Matched cohort study of external cephalic version in women with previous cesarean delivery.

PubMed

Keepanasseril, Anish; Anand, Keerthana; Soundara Raghavan, Subrahmanian

2017-07-01

To evaluate the efficacy and safety of external cephalic version (ECV) among women with previous cesarean delivery. A retrospective study was conducted using data for women with previous cesarean delivery and breech presentation who underwent ECV at or after 36 weeks of pregnancy during 2011-2016. For every case, two multiparous women without previous cesarean delivery who underwent ECV and were matched for age and pregnancy duration were included. Characteristics and outcomes were compared between groups. ECV was successful for 32 (84.2%) of 38 women with previous cesarean delivery and 62 (81.6%) in the control group (P=0.728). Multivariate regression analysis confirmed that previous cesarean was not associated with ECV success (odds ratio 1.89, 95% confidence interval 0.19-18.47; P=0.244). Successful vaginal delivery after successful ECV was reported for 19 (59.4%) women in the previous cesarean delivery group and 52 (83.9%) in the control group (P<0.001). No ECV-associated complications occurred in women with previous cesarean delivery. To avoid a repeat cesarean delivery, ECV can be offered to women with breech presentation and previous cesarean delivery who are otherwise eligible for a trial of labor. © 2017 International Federation of Gynecology and Obstetrics.

Time trends in births and cesarean deliveries among women with disabilities.

PubMed

Horner-Johnson, Willi; Biel, Frances M; Darney, Blair G; Caughey, Aaron B

2017-07-01

Although it is likely that childbearing among women with disabilities is increasing, no empirical data have been published on changes over time in the numbers of women with disabilities giving birth. Further, while it is known that women with disabilities are at increased risk of cesarean delivery, temporal trends in cesarean deliveries among women with disabilities have not been examined. To assess time trends in births by any mode and in primary cesarean deliveries among women with physical, sensory, or intellectual/developmental disabilities. We conducted a retrospective cohort study using linked vital records and hospital discharge data from all deliveries in California, 2000-2010 (n = 4,605,061). We identified women with potential disabilities using ICD-9 codes. We used descriptive statistics and visualizations to examine time patterns. Logistic regression analyses assessed the association between disability and primary cesarean delivery, stratified by year. Among all women giving birth, the proportion with a disability increased from 0.27% in 2000 to 0.80% in 2010. Women with disabilities had significantly elevated odds of primary cesarean delivery in each year, but the magnitude of the odds ratio decreased over time from 2.60 (95% CI = 2.25 = 2.99) in 2000 to 1.66 (95% CI = 1.51-1.81) in 2010. Adequate clinician training is needed to address the perinatal care needs of the increasing numbers of women with disabilities giving birth. Continued efforts to understand cesarean delivery patterns and reasons for cesarean deliveries may help guide further reductions in proportions of cesarean deliveries among women with disabilities relative to women without disabilities. Copyright © 2017 Elsevier Inc. All rights reserved.

Obstetrician perceptions of the causes of high cesarean delivery rates in Turkey.

PubMed

Küçük, Mert

2017-07-01

To assess obstetricians' perceptions surrounding cesarean delivery rates in Turkey. The present cross-sectional descriptive study was performed between May 1 and June 30, 2016. Practicing obstetricians with contact details known by the researchers and those attending a conference in Turkey were asked to complete a self-administered questionnaire that collected demographic data and information on participants' opinions, beliefs, knowledge, attitudes, and practices related to cesarean delivery. There were 100 obstetricians who responded to the survey. Awareness of high cesarean delivery rates was reported by 96 (96%) participants and 95 (95%) respondents said they were supportive of efforts to reduce it. There were 60 (60%), 83 (83%), and 100 (100%) participants aware of associations between high cesarean delivery rates and increased maternal and infant mortality; increased risk of uterine rupture; and increased risk of placenta previa, placenta accreta, and emergency cesarean hysterectomy, respectively. The most commonly reported reason for high cesarean delivery rates was high compensation costs during medical litigation legal proceedings, reported by all 100 (100%) participants. Participants were generally aware of the risks associated with high cesarean delivery rates. The results suggest that the greatest concern among obstetricians who perform cesarean deliveries was malpractice litigation. © 2017 International Federation of Gynecology and Obstetrics.

Adhesion barriers at cesarean delivery: advertising compared with the evidence.

PubMed

Albright, Catherine M; Rouse, Dwight J

2011-07-01

Cesarean delivery, the most common surgery performed in the United States, is complicated by adhesion formation in 24-73% of cases. Because adhesions have potential sequelae, different synthetic adhesion barriers are currently heavily marketed as a means of reducing adhesion formation resultant from cesarean delivery. However, their use for this purpose has been studied in only two small, nonblinded and nonrandomized trials, both of which were underpowered and subject to bias. Neither demonstrated improvement in meaningful clinical outcomes. In the only cost-effectiveness analysis of adhesion barriers to date, the use of synthetic adhesion barriers was cost-effective only when the subsequent rate of small bowel obstruction was at least 2.4%, a rate far higher than that associated with cesarean delivery. In fact, intra-abdominal adhesions from prior cesarean delivery rarely cause maternal harm and have not been demonstrated to adversely affect perinatal outcome. Based on our review of the available literature, we think the use of adhesion barriers at the time of cesarean delivery would be ill-advised at the present time.

Hyperbaric versus plain bupivacaine for spinal anesthesia for cesarean delivery.

PubMed

Heng Sia, Alex Tiong; Tan, Kok Hian; Sng, Ban Leong; Lim, Yvonne; Chan, Edwin S Y; Siddiqui, Fahad Javaid

2015-01-01

Bupivacaine is an amide local anesthetic used in hyperbaric and plain forms administered as spinal anesthesia for cesarean delivery. In this systematic review, we summarized the effectiveness and safety of hyperbaric versus plain bupivacaine in providing anesthesia for cesarean delivery. We considered the adequacy of anesthesia for completion of cesarean delivery and the need for interventions to treat complications. We searched the CENTRAL, MEDLINE, and EMBASE databases. We imposed no language restriction. We included all randomized controlled trials involving patients undergoing spinal anesthesia for elective cesarean delivery that compared the use of hyperbaric bupivacaine with plain bupivacaine. We included 6 studies with a total of 394 patients in this review. These studies have small sample size, few observed events, differences in methodology, and insufficient information pertaining to assessment of risk of bias. This prevented us from calculating pooled estimates. Results show that there is no compelling evidence in favor of the use of intrathecal plain or hyperbaric bupivacaine for spinal anesthesia for cesarean delivery. There is a lack of clear evidence regarding the superiority of hyperbaric compared with plain bupivacaine for spinal anesthesia for cesarean delivery. The need for conversion to general anesthesia because of failed spinal anesthesia is an important clinical outcome, but current data are insufficient to compare spinal anesthesia induced with hyperbaric compared with plain bupivacaine for this outcome. Further research is required.

Effect of severity of illness on cesarean delivery rates in Washington State.

PubMed

Hitti, Jane; Walker, Suzan; Benedetti, Thomas J

2017-10-01

Hospitals and providers are increasingly held accountable for their cesarean delivery rates. In the perinatal quality improvement arena, there is vigorous debate about whether all hospitals can be held to the same benchmark for an acceptable cesarean rate regardless of patient acuity. However, the causes of variation in hospital cesarean delivery rates are not well understood. We sought to evaluate the association and temporal trends between severity of illness at admission and the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. We hypothesized that hospitals with higher patient acuity would have higher cesarean delivery rates and that this pattern would persist over time. In this cross-sectional analysis, we analyzed aggregate hospital-level data for all nonmilitary hospitals in Washington State with ≥100 deliveries/y during federal fiscal years 2010 through 2014 (287,031 deliveries). Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System, which includes inpatient demographic, diagnosis, procedure, and discharge information derived from hospital billing systems. Age, admission diagnoses and procedure codes were converted to patient-level admission severity-of-illness scores using the All Patient Refined Diagnosis Related Groups classification system. This system is widely used throughout the United States to adjust hospital data for severity of illness. Mean admission hospital-level severity-of-illness scores were calculated for each fiscal year among the term singleton vertex population with no history of cesarean delivery. We used linear regression to evaluate the association between hospital admission severity of illness and the primary term singleton vertex cesarean delivery rate, calculated Pearson correlation coefficients, and compared regression line slopes and 95% confidence intervals for each fiscal year. Hospitals were diverse with respect to delivery volume, level of care

Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital.

PubMed

Dessole, Salvatore; Cosmi, Erich; Balata, Antonio; Uras, Luisa; Caserta, Donatella; Capobianco, Giampiero; Ambrosini, Guido

2004-11-01

The purpose of this study was to investigate the incidence, type, location, and risk factors of accidental fetal lacerations during cesarean delivery. Total deliveries, cesarean deliveries, and neonatal records for documented accidental fetal lacerations were reviewed retrospectively in our level III university hospital. The gestational age, the presenting part of the fetus, the cesarean delivery indication, the type of incision, and the surgeon who performed the procedure were recorded. Cesarean deliveries were divided into scheduled, unscheduled, and emergency procedures. Fetal lacerations were divided into mild, moderate, and severe. Neonatal follow-up examinations regarding laceration sequelae were available for 6 months. Of 14926 deliveries, 3108 women were delivered by cesarean birth (20.82%). Neonatal records documented 97 accidental fetal lacerations. Of these accidental lacerations, 94 were mild; 2 were moderate, and 1 was severe. The overall rate of accidental fetal laceration per cesarean delivery was 3.12%; the accidental laceration rate in the cohort of fetuses was 2.46%. The crude odds ratios were 0.34 for scheduled procedures, 0.57 for unscheduled procedures, and 1.7 for emergency procedures. The risk for fetal accidental lacerations was higher in fetuses who underwent emergency cesarean birth and lower for unscheduled and scheduled cesarean births (P < .001). Fetal accidental laceration may occur during cesarean delivery; the incidence is significantly higher during emergency cesarean delivery compared with elective procedures. The patient should be counseled about the occurrence of fetal laceration during cesarean delivery to avoid litigation.

Maternal obesity and rate of cesarean delivery in Djibouti.

PubMed

Minsart, Anne-Frederique; N'guyen, Thai-Son; Dimtsu, Hirut; Ratsimanresy, Rachel; Dada, Fouad; Ali Hadji, Rachid

2014-11-01

To calculate the prevalence of maternal obesity and to determine the relation between obesity and cesarean delivery in an urban hospital in Djibouti. In an observational cohort study, all women who had a live birth or stillbirth between October 2012 and November 2013 were considered for inclusion. Body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was calculated throughout pregnancy, and women with a BMI of at least 30.0 were deemed to be obese. Multivariate logistic regression analyses were used to evaluate the relation between cesarean and obesity. Overall, 100 (24.8%) of 404 women were obese before 14 weeks of pregnancy, as were 112 (25.2%) of 445 before 22 weeks, and 200 (43.2%) of 463 at delivery. Obesity before 22 weeks was associated with a 127% excess risk of cesarean delivery (adjusted odds ratio 2.27; 95% CI 1.07-4.82; P=0.032). Similar trends were found when the analyses were limited to the subgroup of women without a previous cesarean delivery or primiparae. Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Hospital volume and cesarean delivery among low-risk women in a nationwide sample.

PubMed

Clapp, M A; James, K E; Melamed, A; Ecker, J L; Kaimal, A J

2018-02-01

We sought to determine if hospital delivery volume was associated with a patient's risk for cesarean delivery in low-risk women. This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal-Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient's odds for cesarean delivery. The range of cesarean delivery rates was 2.4-51.2% among low-risk patients, and the median was 16.5% (IQR 12.8-20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient's odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188). Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

An economic analysis of trial of labor after cesarean delivery.

PubMed

Friedman, Alexander M; Ananth, Cande V; Chen, Ling; D'Alton, Mary E; Wright, Jason D

2016-01-01

Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD). A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model. A total of 485,247 women were identified, including 365,596 (75.3%) cesarean deliveries without labor, 41,988 (8.6%) successful and 77,663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities. TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors.

Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate

PubMed Central

Vadnais, Mary A.; Hacker, Michele R.; Shah, Neel T.; Jordan, JoAnn; Modest, Anna M.; Siegel, Molly; Golen, Toni H.

2018-01-01

Background The nulliparous term singleton vertex (NTSV) cesarean delivery rate has been recognized as a meaningful benchmark. Variation in the NTSV cesarean delivery rate among hospitals and providers suggests many hospitals may be able to safely improve their rates. The NTSV cesarean delivery rate at the authors’ institution was higher than state and national averages. This study was conducted to determine the influence of a set of quality improvement interventions on the NTSV cesarean delivery rate. Methods From 2008 through 2015, at a single tertiary care academic medical center, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the NTSV cesarean delivery rate. Data on mode of delivery, maternal outcomes, and neonatal outcomes were collected from birth certificates and administrative claims data. The Cochran-Armitage test and linear regression were used to calculate the p-trend for categorical and continuous variables, respectively. Results More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed. Conclusion Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery. PMID:28334563

Clinical indications for cesarean delivery among women living with female genital mutilation.

PubMed

Rodriguez, Maria I; Say, Lale; Abdulcadir, Jasmine; Hindin, Michelle J

2017-10-01

To compare primary indications for cesarean delivery among patients with different female genital mutilation (FGM) status. The present secondary analysis included data from women who underwent trial of labor resulting in cesarean delivery at 28 obstetric centers in six African countries between November 1, 2001, and March 31, 2003. Associations between cesarean delivery indications and FGM status were assessed using descriptive statistics and multivariable multinomial logistic regression. Data from 1659 women (480 patients with no type of FGM and 1179 patients with FGM [any type]) were included; cesarean delivery indications were collapsed into five categories (fetal indications, maternal factors, stage 1 arrest, stage 2 arrest, and other). The incidence of a clear medical indication for cesarean delivery did not differ between the groups (P=0.320). Among patients without a clear indication for cesarean delivery, women with FGM were more likely to have undergone cesarean delivery for maternal factors (adjusted relative risk ratio [aRRR] 3.92, 95% confidence interval [CI] 1.3-11.71), stage 1 arrest (aRRR 7.74, 95% CI 1.33-45.07), stage 2 arrest (aRRR 6.63, 95% CI 3.74-11.73), or other factors (aRRR 2.41, 95% CI 1.04-5.60) rather than fetal factors compared with women who had no type of FGM. Among women with unclear medical indications, FGM was associated with cesarean delivery being performed for maternal factors or arrest disorders. © 2017 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.

Variation in Cesarean Birth Rates by Labor and Delivery Nurses.

PubMed

Edmonds, Joyce K; O'Hara, Michele; Clarke, Sean P; Shah, Neel T

To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses. Retrospective cohort study. One high-volume labor and delivery unit at an academic medical center in a major metropolitan area. Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation. Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses. Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile. The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed. Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

Trial of Labor Compared With Cesarean Delivery in Superobese Women.

PubMed

Grasch, Jennifer L; Thompson, Jennifer L; Newton, J Michael; Zhai, Amy W; Osmundson, Sarah S

2017-11-01

To examine whether labor compared with planned cesarean delivery is associated with increased maternal and neonatal morbidity. We conducted a retrospective cohort study of all women with body mass indexes (BMIs) at delivery of 50 or greater delivering a live fetus at 34 weeks of gestation of greater between January 1, 2008, and December 31, 2015. Pregnancies with multiple gestations and major fetal anomalies were excluded. The primary outcome was a composite of maternal and neonatal morbidity and was estimated to be 50% in superobese women based on institutional data. A sample size of 338 women determined the study period and was selected to show a 30% difference in the incidence of the primary outcome between the two groups. Multivariate logistic regression adjusted for potential confounders. There were 344 women with BMIs of 50 or greater who met eligibility criteria, of whom 201 (58%) labored and 143 (42%) underwent planned cesarean delivery. Women who labored were younger, more likely to be nulliparous, and less likely to have pre-existing diabetes. Among women who labored, 45% underwent a cesarean delivery, most commonly for labor arrest (61%) or nonreassuring fetal status (28%). Composite maternal and neonatal morbidity was reduced among women who labored even after adjusting for age, parity, pre-existing diabetes, and prior cesarean delivery (adjusted odds ratio 0.42, 95% CI 0.24-0.75). In the subgroup of women (n=234) who underwent a cesarean delivery, whether planned (n=143) or after labor (n=91), there were no differences in maternal and neonatal morbidity except that severe maternal morbidity was increased in women (n=12) who labored (8.8% compared with 2.1%, relative risk 4.2, 95% CI 1.14-15.4). Despite high rates of cesarean delivery in women with superobesity, labor is associated with lower composite maternal and neonatal morbidity. Severe maternal morbidity may be higher in women who require a cesarean delivery after labor.

Sonographic large fetal head circumference and risk of cesarean delivery.

PubMed

Lipschuetz, Michal; Cohen, Sarah M; Israel, Ariel; Baron, Joel; Porat, Shay; Valsky, Dan V; Yagel, Oren; Amsalem, Hagai; Kabiri, Doron; Gilboa, Yinon; Sivan, Eyal; Unger, Ron; Schiff, Eyal; Hershkovitz, Reli; Yagel, Simcha

2018-03-01

Persistently high rates of cesarean deliveries are cause for concern for physicians, patients, and health systems. Prelabor assessment might be refined by identifying factors that help predict an individual patient's risk of cesarean delivery. Such factors may contribute to patient safety and satisfaction as well as health system planning and resource allocation. In an earlier study, neonatal head circumference was shown to be more strongly associated with delivery mode and other outcome measures than neonatal birthweight. In the present study we aimed to evaluate the association of sonographically measured fetal head circumference measured within 1 week of delivery with delivery mode. This was a multicenter electronic medical record-based study of birth outcomes of primiparous women with term (37-42 weeks) singleton fetuses presenting for ultrasound with fetal biometry within 1 week of delivery. Fetal head circumference and estimated fetal weight were correlated with maternal background, obstetric, and neonatal outcome parameters. Elective cesarean deliveries were excluded. Multinomial regression analysis provided adjusted odds ratios for instrumental delivery and unplanned cesarean delivery when the fetal head circumference was ≥35 cm or estimated fetal weight ≥3900 g, while controlling for possible confounders. In all, 11,500 cases were collected; 906 elective cesarean deliveries were excluded. A fetal head circumference ≥35 cm increased the risk for unplanned cesarean delivery: 174 fetuses with fetal head circumference ≥35 cm (32%) were delivered by cesarean, vs 1712 (17%) when fetal head circumference <35 cm (odds ratio, 2.49; 95% confidence interval, 2.04-3.03). A fetal head circumference ≥35 cm increased the risk of instrumental delivery (odds ratio, 1.48; 95% confidence interval, 1.16-1.88), while estimated fetal weight ≥3900 g tended to reduce it (nonsignificant). Multinomial regression analysis showed that fetal head circumference ≥35 cm

Association between rising professional liability insurance premiums and primary cesarean delivery rates.

