 60, 66% vs. n = 54, 58%; OR 2.34). Mean 'treatment' cost for women receiving psycho-education was AUS$72. Mean cost for health services excluding the cost of psycho-education, was less in the intervention group (AUS$1193 vs. AUS$1236), but not significant (p = 0.78). For every five women who received midwife counselling, one caesarean section was averted. The incremental healthcare cost to prevent one caesarean section using this intervention was AUS$145. Costs of delivering midwife psycho-education to women with childbirth fear during pregnancy are offset by improved vaginal birth rates and reduction in caesarean section numbers. Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012 (retrospectively registered one week after enrolment of first participant).

The breech presentation and the vertex presentation following an external version represent risk factors for neonatal hip instability.

PubMed

Andersson, J E; Odén, A

2001-08-01

The aim of this study was to evaluate the frequency and type of hip-joint instability and the frequency of hip dislocation requiring treatment in neonates who had been lying in the breech presentation and were delivered vaginally after an external version or by caesarean section, and to compare them with neonates who were naturally in the vertex presentation. Breech presentations without ongoing labour were subjected to an attempted external version and, in cases where this proved unsuccessful or where labour had started, to deliver by caesarean section. None of the breech presentations was vaginally delivered. The anterior-dynamic ultrasound method was used to assess the hip-joint status of the neonates. Out of 6,571 foetuses, 257 were in breech presentation after 36 wk of pregnancy. Sixty-two were vaginally delivered following an external version to vertex presentation and 195 were delivered by caesarean section, 75 of these following unsuccessful attempts to perform a version. Treatment for congenital hip-joint dislocation was performed on 0.2%. Out of the breech presentations, 1.0% of those delivered by caesarean section were treated, while in those with vaginal delivery following an external version the treatment frequency was 3.2%. No case of late diagnosed hip dislocation was recorded. Significant differences in frequency of hip-joint instability and treatment were found between (i) neonates delivered in breech presentation and those delivered with vertex presentation, (ii) infants delivered in vertex presentation, naturally or after successful version, and (iii) those delivered by caesarean section with or without attempted external version and those delivered with vortex presentation. Breech presentation predisposes to increased hip instability. The instability is present prior to delivery and is certainly not a primary result of delivery forces. Both breech and vertex presentations following an external or spontaneous version should be considered as risk factors for neonatal hip instability.

Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study.

PubMed

Palmer, E; Ciechanowicz, S; Reeve, A; Harris, S; Wong, D J N; Sultan, P

2018-07-01

We conducted a 5-year retrospective cohort study on women undergoing caesarean section to investigate factors influencing the operating room-to-incision interval. Time-to-event analysis was performed for category-1 caesarean section using a Cox proportional hazards regression model. Covariates included: anaesthetic technique; body mass index; age; parity; time of delivery; and gestational age. Binary logistic regression was performed for 5-min Apgar score ≥ 7. There were 677 women who underwent category-1 caesarean section and who met the entry criteria. Unadjusted median (IQR [range]) operating room-to-incision intervals were: epidural top-up 11 (7-17 [0-87]) min; general anaesthesia 6 (4-11 [0-69]) min; spinal 13 (10-20 [0-83]) min; and combined spinal-epidural 24 (13-35 [0-75]) min. Cox regression showed general anaesthesia to be the most rapid method with a hazard ratio (95%CI) of 1.97 (1.60-2.44; p < 0.0001), followed by epidural top-up (reference group), spinal anaesthesia 0.79 (0.65-0.96; p = 0.02) and combined spinal-epidural 0.48 (0.35-0.67; p < 0.0001). Underweight and overweight body mass indexes were associated with longer operating room-to-incision intervals. General anaesthesia was associated with fewer 5-min Apgar scores ≥ 7 with an odds ratio (95%CI) of 0.28 (0.11-0.68; p < 0.01). There was no difference in neonatal outcomes between the first and fifth quintiles for operating room-to-incision intervals. General anaesthesia is associated with the most rapid operating room-to-incision interval for category-1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room-to-incision intervals were not associated with worse neonatal outcomes. © 2018 The Association of Anaesthetists of Great Britain and Ireland.

Comparison of epidural oxycodone and epidural morphine for post-caesarean section analgesia: A randomised controlled trial

PubMed Central

Sng, Ban Leong; Kwok, Sarah Carol; Mathur, Deepak; Ithnin, Farida; Newton-Dunn, Clare; Assam, Pryseley Nkouibert; Sultana, Rehena; Sia, Alex Tiong Heng

2016-01-01

Background and Aims: Epidural morphine after caesarean section may cause moderate to severe pruritus in women. Epidural oxycodone has been shown in non-obstetric trials to reduce pruritus when compared to morphine. We hypothesised that epidural oxycodone may reduce pruritus after caesarean section. Methods: A randomised controlled trial was conducted in pregnant women at term who underwent caesarean section with combined spinal-epidural technique initiated with intrathecal fentanyl 15 μg. Women received either epidural morphine 3 mg or epidural oxycodone 3 mg via the epidural catheter after delivery. The primary outcome was the incidence of pruritus at 24 h after caesarean section. The secondary outcomes were the pruritus scores, treatment for post-operative nausea and vomiting (PONV), pain scores and maternal satisfaction. Results: One hundred women were randomised (group oxycodone O = 50, morphine M = 50). There was no difference between Group O and M in the incidence of pruritus (n [%] 28 [56%] vs. 31 [62%], P = 0.68) and the worst pruritus scores (mean [standard deviation] 2.6 (2.8) vs. 3.3 [3.1], P = 0.23), respectively. Both groups had similar pain scores at rest (2.7 [2.3] vs. 2.0 [2.7], P = 0.16) and sitting up (5.0 [2.3] vs. 4.6 [2.4], P = 0.38) at 24 h. Pruritus scores were lower at 4–8, 8–12 and 12–24 h with oxycodone, but pain scores were higher. Both groups had a similar need for treatment of PONV and maternal satisfaction with analgesia. Conclusion: There was no difference in the incidence of pruritus at 24 h between epidural oxycodone and morphine. However, pruritus scores were lower with oxycodone between 4 and 24 h after surgery with higher pain scores in the same period. PMID:27053782

A randomized study comparing skin closure in cesarean sections: staples vs subcuticular sutures.

PubMed

Rousseau, Julie-Anne; Girard, Karine; Turcot-Lemay, Lucile; Thomas, Nancy

2009-03-01

We sought to compare postoperative pain according to the skin closure method (subcuticular sutures vs staples) after an elective term cesarean section. A randomized controlled trial of 101 women was performed. Women were randomly assigned to subcuticular sutures or staples. Operative technique and postoperative analgesia were standardized. Stratification was used for primary vs repeat cesareans. Analog pain and satisfaction scales ranging from 0-10 were completed at postoperative days 1 and 3, and at 6 weeks postoperatively. A digital photograph of the incision was taken at 6 weeks postoperatively and evaluated by 3 independent blinded observers. Pain at 6 weeks postoperatively was significantly less in the staple group (0.17 vs 0.51; P = .04). Operative time was shorter in that group (24.6 vs 32.9 minutes; P < .0001). No difference was noted for incision appearance and women's satisfaction. Staples are the method of choice for skin closure for elective term cesareans in our population.

First birth Caesarean section and subsequent fertility: a population-based study in the USA, 2000-2008.

PubMed

Kjerulff, K H; Zhu, J; Weisman, C S; Ananth, C V

2013-12-01

Is first birth Caesarean delivery associated with a lower likelihood of subsequent childbearing when compared with first birth vaginal delivery? In this study of US women whose first delivery was in 2000, those who had a Caesarean delivery were less likely to have a subsequent live birth than those who delivered vaginally. Some studies have reported lower birth rates subsequent to Caesarean delivery in comparison with vaginal delivery, while other studies have reported no difference. We conducted a retrospective cohort study of 52 498 women who had a first singleton live birth in the State of Pennsylvania, USA in 2000 and were followed to the end of 2008 via Pennsylvania birth certificate records to identify subsequent live births during the 8- to 9-year follow-up period. Birth certificate records of first singleton births were linked to the hospital discharge data for each mother and newborn, and linked to all birth certificate records for each mother's subsequent deliveries which occurred in 2000 to the end of 2008. Poisson regression models were used to evaluate the association between first birth factors and whether or not there was a subsequent live birth during the follow-up period. Over an average of 8.5 years of follow-up, 40.2% of women with a Caesarean first birth did not have a subsequent live birth, compared with 33.1% of women with a vaginal first birth (risk ratio (RR): 1.21, 95% confidence interval (CI): 1.18-1.25). Adjustment for the demographic confounders of maternal age, race, education, marital status and health insurance coverage attenuated the RR to 1.16 (95% CI: 1.13-1.19). Specific pregnancy and childbirth-related complications associated with not having a subsequent live birth included diabetes-related disorders, abnormalities of organs and soft tissues of the pelvis, fetal abnormalities, premature or prolonged rupture of membranes, hypertensive disorders, amnionitis, fetal distress and other maternal health problems. However, adjustment for the pregnancy and childbirth complications had little effect on the RR of not having a subsequent live birth (RR = 1.15, 95% CI: 1.11-1.19). We were unable to distinguish between women who did not have a subsequent live birth and those who moved out of the state, which may have introduced a selection bias if those who had Caesarean births were more likely to emigrate than those who delivered vaginally. In addition we were unable to measure pre-pregnancy body mass index, weight gain during pregnancy and prior infertility, which would have been helpful in our efforts to reduce selection bias. The results of this study provide further corroboration of previous studies that have reported reduced fertility subsequent to Caesarean section in comparison with vaginal delivery. This study was funded by the US National Institute of Child Health and Human Development (NICHD, R01-HD052990). No competing interests are declared.

The OptiMUM-study: EMDR therapy in pregnant women with posttraumatic stress disorder after previous childbirth and pregnant women with fear of childbirth: design of a multicentre randomized controlled trial

PubMed Central

Baas, M. A. M.; Stramrood, C. A. I.; Dijksman, L. M.; de Jongh, A.; van Pampus, M. G.

2017-01-01

ABSTRACT Background: Approximately 3% of women develop posttraumatic stress disorder (PTSD) after giving birth, and 7.5% of pregnant women show a pathological fear of childbirth (FoC). FoC or childbirth-related PTSD during (a subsequent) pregnancy can lead to a request for an elective caesarean section as well as adverse obstetrical and neonatal outcomes. For PTSD in general, and several subtypes of specific phobia, eye movement desensitization and reprocessing (EMDR) therapy has been proven effective, but little is known about the effects of applying EMDR during pregnancy. Objective: To describe the protocol of the OptiMUM-study. The main aim of the study is to determine whether EMDR therapy is an effective and safe treatment for pregnant women with childbirth-related PTSD or FoC. In addition, the cost-effectiveness of this approach will be analysed. Method: The single-blind OptiMUM-study consists of two two-armed randomized controlled trials (RCTs) with overlapping design. In several hospitals and community midwifery practices in Amsterdam, the Netherlands, all eligible pregnant women with a gestational age between eight and 20 weeks will be administered the Wijma delivery expectations questionnaire (WDEQ) to asses FoC. Multiparous women will also receive the PTSD checklist for DSM-5 (PCL-5) to screen for possible PTSD. The clinician administered PTSD scale (CAPS-5) will be used for assessing PTSD according to DSM-5 in women scoring above the PCL-5 cut-off value. Fifty women with childbirth-related PTSD and 120 women with FoC will be randomly allocated to either EMDR therapy carried out by a psychologist or care-as-usual. Women currently undergoing psychological treatment or women younger than 18 years will not be included. Primary outcome measures are severity of childbirth-related PTSD or FoC symptoms. Secondary outcomes are percentage of PTSD diagnoses, percentage caesarean sections, subjective childbirth experience, obstetrical and neonatal complications, and health care costs. Results: The results are meant to provide more insight about the safety and possible effectiveness of EMDR therapy during pregnancy for women with PTSD or FoC. Conclusion: This study is the first RCT studying efficacy and safety of EMDR in pregnant women with PTSD after childbirth or Fear of Childbirth. PMID:28348720

The rise in caesarean birth rate in Sagamu, Nigeria: reflection of changes in obstetric practice.

PubMed

Oladapo, O T; Sotunsa, J O; Sule-Odu, A O

2004-06-01

A retrospective and comparative study of women delivered by caesarean section over two different 3-year periods was conducted at Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. The caesarean section rate (CSR) increased from 10.3% in 1989-1991 to 23.1% in 2000-2003. The most frequent indication in both periods was different: prolonged/obstructed labour (20.0%) in 1989-1991 and antepartum haemorrhage (14.9%) in 2000-2003. Malpresentation, antepartum haemorrhage and pre-eclampsia/eclampsia were responsible for 51.7% of the difference in the CSR recorded between both periods. The CSR rose from 13.3% to 25.0% while the instrumental vaginal delivery (IVD) rate decreased significantly by 11.4% among the nulliparous women between the periods. Increase in CSR can be attributed mainly to reduction in IVD rate and alteration in the management of labour complications and induction policy. Strategies to reduce the CSR should cut across all indications and focus on encouraging instrumental vaginal deliveries, especially among nulliparous women.

Did the strategy of skilled attendance at birth reach the poor in Indonesia?

PubMed

Hatt, Laurel; Stanton, Cynthia; Makowiecka, Krystyna; Adisasmita, Asri; Achadi, Endang; Ronsmans, Carine

2007-10-01

To assess whether the strategy of "a midwife in every village" in Indonesia achieved its aim of increasing professional delivery care for the poorest women. Using pooled Demographic and Health Surveys (DHS) data from 1986-2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesias health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. There was no change in rates of professional attendance or caesarean section before the programmes full implementation (1986-1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles -- 11% per year compared with 6% per year for women in the middle quintile (P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor.

Randomised trial of amnioinfusion during labour with meconium stained amniotic fluid.

PubMed

Rathor, Asmita Muthal; Singh, Ruchira; Ramji, S; Tripathi, Reva

2002-01-01

To assess the effect of amnioinfusion during labour with meconium stained amniotic fluid on caesarean section rate and perinatal outcome. Prospective randomised controlled study. A tertiary care teaching hospital in India. Women in labour at term with meconium stained amniotic fluid. Two hundred women in labour with > or = 37 weeks gestation, single cephalic presentation with moderate or thick meconium were randomised to control and amnioinfusion groups at a 1:1 ratio. Amnioinfusion was performed using 500 mL of normal saline over a period of 30 minutes in a study group. The control group received routine care. Both groups had intermittent auscultation of fetal heart rate during labour. The primary outcome measure was caesarean section rate. Secondary outcome measures were meconium aspiration syndrome, 1 minute and 5 minute apgar < 7, hypoxic ischaemic encephalopathy, neonatal intensive care unit admission, meconium at the level of vocal cords. The caesarean section rate in the amnioinfusion group was less than the control group (RR 0.47; 95% CI 0.24-0.93). Amnioinfusion was associated with a significant decrease in the incidence of meconium at the vocal cords (P = 0.001); improvement in 1 minute apgar scores (P < 0.05), respiratory distress (P = 0.002) and fewer admissions to nursery compared with the controls. This sample size was inadequate to study the impact on meconium aspiration syndrome. Amnioinfusion in an under resourced labour ward decreases caesarean section rates and fetal morbidity.

Cost-effectiveness of antenatal screening for neonatal alloimmune thrombocytopenia.

PubMed

Killie, M K; Kjeldsen-Kragh, J; Husebekk, A; Skogen, B; Olsen, J A; Kristiansen, I S

2007-05-01

To estimate the costs and health consequences of three different screening strategies for neonatal alloimmune thrombocytopenia (NAIT). Cost-utility analysis on the basis of a decision tree that incorporates the relevant strategies and outcomes. Three health regions in Norway encompassing a 2.78 million population. Pregnant women (n = 100,448) screened for human platelet antigen (HPA) 1a and anti-HPA 1a antibodies, and their babies. Decision tree analysis. In three branches of the decision tree, pregnant women entered a programme while in one no screening was performed. The three different screening strategies included all HPA 1a negative women, only HPA 1a negative, HLA DRB3*0101 positive women or only HPA 1a negative women with high level of anti-HPA 1a antibodies. Included women underwent ultrasound examination and elective caesarean section 2-4 weeks before term. Severely thrombocytopenic newborn were transfused immediately with compatible platelets. Quality-adjusted life years (QALYs) and costs. Compared with no screening, a programme of screening and subsequent treatment would generate between 210 and 230 additional QALYs among 100,000 pregnant women, and at the same time, reduce health care costs by approximately 1.7 million euros. The sensitivity analyses indicate that screening is cost effective or even cost saving within a wide range of probabilities and costs. Our calculations indicate that it is possible to establish an antenatal screening programme for NAIT that is cost effective.

Study of post dural puncture headache with 27G Quincke & Whitacre needles in obstetrics/non obstetrics patients.

PubMed

Srivastava, Vibhu; Jindal, Parul; Sharma, J P

2010-06-01

The proposed study was carried out in the department of Anaesthesiology, Intensive care & Pain management, Himalayan Institute of Medical Sciences. Swami Rama Nagar, Dehradun. A total of 120 patients of ASA I & II obstetric & non-obstetric undergoing elective/emergency surgery under subarachnoid block were included under the study. To evaluate the frequency of PDPH during spinal anaesthesia using 27 gauge Quincke vs 27G whitacre needle in obstetric/non obstetric patient. In our study patients were in the age group of 15-75 years. Most of the patients in our study belong to ASA Grade I. There was 2%, 1%, 4% and 3% hypotension in-group A, B, C, D respectively. There was 2%, 4% shivering in-group A, C respectively and 1% each in group B, D. In our study failed spinal with 27G Quincke needle was in one case (3.33%) in-group C where successful subarachnoid was performed with a thicken spinal needle 23G Quincke. There was no incidence of PDPH in-group A and D, while 1 (2%) patient in-group B and 2 (4%) in group C. All the three patients were for lower section caesarean section and were young and had undergone more than one attempt to perform spinal block. The headache severity was from mild to moderate and no epidural blood patch was applied.

Sleep-wake cycle of the healthy term newborn infant in the immediate postnatal period.

PubMed

Korotchikova, Irina; Stevenson, Nathan J; Livingstone, Vicki; Ryan, C Anthony; Boylan, Geraldine B

2016-04-01

To examine sleep-wake cycle (SWC) composition of healthy term infants in the immediate postnatal period using EEG, and investigate factors that might influence it. Multichannel video-EEG was recorded for a median of 61.9 min (IQR: 60.0-69.3). The absolute and relative scores of sleep states were calculated for each infant's recording. Parametric/non-parametric statistical tests and multiple linear regression analysis were used to investigate the influence of perinatal factors on SWC composition. Eighty healthy term infants aged 1-36 h were studied. A well-developed SWC was evident as early as within the first 6h after birth. The mean (SD) percentage of active sleep (AS) was 52.1% (12.9) and quiet sleep (QS) was 38.6% (12.5). AS was longer and QS shorter in infants delivered by elective caesarean section (CS) compared to infants delivered by vaginal delivery or emergency CS. This is the first large cohort EEG study that has quantified neonatal sleep. SWC is clearly present immediately after birth, it is dominated by AS, and is influenced by mode of delivery. This knowledge of the early neonatal EEG/SWC can be used as reference data for EEG studies of neurologically compromised infants. Copyright © 2015 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Efficacy of the Bilateral Ilioinguinal-Iliohypogastric Block with Intrathecal Morphine for Postoperative Cesarean Delivery Analgesia

PubMed Central

Vallejo, Manuel C.; Steen, Talora L.; Cobb, Benjamin T.; Phelps, Amy L.; Pomerantz, Joel M.; Orebaugh, Steven L.; Chelly, Jacques E.

2012-01-01

The ilioinguinal-iliohypogastric (IIIH) block is frequently used as multimodal analgesia for lower abdominal surgeries. The aim of this study is to compare the efficacy of IIIH block using ultrasound visualization for reducing postoperative pain after caesarean delivery (CD) in patients receiving intrathecal morphine (ITM) under spinal anesthesia. Participants were randomly assigned to 1 of 3 treatment groups for the bilateral IIIH block: Group A = 10 mL of 0.5% bupivacaine, Group B = 10 mL of 0.5% bupivacaine on one side and 10 mL of a normal saline (NSS) placebo block on the opposite side, and Group C = 10 mL of NSS placebo per side. Pain and nausea scores, treatment for pain and nausea, and patient satisfaction were recorded for 48 hours after CD. No differences were noted with respect to pain scores or treatment for pain over the 48 hours. There were no differences to the presence of nausea (P = 0.64), treatment for nausea (P = 0.21), pruritus (P = 0.39), emesis (P = 0.35), or patient satisfaction (P = 0.29). There were no differences in pain and nausea scores over the measured time periods (MANOVA, P > 0.05). In parturients receiving ITM for elective CD, IIIH block offers no additional postoperative benefit for up to 48 hours. PMID:23304075

Potency of umbilical cord blood- and Wharton's jelly-derived mesenchymal stem cells for scarless wound healing.

PubMed

Doi, Hanako; Kitajima, Yuriko; Luo, Lan; Yan, Chan; Tateishi, Seiko; Ono, Yusuke; Urata, Yoshishige; Goto, Shinji; Mori, Ryoichi; Masuzaki, Hideaki; Shimokawa, Isao; Hirano, Akiyoshi; Li, Tao-Sheng

2016-01-05

Postnatally, scars occur as a consequence of cutaneous wound healing. Scarless wound healing is highly desired for patients who have undergone surgery or trauma, especially to exposed areas. Based on the properties of mesenchymal stem cells (MSCs) for tissue repair and immunomodulation, we investigated the potential of MSCs for scarless wound healing. MSCs were expanded from umbilical cord blood (UCB-MSCs) and Wharton's jelly (WJ-MSCs) from healthy donors who underwent elective full-term pregnancy caesarean sections. UCB-MSCs expressed lower levels of the pre-inflammatory cytokines IL1A and IL1B, but higher levels of the extracellular matrix (ECM)-degradation enzymes MMP1 and PLAU compared with WJ-MSCs, suggesting that UCB-MSCs were more likely to favor scarless wound healing. However, we failed to find significant benefits for stem cell therapy in improving wound healing and reducing collagen deposition following the direct injection of 1.0 × 10(5) UCB-MSCs and WJ-MSCs into 5 mm full-thickness skin defect sites in nude mice. Interestingly, the implantation of UCB-MSCs tended to increase the expression of MMP2 and PLAU, two proteases involved in degradation of the extracellular matrix in the wound tissues. Based on our data, UCB-MSCs are more likely to be a favorable potential stem cell source for scarless wound healing, although a better experimental model is required for confirmation.

The roles of the cyclo-oxygenases types one and two in prostaglandin synthesis in human fetal membranes at term.

PubMed

Sawdy, R J; Slater, D M; Dennes, W J; Sullivan, M H; Bennett, P R

2000-01-01

The aim of this study was to determine the relative contributions of cyclo-oxygenase (COX) types 1 and 2 to prostaglandin synthesis at term. Fetal membranes were collected from 6 pregnancies after elective caesarean section at term, prior to labour. The presence of COX-1 and COX-2 protein was determined using Western analysis. The relative contributions of the two isoforms of COX to prostaglandin synthesis were determined by incubation of fetal membrane discs with either a COX-2 selective inhibitor, SC236, or a COX-1 selective inhibitor, SC560, and measurement of prostaglandin release during 24 h using enzyme-linked immuno-sorbent assay (ELISA). Both COX-1 and COX-2 protein were demonstrated in amnion and chorion-decidua. The COX-2 selective inhibitor, SC-236, significantly reduced prostaglandin synthesis, both in its COX-2 specific and higher, non-specific concentration ranges. The COX-1 selective inhibitor, SC-560, had no effect upon prostaglandin synthesis in its COX-1 specific concentration range, but did significantly reduce prostaglandin synthesis at higher, non-selective concentrations. Fetal membranes contain both COX-1 and COX-2 at term, but only COX-2 contributes towards prostaglandin synthesis. COX-2 selective NSAI drugs will be as effective as non-selective agents in inhibition of fetal membrane prostaglandin synthesis and may represent a new strategy for tocolysis. Copyright 2000 Harcourt Publishers Ltd.

Development of composite outcomes for individual patient data (IPD) meta-analysis on the effects of diet and lifestyle in pregnancy: a Delphi survey.