PubMed

Murthy, Karna; Grobman, William A; Lee, Todd A; Holl, Jane L

2007-12-01

To estimate the association between changes in Illinois professional liability premiums for obstetrician-gynecologists and singleton primary cesarean delivery rates. Data from the National Center for Health Statistics were used to identify all singleton births between 37 weeks and 44 weeks of gestation occurring in Illinois from 1998 through 2003. Primary cesarean delivery rates for women delivered between 37 weeks and 44 weeks of gestation per 1,000 gravid women eligible to have a primary cesarean delivery were calculated for each Illinois county. The annual medical professional liability premium for each county in Illinois was represented by the reported professional liability insurance rate charges (adjusted to 2004 dollars) from the ISMIE Mutual Insurance Company. Separate analyses were conducted for nulliparous and multiparous women. The independent association between county-level primary cesarean delivery rates and the previous year's insurance premiums was evaluated using linear regression models. During the study period, 817,521 women were eligible for inclusion in the analysis. The county-level mean primary cesarean delivery rate increased from 126 to 163 per 1,000 (P<.001) eligible women, whereas the mean annual medical professional liability insurance premiums also rose significantly (from $60,766 in 1997 to $83,167 in 2002, P<.001). Multivariable analyses demonstrated that for each annual $10,000 insurance premium increase, the primary cesarean delivery rate increased by 15.7 per 1,000 for nulliparous women. This association also was evident for multiparous women, who had an increase in cesarean deliveries of 4.7 per 1,000 for every $10,000 increase. Higher rates of primary cesarean delivery are associated with increased medical professional liability premiums for obstetrician-gynecologists in Illinois. II.

Circulating maternal cortisol levels during vaginal delivery and elective cesarean section.

PubMed

Stjernholm, Ylva Vladic; Nyberg, Annie; Cardell, Monica; Höybye, Charlotte

2016-08-01

Maternal S-cortisol levels increase throughout pregnancy and peak in the third trimester. Even higher levels are seen during the physical stress of delivery. Since analgesia for women in labor has improved, it is possible that maternal stress during labor is reduced. The aim of this study was to compare maternal S-cortisol during vaginal delivery and elective cesarean section. Twenty healthy women with spontaneous vaginal delivery and healthy women (n = 20) undergoing elective cesarean section were included in the study. S-cortisol was measured during three stages of spontaneous vaginal delivery (tvd1, tvd2 and tvd3), as well as before and after elective cesarean section (tcs1 and tcs2). In the vaginal delivery group, mean S-cortisol at tvd1 was 1325 ± 521 nmol/L, at tvd2 1559 ± 591 nmol/L and at tvd3 1368 ± 479 nmol/L. In the cesarean section group, mean S-cortisol at tcs1 was 906 ± 243 nmol/L and at tcs2 831 ± 257 nmol/L. S-cortisol was higher in the vaginal delivery group at the onset of labor as compared to the cesarean section preoperative group (p = 0.006). There were also significant differences between S-cortisol levels postpartum as compared to postoperatively (p < 0.001). Maternal S-cortisol was higher during vaginal delivery compared to elective cesarean section, indicating higher stress levels. A reduction in the hydrocortisone dose at childbirth in women with adrenal insufficiency should be considered, particularly in women undergoing an elective cesarean section.

Uterine massage for preventing postpartum hemorrhage at cesarean delivery: Which evidence?

PubMed

Saccone, Gabriele; Caissutti, Claudia; Ciardulli, Andrea; Berghella, Vincenzo

2018-04-01

Cesarean delivery could be complicated by postpartum hemorrhage (PPH), the first cause of maternal death. To evaluate the efficacy of uterine massage in preventing postpartum hemorrhage at cesarean delivery. Electronic databases from their inception until October 2017. We included all RCTs comparing uterine massage alone or as part of the active management of labor before or after delivery of the placenta, or both, with non-massage in the setting of cesarean delivery. The primary outcome was PPH, defined as blood loss >1000 mL. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Only 3 RCTs comparing uterine massage vs no uterine massage were found. The quality of these 3 trials in general was very low with high or unclear risk of bias. All of them included only women in the setting of spontaneous vaginal delivery and none of them included cesarean delivery, and therefore the meta-analysis was not feasible. There is not enough evidence to determine if uterine massage prevents postpartum hemorrhage at cesarean delivery. Copyright © 2018 Elsevier B.V. All rights reserved.

New labor management guidelines and changes in cesarean delivery patterns.

PubMed

Rosenbloom, Joshua I; Stout, Molly J; Tuuli, Methodius G; Woolfolk, Candice L; López, Julia D; Macones, George A; Cahill, Alison G

2017-12-01

In 2010 the Consortium on Safe Labor published labor curves. It was proposed that the rate of cesarean delivery could be lowered by avoiding the diagnosis of arrest of dilation before 6 cm. However, there is little information on the uptake of the guidelines and on changes in cesarean delivery rates that may have occurred. The objective of the study was to test the following hypotheses: (1) among patients laboring at term, rates of arrest of dilation disorders have decreased, leading to a decrease in the rate of cesarean delivery; (2) in the second stage, pushing duration prior to diagnosis of arrest of descent has increased, also leading to a reduction in the rate of cesarean delivery for this indication. As a secondary aim, we investigated changes in maternal and neonatal morbidity. This was a secondary analysis of a prospective cohort study of all patients presenting at ≥37 weeks' gestation from 2010 through 2014 with a nonanomalous vertex singleton and no prior history of cesarean delivery. Rates of cesarean delivery, arrest of dilation, and changes in rates of maternal and neonatal morbidity were calculated in crude and adjusted models. Cervical dilation at diagnosis of the arrest of dilation, time spent at the maximal dilation prior to diagnosis of arrest of dilation, and time in the second stage prior to the diagnosis of arrest of descent were compared over the study period. There were 7845 eligible patients. The cesarean delivery rate in 2010 was 15.8% and, in 2014, 17.7% (P trend = .51). In patients undergoing cesarean delivery for the arrest of dilation, the median cervical dilation at the time of cesarean delivery was at 5.5 cm in 2010 and 6.0 cm in 2014 (P trend = .94). In these patients, there was an increase in the time spent at last dilation: 3.8 hours in 2010 to 5.2 hours in 2014 (P trend = .02). There was no change in the frequency of patients diagnosed with the arrest of dilation at <6 cm: 51.4% in 2010 and 48.6% in 2014 (P trend = .56

Cesarean delivery and risk of inflammatory bowel disease: a systematic review and meta-analysis.

PubMed

Li, Yi; Tian, Yun; Zhu, Weiming; Gong, Jianfeng; Gu, Lili; Zhang, Wei; Guo, Zhen; Li, Ning; Li, Jieshou

2014-07-01

It has been considered that cesarean delivery is a risk factor for the two subtypes of inflammatory bowel diseases (IBDs): Crohn's disease (CD) and ulcerative colitis (UC). The aim of this meta-analysis was to examine the relationship between cesarean delivery and the development of IBD. We searched the articles retrieved by PubMed, MEDLINE and EMBASE databases to identify observational studies regarding the relationship between cesarean section and the development of CD and/or UC. Pooled odds ratios were calculated for each relationship. Nine studies evaluated the potential association between cesarean delivery and the development of IBD and met all of our inclusion criteria. The pooled data from six included studies indicated cesarean delivery was a risk factor for CD (95% confidence interval [CI]: 1.12-1.70; p = 0.003). Likewise, we observed a positive association between cesarean delivery and pediatric CD (95% CI: 1.06-1.35; p = 0.005). However, results from the four included studies for UC indicated the rate of cesarean section in UC patients was not higher than that of control subjects (95% CI: 0.87-1.32; p = 0.54). Overall, we did not observe a positive relationship between cesarean delivery and IBD (95% CI: 0.99-1.30; p = 0.08). Results of this meta-analysis support the hypothesis that cesarean delivery was associated with the risk of CD but not of UC. The total rate of cesarean delivery of IBD patients was similar with that of control subjects.

Early elective cesarean delivery before 36 weeks vs late spontaneous delivery in infants with gastroschisis.

PubMed

Hadidi, Ahmed; Subotic, Ulrike; Goeppl, Maximilian; Waag, Karl-L

2008-07-01

The aim of this study is to assess the value of early elective cesarean delivery for patients with gastroschisis in comparison with late spontaneous delivery. Analysis of infants with gastroschisis admitted between 1986 and 2006 at a tertiary care center was performed. The findings were analyzed statistically. Eighty-six patients were involved in the study. This included 15 patients who underwent emergency cesarean delivery (EM CD group) because of fetal distress and/or bowel ischemia. The remaining 71 patients born electively were stratified into 4 groups. The early elective cesarean delivery (ECD) group included 23 patients born by ECD before 36 weeks; late vaginal delivery (LVD) group included 23 patients who had LVD after 36 weeks; 24 patients had LCD after 36 weeks because of delayed diagnosis that resulted in late referral; and 1 patient had early spontaneous vaginal delivery (EVD group) before 36 weeks. The mean time to start oral feeding, incidence of complications, and primary closure were significantly better in the ECD group than in the LVD group. The duration of ventilation and the length of stay were shorter in ECD group, but the difference was not statistically significant. Elective cesarean delivery before 36 weeks allows earlier enteral feeding and is associated with less complications and higher incidence of primary closure (statistically significant).

Geographic variation in cesarean delivery in the United States by payer.

PubMed

Henke, Rachel Mosher; Wier, Lauren M; Marder, William D; Friedman, Bernard S; Wong, Herbert S

2014-11-19

The rate of cesarean delivery in the United States is variable across geographic areas. The aims of this study are two-fold: (1) to determine whether the geographic variation in cesarean delivery rate is consistent for private insurance and Medicaid (2) to identify the patient, population, and market factors associated with cesarean rate and determine if these factors vary by payer. We used the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) to measure the cesarean rate at the Core-Based Statistical Area (CBSA) level. We linked the hospitalization data to data from other national sources to measure population and market characteristics. We calculated unadjusted and risk-adjusted CBSA cesarean rates by payer. For the second aim, we estimated a hierarchical logistical model with the hospitalization as the unit of analysis to determine the factors associated with cesarean delivery. The average CBSA cesarean rate for women with private insurance was higher (18.9 percent) than for women with Medicaid (16.4 percent). The factors predicting cesarean rate were largely consistent across payers, with the following exceptions: women under age 18 had a greater likelihood of cesarean section if they had Medicaid but had a greater likelihood of vaginal birth if they had private insurance; Asian and Native American women with private insurance had a greater likelihood of cesarean section but Asian and Native American women with Medicaid had a greater likelihood of vaginal birth. The percent African American in the population predicted increased cesarean rates for private insurance only; the number of acute care beds per capita predicted increased cesarean rate for women with Medicaid but not women with private insurance. Further we found the number of obstetricians/gynecologists per capita predicted increased cesarean rate for women with private insurance only, and the number of midwives per capita predicted increased vaginal birth rate for women

Labor induction and cesarean delivery: A prospective cohort study of first births in Pennsylvania, USA.

PubMed

Kjerulff, Kristen H; Attanasio, Laura B; Edmonds, Joyce K; Kozhimannil, Katy B; Repke, John T

2017-09-01

Mode of delivery at first childbirth largely determines mode of delivery at subsequent births, so it is particularly important to understand risk factors for cesarean delivery at first childbirth. In this study, we investigated risk factors for cesarean delivery among nulliparous women, with focus on the association between labor induction and cesarean delivery. A prospective cohort study of 2851 nulliparous women with singleton pregnancies who attempted vaginal delivery at hospitals in Pennsylvania, 2009-2011, was conducted. We used nested logistic regression models and multiple mediational analyses to investigate the role of three groups of variables in explaining the association between labor induction and unplanned cesarean delivery-the confounders of maternal characteristics and indications for induction, and the mediating (intrapartum) factors-including cervical dilatation, labor augmentation, epidural analgesia, dysfunctional labor, dystocia, fetal intolerance of labor, and maternal request of cesarean during labor. More than a third of the women were induced (34.3%) and 24.8% underwent cesarean delivery. Induced women were more likely to deliver by cesarean (35.9%) than women in spontaneous labor (18.9%), unadjusted OR 2.35 (95% CI 1.97-2.79). The intrapartum factors significantly mediated the association between labor induction and cesarean delivery (explaining 76.7% of this association), particularly cervical dilatation <3 cm at hospital admission, fetal intolerance of labor, and dystocia. The indications for labor induction only explained 6.2%. Increased risk of cesarean delivery after labor induction among nulliparous women is attributable mainly to lower cervical dilatation at hospital admission and higher rates of labor complications. © 2017 Wiley Periodicals, Inc.

Indications for Cesarean Delivery in Mexico: Evaluation of Appropriate Use and Justification.

PubMed

Aranda-Neri, Juan Carlos; Suárez-López, Leticia; DeMaria, Lisa M; Walker, Dilys

2017-03-01

Cesarean delivery is one of the most widely used surgical interventions in Latin America and in many cases it is performed with no clear medical indication. Our objective was to analyze the relationship between reported indications for a cesarean and support for that indication in the clinical record in four Mexican hospitals, during the 2006-2007 period. The data are from 604 (37.1%) women from a total of 1,625 who were admitted to the hospital in labor, and who gave birth through cesarean. Multivariate logistical regression analysis was used to explore the association between indications for clinically justified or unjustified surgery and other clinical and sociodemographic variables. Supporting clinical information for indications of cesarean delivery were found in only 45 percent of the cases considered. The adjusted statistical analysis showed that the variables associated with an unjustified indication for cesarean were: not having had a prior birth (OR 1.84 [95% CI 1.16-2.89]), having a maximum cervical dilation of 4 centimeters or less at time of cesarean (OR 2.44 [95% CI 1.53-3.87]), and having received care in a private hospital (OR 6.11 [95% CI 1.90-19.57]). The indications for cesarean related to labor dynamics were those least supported. Not having had a prior birth poses the greatest risk of having a poorly supported indication for a cesarean delivery. It would be prudent to institute audits, and greater requirements for and surveillance of documentation for cesarean delivery indications. © 2016 Wiley Periodicals, Inc.

Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis.

PubMed

Caissutti, Claudia; Saccone, Gabriele; Zullo, Fabrizio; Quist-Nelson, Johanna; Felder, Laura; Ciardulli, Andrea; Berghella, Vincenzo

2017-09-01

To assess the efficacy of vaginal cleansing before cesarean delivery in reducing postoperative endometritis. MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library were searched from their inception to January 2017. Selection criteria included all randomized controlled trials comparing vaginal cleansing (ie, intervention group) with a control group (ie, either placebo or no intervention) in women undergoing cesarean delivery. Any method of vaginal cleansing with any type of antiseptic solution was included. The primary outcome was the incidence of endometritis. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% CI. Sixteen trials (4,837 women) on vaginal cleansing immediately before cesarean delivery were identified as relevant and included in the review. In most of the included studies, 10% povidone-iodine was used as an intervention. The most common way to perform the vaginal cleansing was the use of a sponge stick for approximately 30 seconds. Women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% compared with 8.8%; RR 0.52, 95% CI 0.37-0.72; 15 studies, 4,726 participants) and of postoperative fever (9.4% compared with 14.9%; RR 0.65, 95% CI 0.50-0.86; 11 studies, 4,098 participants) compared with the control group. In the planned subgroup analyses, the reduction in the incidence of endometritis with vaginal cleansing was limited to women in labor before cesarean delivery (8.1% compared with 13.8%; RR 0.52, 95% CI 0.28-0.97; four studies, 440 participants) or those with ruptured membranes (4.3% compared with 20.1%; RR 0.23, 95% CI 0.10-0.52; three studies, 272 participants). Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. Because it is generally inexpensive and a

Opinions of women towards cesarean delivery and priority issues of care in the postpartum period.

PubMed

Kisa, Sezer; Zeyneloğlu, Simge

2016-05-01

This study was conducted, in order to determine the opinions of women who had a cesarean delivery and the problems that they faced in the postpartum period. This descriptive study was conducted with 337 women who delivered babies by cesarean section. The data were collected using a semi-structured questionnaire. The results of the study showed that 53.4% of women underwent cesarean delivery for the first time, and 83.1% said that it was the obstetrician's decision to have a cesarean delivery. More than half of the women (61.1%) had a negative experience with cesarean delivery due to postpartum pain (44.7%) and inability to care for their infant (35.9%). The most common problems associated with cesarean delivery were postpartum pain (96.1%), back pain (68.2%), problems passing gas (62.0%), bleeding (56.1%), breastfeeding problems (49.6%) and limitation of movement (43.6%) respectively. Understanding the the opinions and problems of women towards cesarean delivery assists healthcare professionals in identifying better ways to provide appropriate care and support. Copyright © 2015 Elsevier Inc. All rights reserved.

Women's Psychological Adjustment Following Emergency Cesarean versus Vaginal Delivery.