PubMed

Rogozinska, E; D'Amico, M I; Khan, K S; Cecatti, J G; Teede, H; Yeo, S; Vinter, C A; Rayanagoudar, G; Barakat, R; Perales, M; Dodd, J M; Devlieger, R; Bogaerts, A; van Poppel, M N M; Haakstad, L; Shen, G X; Shub, A; Luoto, R; Kinnunen, T I; Phelan, S; Poston, L; Scudeller, T T; El Beltagy, N; Stafne, S N; Tonstad, S; Geiker, N R W; Ruifrok, A E; Mol, B W; Coomarasamy, A; Thangaratinam, S

2016-01-01

To develop maternal, fetal, and neonatal composite outcomes relevant to the evaluation of diet and lifestyle interventions in pregnancy by individual patient data (IPD) meta-analysis. Delphi survey. The International Weight Management in Pregnancy (i-WIP) collaborative network. Sample Twenty-six researchers from the i-WIP collaborative network from 11 countries. A two-generational Delphi survey involving members of the i-WIP collaborative network (26 members in 11 countries) was undertaken to prioritise the individual outcomes for their importance in clinical care. The final components of the composite outcomes were identified using pre-specified criteria. Composite outcomes considered to be important for the evaluation of the effect of diet and lifestyle in pregnancy. Of the 36 maternal outcomes, nine were prioritised and the following were included in the final composite: pre-eclampsia or pregnancy-induced hypertension, gestational diabetes mellitus (GDM), elective or emergency caesarean section, and preterm delivery. Of the 27 fetal and neonatal outcomes, nine were further evaluated, with the final composite consisting of intrauterine death, small for gestational age, large for gestational age, and admission to a neonatal intensive care unit (NICU). Our work has identified the components of maternal, fetal, and neonatal composite outcomes required for the assessment of diet and lifestyle interventions in pregnancy by IPD meta-analysis. © 2015 Royal College of Obstetricians and Gynaecologists.

[Two observations of evisceration after caesarean section performed according the so-called Stark procedure].

PubMed

Fournié, A; Madzou, S; Sentilhes, L; Descamps, P

2008-12-01

Two cases of evisceration after caesarean sections performed according the Misgav Ladach General Hospital procedure (Stark's procedure) are reported. In these cases, omentum was sutured between the edges of fascia recti, creating a weakness of the abdominal sheath. These cases claim about a strict procedure for fascia suture. Also, these cases question about the parietal peritoneal closure and the drawing of rectus muscles, which are vertical breaks; so, these sutures close transversal incision of the abdominal wall with cross sutures, which are very secure.

Anaesthesia for caesarean section in a patient with acute generalised pustular psoriasis.

PubMed

Samieh-Tucker, A; Rupasinghe, M

2007-10-01

We describe a 30-year-old parturient with acute generalised pustular psoriasis who presented for urgent caesarean section. A multidisciplinary team was involved and general anaesthesia was used successfully. Management of this condition is discussed and the literature reviewed. While generalised pustular psoriasis or impetigo herpetiformis is well recognised in pregnancy, it has not hitherto been reported in obstetric anaesthesia literature. The purpose of this article is to delineate the clinical picture of this disease, its treatment, and the effect on the mother and the fetus.

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study

PubMed Central

Razum, Oliver; Reiss, Katharina; Breckenkamp, Jürgen; Kaufner, Lutz; Brenne, Silke; Bozorgmehr, Kayvan; Borde, Theda; David, Matthias

2017-01-01

Objective Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). Design Cross-sectional study. Setting Three obstetric hospitals in Berlin, Germany. Methods Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. Results The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). Conclusions We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery). PMID:28827247

Cost-effectiveness of breech version by acupuncture-type interventions on BL 67, including moxibustion, for women with a breech foetus at 33 weeks gestation: a modelling approach.

PubMed

van den Berg, Ineke; Kaandorp, Guido C; Bosch, Johanna L; Duvekot, Johannes J; Arends, Lidia R; Hunink, M G Myriam

2010-04-01

To assess, using a modelling approach, the effectiveness and costs of breech version with acupuncture-type interventions on BL67 (BVA-T), including moxibustion, compared to expectant management for women with a foetal breech presentation at 33 weeks gestation. A decision tree was developed to predict the number of caesarean sections prevented by BVA-T compared to expectant management to rectify breech presentation. The model accounted for external cephalic versions (ECV), treatment compliance, and costs for 10,000 simulated breech presentations at 33 weeks gestational age. Event rates were taken from Dutch population data and the international literature, and the relative effectiveness of BVA-T was based on a specific meta-analysis. Sensitivity analyses were conducted to evaluate the robustness of the results. We calculated percentages of breech presentations at term, caesarean sections, and costs from the third-party payer perspective. Odds ratios (OR) and cost differences of BVA-T versus expectant management were calculated. (Probabilistic) sensitivity analysis and expected value of perfect information analysis were performed. The simulated outcomes demonstrated 32% breech presentations after BVA-T versus 53% with expectant management (OR 0.61, 95% CI 0.43, 0.83). The percentage caesarean section was 37% after BVA-T versus 50% with expectant management (OR 0.73, 95% CI 0.59, 0.88). The mean cost-savings per woman was euro 451 (95% CI euro 109, euro 775; p=0.005) using moxibustion. Sensitivity analysis showed that if 16% or more of women offered moxibustion complied, it was more effective and less costly than expectant management. To prevent one caesarean section, 7 women had to use BVA-T. The expected value of perfect information from further research was euro0.32 per woman. The results suggest that offering BVA-T to women with a breech foetus at 33 weeks gestation reduces the number of breech presentations at term, thus reducing the number of caesarean sections, and is cost-effective compared to expectant management, including external cephalic version. Copyright (c) 2010 Elsevier Ltd. All rights reserved.

How does delivery method influence factors that contribute to women's childbirth experiences?

PubMed

Carquillat, Pierre; Boulvain, Michel; Guittier, Marie-Julia

2016-12-01

whether delivery method influences factors contributing to women's childbirth experience remains debated. we compared subjective childbirth experience according to different delivery methods. this study used a cross-sectional design. the setting comprised two university hospitals: one in Geneva, Switzerland and one in Clermont-Ferrand, France. a total of 291 primiparous women were recruited from July 2014 to January 2015 during their stay in the maternity wards. The mean age of the participants was 30.8 (SD=4.7) years, and most were Swiss or European (86%). the 'Questionnaire for Assessing Childbirth Experience' was sent between four and six weeks after delivery. Clinimetric and psychometric approaches were used to assess childbirth experience according to delivery method. the mean scores of the four questionnaire dimensions varied significantly by delivery method. 'First moments with the newborn' was more negatively experienced by women from the caesarean section group compared to those who delivered vaginally (p<0.001). Similar results regarding the dimension of 'emotional status' were also observed, as women who delivered by caesarean section felt more worried, less secure, and less confident (p=0.001). 'Relationship with staff' significantly differed between groups (p=0.047) as more negative results were shown in the 'unexpected medical intervention groups' (i.e. emergency caesarean section and instrumental delivered vaginally). Women's 'feelings at one-month post partum' in the emergency caesarean section group were less satisfactory than the other groups. Delivery method and other obstetric variables explained only a low proportion of the total variance in the global scores (R 2 adjusted=0.18), which emphasized the importance of subjective factors in women's childbirth experience. a comparison of best expected positive responses to each item (clinimetric approach) showed useful results for clinicians. This research indicated that delivery method influenced key factors (psychometric approach) of the childbirth experience. delivery method should not be considered alone and health professionals should focus on what is important for women to foster a more positive experience. In addition, women who have had an emergency caesarean section require special attention during post partum. Copyright © 2016 Elsevier Ltd. All rights reserved.

An evaluation of prostaglandin E2 vaginal gel use in practice.

PubMed

Taylor, S J; Peat, J K; Armour, C L

1999-08-01

The purpose of this study was to investigate the effectiveness of prostaglandin E2 vaginal gel as used in practice, rather than its efficacy as assessed in randomised, controlled, clinical trials. This product is used to ripen the cervix prior to induction of labour, sometimes making unnecessary the use of the standard treatment for induction, artificial rupture of the membranes (ARM) plus oxytocin. In this study, effectiveness of the gel was assessed in terms of changes in mode of delivery, and in particular the risk of Caesarean section. An historical control was used and the risk of Caesarean section for women induced in the 1990/91 (before the introduction of the gel) was compared with that for women induced in 1992/93 (after the introduction of the gel). Maternal characteristics which may have been different in the two groups and factors which might influence the risk of Caesarean section were controlled for statistically using logistic regression, thus reducing any bias towards one group. After adjusting for the factors which had a significant effect on the process of labour from induction to birth, it was found that the risk of Caesarean section was not significantly lower in the 1992/93-time period, when the gel was in regular use, from that in the 2 years prior to its introduction (Odds ratio 1.09, CI95% 0.88, 1.36). Following the introduction of PGE2 gel, no difference in effectiveness, as measured in terms of mode of delivery, was detected in this study of practice, which included patients with more complex obstetric problems.

Indications of caesarean section in overweight and obese versus normal-weight pregnant women: a retrospective cohort study.

PubMed

Fernández Alba, Juan Jesús; Paublete Herrera, Carmen; Vilar Sanchez, Angel; Gonzalez-Macias, Carmen; Castillo Lara, Maria; Torrejón, Rafael; Moreno Corral, Luis Javier

2018-02-01

The aim of this study was to test the hypothesis that indications of c-section in overweight or obese pregnant women are different from those with normal-weight. Retrospective cohort study at University Hospital of Puerto Real (Cádiz-Spain). We compared frequency distribution of c-section indications in overweight and obese versus normal-weight. The risk of c-section by different indications was calculated as relative risk. A total of 4685 births were included in the study. There are significant differences in the frequency distribution of caesarean indications among normal weight and overweight or obese women. In overweight, we found an increased risk of c-section due to previous c-section (RR: 1.73; confidence interval [CI] 95% 1.24-2.42), obstructed/non-progressive labour (RR: 1.34; CI 95% 1.03-1.75), failed induction of labour (RR: 2.38; CI 95% 1.30-4.34) and foetal distress (RR: 1.73; CI 95% 1.21-2.49). This risk was even higher in obese women: previous c-section (RR: 3.25; CI 95% 2.24-4.71), obstructed/non-progressive labour (RR: 2; CI 95% 1.45-2.77), failed induction (RR: 2.52; CI 95% 1.15-5.51) and foetal distress (RR: 2.35; CI 95% 1.51-3.65). The risk of caesarean section due to previous caesarean section, obstructed/non-progressive labour, failed induction of labour or foetal distress is greater in overweight and obese than in normal-weight. This increase in risk also increases progressively as maternal BMI increases.

Obstetric outcomes of pre-induction of labor with a 200 μg misoprostol vaginal insert.

PubMed

Jagielska, Iwona; Kazdepka-Ziemińska, Anita; Tyloch, Małgorzata; Sopońska-Brzoszczyk, Paulina; Nowak, Karina; Dziedzic, Dawid; Dzikowska, Ewa; Grabiec, Marek

2017-01-01

Labor induction is indicated in 20% to 40% of pregnancies. Over half of pregnancies qualified for the induction of labor require stimulation of the cervix to ripen. The drug used increasingly more often in pre-induction is the PGE-1 pros-taglandin analog - misoprostol 200 μg. The study includes a total of 100 patients qualified for labor pre-induction with Misodel® (miso-prostol 200 μg vaginal insert). The study group comprises two subgroups: primigravidas and multiparas. Assessments included: indications for labor pre-induction, time from Misodel application to delivery, caesarean section rate and indica-tions, duration of first and second stage of labor, rate of vaginal deliveries, need for oxytocin or fenoterol administration side effects and newborn condition. The most common indication for labor induction was gestational diabetes and pregnancy past term. The average time to vaginal delivery was 14 h 45 min, time to the onset of active phase of labor - 11 h 45 min, time to membranes' rupture - 15 h, time to vaginal delivery - 14 h 18 min. The times of multiparas were significantly shorter. The rate of vaginal deliveries within 12 hours amounted to 42.42%, while within 24 hours it reached 83.33%. The overall caesarean section rate was 33%. The most common indication for caesarean section was the risk of intrauterine hypoxia. Tachysystole and hyperstimulation was observed in 4% of cases, while abnormalities in the cardiotocographic tracing in 43%. Misodel is an effective method for labor pre-induction, without affecting the caesarean section rate and has no adverse effect on the newborn condition.

Effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia

PubMed Central

Wang, Changsheng; Liu, Shijiang; Han, Chuanbao; Yu, Min; Hu, Youli; Liu, Cunming

2017-01-01

Objective To investigate the neonatal effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia. Methods Forty parturients with a single newborn who were scheduled for caesarean section were enrolled. Patients received 0.5 µg/kg dexmedetomidine 10 min after epidural anaesthesia, followed by 0.5 µg/kg/h until abdominal closure (Dex group) or infusion of normal saline (NS group). Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were monitored before infusion (T0), 10 min after infusion (T1), at delivery (T2), and at the end of the operation (T3). Umbilical vein and artery blood was collected. Apgar scores were evaluated at 1 and 5 min after delivery. Results SBP, DBP, and HR in the Dex group were decreased at T3 compared with T0 (116 ± 10.4 vs 111 ± 9.2 mmHg, 74 ± 6.7 vs 66 ± 7.9 mmHg, 91 ± 12.1 vs 71 ± 8.4 beats/min, respectively, P < 0.05). HR was lower at T1, T2, and T3 in the Dex group compared with the NS group (P < 0.05). There were no significant differences in blood gases and Apgar scores between the groups (P > 0.05). Conclusion Dexmedetomidine during caesarean section under epidural anaesthesia is beneficial to parturients. The placental transfer rate is 0.68. PMID:28449631

Maternal and neonatal outcomes in women with colorectal endometriosis.

PubMed

Thomin, A; Belghiti, J; David, C; Marty, O; Bornes, M; Ballester, M; Roman, H; Daraï, E

2018-05-01

To evaluate delivery and neonatal outcomes in women with resected or in situ bowel endometriosis. Retrospective cohort study. France. Analysis of 72 pregnancies from 67 women followed for colorectal endometriosis from 2001 to 2014 in six centres including two university expert centres for endometriosis. Univariate analysis of maternal and neonatal outcomes. Routes for delivery and rate of complications. The colorectal surgery group comprised 41 women and the in situ colorectal group, 26 women. Overall, half of the women underwent caesarean section. A high incidence of postoperative complications (39%) was observed after caesarean section with no difference between the groups. Surgical difficulties at newborn extraction (22%) and postoperative complications (39%) occurred more often in women with anterior deep infiltrating endometriosis (respectively 63 versus 11%, P = 0.007 and 67% versus 26%, P = 0.046) independently of prior surgery for endometriosis. In the remaining half, vaginal delivery required an operative procedure in 28% of the women with a significant increase in postpartum complications compared with those who did not require a procedure (P = 0.001). Overall, the incidence of postpartum complications was lower after vaginal delivery (14%) than after caesarean section (39%) (P = 0.03). Pregnant women with colorectal endometriosis, irrespective of prior surgery, should be informed of the high risk of delivery by caesarean section. Vaginal delivery is preferrable in this setting because of the lower incidence of postpartum complications. Due to the incidence of postpartum complications whatever the route of delivery, women should receive level III maternal care. © 2016 Royal College of Obstetricians and Gynaecologists.

[Hospital infection in the maternity department. 3 years of surveillance in 9,204 deliveries of which 1,333 were cesarean sections].

PubMed

Tissot-Guerraz, F; Moussy, L; Agniel, F; André, A; Reverdy, M E; Miellet, C C; Audra, P; Putet, G; Sepetjan, M; Dargent, D

1990-01-01

Hospital or nosocomial infection, or infection acquired in hospitals, is a health problem in all hospital departments and particularly in the maternity department. We report on a prospective survey of surveillance of hospital-acquired infections both from the mother and the baby's point of view after delivery vaginally or with caesarean carried out at the obstetrical clinic of the Edouard Herriot Hospital in Lyon (France) over three successive years with a series of 9,204 deliveries. The incidence of infection in women who were delivered without caesarean section was 1.37% when urinary tract infections had been excluded but 13% in women who had caesarean sections. Endometritis, skin infections and urinary tract infections were the leading causes. As far as the newborn were concerned, hospital infection ran at about 2.60% and this in the main was due to staphylococcal pustules in the skin. These figures are still too high and prevention should be based on more information given and more care taken by the whole staff of such a hospital.

Use of Electrocautery for Coagulation and Wound Complications in Caesarean Sections

PubMed Central

Moreira, Cristiane M.; Amaral, Eliana

2014-01-01

Objective. To evaluate the safety of electrocautery for coagulation during Caesarean sections. Study Design. A randomized, controlled, clinical pilot study was performed at a university maternity hospital. After admission for delivery and decision to perform a C-section, volunteers were randomized to either the intervention group (use of electrocautery for coagulation) or nonintervention group. The women were examined at the time of postpartum discharge (day 3), at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were calculated. Results. No significant differences were found between the two groups. Only 2.8% of patients in the intervention group developed surgical wound complications during hospitalization. However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84–2.60). Conclusion. Further studies should confirm whether the use of electrocautery for coagulation does not increase the risk of surgical wound complications in patients undergoing Caesarean sections. PMID:25143985

Use of electrocautery for coagulation and wound complications in Caesarean sections.

PubMed

Moreira, Cristiane M; Amaral, Eliana

2014-01-01

To evaluate the safety of electrocautery for coagulation during Caesarean sections. A randomized, controlled, clinical pilot study was performed at a university maternity hospital. After admission for delivery and decision to perform a C-section, volunteers were randomized to either the intervention group (use of electrocautery for coagulation) or nonintervention group. The women were examined at the time of postpartum discharge (day 3), at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were calculated. No significant differences were found between the two groups. Only 2.8% of patients in the intervention group developed surgical wound complications during hospitalization. However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84-2.60). Further studies should confirm whether the use of electrocautery for coagulation does not increase the risk of surgical wound complications in patients undergoing Caesarean sections.

Caesarean in mare by Marcenac incision under local anaesthesia.

PubMed

Ninu, A R; Saxena, A C; Sivanarayanan, T B; Remya, V; Binsila, B K; Maiti, S K; Zama, M M S

2015-01-01

A nulliparous non-descript mare was presented with a complaint of dystocia. The mare was recumbent and physical examination revealed that the animal was in shock. There was no straining and foetal forelimbs were visible outside the vulva. The foetus was dead as there was no pedal reflex. Vaginal examination revealed anterior presentation with dorso-sacral position and rigid lateral head deviation. Pre-operatively, the mare was given 5 ml Tetanus toxoid and 3 g Ceftriaxone as intramuscular injection, and 5 ml Dexamethasone in 15 L of 5% Dextrose Normal Saline (DNS) as intravenous (i/v) infusion. As pelvic space was inadequate and the mal posture was not correctable, manual correction or foetotomy could not be attempted and therefore caesarean section was planned. Condition of the animal warranted the use of local anaesthetic infiltration instead of general anesthesia. Post-operative care included intravenous fluids, anti-inflammatory/analgesics and daily antiseptic dressing. The owner reported uneventful recovery. The authors would like to conclude the case as a rare emergency caesarean in equine where the surgery was done with animal in lateral recumbency employing a Marcenac incision under local anaesthesia.

Role of fine needle aspiration cytology and cell block in diagnosis of scar endometriosis: A case report

PubMed Central

Dash, Sashibhusan; Panda, Sasmita; Rout, Niranjan; Samantaray, Sagarika

2015-01-01

Presence of endometrial glands and stroma in places other than the uterus is called endometriosis. It can be pelvic or extra-pelvic. Abdominal scar endometriosis is an extra-pelvic endometriosis that can occur after surgery involving the uterus. Post-caesarean section, scar endometriosis is a rare event. The diagnosis is frequently made only after excision of disease tissue. We present a case of post-caesarean section abdominal scar endometriosis presenting as a tumor on the abdominal wall, which was diagnosed by fine needle aspiration cytology and confirmed by cell block preparation. PMID:25948955

Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis

PubMed Central

2013-01-01

Background Caesarean delivery has increased worldwide, however, the effects on fertility are largely unknown. This systematic review aims to compare subsequent sub-fertility (time to next pregnancy or birth) among women with a Caesarean delivery to women with a vaginal delivery. Methods Systematic review of the literature including seven databases: CINAHL; the Cochrane Library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge (1945 - October 2012), using detailed search-strategies and reference list cross-checking. Cohort, case–control and cross-sectional studies were included. Two assessors reviewed titles, abstracts, and full articles using standardised data abstraction forms and assessed study quality. Results 11 articles were eligible for inclusion in the systematic review, of these five articles which adjusted for confounders were combined in a meta-analysis, totalling 750,407 women using fixed-effect models. Previous Caesarean delivery was associated with an increased risk of sub-fertility [pooled odds ratio (OR) 0.90; 95% CI 0.86, 0.93]. Subgroup analyses by parity [primiparous women: OR 0.91; 95% CI 0.87, 0.96; not limited to primiparous women: OR 0.81; 95% CI 0.73, 0.90]; by publication date (pre-2000: OR 0.80, 95% CI 0.68, 0.94; post-2000: OR 0.90, 95% CI 0.86, 0.94); by length of follow-up (<10 years: OR 0.81, 95% CI 0.73, 0.90; >10 years: OR 0.91, 95% CI 0.87, 0.96); by indication for mode of delivery (specified: 0.92, 95% CI 0.88, 0.97; not specified: OR 0.81, 95% CI 0.73, 0.90); by cohort size (<35,000: OR 0.79, 95% CI 0.67, 0.92; >35,000: OR 0.90, 95% CI 0.87, 0.95), by definition of sub-fertility used divided into (birth interval [BI]: OR 0.89, 95% CI 0.84, 0.94; inter-pregnancy interval [IPI]: OR 0.91, 95% CI 0.85, 0.97; and categorical measures: OR 0.81, 95% CI 0.73, 0.90); continuous measures: OR 0.91, 95% CI 0.87, 0.96) were performed. Results of the six studies not included in the meta-analysis (which did not adjust for confounders) are presented individually. Conclusions The meta-analysis shows an increased waiting time to next pregnancy and risk of sub-fertility among women with a previous Caesarean delivery. However, included studies are limited by poor epidemiological methods such as variations in the definition of time to next pregnancy, lack of confounding adjustment, or details of the indication for Caesarean delivery. Further research of a more robust methodological quality to better explore any underlying causes of sub-fertility and maternal intent to delay childbearing is warranted. PMID:23981569

Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a qualitative study from countries with high VBAC rates.

PubMed

Lundgren, Ingela; van Limbeek, Evelien; Vehvilainen-Julkunen, Katri; Nilsson, Christina

2015-08-28

The most common reason for caesarean section (CS) is repeat CS following previous CS. Vaginal birth after caesarean section (VBAC) rates vary widely in different healthcare settings and countries. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Interview studies with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of 'OptiBIRTH', an ongoing research project. The study reported here is based on interviews in high VBAC countries. The aim of the study was to investigate the views of clinicians working in countries with high VBAC rates on factors of importance for improving VBAC rates. Individual (face-to-face or telephone) interviews and focus group interviews with clinicians (in different maternity care settings) in three countries with high VBAC rates were conducted during 2012-2013. In total, 44 clinicians participated: 26 midwives and 18 obstetricians. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country. The findings are presented in four main categories with subcategories. First, a common approach is needed, including: feeling confident with VBAC, considering VBAC as the first alternative, communicating well, working in a team, working in accordance with a model and making agreements with the woman. Second, obstetricians need to make the final decision on the mode of delivery while involving women in counselling towards VBAC. Third, a woman who has a previous CS has a similar need for support as other labouring women, but with some extra precautions and additional recommendations for her care. Finally, clinicians should help strengthen women's trust in VBAC, including building their trust in giving birth vaginally, recognising that giving birth naturally is an empowering experience for women, alleviating fear and offering extra visits to discuss the previous CS, and joining with the woman in a dialogue while leaving the decision about the mode of birth open. This study shows that, according to midwives and obstetricians from countries with high VBAC rates, the important factors for improving the VBAC rate are related to the structure of the maternity care system in the country, to the cooperation between midwives and obstetricians, and to the care offered during pregnancy and birth. More research on clinicians' perspectives is needed from countries with low, as well as high, VBAC rates.

[Lower Uterine Segment Trial: A pragmatic open multicenter randomized trial].

PubMed

Rozenberg, P; Deruelle, P; Sénat, M-V; Desbrière, R; Winer, N; Simon, E; Ville, Y; Kayem, G; Boutron, I

2018-04-01

The data from literature show that trial of labor and elective repeat cesarean delivery after a prior cesarean delivery both present significant risks and benefits, and these risks and benefits differ for the woman and her fetus. The benefits to the woman can be at the expense of her fetus and vice-versa. This uncertainty is compounded by the scarcity of high-level evidence that preclude accurate quantification of the risks and benefits that could help provide a fair counseling about a trial of labor and elective repeat cesarean delivery. An interesting way of research is to evaluate the potential benefits of a decision rule associated to the ultrasound measurement of the lower uterine segment (LUS). Indeed, ultrasonography may be helpful in determining a specific risk for a given patient by measuring the thickness of the LUS, i,e, the thickness of the cesarean delivery scar area. Although only small and often methodologically biased data have been published, they look promising as their results are concordant: ultrasonographic measurements of the LUS thickness is highly correlated with the intraoperative findings at cesarean delivery. Furthermore, the thinner the LUS becomes on ultrasound, the higher the likelihood of a defect in the LUS. Finally, ultrasound assessment of LUS has an excellent negative predictive value for the risk of uterine defect. Therefore, this exam associated with a rule of decision could help to reduce the rate of elective repeat cesarean delivery and especially to reduce the fetal and maternal mortality and morbidity related to trial of labor after a prior cesarean delivery. This is a pragmatic open multicenter randomized trial with two parallel arms. Randomization will be centralized and computerized. Since blindness is impossible, an adjudication committee will evaluate the components of the primary composite outcome in order to avoid evaluation bias. An interim analysis will be planned mid-strength of the trial. Ultrasound will be performed by expert sonographers after certification by the main investigator. Women aged 18 years or older are eligible for this trial if they have a singleton pregnancy in cephalic presentation at a gestational age from 36 to 38 weeks, a previous low transverse cesarean delivery and sign the informed consent sheet. Women will be asked to participate in this study when they reach a term of 36 to 38 weeks of gestation. After agreement, women will be randomized into two groups: in the study group, they will have the LUS measured by ultrasound and the patient will be informed that, based on a threshold value of 3.5mm for the ultrasound measurement of the LUS thickness, the patient with a higher measurement will be considered at low risk and will be encouraged to choose a trial of labor whereas the patient with a measurement is equal to or less than this threshold will be considered at risk and encouraged to choose an elective repeat cesarean; in the control group, ultrasound LUS measurement will not be performed. The mode of delivery will be decided according to standard practice at the center. The primary composite outcome will include: uterine rupture, uterine dehiscence, hysterectomy, thromboembolic complications, transfusion, endometritis, maternal mortality, fetal prenatal and intrapartum mortality, hypoxic-ischemic encephalopathy and neonatal mortality. This trial assesses the efficacy of ultrasound measurement of the lower uterine segment in women with a prior cesarean delivery in reducing fetal and maternal morbidity and mortality and it will provide evidence in order to establish clinical recommendations. ClinicalTrials.gov identifier: NCT01916044 (date of registration: 5 August 2013). Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for squamous cell carcinoma of the thoracic esophagus.