ERIC Educational Resources Information Center

Padawer, Jill A.; And Others

1988-01-01

Investigated psychological adjustment and satisfaction in women who had given birth vaginally or by cesarean section. Cesarean mothers reported significantly less satisfaction with the delivery than did vaginal mothers; however no differences were found in postpartum psychological adjustment as measured by depression, anxiety, and confidence in…

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.

[Severe Adverse Pregnancy Outcomes in Placenta Previa and Prior Cesarean Delivery].

PubMed

Zhou, Mi; Chen, Meng; Zhang, Li; He, Guo-Lin; He, Lei; Wei, Qiang; Li, Tao; Liu, Xing-Hui

2017-09-01

To investigate the severe adverse pregnancy outcomes in pregnancies with placenta previa and prior cesarean delivery and its risk factors. This retrospective casecontrol study reviewed all pregnancies with placenta previa and prior cesarean delivery delivered by repeat cesarean section in our institution between January 2005 and June 2015,and investigated the incidence of severe adverse pregnancy outcome. A composite of severe adverse pregnancy outcomes (including transfusion of 10 units or more red blood cells,maternal ICU admission,unanticipated injuries,repeat operation,hysterectomy,and maternal death) and other maternal and neonatal outcomes were described. Univariate and multivariable logistic regression analysis were used to quantify the effects of risk factors on severe adverse pregnancy outcomes. There were 478 women with placenta previa and prior cesarean delivery in our hospital over the last decade. The average age of them was 32.5±4.8 years old,most women were beyond 30 years old,the average gravidity and parity were 4 and 1,131 cases (27.4%) had severe adverse pregnancy outcomes. Transfusion of 10 units or more red blood cells happened in 75 cases (15.7%,75/478); 44 cases (9.2%,44/478) necessitated maternal ICU admission; unanticipated bladder injury occurred in 11 cases,but non ureter or bowel injury happened; All 4 repeat operations were due to delayed hemorrhage after conservative management during cesarean delivery,and an emergent hysterectomy was performed for all of the 4 cases. Hysterectomy (107 cases,22.4%) was the most common severe adverse pregnancy outcome. Among all 311 morbidly adherent placenta cases finally confirmed by pathological or surgical findings or both,only 172 (55.3%) were suspected before delivery. Multivariable logistic regression analysis showed that the risk of severe adverse pregnancy outcomes was significantly increased by pernicious placenta previa (i.e. anterior placenta overlying the prior cesarean scar),suspicion of

Exercise during pregnancy and risk of cesarean delivery in nulliparous women: a large population-based cohort study.

PubMed

Owe, Katrine Mari; Nystad, Wenche; Stigum, Hein; Vangen, Siri; Bø, Kari

2016-12-01

Vaginal delivery for the first birth is of great importance for further obstetric performance for the individual woman. Given the rising cesarean delivery rates worldwide over the past decades, a search for modifiable factors that are associated with cesarean delivery is needed. Exercise may be a modifiable factor that is associated with type of delivery, but the results of previous studies are not conclusive. The purpose of this study was to investigate the association between exercise during pregnancy and cesarean delivery, both acute and elective, in nulliparous women. We conducted a population-based cohort study that involved 39,187 nulliparous women with a singleton pregnancy who were enrolled in the Norwegian Mother and Child Cohort Study between 2000 and 2009. All women answered 2 questionnaires in pregnancy weeks 17 and 30. Acute and elective cesarean delivery data were obtained from the Medical Birth Registry of Norway. Information on exercise frequency and type was assessed prospectively by questionnaires in pregnancy weeks 17 and 30. Generalized linear models estimated risk differences of acute and elective cesarean delivery for different frequencies and types of exercise during pregnancy weeks 17 and 30. We used restricted cubic splines to examine dose-response associations of exercise frequency and acute cesarean delivery. A test for nonlinearity was also conducted. The total cesarean delivery rate was 15.4% (n=6030), of which 77.8% (n=4689) was acute cesarean delivery. Exercise during pregnancy was associated with a reduced risk of cesarean delivery, particularly for acute cesarean delivery. A nonlinear association was observed for exercise frequency in weeks 17 and 30 and risk of acute cesarean delivery (test for nonlinearity, P=.003 and P=.027, respectively). The largest risk reduction was observed for acute cesarean delivery among women who exercised >5 times weekly during weeks 17 (-2.2%) and 30 (-3.6%) compared with nonexercisers (test for trend

Prevention of the first cesarean delivery.

PubMed

Spong, Catherine Y

2015-06-01

Education of providers and patients on the importance of vaginal delivery, for the current pregnancy as well as future pregnancies, is essential to reverse the current trend of primary cesareans. When discussing cesarean with patients, counseling should include the effect on subsequent pregnancy risks including the possibility of uterine rupture and placentation abnormalities. In addition, counseling must include the concept that normal labor takes time. Re-education on the natural process of labor, the importance of allowing the time needed, and patience with the duration of pregnancy and process of labor is essential. Published by Elsevier Inc.

National health insurance, physician financial incentives, and primary cesarean deliveries in Taiwan.

PubMed

Tsai, Yi-Wen; Hu, Teh-Wei

2002-09-01

Taiwan's National Health Insurance Program (NHI) was implemented on March 1, 1995. This study analyzed the influences of the Case Payment method of reimbursement for inpatient care and of physician financial incentives on a woman's choice for primary cesarean delivery. Logistic regressions were used to analyze 11 788 first-time deliveries in a nonprofit hospital system between March 1, 1994, and February 29, 1996. After implementation of the NHI's Case Payment scheme, the likelihood that a woman would choose primary cesarean delivery increased by four to five times compared with the choice behavior of uninsured individuals prior to NHI (P <.0001). Out-of-pocket payment discourages the selection of primary cesarean delivery. No robust statistics were found relating physician financial incentives to delivery choice.

Predictors of emergency cesarean delivery among international migrant women in Canada.

PubMed

Gagnon, Anita J; Merry, Lisa; Haase, Kristen

2013-06-01

To determine the predictors of emergency cesarean delivery among international migrant women. Between February 2006 and May 2009, 1025 postpartum migrant women were recruited from 12 hospitals in Toronto, Montreal, and Vancouver. Logistic regression was used to model migration, social, health service, and biomedical factors predictive of emergency cesarean. Overall, 14% percent of participants underwent emergency cesarean. The greatest risk was for women having their first delivery (odds ratio [OR], 5.9; 95% confidence interval [CI], 3.1-11.3); newborns weighing 4000g or more (OR, 3.5; 95% CI, 1.9-6.5); no health insurance (OR, 2.8; 95% CI, 1.2-6.4); delivery on a Friday (OR, 2.2; 95% CI, 1.2-3.9); incomes of less than 30 000 Canadian dollars (OR, 1.9; 1.2-3.0); and induced labor (OR, 1.8; 95% CI, 1.1-3.0). Compared with immigrants, asylum seekers (OR, 0.3; 95% CI, 0.2-0.6) and refugees (OR, 0.5; 95% CI, 0.2-1.0) were protected against emergency cesarean. Indicators specific to, or more common among, migrants were informative in assessing the likelihood of emergency cesarean. The risk associated with being uninsured, day of delivery, income, and immigration class suggests the importance of considering non-biomedical factors in reducing the need for emergency cesarean among migrants. Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates.

PubMed

Yee, Lynn M; Costantine, Maged M; Rice, Madeline Murguia; Bailit, Jennifer; Reddy, Uma M; Wapner, Ronald J; Varner, Michael W; Thorp, John M; Caritis, Steve N; Prasad, Mona; Tita, Alan T N; Sorokin, Yoram; Rouse, Dwight J; Blackwell, Sean C; Tolosa, Jorge E

2017-12-01

To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity. This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008-2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery. A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36-1.59; Asian adjusted OR 1.26, 95% CI 1.14-1.40; Hispanic adjusted OR 1.17, 95% CI 1.07-1.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Nonapplication of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or

Regional Gradients in Institutional Cesarean Delivery Rates: Evidence from Five Countries in Asia.

PubMed

Sepehri, Ardeshir; Guliani, Harminder

2017-03-01

Although the influence of the type of institutional setting on the risk of cesarean birth is well documented, less is known about the regional variations in institution-specific cesarean rates within countries. Our purpose was to examine regional variations in cesarean rates across public and private facilities in five Asian countries with a sizeable private sector: Bangladesh, India, Indonesia, Pakistan, and the Philippines. Demographic Health Survey data and a hierarchical model were used to assess regional variations in the mode of delivery while controlling for a wide range of socioeconomic, demographic, and maternal risk factors. The risk of cesarean birth was greater in a private facility than in a government hospital by 36-48 percent in India and Indonesia and by 130 percent in Bangladesh. Regional gradients in cesarean birth were found to be steeper for deliveries in private facilities than in government hospitals in India, Indonesia, and the Philippines. The residents of India's high-use states were 55 percent more likely to undergo a cesarean delivery in a government hospital and 83 percent more likely in a private facility than their counterparts in the medium-use states. Similarly, compared to the residents of the Philippines's medium-use provinces, giving birth in a government facility increased the likelihood of a cesarean delivery by 84 percent and by 173 percent in a private facility. Large regional variations in cesarean rates suggest the need for more informed clinical decision making with respect to the selection of cases for cesarean delivery and the establishment of well-developed guidelines and standards at the provincial or state levels. © 2016 Wiley Periodicals, Inc.

Physical and Organizational Job Stressors in Pregnancy and Associations With Primary Cesarean Deliveries.

PubMed

Guendelman, Sylvia; Gemmill, Alison; Hosang, Nap; MacDonald, Leslie A

2017-06-01

The aim of this study was to assess the relationship between exposure to physical and organizational job stressors during pregnancy and cesarean delivery. We sampled 580 employed women in California who participated in a nested population-based case-control study of birth outcomes. Adjusted multivariate regression analyses estimated associations between heavy lifting, frequent bending, high noise, extreme temperature, prolonged standing and organizational stressors (shift work, inflexible schedules, effort-reward ratio), and primary cesarean (vs vaginal) delivery, controlling for covariates. Women occupationally exposed had higher odds of cesarean. Those exposed to daily manual lifting more than 15 pounds [adjusted odds ratio = 2.54; 95% confidence interval (95% CI) 1.21 to 5.32] and at least four physical job stressors (adjusted odds ratio = 3.49; 95% CI 1.21 to 10.09) had significantly elevated odds of cesarean delivery. Exposed morbid women experienced greater risk; risk was lower among those with schedule flexibility. Associations were found between modifiable exposure to physical job stressors during pregnancy and cesarean delivery.

Misrecognition of need: women's experiences of and explanations for undergoing cesarean delivery.

PubMed

Tully, Kristin P; Ball, Helen L

2013-05-01

International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed 'on request.' The categorization of cesareans into 'emergency' and 'elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of 'choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from 'prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the 'too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the 'need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for

Employment during pregnancy and obstetric intervention without medical reason: labor induction and cesarean delivery.

PubMed

Kozhimannil, Katy Backes; Attanasio, Laura B; Johnson, Pamela Jo; Gjerdingen, Dwenda K; McGovern, Patricia M

2014-01-01

Rising rates of labor induction and cesarean delivery, especially when used without a medical reason, have generated concern among clinicians, women, and policymakers. Whether employment status affects pregnant women's childbirth-related care is not known. We estimated the relationship between prenatal employment and obstetric procedures, distinguishing whether women reported that the induction or cesarean was performed for medical reasons. Using data from a nationally representative sample of women who gave birth in U.S. hospitals (n = 1,573), we used propensity score matching to reduce potential bias from nonrandom selection into employment. Outcomes were cesarean delivery and labor induction, with and without a self-reported medical reason. Exposure was prenatal employment status (full-time employment, not employed). We conducted separate analyses for unmatched and matched cohorts using multivariable regression models. There were no differences in labor induction based on employment status. In unmatched analyses, employed women had higher odds of cesarean delivery overall (adjusted odds ratio [AOR], 1.45; p = .046) and cesarean delivery without medical reason (AOR, 1.94; p = .024). Adding an interaction term between employment and college education revealed no effects on cesarean delivery without medical reason. There were no differences in cesarean delivery by employment status in the propensity score-matched analysis. Full-time prenatal employment is associated with higher odds of cesarean delivery, but this association was not explained by socioeconomic status and no longer existed after accounting for sociodemographic differences by matching women employed full time with similar women not employed during pregnancy. Copyright © 2014 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.

Clinicians' practice environment is associated with a higher likelihood of recommending cesarean deliveries.

PubMed

Cheng, Yvonne W; Snowden, Jonathan M; Handler, Stephanie; Tager, Ira B; Hubbard, Alan; Caughey, Aaron B

2014-08-01

Little data exist regarding clinicians' role in the rising annual incidence rate of cesarean delivery in the US. We aimed to examine if clinicians' practice environment is associated with recommending cesarean deliveries. This is a survey study of clinicians who practice obstetrics in the US. This survey included eight clinical vignettes and 27 questions regarding clinicians' practice environment. Chi-square test and multivariable logistic regression were used for statistical comparison. Of 27 675 survey links sent, 3646 clinicians received and opened the survey electronically, and 1555 (43%) participated and 1486 (94%) completed the survey. Clinicians were categorized into three groups based on eight common obstetric vignettes as: more likely (n = 215), average likelihood (n = 1099), and less likely (n = 168) to recommend cesarean. Clinician environment factors associated with a higher likelihood of recommending cesarean included Laborists/Hospitalists practice model (p < 0.001), as-needed anesthesia support (p = 0.003), and rural/suburban practice setting (p < 0.001). We identified factors in clinicians' environment associated with their likelihood of recommending cesarean delivery. The decision to recommend cesarean delivery is a complicated one and is likely not solely based on patient factors.

Women's attitudes toward mode of delivery in South Korea--a society with high cesarean section rates.

PubMed

Lee, Sang-Il; Khang, Young-Ho; Lee, Moo-Song

2004-06-01

In South Korea, cesarean section rates (i.e., the proportion of all live births delivered by cesarean section) approached 40 percent in 2000. The relative contribution of physicians and women to this high rate has been a source of debate. This study explored attitudes toward mode of delivery among South Korean women. A nationwide cross-sectional telephone survey of 505 Korean women aged 20 to 49 years was conducted using a proportionate quota and systematic random sampling method. The response rate was 57.3 percent. Data were collected using a structured questionnaire consisting of 7 questions about vaginal and cesarean delivery. Over 95 percent of women preferred vaginal delivery during pregnancy and were willing to recommend this method to others. Of the women who delivered by cesarean section, 10.6 percent stated that they had requested a cesarean birth. Attitudes toward vaginal or cesarean delivery differed significantly according to a woman's education level. Most study participants showed more favorable attitudes toward vaginal delivery than cesarean delivery. This result does not support the assumption that the upsurge of cesarean section rates in South Korea is associated with women's positive attitudes toward cesarean section. The main cause of the rapid rise of cesarean section rates in South Korea during the past two decades have its origins in health care practitioners and the health care system in which they work.

Employment during pregnancy and obstetric intervention without medical reason: labor induction and cesarean delivery

PubMed Central

Kozhimannil, Katy Backes; Attanasio, Laura B.; Johnson, Pamela Jo; Gjerdingen, Dwenda K.; McGovern, Patricia M.

2014-01-01

Background Rising rates of labor induction and cesarean delivery, especially when used without a medical reason, have generated concern among clinicians, women, and policymakers. Whether employment status affects pregnant women's childbirth-related care is not known. We estimated the relationship between prenatal employment and obstetric procedures, distinguishing whether women reported that the induction or cesarean was performed for medical reasons. Methods Using data from a nationally-representative sample of women who gave birth in U.S. hospitals (N=1,573), we used propensity score matching to reduce potential bias from non-random selection into employment. Outcomes were cesarean delivery and labor induction, with and without a self-reported medical reason. Exposure was prenatal employment status (full-time employment, not employed). We conducted separate analyses for unmatched and matched cohorts using multivariable regression models. Findings There were no differences in labor induction based on employment status. In unmatched analyses, employed women had higher odds of cesarean delivery overall (adjusted odds ratio (AOR) = 1.45, p=0.046) and cesarean delivery without medical reason (AOR=1.94, p=0.024). Adding an interaction term between employment and college education revealed no significant effects on cesarean without medical reason. There were no significant differences in cesarean delivery by employment status in the propensity score matched analysis. Conclusions Full-time prenatal employment is associated with higher odds of cesarean delivery, but this association was not explained by socio-economic status and no longer existed after accounting for socio-demographic differences by matching women employed full-time with similar women not employed during pregnancy. PMID:25213740

The risk of placenta accreta following primary cesarean delivery.

PubMed

Zeevi, Gil; Tirosh, Dan; Baron, Joel; Sade, Maayan Yitshak; Segal, Adi; Hershkovitz, Reli

2018-05-01

To (a) evaluate the risk for placenta accreta following primary cesarean section (CS), in regard to the stage of labor, the cesarean section was taken (elective prelabor vs. unplanned during labor); and (b) investigate whether the association between placenta accreta and maternal and neonatal complications is modified by the type of the primary CS. In a population-based retrospective cohort study, we included all singleton deliveries occurred in Soroka University Medical Center between 1991 and 2015, of women who had a history of a single CS. The deliveries were divided into three groups according to the delivery stage the primary CS was carried out: 'Unplanned 1' (first stage-up to 10 cm), 'Unplanned 2' (second stage-10 cm) and 'Elective' prelabor CS. We assessed the association between the study group and placenta accreta using logistic generalized estimation equation (GEE) models. We additionally assessed maternal and neonatal complications associated with placenta accreta among women who had elective and unplanned CS separately. We included 22,036 deliveries to 13,727 women with a history of one CS, of which 0.9% (n = 207) had placenta accreta in the following pregnancies: 12% (n = 25) in the 'Unplanned 1' group, 7.2% (n = 15) in the ' Unplanned 2' group and 80.8% (n = 167) in the 'elective' group. We found no difference in the risk for subsequent placenta accreta between the groups. In a stratified analysis by the timing of the primary cesarean delivery, the risk for maternal complications, associated with placenta accreta, was more pronounced among women who had an unplanned CS (OR 27.96, P < 0.01) compared to women who had an elective cesarean delivery (OR 13.72, P < 0.01). The stage in which CS is performed has no influence on the risk for placenta accreta in the following pregnancies, women who had an unplanned CS are in a higher risk for placenta accrete-associated maternal complications. This should be taken into consideration while

Comparison of Breast Crawl Between Infants Delivered by Vaginal Delivery and Cesarean Section.