PubMed

Onozawa, Masakatsu; Nihei, Keiji; Ishikura, Satoshi; Minashi, Keiko; Yano, Tomonori; Muto, Manabu; Ohtsu, Atsushi; Ogino, Takashi

2009-08-01

There are some reports indicating that prophylactic three-field lymph node dissection for esophageal cancer can lead to improved survival. But the benefit of ENI in CRT for thoracic esophageal cancer remains controversial. The purpose of the present study is to retrospectively evaluate the efficacy of elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for thoracic esophageal cancer. Patients with squamous cell carcinoma (SCC) of the thoracic esophagus newly diagnosed between February 1999 and April 2001 in our institution was recruited from our database. Definitive chemoradiotherapy consisted of two cycles of cisplatin/5FU repeated every 5 weeks, with concurrent radiation therapy of 60 Gy in 30 fractions. Up to 40 Gy radiation therapy was delivered to the cervical, periesophageal, mediastinal and perigastric lymph nodes as ENI. One hundred two patients were included in this analysis, and their characteristics were as follows: median age, 65 years; male/female, 85/17; T1/T2/T3/T4, 16/11/61/14; N0/N1, 48/54; M0/M1, 84/18. The median follow-up period for the surviving patients was 41 months. Sixty patients achieved complete response (CR). After achieving CR, only one (1.0%; 95% CI, 0-5.3%) patient experienced elective nodal failure without any other site of recurrence. In CRT for esophageal SCC, ENI is effective for preventing regional nodal failure. Further evaluation of whether ENI leads to an improved overall survival is needed.

Intrapartum intervention rates and perinatal outcomes following induction of labour compared to expectant management at term from an Australian perinatal centre.

PubMed

Zhao, Yi; Flatley, Christopher; Kumar, Sailesh

2017-02-01

Induction of labor (IOL) is a common obstetric intervention, yet its impact on intervention rates and perinatal outcomes is conflicting. To evaluate the impact of IOL on intrapartum intervention rates and perinatal outcomes in women with singleton pregnancies at term. This was a retrospective, cross-sectional study of term singleton deliveries at the Mater Mother's Hospital in Brisbane, Australia in 2007-2013. The IOL cohort was compared to an expectantly managed group. Of the final cohort (44 698 women), 64.4% had expectant management and 35.6% had IOL. Multivariate analyses showed that IOL was associated with lower odds of spontaneous vaginal delivery from ≥37 weeks gestation. The risk of emergency caesarean for non-reassuring fetal status was also higher in the IOL cohort at 40 and 41 weeks gestation. For women who were managed expectantly, the highest rate of spontaneous vaginal delivery and the lowest rate of emergency caesareans occurred at 39 weeks gestation. For women who underwent IOL, the nadir emergency caesarean rate and the highest spontaneous vaginal delivery rate was also at 39 weeks. Rates of neonatal intensive car unit admission were higher in the IOL group at 37 weeks (adjusted odds ratio (aOR) 3.11, 95% CI: 2.62-3.68) and 38 weeks (aOR 1.78, 95% CI: 1.55-2.04) and lower at >42 weeks (OR 0.35, 95% CI: 0.14-0.81) respectively. IOL compared to expectant management is associated with lower spontaneous vaginal delivery rates and increased risk of emergency caesarean for intrapartum fetal compromise with broadly comparable perinatal outcomes. © 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Maternal Prepregnancy Body Mass Index and Gestational Weight Gain on Pregnancy Outcomes

PubMed Central

Li, Nan; Liu, Enqing; Guo, Jia; Pan, Lei; Li, Baojuan; Wang, Ping; Liu, Jin; Wang, Yue; Liu, Gongshu; Baccarelli, Andrea A.; Hou, Lifang; Hu, Gang

2013-01-01

Objective The aim of the present study was to evaluate the single and joint associations of maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG) with pregnancy outcomes in Tianjin, China. Methods Between June 2009 and May 2011, health care records of 33,973 pregnant women were collected and their children were measured for birth weight and birth length. The independent and joint associations of prepregnancy BMI and GWG based on the Institute of Medicine (IOM) guidelines with the risks of pregnancy and neonatal outcomes were examined by using Logistic Regression. Results After adjustment for all confounding factors, maternal prepregnancy BMI was positively associated with risks of gestational diabetes mellitus (GDM), pregnancy-induced hypertension, caesarean delivery, preterm delivery, large-for-gestational age infant (LGA), and macrosomia, and inversely associated with risks of small-for-gestational age infant (SGA) and low birth weight. Maternal excessive GWG was associated with increased risks of pregnancy-induced hypertension, caesarean delivery, LGA, and macrosomia, and decreased risks of preterm delivery, SGA, and low birth weight. Maternal inadequate GWG was associated with increased risks of preterm delivery and SGA, and decreased risks of LGA and macrosomia, compared with maternal adequate GWG. Women with both prepregnancy obesity and excessive GWG had 2.2–5.9 folds higher risks of GDM, pregnancy-induced hypertension, caesarean delivery, LGA, and macrosomia compared with women with normal prepregnancy BMI and adequate GWG. Conclusions Maternal prepregnancy obesity and excessive GWG were associated with greater risks of pregnancy-induced hypertension, caesarean delivery, and greater infant size at birth. Health care providers should inform women to start the pregnancy with a BMI in the normal weight category and limit their GWG to the range specified for their prepregnancy BMI. PMID:24376527

Labour dystocia--risk of recurrence and instrumental delivery in following labour--a population-based cohort study.

PubMed

Sandström, A; Cnattingius, S; Wikström, A K; Stephansson, O

2012-12-01

To investigate risk of recurrence of labour dystocia and mode of delivery in second labour after taking first labour and fetal and maternal characteristics into account. A population-based cohort study. The Swedish Medical Birth Register from 1992 to 2006. A total of 239 953 women who gave birth to their first and second singleton infants in cephalic presentation at ≥ 37 weeks of gestation with spontaneous onset of labour. We used logistic regression analysis to estimate crude and adjusted odds ratios. Labour dystocia and mode of delivery in second labour. Overall labour dystocia affected only 12% of women with previous dystocia. Regardless of mode of first delivery, rates of dystocia in the second labour were higher in women with than without previous dystocia, but were more pronounced in women with previous caesarean section (34%). Analyses with risk score groups for dystocia (risk factors were long interpregnancy interval, maternal age ≥ 35 years, obesity, short maternal stature, not cohabiting and post-term pregnancy) showed that risk of instrumental delivery in second labour increased with previous dystocia and increasing risk score. Among women with trial of labour after caesarean section with previous dystocia and a risk score of 3 or more, 66% had a vaginal instrumental or caesarean delivery (17 and 49%, respectively). In women with trial of labour after caesarean section without previous dystocia and a risk score of 0, corresponding risk was 32% (14 and 18%, respectively). Previous labour dystocia increases the risk of dystocia in subsequent delivery. Taking first labour and fetal and maternal characteristics into account is important in the risk assessments for dystocia and instrumental delivery in second labour. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

[Fewer caesarean sections for breech presentation following external cephalic version according to a protocol in a special office visit].

PubMed

Kuppens, S M I; Hasaart, T H M; van der Donk, M W P; Huibers, M; Franssen, M J; de Becker, B M J; Wijnen, H A A; Pop, V J M

2008-06-07

Identification of determinants affecting the outcome of external cephalic version (ECV) in breech presentation, and investigation of the impact of ECV--performed according to a standardized protocol in an outpatient clinic--on the mode of delivery. Retrospective analysis. In 2003 a standardized protocol of ECV was developed in the outpatient clinic for obstetrics of the Catharina Hospital in Eindhoven, the Netherlands; it was tested in 'version office visits'. Obstetric characteristics of all pregnant women who underwent attempts of ECV in the clinic from January 2004 until June 2006 during these sessions, and the subsequent births, were analysed. 85% of all ECVs were performed by the same hospital midwife and gynaecologist, in accordance with the protocol. ECV was successful in 96 of 209 pregnant women (46%). In 1 pregnant woman an emergency caesarean section was performed after ECV because of partial abruptio placentae. Nulliparity, incomplete breech presentation and low birth weight of the baby were associated with a lower success rate of ECV in this study. In the group with a successful ECV the percentage of caesarean deliveries was substantially lower (9 versus 83%; odds ratio: 0.21; 95% CI: 0.09-0.51). A regular team consisting of a hospital midwife and a gynaecologist working according to a standardized protocol for ECV in a case of breech presentation proved successful: the number of term breech presentations substantially diminished and therefore the percentage of caesarean sections was lower in the group in which ECV had been successful. This could have considerable impact on health care in the Netherlands in terms of reduced maternal morbidity and cost savings.

Maternal and fetal effect of misgav ladach cesarean section in nigerian women: a randomized control study.

PubMed

Ezechi, Oc; Ezeobi, Pm; Gab-Okafor, Cv; Edet, A; Nwokoro, Ca; Akinlade, A

2013-10-01

The poor utilisation of the Misgav-Ladach (ML) caesarean section method in our environment despite its proven advantage has been attributed to several factors including its non-evaluation. A well designed and conducted trial is needed to provide evidence to convince clinician of its advantage over Pfannenstiel based methods. To evaluate the outcome of ML based caesarean section among Nigerian women. Randomised controlled open label study of 323 women undergoing primary caesarean section in Lagos Nigeria. The women were randomised to either ML method or Pfannenstiel based (PB) caesarean section technique using computer generated random numbers. The mean duration of surgery (P < 0.001), time to first bowel motion (P = 0.01) and ambulation (P < 0.001) were significantly shorter in the ML group compared to PB group. Postoperative anaemia (P < 0.01), analgesic needs (P = 0.02), extra suture use, estimated blood loss (P < 0.01) and post-operative complications (P = 0.001) were significantly lower in the ML group compared to PB group. Though the mean hospital stay was shorter (5.8 days) in the ML group as against 6.0 days, the difference was not significant statistically (P = 0.17). Of the fetal outcome measures compared, it was only in the fetal extraction time that there was significant difference between the two groups (P = 0.001). The mean fetal extraction time was 162 sec in ML group compared to 273 sec in the PB group. This study confirmed the already established benefit of ML techniques in Nigerian women, as it relates to the postoperative outcomes, duration of surgery, and fetal extraction time. The technique is recommended to clinicians as its superior maternal and fetal outcome and cost saving advantage makes it appropriate for use in poor resource setting.

Incidence and Risk Factors for Placenta Accreta/Increta/Percreta in the UK: A National Case-Control Study

PubMed Central

Fitzpatrick, Kathryn E.; Sellers, Susan; Spark, Patsy; Kurinczuk, Jennifer J.; Brocklehurst, Peter; Knight, Marian

2012-01-01

Background Placenta accreta/increta/percreta is associated with major pregnancy complications and is thought to be becoming more common. The aims of this study were to estimate the incidence of placenta accreta/increta/percreta in the UK and to investigate and quantify the associated risk factors. Methods A national case-control study using the UK Obstetric Surveillance System was undertaken, including 134 women diagnosed with placenta accreta/increta/percreta between May 2010 and April 2011 and 256 control women. Results The estimated incidence of placenta accreta/increta/percreta was 1.7 per 10,000 maternities overall; 577 per 10,000 in women with both a previous caesarean delivery and placenta praevia. Women who had a previous caesarean delivery (adjusted odds ratio (aOR) 14.41, 95%CI 5.63–36.85), other previous uterine surgery (aOR 3.40, 95%CI 1.30–8.91), an IVF pregnancy (aOR 32.13, 95%CI 2.03–509.23) and placenta praevia diagnosed antepartum (aOR 65.02, 95%CI 16.58–254.96) had raised odds of having placenta accreta/increta/percreta. There was also a raised odds of placenta accreta/increta/percreta associated with older maternal age in women without a previous caesarean delivery (aOR 1.30, 95%CI 1.13–1.50 for every one year increase in age). Conclusions Women with both a prior caesarean delivery and placenta praevia have a high incidence of placenta accreta/increta/percreta. There is a need to maintain a high index of suspicion of abnormal placental invasion in such women and preparations for delivery should be made accordingly. PMID:23300807

The effects of labor and delivery on maternal and neonatal outcomes in term twins: a retrospective cohort study.

PubMed

Wenckus, D J; Gao, W; Kominiarek, M A; Wilkins, I

2014-08-01

To compare maternal and neonatal outcomes in twins undergoing a trial of labor versus pre-labor caesarean. Retrospective cohort study. 19 US hospitals from the Consortium on Safe Labor. Of 2225 twin sets ≥36 weeks' gestation. Maternal (abruption, estimated blood loss, postpartum haemorrhage, transfusion, chorioamnionitis, hysterectomy, ICU admission, death) and neonatal outcomes (birth injury, 5-minute Apgar <7, NICU admission, RDS, TTN, sepsis, asphyxia, NICU length of stay, death) were compared between the trial of labour and pre-labour caesarean groups with univariate and multivariate logistic and linear regression analyses. Similar analyses were performed for actual delivery modes. Maternal and neonatal outcomes. Among the 2225 twin sets, 1078 had a trial of labour, and 65.9% of those delivered vaginally. There was an increased risk for postpartum haemorrhage [OR 2.5, 95% confidence interval (CI) 1.4-4.5] and blood transfusion (OR 1.9, 95%CI 1.2-3.2) for the trial of labour compared with pre-labour caesarean groups. Birth injury only occurred in the trial of labour group, 1% Twin A, 0.4% Twin B. Both twins had a higher risk of 5-minute Apgar <7 with trial of labour compared to pre-labour caesarean (A: OR 3.9, 95%CI 1.05-14.5; B: OR 3.9, 95%CI 1.3-12.3). Term twins undergoing a trial of labour have increased maternal haemorrhage and transfusions along with neonatal birth trauma and lower Apgar scores, but these absolute neonatal occurrences were rare. Trial of labour in twins remains a safe and reasonable option in appropriately selected cases. © 2014 Royal College of Obstetricians and Gynaecologists.

Increasing the availability and quality of caesarean section in Tanzania.

PubMed

Nyamtema, A; Mwakatundu, N; Dominico, S; Mohamed, H; Shayo, A; Rumanyika, R; Kairuki, C; Nzabuhakwa, C; Issa, O; Lyimo, C; Kasiga, I; van Roosmalen, J

2016-09-01

To describe the results of increasing availability and quality of caesarean deliveries and anaesthesia in rural Tanzania. Before-after intervention study design. Rural Tanzania. Ten health centres located in rural areas were upgraded to provide comprehensive emergency obstetric care (CEmOC) and the four related district hospitals were supported. Upgrading entailed constructing and equipping maternity blocks, operation rooms and laboratories; installing solar systems, backup generators and water supply systems. Associate clinicians were trained in anaesthesia and in CEmOC. Mentoring and audit of reasons for caesarean section (CS) and maternal deaths were carried out. Measures of interest were compared using analysis of variance (ANOVA) statistical tests. Trends in CS rates, proportion of unjustified CS, use of spinal anaesthesia, and the risk of death from complications related to CS and anaesthesia. During the audit period (2012-2014), 5868 of 58 751 deliveries were by CS (10%). The proportion of CS considered to be unjustified decreased from 30 to 17% in health centres (P = 0.02) and from 37 to 20% in hospitals (P < 0.001). Practice of spinal anaesthesia for CS increased from 10% to 64% in hospitals (P < 0.001). Of 110 maternal deaths, 18 (16.4%) were associated with complications of CS, giving a risk of 3.1 per 1000 CS; three (2.7%) were judged to be anaesthetic-associated deaths with a risk of 0.5 per 1000 caesarean deliveries. Increasing availability and quality of CS by improving infrastructure, training and audit of reasons for CS is feasible, acceptable and required in low resource settings. Increasing availability and quality of CS in rural Africa is feasible. © 2016 Royal College of Obstetricians and Gynaecologists.

Assessing the height of block for caesarean section over the past three decades: trends from the literature.

PubMed

Hoyle, J; Yentis, S M

2015-04-01

There are multiple methods of assessing the height of block before caesarean section under regional anaesthesia, and surveys of practice suggest considerable variation in practice. So far, little emphasis has been placed on the guidance to be gained from published research literature or textbooks. We therefore set out to investigate the methods of block assessment documented in published articles and textbooks over the past 30 years. We performed two searches of PubMed for randomised clinical trials with caesarean section and either spinal anaesthesia or epidural anaesthesia as major Medical Subject Headings. A total of 284 papers, from 1984 to 2013, were analysed for methods of assessment of sensory and motor block, and the height of block deemed adequate for surgery. We also examined 45 editions of seven anaesthetic textbooks spanning 1950-2014 for recommended methods of assessment and height of block required for caesarean section. Analysis of published papers demonstrated a wide variation in techniques, though there has been a trend towards the increased use of touch, and an increased use of a block height of T5 over the study period. Only 115/284 (40.5%) papers described the method of assessing motor block, with most of those that did (102/115; 88.7%) describing it as the 'Bromage scale', although only five of these (4.9%) matched the original description by Bromage. The required height of block recommended by textbooks has risen over the last 30 years to T4, although only four textbooks made any recommendation about the preferred sensory modality. The variation in methods suggested by surveys of practice is reflected in variation in published trials, and there is little consensus or guidance in anaesthetic textbooks. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Effects of early augmentation of labour with amniotomy and oxytocin in nulliparous women: a meta-analysis.

PubMed

Fraser, W; Vendittelli, F; Krauss, I; Bréart, G

1998-02-01

To estimate the effects among nulliparae of early augmentation with amniotomy and oxytocin on caesarean delivery, and on other indicators of maternal and neonatal morbidity including transfusion. Apgar score < 7 at 5 minutes, and admission to the special care nursery. Meta-analysis. Published studies were identified through manual and computerised searches. Two unpublished studies were identified through direct communication with the investigators. Twelve trials were identified which compared a policy of early labour augmentation including amniotomy followed by oxytocin with a less active form of management. Two methodologically unacceptable studies were excluded. Studies were grouped according to whether they admitted only women with abnormal progress (therapy trials: n = 3) or accepted women with normal labour (prevention trials: n = 7). Unstratified analysis did not provide support for the hypothesis that early augmentation reduces the risk of caesarean section (typical odds ratio [OR] 0.9; 95% CI 0.7-1.1). The typical odds ratio for prevention trials was similar to that obtained in the unstratified analysis (typical OR 0.9, 95% CI 0.7-1.2). Although only a small number of women have been randomised in therapy trials, a trend toward a reduction in the rate of caesarean section with early intervention was seen in this group (typical OR 0.6, 95% CI 0.2-1.4). Early augmentation does not appear to provide benefit over a more conservative form of management in the context of care of nulliparous women with mild delays in the progress of labour. In the context of established delay in labour, an active policy of augmentation may reduce the risk of caesarean section. However, only three small trials have been performed in this context, and they do not have adequate power to allow firm conclusions to be drawn.

[The Application of Internal Iliac Artery Balloon Occlusion in Pernicious Placenta Previa].

PubMed

Qi, Xiao-Rong; Liu, Xing-Hui; You, Yong; Wang, Xiao-Dong; Zhou, Rong; Xing, Ai-Yun; Zhang, Li; Ning, Gang; Zhao, Fu-Min; Li, Kai-Ming

2016-07-01

To evaluate the clinical application value of internal iliac artery balloon occlusion in pernicious placenta previa. We retrospectively reviewed the medical records of the patients of pernicious placenta previa in a single center from Jan, 2010 to Jan, 2015. The patients were divided into two groups, internal iliac artery balloon occlusion group and the control group without endovascular intervention. Blood loss in operation, volume of transfused blood products, caesarean hysterectomy, operating time, hospital days after operation and postoperative morbidity were compared between the two groups. The balloon occlusion group had significantly less blood loss, the volume of transfused blood products, caesarean hysterectomy, hospital day after operation than the control group had. There was no statistical difference in operating time, intensive care units (ICU), hypotension, infection, hypoxemia, bladder injury, bowel obstruction, neonatal asphyxia between the two groups. The balloon occlusion group had significantly higher rate in coagulopathy, hypoalbuminemia, electrolyte imbalance. Among the patients whose uterus were preserved, the blood loss was not significantly difference between the two groups. Among the patients with the complication of placenta accreta, caesarean hysterectomy was less in balloon group, and blood loss between the two groups was not significantly different. Among the patients without placenta accrete, the blood loss was less in balloon group, and caesarean hysterectomy between the two groups was not significantly different. The risk of hysterectomy in balloon group was related to placenta accreta, uterine arteries engorgement, placental invasive serosa, taking placenta by hand, placental invasive bladder, barrel-shaped thickening of lower uterine segment, unable to remove placenta. Internal iliac artery balloon occlusion is an effective treatment for pernicious placenta previa.

Local anaesthetic wound infiltration used for caesarean section pain relief: a meta-analysis.

PubMed

Li, Xiangnan; Zhou, Miao; Shi, Xuan; Yang, Haiqin; Li, Yonghua; Li, Jian; Yang, Mei; Yuan, Hongbin

2015-01-01

Local anaesthetic wound infiltration techniques were reported to reduce opiate requirements and pain scores in women undergoing caesarean section (CS). However, the results were conflicting. The primary aim of this meta-analysis was to assess whether local analgesia could reduce pain intensity when injected via wound catheters. A search of randomized clinical trials (RCTs) evaluating local analgesia in caesarean surgery in PubMed, EMBASE and the Cochrane database was performed. Cumulative morphine consumption and pain scores at rest at different time point after surgery were extracted and synthesized using random or fixed model for meta-analysis. Subgroup analysis was performed according to incision type and administration regimen. Nine RCTs with a total of 512 patients were included. Cumulative morphine consumption was lower in LA group compared with placebo group in the first 12 h (SMD = -0.736, 95% CI (-1.105, -0.368)), 24 h (SMD = -0.378, 95% CI (-0.624, -0.132)) and 48 h after surgery (SMD = -0.913, 95% CI (-1.683 to -0.143)). Lower morphine consumption was observed in the first 6 h after surgery but the reduction failed to meet the common level of significance. Pain scores was significantly reducedat 12 h but not 6 h after surgery in the LA group compared with placebo group. At 24 h and 48 h after surgery, the pain sore was lower but the difference did not meet the common level of significance. Lower rate of post-operative nausea was observed in the LA group. Local anaesthetic wound infiltration can reduce morphine requirements and the rate of patients suffer nausea but not pain scores after caesarean section. Further procedure-specific RCTs were encouraged to confirm the efficacy of local anaesthetic wound infiltration techniques.

Developing a set of consensus indicators to support maternity service quality improvement: using Core Outcome Set methodology including a Delphi process.

PubMed

Bunch, K J; Allin, B; Jolly, M; Hardie, T; Knight, M

2018-05-16

To develop a core metric set to monitor the quality of maternity care. Delphi process followed by a face-to-face consensus meeting. English maternity units. Three representative expert panels: service designers, providers and users. Maternity care metrics judged important by participants. Participants were asked to complete a two-phase Delphi process, scoring metrics from existing local maternity dashboards. A consensus meeting discussed the results and re-scored the metrics. In all, 125 distinct metrics across six domains were identified from existing dashboards. Following the consensus meeting, 14 metrics met the inclusion criteria for the final core set: smoking rate at booking; rate of birth without intervention; caesarean section delivery rate in Robson group 1 women; caesarean section delivery rate in Robson group 2 women; caesarean section delivery rate in Robson group 5 women; third- and fourth-degree tear rate among women delivering vaginally; rate of postpartum haemorrhage of ≥1500 ml; rate of successful vaginal birth after a single previous caesarean section; smoking rate at delivery; proportion of babies born at term with an Apgar score <7 at 5 minutes; proportion of babies born at term admitted to the neonatal intensive care unit; proportion of babies readmitted to hospital at <30 days of age; breastfeeding initiation rate; and breastfeeding rate at 6-8 weeks. Core outcome set methodology can be used to incorporate the views of key stakeholders in developing a core metric set to monitor the quality of care in maternity units, thus enabling improvement. Achieving consensus on core metrics for monitoring the quality of maternity care. © 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.