PubMed

Heidarzadeh, Mohammad; Hakimi, Sevil; Habibelahi, Abbas; Mohammadi, Marzieh; Shahrak, Shakiba Pourasad

2016-05-12

Exclusive breastfeeding is the single most cost-effective intervention to reduce infant mortality. Breast crawl (BC) is deemed a natural way for the baby to behave immediately after delivery. BC is the method that may help initiation of breastfeeding in the most natural way. The aim of this study is to compare successful BC between neonates born through vaginal delivery and those born through cesarean section (CS) and factors associated with a positive outcome. Participants were mothers who delivered their babies during the period of October 2012 to December 2013 in Alzahra Hospital in Tabriz, through cesarean or vaginal delivery. Infants were placed prone on their mothers' abdomen after delivery. Data show that babies delivered through vaginal delivery had significantly more success in BC than babies born through the cesarean delivery (88.01% versus 11.21%). Moreover, babies in the CS group used significantly less time to achieve BC (45 versus 28 minutes). There is a remarkable difference in completion and length of time used to achieve BC between infants with regard to the delivery mode. Encouraging BC in all dyads, especially in cesarean births, may unduly delay the infant's first breastfeed.

Changes in Cesarean Delivery Rates by Gestational Age: United States, 1996-2011

MedlinePlus

... cesarean delivery rate : Number of births in multiple pregnancies delivered by cesarean per 100 multiple births. Gestational age categories Early preterm : Births prior to 34 completed weeks of ...

Cesarean Delivery in the United States 2005 - 2014: A Population-Based Analysis Using the Robson Ten Group Classification System.

PubMed

Hehir, Mark P; Ananth, Cande V; Siddiq, Zainab; Flood, Karen; Friedman, Alexander M; D'Alton, Mary E

2018-04-12

Cesarean delivery has increased steadily in the United States over recent decades with significant downstream health consequences. The World Health Organization has endorsed the Robson Ten Group Classification System (TGCS) as a global standard to facilitate analysis and comparison of cesarean delivery rates. Our objective was to apply the TGCS to a nationwide cohort in the United States over a 10-year period. This population-based analysis applied the TGCS to all births in the United States from 2005-2014, recorded in the 2003-revised birth certificate format. Over the study 10-year period 27,044,217 deliveries met inclusion criteria. Five parameters (parity including previous cesarean, gestational age, labor onset, fetal presentation and plurality), identifiable on presentation for delivery, were used to classify all women included into one of ten groups. The overall cesarean rate was 31.6%. Group 3 births (singleton, term, cephalic multiparas in spontaneous labor) were most common, while Group 5 births (those with a previous cesarean) accounted for the most cesarean deliveries increasing from 27% of all cesareans in 2005-06 to over 34% in 2013-14. Breech pregnancies (Groups 6 and 7) had cesarean rates above 90%. Primiparous and multiparous women who had a prelabor cesarean [Groups 2(b) and 4(b)] accounted for over one quarter of all cesarean deliveries. Women with a previous cesarean delivery represent an increasing proportion of cesarean deliveries. Use of the Robson criteria allows standardised comparisons of data and identifies clinical scenarios driving changes in cesarean rates. Hospitals and health organisations can use the TGCS to evaluate quality and processes associated with cesarean delivery. Copyright © 2018 Elsevier Inc. All rights reserved.

[Relationship between the risk of emergency cesarean section for nullipara with the prepregnancy body mass index or gestational weight gain].

PubMed

Zhao, R F; Zhang, W Y; Zhou, L

2017-11-25

Objective: To investigate the risk of emergency cesarean section during labor with the pre-pregnancy body mass index or gestational weight gain. Methods: A total of 6 908 healthy nullipara with singleton pregnancy and cephalic presentation who was in term labor in Beijing Obstetrics and Gynecology Hospital from August 1(st), 2014 to September 30(th), 2015 were recruited. They were divided into two groups, the vaginal delivery group (92.88%, 6 416/6 908) and the emergency cesarean section group (7.12%, 492/6 908). According to WHO body mass index (BMI) classification criteria and the pre-pregnancy BMI, the 6 908 women were divided into three groups, the underweight group(BMI<18.5 kg/m(2); 17.39%, 1 201/6 908), the normal weight group(18.5-24.9 kg/m(2); 73.00%, 5 043/6 908), the overweight and obese group (≥ 25.0 kg/m(2); 9.61%, 664/6 908). According to the guidelines of Institute of Medicine (IOM) , they were divided into three groups, the inadequate gestational weight gain (GWG) group (16.72%, 1 155/6 908), the appropriate GWG group (43.11%, 2 978/6 908), the excessive GWG group (40.17%, 2 775/6 908). Unadjusted and adjusted odds ratio ( OR ) and confidence interval ( CI ) of the risk of emergency cesarean section were calculated by bivariate logistic regression. Results: (1) Comparing to the vaginal delivery group, women in the emergency cesarean section group were older, with a lower education level. Their prepregnancy BMI was higer and had more gestational weight gain. They had higher morbidity of pregnancy induced hypertension and gestational diabetes mellitus. Comparing to the vaginal delivery group, the neonates in the emergency cesarean section group were elder in gestational week, with higher birth weight. More male infants and large for gestation age infants were seen in the emergency cesarean section group (all P <0.05) . (2) Overweight and obesity were associated with the increased risk of emergency cesarean section for nullipara, with the unadjusted

Likelihood of cesarean delivery after applying leading active labor diagnostic guidelines.

PubMed

Neal, Jeremy L; Lowe, Nancy K; Phillippi, Julia C; Ryan, Sharon L; Knupp, Amy M; Dietrich, Mary S; Thung, Stephen F

2017-06-01

Friedman, the United Kingdom's National Institute for Health and Care Excellence (NICE), and the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) support different active labor diagnostic guidelines. Our aims were to compare likelihoods for cesarean delivery among women admitted before vs in active labor by diagnostic guideline (within-guideline comparisons) and between women admitted in active labor per one or more of the guidelines (between-guideline comparisons). Active labor diagnostic guidelines were retrospectively applied to cervical examination data from nulliparous women with spontaneous labor onset (n = 2573). Generalized linear models were used to determine outcome likelihoods within- and between-guideline groups. At admission, 15.7%, 48.3%, and 10.1% of nulliparous women were in active labor per Friedman, NICE, and ACOG/SMFM diagnostic guidelines, respectively. Cesarean delivery was more likely among women admitted before vs in active labor per the Friedman (AOR 1.75 [95% CI 1.08-2.82] or NICE guideline (AOR 2.55 [95% CI 1.84-3.53]). Between guidelines, cesarean delivery was less likely among women admitted in active labor per the NICE guideline, as compared with the ACOG/SMFM guideline (AOR 0.55 [95% CI 0.35-0.88]). Many nulliparous women are admitted to the hospital before active labor onset. These women are significantly more likely to have a cesarean delivery. Diagnosing active labor before admission or before intervention to speed labor may be one component of a multi-faceted approach to decreasing the primary cesarean rate in the United States. The NICE diagnostic guideline is more inclusive than Friedman or ACOG/SMFM guidelines and its use may be the most clinically useful for safely lowering cesarean rates. © 2017 Wiley Periodicals, Inc.

Accuracy of Blood Loss Measurement during Cesarean Delivery.

PubMed

Doctorvaladan, Sahar V; Jelks, Andrea T; Hsieh, Eric W; Thurer, Robert L; Zakowski, Mark I; Lagrew, David C

2017-04-01

Objective  This study aims to compare the accuracy of visual, quantitative gravimetric, and colorimetric methods used to determine blood loss during cesarean delivery procedures employing a hemoglobin extraction assay as the reference standard. Study Design  In 50 patients having cesarean deliveries blood loss determined by assays of hemoglobin content on surgical sponges and in suction canisters was compared with obstetricians' visual estimates, a quantitative gravimetric method, and the blood loss determined by a novel colorimetric system. Agreement between the reference assay and other measures was evaluated by the Bland-Altman method. Results  Compared with the blood loss measured by the reference assay (470 ± 296 mL), the colorimetric system (572 ± 334 mL) was more accurate than either visual estimation (928 ± 261 mL) or gravimetric measurement (822 ± 489 mL). The correlation between the assay method and the colorimetric system was more predictive (standardized coefficient = 0.951, adjusted R 2  = 0.902) than either visual estimation (standardized coefficient = 0.700, adjusted R 2  = 00.479) or the gravimetric determination (standardized coefficient = 0.564, adjusted R 2  = 0.304). Conclusion  During cesarean delivery, measuring blood loss using colorimetric image analysis is superior to visual estimation and a gravimetric method. Implementation of colorimetric analysis may enhance the ability of management protocols to improve clinical outcomes.

Accuracy of Blood Loss Measurement during Cesarean Delivery

PubMed Central

Doctorvaladan, Sahar V.; Jelks, Andrea T.; Hsieh, Eric W.; Thurer, Robert L.; Zakowski, Mark I.; Lagrew, David C.

2017-01-01

Objective This study aims to compare the accuracy of visual, quantitative gravimetric, and colorimetric methods used to determine blood loss during cesarean delivery procedures employing a hemoglobin extraction assay as the reference standard. Study Design In 50 patients having cesarean deliveries blood loss determined by assays of hemoglobin content on surgical sponges and in suction canisters was compared with obstetricians' visual estimates, a quantitative gravimetric method, and the blood loss determined by a novel colorimetric system. Agreement between the reference assay and other measures was evaluated by the Bland–Altman method. Results Compared with the blood loss measured by the reference assay (470 ± 296 mL), the colorimetric system (572 ± 334 mL) was more accurate than either visual estimation (928 ± 261 mL) or gravimetric measurement (822 ± 489 mL). The correlation between the assay method and the colorimetric system was more predictive (standardized coefficient = 0.951, adjusted R2 = 0.902) than either visual estimation (standardized coefficient = 0.700, adjusted R2 = 00.479) or the gravimetric determination (standardized coefficient = 0.564, adjusted R2 = 0.304). Conclusion During cesarean delivery, measuring blood loss using colorimetric image analysis is superior to visual estimation and a gravimetric method. Implementation of colorimetric analysis may enhance the ability of management protocols to improve clinical outcomes. PMID:28497007

Assessing the role of case mix in cesarean delivery rates.

PubMed

Lieberman, E; Lang, J M; Heffner, L J; Cohen, A

1998-07-01

Implicit in comparisons of unadjusted cesarean rates for hospitals and providers is the assumption that differences result from management practices rather than differences in case mix. This study proposes a method for comparison of cesarean rates that takes the effect of case mix into account. All women delivered of infants at our institution from December 1, 1994, through July 31, 1995, were classified according to whether they received care from community-based practitioners (N=3913) or from the hospital-based practice that serves a higher-risk population (N=1556). Women were categorized according to both obstetric history (nulliparas, multiparas without a previous cesarean, multiparas with a previous cesarean) and the presence of obstetric conditions influencing the risk of cesarean delivery (multiple birth, breech presentation or transverse lie, preterm, no trial of labor for a medical indication). We determined the percent of women in each parity-obstetric condition subgroup and calculated a standardized cesarean rate for the hospital-based practice using the case mix of the community-based practitioners as the standard. The crude cesarean rate was higher for the hospital-based practice (24.4%) than for the community-based practitioners (21.5%), a rate difference of 2.9% (95% confidence interval=0.4%, 5.4%; P=.02). However, the proportion of women falling into categories conferring a high risk of cesarean delivery (multiple pregnancy, breech presentation or transverse lie, preterm, no trial of labor permitted) was twice as high for the hospital-based practice (24.4% hospital, 12.1% community). The standardization indicates that if the hospital-based practitioners had the same case mix as community-based practitioners, their overall cesarean rate would be 20.1%, similar to the 21.5% rate of community providers (rate difference=-1.4%, 95% confidence interval =-3.1%, 0.3%; P=.11). Standardization for case mix provides a mechanism for distinguishing differences

A Native American Community with a 7% Cesarean Delivery Rate: Does Case Mix, Ethnicity, or Labor Management Explain the Low Rate?

PubMed Central

Leeman, Lawrence; Leeman, Rebecca

2003-01-01

PURPOSE Cesarean delivery rates vary widely across populations. Studying communities with low rates of cesarean delivery may identify practices that can lower the cesarean rate. METHODS A population-based historical cohort study included all pregnant women (N = 1132) from 1992 through 1996 in a predominantly Native American region of northwestern New Mexico known to have a high prevalence of gestational diabetes and preeclampsia. The outcomes studied included delivery type (eg, cesarean, operative vaginal, spontaneous vaginal), indication for cesarean delivery, presence of obstetrical risk factors, and use of labor induction or augmentation. RESULTS The cesarean delivery rate of the study group (7.3%) was only 35% of the 1996 US rate of 20.7%. Among study participants, the relative risk of a primary cesarean delivery for dystocia was 0.22 (95% CI, 0.14, 0.35). Trial of labor after cesarean delivery was attempted by 93% of study participants compared with 42% of women nationwide in 1994. The cesarean delivery rates for women with diabetes in pregnancy (11.5% versus 35.4%) and preeclampsia (14.8% versus 37.4%) were significantly lower than nationwide rates. Case-mix analysis comparison with a standardized population and comparison of standard (ie, term, singleton, vertex) primiparous women demonstrate that the low rate of cesarean delivery was not because of a lower prevalence of risk factors. CONCLUSIONS The community’s low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery. PMID:15043178

A Native American community with a 7% cesarean delivery rate: does case mix, ethnicity, or labor management explain the low rate?

PubMed

Leeman, Lawrence; Leeman, Rebecca

2003-01-01

Cesarean delivery rates vary widely across populations. Studying communities with low rates of cesarean delivery may identify practices that can lower the cesarean rate. A population-based historical cohort study included all pregnant women (N = 1132) from 1992 through 1996 in a predominantly Native American region of northwestern New Mexico known to have a high prevalence of gestational diabetes and preeclampsia. The outcomes studied included delivery type (eg, cesarean, operative vaginal, spontaneous vaginal), indication for cesarean delivery, presence of obstetrical risk factors, and use of labor induction or augmentation. The cesarean delivery rate of the study group (7.3%) was only 35% of the 1996 US rate of 20.7%. Among study participants, the relative risk of a primary cesarean delivery for dystocia was 0.22 (95% CI, 0.14, 0.35). Trial of labor after cesarean delivery was attempted by 93% of study participants compared with 42% of women nationwide in 1994. The cesarean delivery rates for women with diabetes in pregnancy (11.5% versus 35.4%) and preeclampsia (14.8% versus 37.4%) were significantly lower than nationwide rates. Case-mix analysis comparison with a standardized population and comparison of standard (ie, term, singleton, vertex) primiparous women demonstrate that the low rate of cesarean delivery was not because of a lower prevalence of risk factors. The community's low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.

Anesthesia for cesarean delivery in the Czech Republic: a 2011 national survey.

PubMed

Stourac, Petr; Blaha, Jan; Klozova, Radka; Noskova, Pavlina; Seidlova, Dagmar; Brozova, Lucie; Jarkovsky, Jiri

2015-06-01

The purpose of this national survey was to determine current anesthesia practices for cesarean delivery in the Czech Republic. In November 2011, we invited all departments of obstetric anesthesia in the Czech Republic to participate in a prospective study to monitor consecutive peripartum obstetric anesthesia procedures. Data were recorded online in the TrialDB database (Yale University, New Haven, CT). The response rate was 51% (49 of 97 departments); participating centers represented 60% of all births in the country during the study period. There were 1943 cases of peripartum anesthesia care, of which 1166 cases (60%) were anesthesia for cesarean delivery. Estimates were weighted based on population distribution of cesarean delivery among types of participating centers. Neuraxial anesthesia was used in 55.6% (95% confidence interval [CI], 52.8%-58.5%); the distribution of anesthesia techniques differed among type of participating center. The rate of neuraxial anesthesia in university hospitals was 55.6% (95% CI, 51.5%-59.6%), 32.4% (95% CI, 26.4%-39.0%) in regional hospitals, and 60.7% (95% CI, 55.2%-66.0%) in local hospitals. The reasons for cesarean delivery under general anesthesia were emergency procedure (67%), refusal of neuraxial blockade by parturient (30%), failure of neuraxial anesthesia (6%), and preoperative administration of low-molecular-weight heparin (3%). Postcesarean analgesia was primarily provided by systemic opioid (66%) and nonopioid analgesics (61%), solely or in combination. Epidural postoperative analgesia was used in 14% of cases. Compared with national neuraxial anesthesia rate data published in the 1990s (6.7% in 1993), there has been an upward trend in the use of neuraxial anesthesia for cesarean delivery during the 21st century (40.5% in 2000) in the Czech Republic. The rate of neuraxial anesthesia use for cesarean delivery has increased in the Czech Republic in the last 2 decades. However, the current rate of general anesthesia is

Vaginal delivery after Misgav-Ladach cesarean section--is the risk of uterine rupture acceptable?

PubMed

Hudić, Igor; Fatusić, Zlatan; Kamerić, Lejla; Misić, Mladen; Serak, Indira; Latifagić, Anela

2010-10-01

To evaluate whether the single-layer closure as is a routine by the Misgav-Ladach method compared to the double-layer closure as used by the Dörfler cesarean method is associated with an increased risk of uterine rupture in the subsequent pregnancy and delivery. The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina. All patients with one previous cesarean section who attempted vaginal birth following cesarean section were managed from 1 January 2002 to 31 December 2008. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous incision other than low transverse, gestational age at delivery less than 37 weeks and induction of delivery. We identified 448 patients who met inclusion criteria. We found that 303 patients had a single-layer closure (Misgav-Ladach) and 145 had a double-layer closure (Dörffler) of the previous uterine incision. There were 35 cases of uterine rupture. Of those patients with previous single-layer closure, 5.28% (16/303) had a uterine rupture compared to 13.11% (19/145) in the double-layer closure group (p<0.05). We have not found that a Misgav-Ladach cesarean section method (single-layer uterine closure) might be more likely to result in uterine rupture in women who attempted a vaginal birth after a previous cesarean delivery. This cesarean section method should find its confirmation in everyday clinical practice.

Efficacy and safety of remifentanil for analgesia in cesarean delivery

PubMed Central

Zhou, Xuan; Jin, Lian-jin; Hu, Chun-yang; Chen, Meng; Li, Ying; Zhang, Yue-shun

2017-01-01

Abstract Background: This study aimed to assess the efficacy and safety of remifentanil as a general anesthetic during cesarean delivery. Material and Methods: Fifty women with singleton pregnancies undergoing cesarean delivery were randomly divided into intervention and control groups, each group containing 25 subjects. Participants in the intervention group received remifentanil (infused at 2 μg/kg/h), whereas subjects in the control group were given dexmedetomidine (infused at 0.4 μg/kg/h). Outcome measurements included mean arterial blood pressure (MAP), heart rate (HR), bispectral index (BIS), Apgar scores at 1 and 5 minutes, and the pH, PCO2, PO2, and base excess (BE) of umbilical venous and arterial blood. Results: Forty-four participants completed the study. Patients in the intervention group did not experience greater effect and safety than those in the control group (P > .05), although MAP and BIS values decreased significantly immediately before laryngoscopy (P < .05). In addition, BIS values were reduced significantly at the time of skin incision, at uterine incision, and immediately after fetal delivery when compared with baseline values in both groups (P < .01). Conclusion: This study concluded that remifentanil and dexmedetomidine exhibited similar efficacy and safety during general anesthesia for cesarean delivery. PMID:29310326

Effects of maternal characteristics on cesarean delivery rates among U.S. Department of Defense healthcare beneficiaries, 1996-2002.

PubMed

Linton, Andrea; Peterson, Michael R; Williams, Thomas V

2004-03-01

National rates of cesarean birth continue a three decade-long escalation, despite widespread recognition that a reduction in the use of the procedure is a continuing appropriate public health goal, as evidenced by the Healthy People 2010 reduction targets. Nonclinical factors associated with cesarean delivery include maternal age, race, socioeconomic status, and insurance coverage. This study compared cesarean delivery rates and trends for the U.S. Department of Defense healthcare beneficiary population from 1996 to 2002 with those observed nationally, and assessed the association of these nonclinical factors with cesarean rate variation in the U.S. Department of Defense healthcare beneficiary population. Hospital discharge and claims records for babies born in the military and civilian hospitals that comprise the Department of Defense healthcare network were used to calculate total and primary cesarean delivery rates and vaginal birth after cesarean (VBAC) rates from 1996 to 2002. Annual cesarean rates for subgroups defined by maternal age, race, and socioeconomic status were calculated to examine rate variations and rate trends within the study population. Pooled data from 1999 to 2002 were used to compare rates across socioeconomic status, stratified by age and race. Statistical significance of the differences calculated for subgroups was assessed using chi-square. Total and primary cesarean delivery rates among the U.S. Department of Defense population were lower than those reported nationally for every year examined. Cesarean delivery and VBAC rate trends in the national and Department of Defense populations were similar. Within the Department of Defense population, total cesarean delivery increased with increasing maternal age and was more highly associated with racial minorities relative to white women. The higher socioeconomic subgroup (defined as active duty, retired, and warrant officers and their families in this study) was generally associated with

Institutional setting and wealth gradients in cesarean delivery rates: Evidence from six developing countries.

PubMed

Sepehri, Ardeshir

2018-06-01

The influence of the type of institutional setting on cesarean delivery is well documented. However, the traditional boundaries between public and private providers have become increasingly blurred with the commercialization of the state health sector that allows providers to tailor the quantity and quality of care according to patients' ability to pay. This study examined wealth-related variations in cesarean rates in six lower- and upper-middle income countries: the Dominican Republic, Egypt, Guatemala, Jordan, Pakistan, and the Philippines. Demographic and Health Survey data and a hierarchical regression model were used to assess wealth-related variations in cesarean rates in government and private hospitals while controlling for a wide range of women's socioeconomic and risk profiles. The odds of undergoing a cesarean delivery were greater in private facilities than government hospitals by 58% in Jordan, 129% in Guatemala, and 262% and 279% in the Dominican Republic and Egypt, respectively. Additional analysis involving interactions between the type of facility and wealth quintiles indicated that wealthier women were more likely to undergo a cesarean birth in government hospitals than poorer women in all countries but the Dominican Republic and Guatemala. Moreover, in both Egypt and Jordan, differences in cesarean rates between government and private hospitals were smaller for the wealthier strata than for the nonwealthy. Large wealth-related variations in the mode of delivery across government and private hospitals suggest the need for well-developed guidelines and standards to achieve a more appropriate selection of cases for cesarean delivery. © 2018 Wiley Periodicals, Inc.

Risks of adverse outcomes in the next birth after a first cesarean delivery.

PubMed

Kennare, Robyn; Tucker, Graeme; Heard, Adrian; Chan, Annabelle

2007-02-01

To estimate the risks of cesarean first birth, compared with vaginal first birth, for adverse obstetric and perinatal outcomes in the second birth. Population-based retrospective cohort study of all singleton, second births in the South Australian perinatal data collection 1998 to 2003 comparing outcomes for 8,725 women who underwent a cesarean delivery for their first birth with 27,313 women who underwent a vaginal first birth. Predictor variables include age, indigenous status, smoking, pregnancy interval, medical and obstetric complications, gestation, patient type, hospital category, and history of ectopic pregnancy, miscarriage, stillbirth or termination of pregnancy. The cesarean delivery cohort had increased risks for malpresentation (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.65-2.06), placenta previa (OR 1.66, 95% CI 1.30-2.11), antepartum hemorrhage (OR 1.23, 95% CI 1.08-1.41), placenta accreta (OR 18.79, 95% CI 2.28-864.6), prolonged labor (OR 5.89, 95% CI 3.91-8.89), emergency cesarean (relative risk 9.37, 95% CI 8.98-9.76) and uterine rupture (OR 84.42, 95% CI 14.64-infinity), preterm birth (OR 1.17, 95% CI 1.04-1.31), low birth weight (OR 1.30, 95% CI 1.14-1.48), small for gestational age (OR 1.12, 95% CI 1.02-1.23), stillbirth (OR 1.56, 95% CI 1.04-2.32), and unexplained stillbirth (OR 2.34, 95% CI 1.26-4.37). The range of the number of primary cesarean deliveries needed to harm included 134 for one additional preterm birth, up to 1,536 for one additional placenta accreta. Cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean. II.

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version.

PubMed

de Hundt, Marcella; Vlemmix, Floortje; Bais, Joke M J; de Groot, Christianne J; Mol, Ben Willem; Kok, Marjolein

2016-01-01

Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2-6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1-8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.

State variation in rates of cesarean and VBAC delivery: 1989 and 1993.

PubMed

Clarke, S C; Taffel, S M

1996-01-01

There is wide variation among states in rates of cesarean and vaginal births after cesarean (VBAC) deliveries. In general, states in the South have the highest cesarean rates, states in the West have the lowest, and states in the Northeast and Midwest are intermediate. Louisiana had the highest overall rate in 1993 (27.7 per 100 births) while Alaska had the lowest rate (15.2). The majority of states had declines in their cesarean rate between 1989 and 1993. Patterns in primary cesarean rates are similar to those of the overall rate-states in the South generally have the highest rates while states in the West have the lowest rates. Primary cesarean rates ranged between a high of 19.6 in Louisiana to a low of 10.6 in Wisconsin. In general, states with low cesarean rates have among the highest rates of VBAC delivery. Alaska had the highest VBAC rate (40.0), which was almost quadruple the rate of Louisiana (11.2), the state with the lowest rate. Most states had substantial increases in VBAC rates between 1989 and 1993. When examining cesarean rates by maternal age and birth order, states with the highest overall rates also have among the highest age/birth order-specific rates. Cesarean rates were lowest for mothers under 25 years of age having a second or higher order birth in Alaska, 10.4, and highest for mothers 35 years of age or over having a first birth in Mississippi, 51.3. Standardized cesarean rates which were adjusted for differences between states in maternal age and birth order distributions did not diminish the variation among areas.

Association of cesarean delivery with anemia in infants and children in 2 large longitudinal Chinese birth cohorts.

PubMed

Li, Hong-tian; Trasande, Leonardo; Zhu, Li-ping; Ye, Rong-wei; Zhou, Yu-bo; Liu, Jian-meng

2015-03-01

Cesarean delivery may reduce placental-fetal transfusion and thus increase the risk of early childhood anemia compared with vaginal delivery, but this notion has not been carefully studied in longitudinal cohorts. The aim was to assess the association of cesarean delivery with anemia in infants and children in 2 longitudinal Chinese birth cohorts from different socioeconomic settings. Cohort 1 was recruited from 5 counties in northeastern China and cohort 2 from 21 counties or cities in southeastern China. Cohort 1 involved 17,423 infants born during 2006-2009 to mothers with early pregnancy baseline hemoglobin concentrations ranging from 100 to 177 g/L, whereas cohort 2 involved 122,777 children born during 1993-1996 to mothers with baseline hemoglobin concentrations ranging from 60 to 190 g/L. The main outcomes were anemia at 6 and 12 mo in cohort 1 and at 58 mo in cohort 2. Multiple logistic regressions were used to estimate adjusted ORs of anemia for cesarean compared with vaginal delivery. Stratified analyses were performed by pre- and postlabor cesarean delivery and according to maternal baseline hemoglobin concentration (≤109, 110-119, 120-129, and ≥130 g/L). Cesarean delivery was not associated with anemia at 6 mo in cohort 1 (adjusted OR: 1.05; 95% CI: 0.93, 1.19); however, cesarean delivery was associated with increased anemia at 12 mo in cohort 1 (adjusted OR: 1.19; 95% CI: 1.04, 1.37) and at 58 mo in cohort 2 (adjusted OR: 1.11; 95% CI: 1.08, 1.15). The positive associations for anemia at 12 and 58 mo were consistent across maternal hemoglobin subgroups and persisted for cesarean delivery subtypes. Cesarean delivery is likely associated with anemia in children, which suggests a possible need for exploring changes in obstetric care that might prevent anemia in cesarean-delivered children. © 2015 American Society for Nutrition.

Cesarean delivery on maternal request: wise use of finite resources? A view from the trenches.

PubMed

Druzin, Maurice L; El-Sayed, Yasser Y

2006-10-01

Cesarean section rates are rising in the United States and were at an all time high of 29 percent in 2004. Within this context, the issue of cesarean section on maternal request has been described as being part of a "perfect storm" of medical, legal and personal choice issues, and the lack of an opposing view. An increasing cesarean section rate adds an economic burden on already highly stressed medical systems. There is an incremental cost of cesarean section compared to vaginal delivery. The issue of cost must also be considered more broadly. Rising cesarean section rates are associated with a longer length of stay and a higher occupancy rate. This high occupancy rate leads to the diversion of critical care obstetric transports and has dramatically reduced patient satisfaction. These diversions, and the resultant inability to provide needed care to pregnant women, represent a profound societal cost. These critical care diversions and reduced patient satisfaction also negatively impact a health care institution's financial bottom line and competitiveness. The impact of a rising cesarean section rate on both short and long-term maternal and neonatal complications, and their associated costs, must also be taken into account. The incidence of placenta accreta is increasing in conjunction with the rising cesarean section rate. The added costs associated with this complication (MRI, Interventional Radiology, transfusion, hysterectomy, and intensive care admission) can be prohibitive. It has also been demonstrated that infants born by scheduled cesarean delivery are more likely to require advanced nursery support (with all its associated expense) than infants born to mothers attempting vaginal delivery. The practice of maternal request cesarean section, with limited good data and obvious inherent risk and expense, is increasing in the USA. Patient autonomy and a woman's right to choose her mode of delivery should be respected. However, in our opinion, based on the

Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism.

PubMed

Lange, Elizabeth M S; Toledo, Paloma; Stariha, Jillian; Nixon, Heather C

2016-08-01

The literature on the anesthetic management of parturients with dwarfism is sparse and limited to isolated case reports. Pregnancy complications associated with dwarfism include an increased risk of respiratory compromise, an increased risk of Cesarean delivery, and an unpredictable degree of anesthesia with neuraxial techniques. Therefore, we conducted this retrospective review to evaluate the anesthetic management of parturients with a diagnosis of dwarfism. We used a query of billing data to identify short statured women who underwent a Cesarean delivery during May 1, 2008 to May 1, 2013. We then hand searched the electronic medical record for qualifying patients with heights < 148 cm and a diagnosis of dwarfism. The extracted data included patient demographics and obstetric and anesthetic information. We identified 13 women with dwarfism who had 15 Cesarean deliveries in total. Twelve of the women had disproportionate dwarfism, and ten of the 15 Cesarean deliveries were due to cephalopelvic disproportion. Neuraxial anesthesia was attempted in 93% of deliveries. The dose chosen for initiation of neuraxial anesthesia was lower than the typical doses used in parturients of normal stature. Neuraxial anesthetic complications included difficult neuraxial placement (64%), high spinal (7%), inadequate surgical level (13%), and unrecognized intrathecal catheter (7%). The data collected suggest that females with a diagnosis of dwarfism may have difficult neuraxial placement and potentially require lower dosages of local anesthetic for both spinal and epidural anesthesia to achieve adequate surgical blockade.

Cesarean delivery rates among family physicians versus obstetricians: a population-based cohort study using instrumental variable methods

PubMed Central

Dawe, Russell Eric; Bishop, Jessica; Pendergast, Amanda; Avery, Susan; Monaghan, Kelly; Duggan, Norah; Aubrey-Bassler, Kris

2017-01-01

Background: Previous research suggests that family physicians have rates of cesarean delivery that are lower than or equivalent to those for obstetricians, but adjustments for risk differences in these analyses may have been inadequate. We used an econometric method to adjust for observed and unobserved factors affecting the risk of cesarean delivery among women attended by family physicians versus obstetricians. Methods: This retrospective population-based cohort study included all Canadian (except Quebec) hospital deliveries by family physicians and obstetricians between Apr. 1, 2006, and Mar. 31, 2009. We excluded women with multiple gestations, and newborns with a birth weight less than 500 g or gestational age less than 20 weeks. We estimated the relative risk of cesarean delivery using instrumental-variable-adjusted and logistic regression. Results: The final cohort included 776 299 women who gave birth in 390 hospitals. The risk of cesarean delivery was 27.3%, and the mean proportion of deliveries by family physicians was 26.9% (standard deviation 23.8%). The relative risk of cesarean delivery for family physicians versus obstetricians was 0.48 (95% confidence interval [CI] 0.41-0.56) with logistic regression and 1.27 (95% CI 1.02-1.57) with instrumental-variable-adjusted regression. Interpretation: Our conventional analyses suggest that family physicians have a lower rate of cesarean delivery than obstetricians, but instrumental variable analyses suggest the opposite. Because instrumental variable methods adjust for unmeasured factors and traditional methods do not, the large discrepancy between these estimates of risk suggests that clinical and/or sociocultural factors affecting the decision to perform cesarean delivery may not be accounted for in our database. PMID:29233843

Reverse Vesicouterine Fold Dissection for Laparoscopic Hysterectomy After Prior Cesarean Deliveries.

PubMed

Nezhat, Camran; Grace, Lindsey A; Razavi, Gity M; Mihailide, Catalina; Bamford, Holden

2016-09-01

Cesarean delivery adhesions, during laparoscopic hysterectomy, can present surgical challenges, including distortion of anatomy, prolonged operating time, and inadvertent injury to nearby structures. At the time of laparoscopic hysterectomy, in patients with significant adhesions from prior cesarean deliveries, we use a reverse inferior to superior vesicouterine fold dissection to mobilize the scarred bladder. We use this as an alternative to the commonly practiced technique of mobilizing the bladder in a superior to inferior fashion at the time of laparoscopic hysterectomy. Fifty-two patients with a median age of 42.5 years are presented. Forty-eight patients were discharged within 3-6 hours postoperatively. Sixteen patients were discharged with Foley catheters, because they were unable to void within the protocol for a fast-track discharge. The catheters were removed between postoperative days 1 and 5. There were no gastrointestinal or genitourinary complications. One patient experienced a delayed vaginal cuff abscess and bleeding, which were managed conservatively. Reverse vesicouterine fold dissection is a useful alternative technique for laparoscopic hysterectomy in women with a history of prior cesarean deliveries.

Comparison of Primary Cesarean Delivery Rates Among Low-Risk Women in Urban and Rural Hospitals in Hawaii.

PubMed

Chang, Ann Lee; Pacheco, Misty; Yoshino, Kurt; Miyamura, Jill; Maddock, Jay

2016-09-01

Objective The purpose of this study was to examine primary cesarean delivery rates among women with low risk pregnancies in urban and rural hospitals in Hawaii. Methods This is a retrospective study of all low-risk women (term, vertex, singleton) who had a primary cesarean delivery in any Hawaii hospital from 2010 to 2011 using a statewide health information database. Hospitals were divided into two categories: rural and urban. Results Of the 27,096 women who met criteria for this study, 7105 (26.2 %) delivered in a rural hospital. Low-risk women who delivered in a rural hospital had a primary cesarean delivery rate of 18.5 % compared to 11.8 % in the urban hospitals, p < .0001. Low-risk women who delivered at rural hospitals had significantly higher unadjusted and adjusted odds ratios for cesarean delivery. The association with rural hospital was stronger after adjusting for confounders, aOR 2.47 (95 % CI 2.23-2.73) compared to unadjusted OR 1.70 (95 % CI 1.58-1.83) for primary cesarean delivery. Conclusions on practice In a geographically isolated population, rates of primary cesarean delivery among low-risk women are significantly higher in rural hospitals. This disparity should be investigated further.