The start of life: a history of obstetrics.

PubMed

Drife, J

2002-05-01

Obstetric intervention originally consisted of extraction of the baby, usually by the breech, to save the mother's life in obstructed labour. Forceps, introduced in the 17th century, were later refined by men-midwives like William Smellie. In Victorian times, Simpson championed chloroform anaesthesia, Lister pioneered antisepsis, and caesarean section was introduced. In 1935, however, Britain's maternal mortality rate was still around 400/100,000. It fell dramatically after antibiotics appeared and is now 11.4. In the 1960s ultrasound and electronic fetal monitoring became widely used. In 2000 the British caesarean section rate reached 20%. Worldwide, childbirth still causes 600,000 maternal deaths a year.

Morbidity and chronic pain following different techniques of caesarean section: A comparative study.

PubMed

Belci, D; Di Renzo, G C; Stark, M; Đurić, J; Zoričić, D; Belci, M; Peteh, L L

2015-01-01

Research examining long-term outcomes after childbirth performed with different techniques of caesarean section have been limited and do not provide information on morbidity and neuropathic pain. The study compares two groups of patients submitted to the 'Traditional' method using Pfannenstiel incision and patients submitted to the 'Misgav Ladach' method ≥ 5 years after the operation. We find better long-term postoperative results in the patients that were treated with the Misgav Ladach method compared with the Traditional method. The results were statistically better regarding the intensity of pain, presence of neuropathic and chronic pain and the level of satisfaction about cosmetic appearance of the scar.

The missing foley catheter: an unusual finding in vesicouterine fistula

PubMed Central

Shephard, Steven N.; Lengmang, Sunday J.

2013-01-01

A 28-year-old G1P1 presented complaining of urine leakage per vaginum following caesarean delivery, accompanied by amenorrhoea, cyclic haematuria and cyclic pelvic pain. Examination findings were suggestive of vesicouterine fistula and the patient was taken for exploratory laparotomy, during which the foley catheter could not be identified within the bladder. During separation of the bladder from the uterus, the catheter was found to be traversing the fistulous tract into the uterine cavity. Vesicouterine fistula is a fairly uncommon type of urogenital fistula that is frequently associated with caesarean section. Surgical treatment remains the mainstay and successfully cured this patient. PMID:24968444

Red, orange and green Caesarean sections: a new communication tool for on-call obstetricians.

PubMed

Dupuis, Olivier; Sayegh, Isabelle; Decullier, Evelyne; Dupont, Corinne; Clément, Henri-Jacques; Berland, Michel; Rudigoz, René-Charles

2008-10-01

To evaluate the effect of a novel communication tool, related to the degree of urgency for Caesarean sections (CSs), on the decision-to-delivery interval for emergency CS. Red CS are very urgent cases corresponding to life-threatening maternal or foetal situations, orange CS are urgent cases and green CS are non-urgent intrapartum CS. We carried out this cohort study in a French maternity hospital. The study included all emergency Caesarean sections during two 6-month periods, before and after introduction of the code. We compared the decision-to-delivery interval of the two study periods. Our study included 174 emergency CS. The mean decision-to-delivery interval after introduction of the code was 31.7 min, significantly shorter (p=0.02) than the 39.6 min interval before introduction of the colour code. Except for the preparation time, each time interval decreased. This included transporting the patient into the operating theatre, and the incision-to-delivery time interval. This study suggests that the use of the three-colour code could significantly shorten the decision-to-delivery interval in emergency CS. Further prospective studies are needed to confirm this result.

Gingival enlargement in a pregnant woman with acute monocytic leukaemia: a case report.

PubMed

Fu, Y-W; Xu, H-Z

2017-09-01

The objective of the present study was to report the case of a pregnant woman with severe gingival enlargement for 3 months with undiagnosed acute leukaemia. The pregnant woman presented with anaemia and generalized gingival enlargement. A provisional diagnosis of gingival enlargement in pregnancy was made. Twelve days after the initial treatment, the patient was referred and admitted to the haematology department of a local hospital with clinical signs of anaemia and thrombocytopenia. Blood count showed a white blood cell count of 9.68 × 10 9 /L, with a haemoglobin count of 64.0 g/L and a platelet count of 17 × 10 9 /L. Bone marrow aspiration showed 94.5% monoblasts, and the morphological diagnosis was acute monocytic leukaemia. One day after admission, the patient delivered a male infant by Caesarean section. Ten days after the Caesarean section, the patient was started on a course of chemotherapy. Pulmonary infection, hypokalaemia, and respiratory failure developed, and the patient died 23 days after the Caesarean section. The present case shows the importance of awareness of severe gingival enlargement as an initial oral sign of acute leukaemia. © 2017 Australian Dental Association.

[Psychoprophylaxis and the rate of cesarean section].

PubMed

Oyuela-García, Juana; Hernández-Herrera, Ricardo Jorge

2010-01-01

The psychoprophylactic programs (PPP) have been widely used in women to face the fear-tension-pain cycle, reducing anxiety and pain during labour. The aim was to demonstrate if a PPP reduces the caesarean rate. 300 low risk pregnant women were included; 100 in the PPP group and 200 in the control group. The PPP participants attended theory and practical sessions; they visited labor, delivery, recovery and hospitalization areas. Chi-square, Student's t test and odds ratio were applied. Pregnancy ended by caesarean section in 35/100 of PPP group and in 99/200 (49.5%) in control group (p < 0.02, OR = 1.8, IC = 1.1-2.9). Maternal complications occurred in 13/100 in the PPP group, and 42/200 (21%) in control group (p = 0.09, RM = 0.56). The newborn (NB) complications were observed in 9/100 in PPP and 46/200 (23%) in control group (p < 0.02, OR = 0.33). In the PPP group, 70% assisted to three or more sessions. Hospital stance in control group, accumulated 17 days more in mothers and 171 days more in NB than in the PPP group. In PPP group observed a caesarean rate reduction with fewer maternal and perinatal complications.

Service quality of delivered care from the perception of women with caesarean section and normal delivery.

PubMed

Tabrizi, Jafar S; Askari, Samira; Fardiazar, Zahra; Koshavar, Hossein; Gholipour, Kamal

2014-01-01

Our aim was to determine the service quality of delivered care for people with Caesarean Section and Normal Delivery. A cross-sectional study was conducted among 200 people who had caesarean section and normal delivery in Al-Zahra Teaching Hospital in Tabriz, north western Iran. Service quality was calculated using: Service Quality = 10 - (Importance × Performance) based on importance and performance of service quality aspects from the postpartum women's perspective.A hierarchical regression analysis was applied in two steps using the enter method to examine the associations between demographics and SQ scores. Data were analysed using the SPSS-17 software. "Confidentiality", "autonomy", "choice of care provider" and "communication" achieved scores at the highest level of quality; and "support group", "prompt attention", "prevention and early detection", "continuity of care", "dignity", "safety", "accessibility and "basic amenities" got service quality score less than eight. Statistically significant relationship was found between service quality score and continuity of care (P=0.008). A notable gap between the participants‟ expectations and what they have actually received in most aspects of provided care. So, there is an opportunityto improve the quality of delivered care.

Comparison of the treatment effects of methoxamine and combining methoxamine with atropine infusion to maintain blood pressure during spinal anesthesia for cesarean delivery: a double blind randomized trial.

PubMed

Luo, X-J; Zheng, M; Tian, G; Zhong, H-Y; Zou, X-J; Jian, D-L

2016-01-01

Hypotension is a common complication of spinal anesthesia for cesarean delivery. Atropine is a vagus nerve blocker that can antagonize vagus excitation to mitigate the reflex bradycardia. We aimed to assess the effect of methoxamine-atropine therapy in treating spinal anesthesia hypotension for cesarean section. This is a double-blind randomized controlled study. Women under spinal anesthesia for elective caesarean delivery received boluses of methoxamine 2 mg alone (Group M, n = 40), or with addition of atropine 0.1 mg (Group MA1, n = 40), atropine 0.2 mg (Group MA2, n = 40) or atropine 0.3 mg (Group MA3, n = 40) upon a maternal systolic pressure ≤ 80% of baseline. The primary endpoint was systolic blood pressure and the secondary endpoints were maternal heart rates, instant neonatal heart rates, umbilical artery pH and umbilical artery base excess. Changes in systolic blood pressure were similar among the four groups. The incidences of bradycardia in groups M and MA1 were significantly higher than those in group MA2 and MA3. The fetal heart rates after delivery in groups MA2 and MA3 were higher than those in group M and MA1 but within the normal range. The acid-base status had no difference in the four groups. Methoxamine-atropine combination has a similar efficacy to methoxamine alone but has an increased hemodynamic stability and a less adverse effect occurrence.

Signs of fetal brain sparing are not related to umbilical cord blood gases at birth.

PubMed

Cheema, Riffat; Dubiel, Mariusz; Gudmundsson, Saemundur

2009-07-01

Fetal chronic hypoxia leads to centralization of circulation in order to spare the vital organs brain, adrenals and the heart. This can be documented by Doppler ultrasound. Increased blood velocity in the fetal middle cerebral artery (MCA) is an acknowledged sign of centralization of circulation in chronic hypoxia, and is called brain sparing. Our aim was to assess the relationship between signs of brain sparing in the MCA and umbilical cord blood gases at birth. A prospective study. Singleton 57 high-risk pregnancies (outcome was compared with 21 normal pregnancies). MCA Doppler was performed within 24 h of elective caesarean section in high-risk pregnancies. Umbilical cord blood gases were analysed at birth. Cord blood gases were related to signs of centralization of fetal circulation in the MCA. No correlation between signs of brain sparing in the MCA and cord blood gases. Apgar score at 5'<7 was seen in three newborns, but only one of these had antenatal signs of brain sparing. Newborns with antenatal brain sparing were admitted more often (p<0.04) and had a longer duration of stay in NICU (p<0.03) compared to newborns without brain sparing. Decreased pulsatility index in MCA is an acknowledged sign of fetal centralization of circulation during chronic hypoxia. However, signs of brain sparing are not related to cord blood gases at birth, which might suggest that redistribution of fetal circulation can maintain normal blood gases for a long time during chronic hypoxia.

Introducing a teaching module to impart communication skills in the learning anaesthesiologists

PubMed Central

Gadre, Vaijayanti Nitin; Kelkar, Kalpana V; Kelkar, Vidya S; Jamkar, Maya A

2015-01-01

Background and Aims: Pre-operative negative valence communications adversely affect intra and post-operative pain experience. This study was conducted to evaluate the teaching of communication skills by teachers in anaesthesia department and whether the post-operative pain is effectively modified due to the skill of communication acquired by students. Methods: All students and teachers in the department participated in the study. Patients with uncomplicated pregnancy posted for elective lower segment caesarean section were involved. Students were taught to explain the anaesthesia plan pre-operatively to the patients in a positive manner. They were taught the practice of giving positive suggestions before any potentially painful stimulus. Pre-operatively all students informed the patients about the conduct of spinal anaesthesia. The teachers evaluated the students performing spinal block. The performance was rated for procedural and interpersonal skills (direct observation of procedural skills [DOPS] and Smith and Kendall Behavioural scale [SKBS] respectively). The extent of cooperation and the ease with which spinal block could be administered correctly by the student was judged by the teacher. Post-operatively students were randomly provided questionnaires to elicit answers from patients. Results: P value DOPS and SKBS (0.567, 0.867) show no significant statistical variation. P > 0.05 = not significant, indicates no significant variation in procedural and behavioural skills of students in two groups. Conclusion: Teaching of communication skills to students showed a demonstrable effect on their pre-operative dialogue with patients. Pain mechanism was effectively modulated by improving patients’ psychology to undergo anaesthesia. PMID:26195834

Maternal height and length of gestation: does this impact on preterm labour in Asian women?

PubMed

Chan, Ben Chong-Pun; Lao, Terence Tzu-Hsi

2009-08-01

Both maternal height and ethnicity may influence the gestation length, but their independent effect is unclear. This study was performed to examine the relationship between maternal height and gestational length in women with singleton pregnancies in a Chinese and southeast Asian population. A retrospective cohort study was performed on women carrying singleton pregnancies with spontaneous labour in a 48-month period managed under our department to determine the relationship between maternal height, expressed in quartiles, with the mean gestational age and incidence of preterm labour. Of the 16 384 women who delivered within this period, the 25th, 50th and 75th percentile values of maternal height were 153 cm, 156 cm and 160 cm respectively. Excluded from analysis were 6597 women because of multifetal pregnancy, teenage pregnancy (maternal age < or = 19 years old), induction of labour or elective caesarean section, or incomplete data due to no antenatal booking in our hospital. Significant differences were found in the maternal weight and body mass index, incidences of multiparity and smokers, gestational age and birthweight among the four quartiles. There was significantly increased incidence of preterm birth between 32 and 37 weeks gestation in women with shorter stature. In our population, maternal height has an influence on gestational length, and the lower three quartiles was associated with increased odds of labour at > 32 to < 37 weeks. This effect should be taken into consideration in the adoption of international recommendations in obstetric management and intervention.

Chronic levothyroxine and acute T3 treatments enhance the amplitude and time course of uterine contractions in human.

PubMed

Corriveau, Stéphanie; Pasquier, Jean-Charles; Blouin, Simon; Bellabarba, Diego; Rousseau, Éric

2013-03-01

This study compares the functional consequences of levothyroxine (T4) treatment during pregnancy as well as the acute affects of triiodothyronine (T3) on spontaneous uterine contractile activities observed in vitro. Uterine biopsies were obtained from consenting women undergoing elective caesarean at term (n = 28). Spontaneous contractile activities from T4-treated pregnant women (n = 8) were compared with control patients (n = 20) by isometric tension measurements. Effects of acute T3 and T4 on control tissues were also monitored. Area under the curve, amplitude, time to peak, duration, and frequency were quantified. In uterine strips from women treated for hypothyroidism, phasic uterine contractions of larger amplitude (+77%) were observed, with a prolonged duration at 90% relaxation (+138%) and reduced frequency (-55%) compared with values of the control group. The addition of exogenous T3 in vitro on control strips induced a significant increase in the duration of the contractions and a significant decrease in frequency (P < 0.05), which partially mimics the results obtained in strips from T4-treated women. Significant modifications of contractile properties were observed in strips from pregnant women treated with levothyroxine, consistent with those observed with the addition of exogenous T3. Clinical practices of modern obstetrics should take into account the effect of thyroid hormones on uterine contractions' time course to ensure a tighter followup at the end of pregnancy to achieve safer delivery.

Geographical, Ethnic and Socio-Economic Differences in Utilization of Obstetric Care in the Netherlands.

PubMed

Posthumus, Anke G; Borsboom, Gerard J; Poeran, Jashvant; Steegers, Eric A P; Bonsel, Gouke J

2016-01-01

All women in the Netherlands should have equal access to obstetric care. However, utilization of care is shaped by demand and supply factors. Demand is increased in high risk groups (non-Western women, low socio-economic status (SES)), and supply is influenced by availability of hospital facilities (hospital density). To explore the dynamics of obstetric care utilization we investigated the joint association of hospital density and individual characteristics with prototype obstetric interventions. A logistic multi-level model was fitted on retrospective data from the Netherlands Perinatal Registry (years 2000-2008, 1.532.441 singleton pregnancies). In this analysis, the first level comprised individual maternal characteristics, the second of neighbourhood SES and hospital density. The four outcome variables were: referral during pregnancy, elective caesarean section (term and post-term breech pregnancies), induction of labour (term and post-term pregnancies), and birth setting in assumed low-risk pregnancies. Higher hospital density is not associated with more obstetric interventions. Adjusted for maternal characteristics and hospital density, living in low SES neighbourhoods, and non-Western ethnicity were generally associated with a lower probability of interventions. For example, non-Western women had considerably lower odds for induction of labour in all geographical areas, with strongest effects in the more rural areas (non-Western women: OR 0.78, 95% CI 0.77-0.80, p<0.001). Our results suggest inequalities in obstetric care utilization in the Netherlands, and more specifically a relative underservice to the deprived, independent of level of supply.

Developing competency in post-graduate students of anaesthesiology for taking informed consent for elective caesarean section.

PubMed

Mehta, Kamla Harshad; Shah, Vandana Saurin; Patel, Kirti Dhirajlal

2017-02-01

Post-graduate medical students (residents) generally lack effective communication skills required to obtain informed consent. The aim of this study was to assess role play and group discussion as teaching/learning tools for improving residents' knowledge on informed consent and competency in communicating while taking informed consent. This prospective, observational study was conducted on 30 anaesthesia residents. They were first observed while obtaining informed consent and their basic knowledge regarding communication skills was checked with a pre-test questionnaire. Then, lecture and group discussion were carried out to increase the knowledge base, and their knowledge gain was checked by the same questionnaire as a post-test. Communication skills were demonstrated by role play and residents were assessed by direct unobtrusive observation using a checklist. Feedback regarding effectiveness of programme was taken from students. Statistical analyses were done using Microsoft Office Excel and SPSS software. Percentage gain was 122.37% for knowledge domain. For communication skills, mean ± standard deviation for checklist was 8.93 ± 1.43 before role play and it improved to 17.96 ± 1.29 after role play. Regarding effectiveness of role play as a teaching/learning tool, 76.66% of residents said they strongly agreed and 23.33% of residents said they agreed. Likert scale for evaluation of programme was graded 4 or 5 by all residents. The knowledge and communication skills required for obtaining informed consent was improved significantly after role playing.

Guidelines for the management of vasa previa.

PubMed

Gagnon, Robert

2009-08-01

To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa. Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality. Published literature on randomized trials, prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery; studies comparing outcomes when vasa previa is diagnosed antenatally vs. intrapartum) and key words (e.g., vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and from national and international medical specialty societies. The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care. The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa. The Society of Obstetricians and Gynaecologists of Canada. A comparison of women who were diagnosed antenatally and those who were not shows respective neonatal survival rates of 97% and 44%, and neonatal blood transfusion rates of 3.4% and 58.5%, respectively. Vasa previa can be diagnosed antenatally, using combined abdominal and transvaginal ultrasound and colour flow mapping; however, many cases are not diagnosed, and not making such a diagnosis is still acceptable. Even under the best circumstances the false positive rate is extremely low. (II-2). 1. If the placenta is found to be low lying at the routine second trimester ultrasound examination, further evaluation for placental cord insertion should be performed. (II-2B) 2. Transvaginal ultrasound may be considered for all women at high risk for vasa previa, including those with low or velamentous insertion of the cord, bilobate or succenturiate placenta, or for those having vaginal bleeding, in order to evaluate the internal cervical os. (II-2B) 3. If vasa previa is suspected, transvaginal ultrasound colour Doppler may be used to facilitate the diagnosis. Even with the use of transvaginal ultrasound colour Doppler, vasa previa may be missed. (II-2B) 4. When vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour. (II-1A) 5. In cases of vasa previa, premature delivery is most likely; therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks to promote fetal lung maturation and to hospitalization at about 30 to 32 weeks. (II-2B) 6. In a woman with an antenatal diagnosis of vasa previa, when there has been bleeding or premature rupture of membranes, the woman should be offered delivery in a birthing unit with continuous electronic fetal heart rate monitoring and, if time permits, a rapid biochemical test for fetal hemoglobin, to be done as soon as possible; if any of the above tests are abnormal, an urgent Caesarean section should be performed. (III-B) 7. Women admitted with diagnosed vasa previa should ideally be transferred for delivery in a tertiary facility where a pediatrician and blood for neonatal transfusion are immediately available in case aggressive resuscitation of the neonate is necessary. (II-3B) 8. Women admitted to a tertiary care unit with a diagnosis of vasa previa should have this diagnosis clearly identified on the chart, and all health care providers should be made aware of the potential need for immediate delivery by Caesarean section if vaginal bleeding occurs. (III-B).

Different classes of antibiotics given to women routinely for preventing infection at caesarean section.

PubMed

Gyte, Gillian M I; Dou, Lixia; Vazquez, Juan C

2014-11-17

Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. It is important to identify the most effective class of antibiotics to use and those with the least adverse effects. To determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and reference lists of retrieved papers. We included randomised controlled trials comparing different classes of prophylactic antibiotics given to women undergoing caesarean section. We excluded trials that compared drugs with placebo or drugs within a specific class; these are assessed in other Cochrane reviews. Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We included 35 studies of which 31 provided data on 7697 women. For the main comparison between cephalosporins versus penicillins, there were 30 studies of which 27 provided data on 7299 women. There was a lack of good quality data and important outcomes often included only small numbers of women.For the comparison of a single cephalosporin versus a single penicillin (Comparison 1 subgroup 1), we found no significant difference between these classes of antibiotics for our chosen most important seven outcomes namely: maternal sepsis - there were no women with sepsis in the two studies involving 346 women; maternal endometritis (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.81 to 1.52, nine studies, 3130 women, random effects, moderate quality of the evidence); maternal wound infection (RR 0.83, 95% CI 0.38 to 1.81, nine studies, 1497 women, random effects, low quality of the evidence), maternal urinary tract infection (RR 1.48, 95% CI 0.89 to 2.48, seven studies, 1120 women, low quality of the evidence) and maternal composite adverse effects (RR 2.02, 95% CI 0.18 to 21.96, three studies, 1902 women, very low quality of the evidence). None of the included studies looked for infant sepsis nor infant oral thrush.This meant we could only conclude that the current evidence shows no overall difference between the different classes of antibiotics in terms of reducing maternal infections after caesarean sections. However, none of the studies reported on infections diagnosed after the initial postoperative hospital stay. We were unable to assess what impact, if any, the use of different classes of antibiotics might have on bacterial resistance. Based on the best currently available evidence, cephalosporins and penicillins have similar efficacy at caesarean section when considering immediate postoperative infections. We have no data for outcomes on the baby, nor on late infections (up to 30 days) in the mother. Clinicians need to consider bacterial resistance and women's individual circumstances.

Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care

PubMed Central

Wei, Shuqin; Wo, Bi Lan; Qi, Hui-Ping; Xu, Hairong; Luo, Zhong-Cheng; Roy, Chantal; Fraser, William D

2014-01-01

Background Caesarean section rates are over 20% in many developed countries. The main diagnosis contributing to the high rate in nulliparae is dystocia or prolonged labour. The present review assesses the effects of a policy of early amniotomy with early oxytocin administration for the prevention of, or the therapy for, delay in labour progress. Objectives To estimate the effects of early augmentation with amniotomy and oxytocin for prevention of, or therapy for, delay in labour progress on the caesarean birth rate and on indicators of maternal and neonatal morbidity. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (15 February 2012), MEDLINE (1966 to 15 February 2012), EMBASE (1980 to 15 February 2012), CINAHL (1982 to 15 February 2012), MIDIRS (1985 to February 2012) and contacted authors for data from unpublished trials. Selection criteria Randomized and quasi-randomized controlled trials that compared oxytocin and amniotomy with expectant management. Data collection and analysis Three review authors extracted data independently. We stratified the analyses into ’Prevention Trials’ and ’Therapy Trials’ according to the status of the woman at the time of randomization. Participants in the ’Prevention Trials’ were unselected women, without slow progress in labour, who were randomized to a policy of early augmentation or to routine care. In ’Treatment Trials’ women were eligible if they had an established delay in labour progress. Main results For this update, we have included a further two new clinical trials. This updated review includes 14 trials, randomizing a total of 8033 women. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of caesarean section; however, the confidence interval (CI) included the null effect (risk ratio (RR) 0.89; 95% CI 0.79 to 1.01; 14 trials; 8033 women). In prevention trials, early augmentation was associated with a modest reduction in the number of caesarean births (RR 0.87; 95% CI 0.77 to 0.99; 11 trials; 7753). A policy of early amniotomy and early oxytocin was associated with a shortened duration of labour (average mean difference (MD) −1.28 hours; 95% CI −1.97 to −0.59; eight trials; 4816 women). Sensitivity analyses excluding four trials with a full package of active management did not substantially affect the point estimate for risk of caesarean section (RR 0.87; 95% CI 0.73 to 1.05; 10 trials; 5165 women). We found no other significant effects for the other indicators of maternal or neonatal morbidity. Authors’ conclusions In prevention trials, early intervention with amniotomy and oxytocin appears to be associated with a modest reduction in the rate of caesarean section over standard care. PMID:22972098

[Idiopathic intracranial hypertension: a caesarean with epidural anaesthesia after bringing the cerebrospinal fluid pressure back to normal].

PubMed

Pérez Rodríguez, M; de Carlos Errea, J; Dorronsoro Auzmendi, M; Batllori Gastón, M

2013-12-01

Idiopathic intracranial hypertension is diagnosed by exclusion. Because of its uncertain physiopathology and infrequent occurrence, its anaesthetic management is not well defined. The patient in this case is a pregnant woman with this disease with no lumbar-peritoneal shunt who was referred for non-urgent caesarean section, consisting of CSF drainage and pressure normalisation before the administration of epidural anaesthesia. We believe this technique can de effective to achieve adequate blockage and increased patient comfort, as well as improving postoperative recovery. Copyright © 2012 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.