Asymptomatic bacteriuria screened by catheterized samples at pregnancy term in women undergoing cesarean delivery.

PubMed

Atacag, T; Yayci, E; Guler, T; Suer, K; Yayci, F; Deren, S; Cetin, A

2015-01-01

The objective of this study was to assess the frequency of urinary tract infection (UTI) with urine samples obtained via catheterization among women undergoing cesarean delivery at term pregnancy. A cross-sectional study involving 159 women in whom cesarean delivery was conducted at term pregnancy after a regular follow-up from first to third trimester. For screening and diagnosis of UTI during antenatal period, the authors used dipstick test and microscopic urinalysis, and urine culture was used in the presence of symptomatic UTI unresponsive to initial antibiotic therapy. A urine sample was obtained immediately after insertion of Foley catheter for urine dipstick test, microscopic urinalysis, and culture during cesarean delivery. Obstetric and UTI data were recorded. Of 159 pregnant women, 95 (59.8%) did not develop UTI during antenatal care. There was no patient with symptomatic UTI at the admission for cesarean delivery. The authors found UTI with urine dipstick and microscopic urinalysis in 12 patients and of them, four patients had no history of UTI, and all the remaining eight patients had asymptomatic UTI during antenatal follow-up. UTI according to urine culture was encountered in three patients, two of them had one episode of UTI, and one had two episodes of UTI during antenatal follow-up. After regular antenatal follow-up screening with urine dipstick, microscopic urinalysis, and counseling of pregnant women regarding UTIs, the frequency of bacteriuria decreases considerably during cesarean delivery.

Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures.

PubMed

Armstrong, Joanne C; Kozhimannil, Katy B; McDermott, Patricia; Saade, George R; Srinivas, Sindhu K

2016-02-01

This report describes the development of a measure of low-risk cesarean delivery by the Society for Maternal-Fetal Medicine (SMFM). Safely lowering the cesarean delivery rate is a priority for maternity care clinicians and health care delivery systems. Therefore, hospital quality assurance programs are increasingly tracking cesarean delivery rates among low-risk pregnancies. Two commonly used definitions of "low risk" are available, the Joint Commission (JC) and the Agency for Healthcare Research and Quality (AHRQ) measures, but these measures are not clinically comprehensive. We sought to refine the definition of the low-risk cesarean delivery rate to enhance the validity of the metric for quality measurement. We created this refined definition-called the SMFM definition-and compared it to the JC and AHRQ measures using claims-based data from the 2011 Nationwide Inpatient Sample of >863,000 births in 612 hospitals. Using these definitions, we calculated means and interquartile ranges (25th-75th percentile range) for hospital low-risk cesarean delivery rates, stratified by hospital size, teaching status, urban/rural location, and payer mix. Across all hospitals, the mean low-risk cesarean delivery rate was lowest for the SMFM definition (12.65%), but not substantially different from the JC and AHRQ measures (13.12% and 13.29%, respectively). We empirically examined the SMFM definition to ensure its validity and utility. This refined definition performs similarly to existing measures and has the added advantage of clinical perspective, enhanced face validity, and ease of use. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparison of Apgar scores in breech presentations between vaginal and cesarean delivery

PubMed Central

Fajar, Jonny Karunia; Andalas, Mohd; Harapan, Harapan

2017-01-01

Objective: The mode of delivery in breech presentation (BP) is controversial. Several studies have reported the advantages and disadvantages of delivery mode in BP. The aim of this study was to compare the Apgar scores in BPs between vaginal and cesarean delivery. Materials and Methods: A retrospective study was conducted at Dr. Zainoel Abidin General Hospital from January 2010 to December 2012. Data on the mode of delivery and Apgar scores at 1 and 5 min for infants with a BP were extracted from the medical records. Logistic regression was employed to assess the correlation between mode of delivery and Apgar scores. In addition, a meta-analysis was conducted to summarize findings from other regions. Results: A total of 205 (3.9%) BPs among 5252 deliveries between January 2010 and December 2012 were analyzed for this study. There were 26% (52 cases) vaginal and 74% (153 cases) cesarean deliveries. The mode of delivery for BP had a significant association with Apgar score at 1 min (odds ratio [OR] 95% confidence interval [CI] = 6.462 [2.476–16.870], P = 0.0001) and 5 min (OR 95% CI = 7.727 [1.416–42.175], P = 0.018). Our meta-analysis showed that the delivery mode had a significant association with Apgar score in BP (OR: 3.69; 95% CI: 2.18–6.26, P = 0.0001). Conclusions: There was a significant association between Apgar scores in BPs and mode of delivery. Our results suggest better outcomes for cesarean than vaginal delivery in BPs. PMID:28757760

Women's antenatal preferences for delivery route in a setting with high cesarean section rates and a medically dominated maternity system.

PubMed

Dweik, Diána; Girasek, Edmond; Töreki, Annamária; Mészáros, Gyula; Pál, Attila

2014-04-01

To assess birth preferences in a sample of Hungarian pregnant women and identify determinants of ambivalence or clear choices for cesarean section throughout pregnancy. Follow-up two-point questionnaire survey. University Department of Obstetrics and Gynecology in Hungary. A total of 413 women with singleton pregnancies where there was no awareness of medical contradictions to vaginal delivery, attending for routine ultrasound examination in mid-pregnancy from November 2011 to March 2012. Questionnaires completed in mid- and late pregnancy (gestational weeks 18-22 and 35-37) including the Wijma Delivery Expectancy/Experience Questionnaire A. Prevalence of women preferring cesarean section or being uncertain about what delivery route to choose, in case they had the choice; their demographic characteristics, attitudes toward birth issues and their Wijma Delivery Expectancy/Experience Questionnaire A scores, compared with women consistent in their preference for vaginal delivery. Of the 413 respondents, 365 (88.4%) were consistent in their preference for vaginal delivery. In logistic regression models the important contributors to describing preferences for cesarean section or uncertain preferences were previous cesarean section and maternal belief that cesarean section is more beneficial than vaginal delivery. The majority of pregnant women preferred vaginal delivery to cesarean section. Neither a higher Wijma Delivery Expectancy/Experience Questionnaire A score nor sociodemographic differences were important determinants of a preference for cesarean section or for an uncertain preference. On the other hand, previous cesarean section and certain preconceived maternal attitudes towards delivery were characteristic for these women. © 2014 Nordic Federation of Societies of Obstetrics and Gynecology.

Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis

PubMed Central

Mishanina, Ekaterina; Rogozinska, Ewelina; Thatthi, Tej; Uddin-Khan, Rehan; Khan, Khalid S.; Meads, Catherine

2014-01-01

Background: Induction of labour is common, and cesarean delivery is regarded as its major complication. We conducted a systematic review and meta-analysis to investigate whether the risk of cesarean delivery is higher or lower following labour induction compared with expectant management. Methods: We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery. Results: We identified 157 eligible RCTs (n = 31 085). Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management (pooled relative risk [RR] 0.88, 95% confidence interval [CI] 0.84–0.93; I2 = 0%). The effect was significant in term and post-term gestations but not in preterm gestations. Meta-regression analysis showed that initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25–0.99; I2 = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79–0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10–9.57; I2 = 0%) with labour induction. Interpretation: The risk of cesarean delivery was lower among women whose labour was induced than among those managed expectantly in term and post-term gestations. There were benefits for the fetus and no increased risk of maternal death. PMID:24778358

Induction of labor versus expectant management for women with a prior cesarean delivery.

PubMed

Palatnik, Anna; Grobman, William A

2015-03-01

Previous studies of induction of labor in the setting of trial of labor after cesarean have compared women undergoing trial of labor after cesarean to those undergoing spontaneous labor. However, the clinically relevant comparison is to those undergoing expectant management. The objective of this study was to compare obstetric outcomes between women undergoing induction of labor and those undergoing expectant management ≥39 weeks of gestation. This was a secondary analysis of data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Cesarean Registry that included women with singleton gestations at a gestational age of ≥39 weeks and a history of 1 low transverse cesarean delivery. Outcomes of induction at 39, 40, and 41 weeks were compared to expectant management beyond each gestational age period using univariable and multivariable analyses. Women with scheduled repeat cesarean deliveries done for the indication of prior cesarean delivery were excluded from the analysis. In all, 12,676 women were eligible for analysis. The rate of vaginal birth after cesarean (VBAC) was higher among women undergoing induction of labor at 39 weeks compared to expectant management (73.8% vs 61.3%, P < .001). The risk of uterine rupture also was higher among women undergoing induction of labor at 39 weeks compared to expectant management (1.4% vs 0.5%, P = .006, respectively). In multivariable analysis, induction of labor at 39 weeks remained associated with a significantly higher chance of VBAC and uterine rupture (odds ratio, 1.31; 95% confidence interval, 1.03-1.67; and odds ratio, 2.73; 95% confidence interval, 1.22-6.12, respectively). Induction of labor at 39 weeks, when compared to expectant management, was associated with a higher chance of VBAC but also of uterine rupture. Copyright © 2015 Elsevier Inc. All rights reserved.

Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial.

PubMed

Blanco, Rafael; Ansari, Tarek; Riad, Waleed; Shetty, Nanda

Effective postoperative analgesia after cesarean delivery enhances early recovery, ambulation, and breastfeeding. In a previous study, we established the effectiveness of the quadratus lumborum block in providing pain relief after cesarean delivery compared with patient-controlled analgesia (morphine). In the current study, we hypothesized that this method would be equal to or better than the transversus abdominis plane block with regard to pain relief and its duration of action after cesarean delivery. Between April 2015 and August 2015, we randomized 76 patients scheduled for elective cesarean delivery under spinal anesthesia to receive the quadratus lumborum block or the transversus abdominis plane block for postoperative pain relief. This trial was registered prospectively (NCT 02489851) [corrected]. Patients in the quadratus lumborum block group used significantly less morphine than the transversus abdominis plane block group (P < 0.05) at 12, 24, and 48 hours but not at 4 and 6 hours after cesarean delivery. This group also had significantly fewer morphine demands than the control group (P < 0.05) at 6, 12, 24, and 48 hours after cesarean delivery. No significant differences in visual analog scale results were shown between the 2 groups at rest or with movement. Calculated total pain relief at rest and with movement were similar (P < 0.001) in both groups. The quadratus lumborum block was more effective in reducing morphine consumption and demands than transversus abdominis plane blocks after cesarean section. This effect was observed up to 48 hours postoperatively.

Effect of early amniotomy on dystocia risk and cesarean delivery in nulliparous women: a randomized clinical trial.

PubMed

Ghafarzadeh, Masoomeh; Moeininasab, Samira; Namdari, Mehrdad

2015-08-01

Artificial rupture of amniotic membranes (amniotomy) which induces or accelerates labor is the most common obstetrical procedure. There is controversy about the effect of early amniotomy on dystocia and cesarean delivery. The study aim was to determine the effect of early amniotomy on the risk of dystocia and cesarean delivery in nulliparous women. This randomized controlled clinical trial was conducted on 300 nulliparous women. They were randomly assigned into the experimental (early amniotomy; artificial amniotomy at cervical dilation ≤ 4 cm) and control (routine management) groups (each 150 women). Length of labor, dystocia, cesarean delivery, placental abruption, and umbilical cord prolapse were compared between the groups. Early amniotomy shortened labor duration significantly in experimental group (7.5 ± 0.7 h) compared to control group (9.9 ± 1.0 h) (P < 0.001). Dystocia (6.7 vs. 25.3 %, P < 0.0001), cesarean delivery (11.3 vs. 39.3 %, P < 0.001), and placental abruption (4.7 vs. 13.3 %, P = 0.009) were significantly lower in experimental group compared to the control group. Multiple logistic regression showed that early amniotomy decreased the odds of dystocia 80.6 % (95 % CI 58.6-90.1 %) and the odds of cesarean section 81.7 % (95 % CI 66.2-90.1 %). Early amniotomy was associated with lower rate of dystocia and cesarean delivery as well as shorter duration of labor.

Reducing the cesarean delivery rates for breech presentations: administration of spinal anesthesia facilitates manipulation to cephalic presentation, but is it cost saving?

PubMed Central

2014-01-01

Background External cephalic version (ECV) is infrequently performed and 98% of breech presenting fetuses are delivered surgically. Neuraxial analgesia can increase the success rate of ECV significantly, potentially reducing cesarean delivery rates for breech presentation. The current study aims to determine whether the additional cost to the hospital of spinal anesthesia for ECV is offset by cost savings generated by reduced cesarean delivery. Methods In our tertiary hospital, three variables manpower, disposables, and fixed costs were calculated for ECV, ECV plus anesthetic doses of spinal block, vaginal delivery and cesarean delivery. Total procedure costs were compared for possible delivery pathways. Manpower data were obtained from management payroll, fixed costs by calculating cost/lifetime usage rate and disposables were micro-costed in 2008, expressed in 2013 NIS. Results Cesarean delivery is the most expensive option, 11670.54 NIS and vaginal delivery following successful ECV under spinal block costs 5497.2 NIS. ECV alone costs 960.21 NIS, ECV plus spinal anesthesia costs 1386.97 NIS. The highest individual cost items for vaginal, cesarean delivery and ECV were for manpower. Expensive fixed costs for cesarean delivery included operating room trays and postnatal hospitalization (minimum 3 days). ECV with spinal block is cheaper due to lower expected cesarean delivery rate and its lower associated costs. Conclusions The additional cost of the spinal anesthesia is offset by increased success rates for the ECV procedure resulting in reduction in the cesarean delivery rate. PMID:24564984

Fear of childbirth and risk of cesarean delivery: a cohort study in six European countries.

PubMed

Ryding, Elsa Lena; Lukasse, Mirjam; Parys, An-Sophie Van; Wangel, Anne-Marie; Karro, Helle; Kristjansdottir, Hildur; Schroll, Anne-Mette; Schei, Berit

2015-03-01

Few studies have examined the mode of birth among women with fear of childbirth, and the results are conflicting. The objective of this study was to assess the association between fear of childbirth and cesarean delivery in North European women. A longitudinal cohort study was conducted among 6,422 pregnant women from Belgium, Iceland, Denmark, Estonia, Norway, and Sweden. Fear of childbirth was measured by the Wijma Delivery Expectancy Questionnaire during pregnancy and linked to obstetric information from hospital records. Among 3,189 primiparous women, those reporting severe fear of childbirth were more likely to give birth by elective cesarean, (OR, 1.66 [95% CI 1.05-2.61]). Among 3,233 multiparous women, severe fear of childbirth increased the risk of elective cesarean (OR 1.87 [95% CI 1.30-2.69]). Reporting lack of positive anticipation, one of six dimensions of fear of childbirth, was most strongly associated with elective cesarean (OR 2.02 [95% CI 1.52-2.68]). A dose-effect pattern was observed between level of fear and risk of emergency cesarean in both primiparous and multiparous women. Indications for cesarean were more likely to be reported as "nonmedical" among those with severe fear of childbirth; 16.7 versus 4.6 percent in primiparous women, and 31.7 versus 17.5 percent in multiparous women. Having severe fear of childbirth increases the risk of elective cesarean, especially among multiparous women. Lack of positive anticipation of the upcoming childbirth seems to be an important dimension of fear associated with cesarean delivery. Counseling for women who do not look forward to vaginal birth should be further evaluated. © 2015 Wiley Periodicals, Inc.

Persistent opioid use following Cesarean delivery: patterns and predictors among opioid naïve women

PubMed Central

Bateman, Brian T.; Franklin, Jessica M.; Bykov, Katsiaryna; Avorn, Jerry; Shrank, William H.; Brennan, Troyen A.; Landon, Joan E.; Rathmell, James P.; Huybrechts, Krista F.; Fischer, Michael A.; Choudhry, Niteesh K.

2016-01-01

Background The incidence of opioid-related death in women has increased five-fold over the past decade. For many women, their initial opioid exposure will occur in the setting of routine medical care. Approximately 1 in 3 deliveries in the U.S. is by Cesarean and opioids are commonly prescribed for post-surgical pain management. Objective The objective of this study was to determine the risk that opioid naïve women prescribed opioids after Cesarean delivery will subsequently become consistent prescription opioid users in the year following delivery, and to identify predictors for this behavior. Study Design We identified women in a database of commercial insurance beneficiaries who underwent Cesarean delivery and who were opioid-naïve in the year prior to delivery. To identify persistent users of opioids, we used trajectory models, which group together patients with similar patterns of medication filling during follow-up, based on patterns of opioid dispensing in the year following Cesarean delivery. We then constructed a multivariable logistic regression model to identify independent risk factors for membership in the persistent user group. Results 285 of 80,127 (0.36%, 95% confidence interval 0.32 to 0.40), opioid-naïve women became persistent opioid users (identified using trajectory models based on monthly patterns of opioid dispensing) following Cesarean delivery. Demographics and baseline comorbidity predicted such use with moderate discrimination (c statistic = 0.73). Significant predictors included a history of cocaine abuse (risk 7.41%; adjusted odds ratio 6.11, 95% confidence interval 1.03 to 36.31) and other illicit substance abuse (2.36%; adjusted odds ratio 2.78, 95% confidence interval 1.12 to 6.91), tobacco use (1.45%; adjusted odds ratio 3.04, 95% confidence interval 2.03 to 4.55), back pain (0.69%; adjusted odds ratio 1.74, 95% confidence interval 1.33 to 2.29), migraines (0.91%; adjusted odds ratio 2.14, 95% confidence interval 1.58 to 2

Perioperative oxygen supplementation and surgical site infection after cesarean delivery: a randomized trial.

PubMed

Duggal, Neena; Poddatoori, Vineela; Poddatorri, Vineela; Noroozkhani, Sara; Siddik-Ahmad, R Iram; Caughey, Aaron B

2013-07-01

To evaluate whether supplemental perioperative oxygen decreases surgical site wound infections or endometritis. This was a prospective, randomized trial. Patients who were to undergo cesarean delivery were recruited and randomly allocated to either 30% or 80% oxygen during the cesarean delivery and for 1 hour after surgery. The obstetricians and patients were blinded to the concentration of oxygen used. Patients were evaluated for wound infection or endometritis during their hospital stay and by 6 weeks postpartum. The primary end point was a composite of either surgical site infection or endometritis. Eight hundred thirty-one patients were recruited. Of these, 415 participants received 30% oxygen perioperatively and 416 received 80% oxygen. The groups were well matched for age, race, parity, diabetes, number of previous cesarean deliveries, and scheduled compared with unscheduled cesarean deliveries. An intention-to-treat analysis was used. There was no difference in the primary composite outcome (8.2% in women who received 30% oxygen compared with 8.2% in women who received 80% oxygen, P=.89), no difference in surgical site infection in the two groups (5.5% compared with 5.8%, P=.98), and no significant difference in endometritis in the two groups (2.7% compared with 2.4%, P=.66), respectively. Women who received 80% supplemental oxygen perioperatively did not have a lower rate of a surgical site infection or endometritis as compared with women who received 30% supplemental oxygen concentration. ClinicalTrials.gov, www.clincaltrials.gov, NCT00876005. I.

Predicting the chance of vaginal delivery after one cesarean section: validation and elaboration of a published prediction model.

PubMed

Fagerberg, Marie C; Maršál, Karel; Källén, Karin

2015-05-01

We aimed to validate a widely used US prediction model for vaginal birth after cesarean (Grobman et al. [8]) and modify it to suit Swedish conditions. Women having experienced one cesarean section and at least one subsequent delivery (n=49,472) in the Swedish Medical Birth Registry 1992-2011 were randomly divided into two data sets. In the development data set, variables associated with successful trial of labor were identified using multiple logistic regression. The predictive ability of the estimates previously published by Grobman et al., and of our modified and new estimates, respectively, was then evaluated using the validation data set. The accuracy of the models for prediction of vaginal birth after cesarean was measured by area under the receiver operating characteristics curve. For maternal age, body mass index, prior vaginal delivery, and prior labor arrest, the odds ratio estimates for vaginal birth after cesarean were similar to those previously published. The prediction accuracy increased when information on indication for the previous cesarean section was added (from area under the receiver operating characteristics curve=0.69-0.71), and increased further when maternal height and delivery unit cesarean section rates were included (area under the receiver operating characteristics curve=0.74). The correlation between the individual predicted vaginal birth after cesarean probability and the observed trial of labor success rate was high in all the respective predicted probability decentiles. Customization of prediction models for vaginal birth after cesarean is of considerable value. Choosing relevant indicators for a Swedish setting made it possible to achieve excellent prediction accuracy for success in trial of labor after cesarean. During the delicate process of counseling about preferred delivery mode after one cesarean section, considering the results of our study may facilitate the choice between a trial of labor or an elective repeat cesarean

Diminishing availability of trial of labor after cesarean delivery in New Mexico hospitals.

PubMed

Leeman, Lawrence M; Beagle, Melissa; Espey, Eve; Ogburn, Tony; Skipper, Betty

2013-08-01

To examine the availability of trial of labor after cesarean delivery (TOLAC) in New Mexico from 1998 to 2012 and maternity care providers' perception of barriers to TOLAC. Hospital maternity unit directors were surveyed regarding TOLAC availability from 1998 to 2012. Maternity care providers (obstetrician-gynecologists, certified nurse-midwives, and family medicine physicians) were surveyed in 2008 regarding resources and barriers to providing TOLAC and emergency cesarean delivery. Trial of labor after cesarean delivery was available in 100% of counties with maternity care units in 1998 (22/22); by 2008, availability decreased to 32% (7/22). After changes in national guidelines, availability increased slightly to 9 of 22 (41%) in 2012. Barriers to TOLAC included anesthesia availability (88%), hospital and medical malpractice policies (80%), malpractice cost (69%), and obstetric surgeon availability (59%). In hospitals without TOLAC services, 73% of maternity care providers indicated a surgeon could be present in the hospital within 20 minutes of the emergency delivery decision; only 43% indicated obstetric anesthesia personnel could be present within 20 minutes (P<.001). Availability of TOLAC in New Mexico has decreased dramatically. Policy changes are needed to support TOLAC access in rural and community hospitals. III.

Using direct clinical observation to assess the quality of cesarean delivery in Afghanistan: an exploratory study

PubMed Central

2014-01-01

Background As part of a National Emergency Obstetric and Newborn Care (EmONC) Needs Assessment, a special study was undertaken in July 2010 to examine the quality of cesarean deliveries in Afghanistan and examine the utility of direct clinical observation as an assessment method in low-resource settings. Methods This cross-sectional assessment of the quality of cesareans at 14 facilities in Afghanistan included a survey of surgeons regarding their routine cesarean practices, direct observation of 29 cesarean deliveries and comparison of observations with facility records for 34 additional cesareans conducted during the 3 days prior to the observation period at each facility. For both observed cases and record reviews, we assessed time intervals between specified points of care-arrival to the ward, first evaluation, detection of a complication, decision for cesarean, incision, and birth. Results All time intervals with the exception of “decision to skin incision” were longer in the record reviews than in observed cases. Prior cesarean was the most common primary indication for all cases. All mothers in both groups observed survived through one hour postpartum. Among newborns there were two stillbirths (7%) in observed births and seven (21%) record reviews. Although our sample is too small to show statistical significance, the difference is noteworthy. In six of the reviewed cesareans resulting in stillbirth, a fetal heart rate was recorded in the operating theater, although four were recorded as macerated. For the two fresh stillbirths, the cesarean surgeries were recorded as scheduled and not urgent. Conclusions Direct observation of cesarean deliveries enabled us to assess a number of preoperative, postoperative, and intraoperative procedures that are often not described in medical records in low resource settings. Comparison of observations with findings from provider interviews and facility records allowed us to infer whether observed practices were typical

Pharmacoeconomic study comparing carbetocin with oxytocin for the prevention of hemorrhage following cesarean delivery in Lima, Peru.

PubMed

Caceda, Sonia Indacochea; Ramos, Richard Rubio; Saborido, Carlos Martín

2018-01-01

Postpartum hemorrhage is one of the main causes of maternal death. Oxytocin has traditionally been used to prevent postpartum hemorrhage. To compare oxytocin with carbetocin, a long-acting analog of oxytocin, for prevention of uterine hemorrhage after cesarean delivery. Clinical data were retrieved from the 2012 Cochrane meta-analysis "Carbetocin for preventing postpartum hemorrhage". A decision tree was constructed. The direct costs were those of medications from the Peruvian official price list (DIGEMID). Costs associated with additional oxytocic drugs, blood transfusions, postpartum hemorrhage kits and hysterectomy were obtained from Hospital Nacional Edgardo Rebagliati Martins. The perspective of the study was that of the payer. The time horizon for calculating quality-adjusted life years (QALYs) was 1 year (2015). Patients who received carbetocin required fewer additional uterotonic agents, had fewer hemorrhages and received fewer blood transfusions. Therefore, the costs associated with these interventions were lower. The incremental cost-effectiveness ratio was S/. 49,918 per QALY gained, which is lower than the threshold we estimated for Peru. Carbetocin is more cost-effective than oxytocin for prevention of uterine hemorrhage after cesarean delivery.

Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences

PubMed Central

2013-01-01

Background About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women´s preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women. Methods This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. The 1st phase of the study was carried out among readers of a popular Italian women´s magazine (Io Donna). In a 2nd phase, the study was complemented by a structured telephone interview. Results A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. The preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). The main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. The main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. The source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives

Cesarean Delivery Rates Vary 10-Fold Among US Hospitals; Reducing Variation May Address Quality, Cost Issues

PubMed Central

Kozhimannil, Katy Backes; Law, Michael R.; Virnig, Beth A.

2013-01-01

Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteen-fold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordination of maternity care, more data collection and measurement, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting. PMID:23459732

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

PubMed

Nilstun, Tore; Habiba, Marwan; Lingman, Göran; Saracci, Rodolfo; Da Frè, Monica; Cuttini, Marina

2008-06-17

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Delivery by Cesarean Section and Early Childhood Respiratory Symptoms and Disorders

PubMed Central

Magnus, Maria C.; Håberg, Siri E.; Stigum, Hein; Nafstad, Per; London, Stephanie J.; Vangen, Siri; Nystad, Wenche

2011-01-01

Studies have indicated that children delivered by cesarean section are at an increased risk of developing wheezing and asthma. This could be the result of an altered immune system development due to delayed gut colonization or of increased neonatal respiratory morbidity. The authors examined the associations between delivery by cesarean section and the development of wheezing, asthma, and recurrent lower respiratory tract infections in children up to 36 months of age among 37,171 children in the Norwegian Mother and Child Cohort Study. Generalized linear models were used in the multivariable analysis. Children delivered by cesarean section had an increased likelihood of current asthma at 36 months of age (relative risk = 1.17, 95% confidence interval: 1.03, 1.32), and the association was stronger among children of nonatopic mothers (relative risk = 1.33, 95% confidence interval: 1.12, 1.58). No increased risk of wheezing or recurrent lower respiratory tract infections was seen among children delivered by cesarean section. Findings were similar among children delivered by acute and elective cesarean section. In conclusion, children delivered by cesarean section may have an increased risk of current asthma at 36 months, but residual confounding cannot be excluded. In future prospective studies, investigators should reexamine this association in different age groups. PMID:22038100

Risk factors for wound disruption following cesarean delivery.

PubMed

Subramaniam, Akila; Jauk, Victoria C; Figueroa, Dana; Biggio, Joseph R; Owen, John; Tita, Alan T N

2014-08-01

Risk factors for post-cesarean wound infection, but not disruption, are well-described in the literature. The primary objective of this study was to identify risk factors for non-infectious post-cesarean wound disruption. Secondary analysis was conducted using data from a single-center randomized controlled trial of staple versus suture skin closure in women ≥24 weeks' gestation undergoing cesarean delivery. Wound disruption was defined as subcutaneous skin or fascial dehiscence excluding primary wound infections. Composite wound morbidity (disruption or infection) was examined as a secondary outcome. Patient demographics, medical co-morbidities, and intrapartum characteristics were evaluated as potential risk factors using multivariable logistic regression. Of the 398 randomized patients, 340, including 26 with disruptions (7.6%) met inclusion criteria and were analyzed. After multivariable adjustments, African-American race (aOR 3.9, 95% CI 1.1-13.8) and staple - as opposed to suture - wound closure (aOR 5.4, 95% CI 1.8-16.1) remained significant risk factors for disruption; non-significant increases were observed for body mass index ≥30 (aOR 2.1, 95% CI 0.6-7.5), but not for diabetes mellitus (aOR 0.9, 95% CI 0.3-2.9). RESULTS for composite wound morbidity were similar. Skin closure with staples, African-American race, and considering the relatively small sample size, potentially obesity are associated with increased risk of non-infectious post-cesarean wound disruption.

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.

Cesarean delivery on maternal request: Can the ethical problem be solved by the principlist approach?

PubMed Central

Nilstun, Tore; Habiba, Marwan; Lingman, Göran; Saracci, Rodolfo; Da Frè, Monica; Cuttini, Marina

2008-01-01

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice). Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging. PMID:18559083

Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial.

PubMed

Valent, Amy M; DeArmond, Chris; Houston, Judy M; Reddy, Srinidhi; Masters, Heather R; Gold, Alison; Boldt, Michael; DeFranco, Emily; Evans, Arthur T; Warshak, Carri R

2017-09-19

The rate of obesity among US women has been increasing, and obesity is associated with increased risk of surgical site infection (SSI) following cesarean delivery. The optimal perioperative antibiotic prophylactic regimen in this high-risk population undergoing cesarean delivery is unknown. To determine rates of SSI among obese women who receive prophylactic oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery. Randomized, double-blind clinical trial comparing oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery for the prevention of SSI in obese women (prepregnancy BMI ≥30) who had received standard intravenous preoperative cephalosporin prophylaxis. Randomization was stratified by intact vs rupture of membranes prior to delivery. The study was conducted at the University of Cincinnati Medical Center, Cincinnati, Ohio, an academic and urban setting, between October 2010 and December 2015, with final follow-up through February 2016. Participants were randomly assigned to receive oral cephalexin, 500 mg, and metronidazole, 500 mg (n = 202 participants), vs identical-appearing placebo (n = 201 participants) every 8 hours for a total of 48 hours following cesarean delivery. The primary outcome was SSI, defined as any superficial incisional, deep incisional, or organ/space infections within 30 days after cesarean delivery. Among 403 randomized participants who were included (mean age, 28 [SD, 6] years; mean BMI, 39.7 [SD, 7.8]), 382 (94.6%) completed the trial. The overall rate of SSI was 10.9% (95% CI, 7.9%-14.0%). Surgical site infection was diagnosed in 13 women (6.4%) in the cephalexin-metronidazole group vs 31 women (15.4%) in the placebo group (difference, 9.0% [95% CI, 2.9%-15.0%]; relative risk, 0.41 [95% CI, 0.22-0.77]; P = .01). There were no serious adverse events, including allergic reaction, reported in either the antibiotic group or the placebo group. Among obese women

The Brazilian Preference: Cesarean Delivery among Immigrants in Portugal

PubMed Central

Teixeira, Cristina; Correia, Sofia; Victora, César G.; Barros, Henrique

2013-01-01

Objective To evaluate how the country of origin affects the probability of being delivered by cesarean section when giving birth at public Portuguese hospitals. Study Design Women delivered of a singleton birth (n = 8228), recruited from five public level III maternities (April 2005–August 2006) during the procedure of assembling a birth cohort, were classified according to the country of origin and her migration status as Portuguese (n = 7908), non-Portuguese European (n = 84), African (n = 77) and Brazilian (n = 159). A Poisson model was used to evaluate the association between country of birth and cesarean section that was measured by adjusted prevalence ratio (PR) and respective 95% confidence intervals (95%CI). Results The cesarean section rate varied from 32.1% in non-Portuguese European to 48.4% in Brazilian women (p = 0.008). After adjustment for potential confounders and compared to Portuguese women as a reference, Brazilian women presented significantly higher prevalence of cesarean section (PR = 1.26; 95%CI: 1.08–1.47). The effect was more evident among multiparous women (PR = 1.39; 95%CI: 1.12–1.73) and it was observed when cesarean section was performed either before labor (PR = 1.43; 95%CI: 0.99–2.06) or during labor (PR = 1.30; 95%CI: 1.07–1.58). Conclusions The rate of cesarean section was significantly higher among Brazilian women and it was independent of the presence of any known risk factors or usual clinical indications, suggesting that cultural background influences the mode of delivery overcoming the expected standard of care and outcomes in public health services. PMID:23555912

Patient-Perceived Pressure from Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of U.S. Women

PubMed Central

Jou, Judy; Kozhimannil, Katy B; Johnson, Pamela Jo; Sakala, Carol

2015-01-01

Objective To determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures. Data Sources/Study Setting Listening to Mothers III, a nationally representative survey of women 18–45 years who delivered a singleton infant in a U.S. hospital July 2011–June 2012 (N = 2,400). Study Design Multivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure. Principal Findings Overall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5–5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3–3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2–8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4–11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0–11.3). Conclusions Patient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider–patient miscommunication and minimize potentially unnecessary procedures may be warranted. PMID:25250981

Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery.

PubMed

Shinar, Shiri; Blecher, Yair; Alpern, Sharon; Many, Ariel; Ashwal, Eran; Amikam, Uri; Cohen, Aviad

2017-05-01

Sterilization via bilateral total salpingectomy is slowly replacing partial salpingectomy, as it is believed to decrease the incidence of ovarian cancer. Our objective was to compare short-term intra and post-operative complication rates of bilateral total salpingectomy versus partial salpingectomy performed during the course of a cesarean delivery. A large series of tubal sterilizations during cesarean sections were studied in a single tertiary medical center between 1/2014 and 8/2016 before and after a policy change was made, switching from partial salpingectomy to total salpingectomy. Patients who underwent bilateral partial salpingectomy using the modified Pomeroy technique were compared with those who underwent total salpingectomy. Operative length, estimated blood loss, postpartum fever, wound infection, need for re-laparotomy, hospitalization length, and blood transfusions were compared. During the study period, 149 women met inclusion criteria. Fifty parturients underwent bilateral total salpingectomy and 99 underwent partial salpingectomy in the course of the cesarean section. Demographic, obstetrical, and surgical characteristics were similar in both groups. Mean cesarean section duration was comparable for partial salpingectomy and total salpingectomy (a median of 35 min in both groups, P = 0.92). Complications were rare in both groups with no significant differences in rates of postpartum fever, wound infection, re-laparotomy, hospitalization length, estimated blood loss, transfusions, and readmissions within 1-month postpartum. Rates of short-term complications are similar in patients undergoing bilateral partial salpingectomy and total salpingectomy during cesarean deliveries, making the latter a feasible alternative to the former.

Mifepristone combined with ethacridine lactate for the second-trimester pregnancy termination in women with placenta previa and/or prior cesarean deliveries.

PubMed

Chen, Chunqin; Lin, Feikai; Wang, Xiaoyun; Jiang, Yaping; Wu, Sufang

2017-01-01

This study was aimed to evaluate the safety and efficacy of the second-trimester medical abortions using mifepristone and ethacridine lactate in women with placenta previa and/or prior cesarean deliveries. The patients who underwent a second-trimester pregnancy termination from January 2009 to December 2015 were retrospectively analyzed. The eligible patients were assigned to four groups based on placentation and cesarean history. The abortion interval (AI), blood loss, hospital stays, incidence of curettage, and transfusion were reviewed. Two women underwent cesarean sections for placenta increta. Finally, 443 patients were enrolled in this study, including 92 with placenta previa, 153 with prior cesarean deliveries, 36 with the both factors, and 236 with normal placentation and no cesarean delivery history. All the included cases had a successful vaginal delivery. There was no significant difference in AI, hospital stay, rate of hemorrhage, and transfusion among the four groups. Patients with prior cesarean section had higher blood loss than the normal group (P = 0.0017), as well as patients with both placenta previa and prior cesarean (P = 0.0018). However, there was no obvious blood loss in patients with placenta previa when compared with normal placetal patients (P = 0.23). No uterine rupture occurred in all patients. Mifepristone combined with ethacridine lactate is safe and effective for patients with low placentation or/and prior cesarean in the second-trimester pregnancy termination.

The synergistic effect of breastfeeding discontinuation and cesarean section delivery on postpartum depression: A nationwide population-based cohort study in Korea.

PubMed

Nam, Jin Young; Choi, Young; Kim, Juyeong; Cho, Kyoung Hee; Park, Eun-Cheol

2017-08-15

The relationships between breastfeeding discontinuation and cesarean section delivery, and the occurrence of postpartum depression (PPD) remain unclear. Therefore, we aimed to investigate the association of breastfeeding discontinuation and cesarean section delivery with PPD during the first 6 months after delivery. Data were extracted from the Korean National Health Insurance Service-National Sample Cohort for 81,447 women who delivered during 2004-2013. PPD status was determined using the diagnosis code at outpatient or inpatient visit during the 6-month postpartum period. Breastfeeding discontinuation and cesarean section delivery were identified from prescription of lactation suppression drugs and diagnosis, respectively. Cox proportional hazards models were used to calculate adjusted hazard ratios. Of the 81,447 women, 666 (0.82%) had PPD. PPD risk was higher in women who discontinued breastfeeding than in those who continued breastfeeding (hazard ratio=3.23, P<0.0001), in women with cesarean section delivery than in those with vaginal delivery (hazard ratio=1.26, P=0.0040), and in women with cesarean section delivery who discontinued breastfeeding than in those with vaginal delivery who continued breastfeeding (hazard ratio=4.92, P<0.0001). Study limitations include low PPD incidence; use of indirect indicators for PPD, breastfeeding discontinuation, and working status, which could introduce selection bias and errors due to miscoding; and potential lack of adjustment for important confounders. Breastfeeding discontinuation and cesarean section delivery were associated with PPD during the 6-month postpartum period. Our results support the implementation of breastfeeding promoting policies, and PPD screening and treatment programs during the early postpartum period. Copyright © 2017 Elsevier B.V. All rights reserved.

Downward trends in surgical site and urinary tract infections after cesarean delivery in a French surveillance network, 1997-2003.

PubMed

Vincent, Agnès; Ayzac, Louis; Girard, Raphaële; Caillat-Vallet, Emmanuelle; Chapuis, Catherine; Depaix, Florence; Dumas, Anne-Marie; Gignoux, Chantal; Haond, Catherine; Lafarge-Leboucher, Joëlle; Launay, Carine; Tissot-Guerraz, Françoise; Fabry, Jacques

2008-03-01

To evaluate whether the adjusted rates of surgical site infection (SSI) and urinary tract infection (UTI) after cesarean delivery decrease in maternity units that perform active healthcare-associated infection surveillance. Trend analysis by means of multiple logistic regression. A total of 80 maternity units participating in the Mater Sud-Est surveillance network. A total of 37,074 cesarean deliveries were included in the surveillance from January 1, 1997, through December 31, 2003. We used a logistic regression model to estimate risk-adjusted post-cesarean delivery infection odds ratios. The variables included were the maternity units' annual rate of operative procedures, the level of dispensed neonatal care, the year of delivery, maternal risk factors, and the characteristics of cesarean delivery. The trend of risk-adjusted odds ratios for SSI and UTI during the study period was studied by linear regression. The crude rates of SSI and UTI after cesarean delivery were 1.5% (571 of 37,074 patients) and 1.8% (685 of 37,074 patients), respectively. During the study period, the decrease in SSI and UTI adjusted odds ratios was statistically significant (R=-0.823 [P=.023] and R=-0.906 [P=.005], respectively). Reductions of 48% in the SSI rate and 52% in the UTI rate were observed in the maternity units. These unbiased trends could be related to progress in preventive practices as a result of the increased dissemination of national standards and a collaborative surveillance with benchmarking of rates.

Effect of combined spinal-epidural analgesia in labor on frequency of emergency cesarean delivery among nulliparous Chinese women.

PubMed

Wang, Fen; Cao, Yun-Xia; Ke, Shan-Gao; Zhu, Tao-Hua; Zhang, Miao

2016-12-01

To determine whether combined spinal-epidural analgesia (CSEA) during labor increases the frequency of emergency cesarean delivery among Chinese nulliparous women. In a retrospective study, the medical records of nulliparous women with a singleton fetus in cephalic presentation who delivered at term at Tongling Maternity Hospital, China, between January 2012 and December 2014 were reviewed. Information about CSEA, mode of delivery, labor duration, oxytocin augmentation, and neonatal outcome was obtained. Logistic regression was used to examine independent associations between CSEA and emergency cesarean after controlling for confounding variables. Among 3456 women included, 1786 (51.7%) received CSEA and 1670 (48.3%) received no labor analgesia. Emergency cesarean was more frequent among CSEA users (219/1786 [12.3%]) than non-users (119/1670 [7.1%]; P<0.001). Among the maternal-fetal variables included in multivariate regression, maternal age, maternal height, cervical dilatation at admission, birth weight, and CSEA use were significantly associated with emergency cesarean. After adjustment, women with CSEA maintained a slightly increased risk for cesarean (adjusted odds ratio 1.54, 95% confidence interval 1.20-2.00). Among Chinese nulliparous women, use of CSEA for labor pain was associated with an increased risk of emergency cesarean delivery; moreover, this effect was maintained after adjustment for other potential obstetric risk factors. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Dinoprostone vaginal insert versus intravenous oxytocin to reduce postpartum blood loss following vaginal or cesarean delivery.

PubMed

Ozalp, E; Tanir, H M; Sener, T

2010-01-01

To compare the impact of a dinoprostone vaginal insert and intravenous oxytocin in reducing blood loss of women undergoing vaginal or cesarean delivery. This study was conducted among term singleton pregnancies delivered vaginally or by elective cesarean section. In the vaginally delivered cases, active management of the third stage of labor was conducted. During cesarean delivery, 20 IU of intravenous oxytocin was administered. Women, who either delivered via the vaginal or abdominal route, were then randomly allocated to receive 10 mg vaginal dinoprostone insert for 12 hours (group I, n: 100) or intravenous oxytocin (group II, n: 100), respectively. Mean blood loss and need for additional uterotonics and postpartum hemoglobin and hematocrit levels at 24 and 36 hours after delivery did not differ between the two groups. Women allocated to the dinoprostone vaginal insert arm experienced more nausea and vomiting. Dinoprostone vaginal insert was as effective as intravenous oxytocin in the prevention of postpartum blood loss.

Cultural implications of differing rates of medically indicated and elective cesarean deliveries for foreign-born versus native-born taiwanese mothers.

PubMed

Huang, Chun-Che; Li, Chung-Yi; Yang, Chiang-Hsing

2012-07-01

The study aimed to assess the number of medically indicated and elective cesarean deliveries among foreign-born and native-born mothers in Taiwan. National Health Insurance (NHI) inpatient datasets in Taiwan between 2001 and 2003 showed 673,830 singleton deliveries, of which 66,687 were to foreign-born mothers and 607,143 were to Taiwan-born mothers. Univariate and multivariate logistic regression models were used to estimate the likelihood of using inpatient services for medically indicated and elective cesarean delivery. During the study period, foreign-born mothers were significantly less likely to undergo medically indicated (odds ratio [OR], 0.82; 95% confidence interval (95% CI), 0.79-0.85) and elective (OR, 0.50; 95% CI, 0.47-0.53) cesarean delivery than Taiwan-born mothers after adjusting for clinical and nonclinical factors. Foreign-born mothers aged 18-50 years are less likely to undergo medically indicated and elective cesarean delivery under Taiwan's NHI coverage. As the birth rate for immigrant women increases, cross-cultural maternity care during pregnancy and childbirth for immigrant mothers needs to be addressed.

A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight.

PubMed

Lipschuetz, Michal; Cohen, Sarah M; Ein-Mor, Eliana; Sapir, Hanna; Hochner-Celnikier, Drorith; Porat, Shay; Amsalem, Hagai; Valsky, Dan V; Ezra, Yossef; Elami-Suzin, Matan; Paltiel, Ora; Yagel, Simcha

2015-12-01

Fetal size impacts on perinatal outcomes. We queried whether the fetal head, as the fetal part interfacing with the birth canal, might impact on obstetric outcomes more than birthweight (BW). We examined associations between neonatal head circumference (HC) and delivery mode and risk of perinatal complications as compared to high BW. This was an electronic medical records-based study of term singleton births (37-42 weeks' gestation) from January 2010 through December 2012 (N = 24,780, 6343 primiparae). We assessed risks of unplanned cesarean or instrumental delivery and maternal and fetal complications in cases with HC or BW ≥95th centile (large HC, high BW) vs those with parameters <95th centile (normal). Newborns were stratified into 4 subgroups: normal HC/normal BW (reference, n = 22,548, primiparae 5862); normal HC/high BW (n = 817, P = 213); large HC/normal BW (n = 878, P = 265); and large HC/high BW (n = 537, P = 103). Multinomial multivariable regression provided adjusted odds ratio (aOR) while controlling for potential confounders. Infants with HC ≥95th centile (n = 1415) were delivered vaginally in 62% of cases, unplanned cesarean delivery 16%, and instrumental delivery 11.2%; 78.4% of infants with HC <95th centile were delivered vaginally, 7.8% unplanned cesarean, and 6.7% instrumental delivery. Odds ratio (OR) for unplanned cesarean was 2.58 (95% confidence interval [CI], 2.22-3.01) and for instrumental delivery OR was 2.13 (95% CI, 1.78-2.54). In contrast, in those with BW ≥95th centile (n = 1354) 80.3% delivered vaginally, 10.2% by unplanned cesarean (OR, 1.2; 95% CI, 1.01-1.44), and 3.4% instrumental delivery (OR, 0.46; 95% CI, 0.34-0.62) compared to infants with BW <95th centile: spontaneous vaginal delivery, 77.3%, unplanned cesarean 8.2%, instrumental 7.1%. Multinomial regression with normal HC/normal BW as reference group showed large HC/normal BW infants were more likely to be delivered by unplanned cesarean (aOR, 3.08; 95% CI, 2

Cesarean childbirth in Puerto Rico: the facts.

PubMed

Vázquez-Calzada, J L

1997-12-01

According to the last Island-wide survey carried out in 1982 in Puerto Rico, the cesarean rate for the trienium of 1980-82 was estimated in 27 percent. Since 1989, an item about the type of delivery has been included in the live birth certificate. These data indicate that the incidence of cesarean deliveries continued to increase and by 1994 it amounted to 31 percent, undoubtedly the highest rate of the world. However, its fluctuation since 1990 suggests that this type of delivery has finally steadied in Puerto Rico. The high proportion of repeated cesareans and the low percentage of vaginal birth after cesarean (VBAC) deliveries were important factors contributing to the overall rate. Unexpectedly high risk mothers such as, adolescents, unwed and those of the lower socioeconomic status had highest cesarean rates than their encounterparts. Similarly, mothers who had the most adequate prenatal care had the highest percentages of surgical deliveries. In spite of dealing with a selected clientele, the cesarean rate in private hospitals was more than twice that of public institutions. In fact, a multiple correlation analysis demonstrate that the type of hospital of delivery was the most important correlate of a cesarean.

Cesarean scar ectopic pregnancy in a patient with multiple prior cesarean sections: a case report.

PubMed

Kiley, Jessica; Shulman, Lee P

2009-04-01

Cesarean scar pregnancy, an abnormal gestation implanted in the hysterotomy site of a previous cesarean section, is a unique type of ectopic pregnancy. Once uncommon, these life-threatening gestations are increasing in frequency. Outcomes depend on a high index of suspicion and early diagnosis. A 39-year-old, gravida 9, para 5-0-3-5, with a history of 5 cesarean deliveries, presented with vaginal bleeding secondary to cesarean scar pregnancy at 8 weeks' gestation. The patient, who desired future fertillty, was successfully treated conservatively with methotrexate and uterine artery embolization. Reports of cesarean scar pregnancies are rising in the literature, and we describe a scar pregnancy in a woman with multiple prior cesareans. Although the relationship between cesarean scar pregnancy and the number of previous cesarean deliveries is unclear, rising cesarean section rates worldwide will further increase overall incidence. The optimal treatment modality remains uncertain, but conservative management is appropriate when desired by the patient and administered under close observation.

The MFMU Cesarean Registry: uterine atony after primary cesarean delivery.

PubMed

Rouse, Dwight J; Leindecker, Sharon; Landon, Mark; Bloom, Steven L; Varner, Michael W; Moawad, Atef H; Spong, Catherine Y; Caritis, Steve N; Harper, Margaret; Wapner, Ronald J; Sorokin, Yoram; Miodovnik, Menachem; O'Sullivan, Mary Jo; Sibai, Baha M; Langer, Oded

2005-09-01

The purpose of this study was to define independent risk factors for uterine atony after primary cesarean delivery, and to assess their overall association with atony in the study cohort. This was a 13-university center prospective observational study. All women who underwent primary cesarean from January 1, 1999 to December 31, 2000 were eligible. Trained and certified research nurses performed systematic data abstraction. The definition of atony required both the clinical diagnosis and the use of methergine or a prostaglandin preparation. Risk factors for uterine atony were assessed in univariable and multivariable logistic regression analyses, and these analyses then used to inform an assessment of the association of the various risk factors with the occurrence of uterine atony in the overall cohort. Twenty-three thousand, three hundred and ninety pregnancies were analyzed. Uterine atony occurred in 1416 women (6%). Several variables were independently associated with atony in a multivariable model, including multiple gestation (odds ratio [OR] 2.40, 95% CI 1.95-2.93), maternal Hispanic race (2.21, 1.90-2.57), induced or augmented labor for >18 hours (2.23, 1.92-2.60), infant birth weight >4500 g (2.05, 1.53-2.69), and clinically diagnosed chorioamnionitis (1.80, 1.55-2.09). However, because the various risk factors were not very powerful, approximately half of the cases of atony were associated with the 2/3 of women lacking a given risk factor or combination of risk factors. Although certain risk factors and uterine atony were clearly associated, the associations are of limited practical clinical use.

A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery.

PubMed

Maged, Ahmed M; Helal, Omneya M; Elsherbini, Moutaz M; Eid, Marwa M; Elkomy, Rasha O; Dahab, Sherif; Elsissy, Maha H

2015-12-01

To study the efficacy and safety of preoperative intravenous tranexamic acid to reduce blood loss during and after elective lower-segment cesarean delivery. A single-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term singleton pregnancy at a center in Cairo, Egypt, between November 2013 and November 2014. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1g tranexamic acid or 5% glucose 15 minutes before surgery. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during cesarean, which was the primary outcome. Analyses included women who received their assigned treatment, whose surgery was 90 minutes or less, and who completed follow-up. Analyses included 100 women in each group. Mean EBL was significantly higher in the placebo group (700.3 ± 143.9 mL) than in the tranexamic acid group (459.4 ±7 5.4 mL; P<0.001). Only six women, all in the placebo group, experienced an EBL of more than 1000 mL. There were no reports of thromboembolic events up to 4 weeks postoperatively. Preoperative administration of tranexamic acid safely reduces blood loss during elective lower-segment cesarean delivery. Australian New Zealand Clinical Trials Registry:ACTRN12615000312549. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

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.

Relationship between Hospital Policies for Labor Induction and Cesarean Delivery and Perinatal Care Quality among Rural U.S. Hospitals.

PubMed

Kozhimannil, Katy B; Hung, Peiyin; Casey, Michelle M; Henning-Smith, Carrie; Prasad, Shailendra; Moscovice, Ira S

2016-01-01

Many hospitals are adopting quality improvement strategies in obstetrics. This study characterized rural U.S. hospitals based on their hospital staffing and clinical management policies for labor induction and cesarean delivery, and assessed the relationship between policies and performance on maternity care quality. We surveyed all 306 rural maternity hospitals in nine states and used data from the Healthcare Cost and Utilization Project Statewide Inpatient Database hospital discharge database. We found staffing policies were more prevalent at lower-volume hospitals (92% vs. 86% for cesarean and 82% vs. 79%, both p < .01). Using multivariable logistic regression, we found hospitals with policies for cesarean delivery had up to 24% lower odds of low-risk cesarean (adjusted odds ratio = 0.76; 95% confidence interval=[0.67-0.86]) and non-indicated cesarean (0.78 [0.70-0.88]), with variability across birth volume. Clinical management and staffing policies are common, but not universal, among rural U.S. hospitals providing obstetric services and are generally positively associated with quality.

Non-invasive mechanical ventilation with spinal anesthesia for cesarean delivery.

PubMed

Erdogan, G; Okyay, D Z; Yurtlu, S; Hanci, V; Ayoglu, H; Koksal, B; Turan, I O

2010-10-01

We present the successful use of perioperative non-invasive mechanical ventilation in a morbidly obese pregnant woman with bronchial asthma, severe preeclampsia and pulmonary edema undergoing an emergency cesarean delivery with spinal anesthesia. The combination of non-invasive mechanical ventilation with neuraxial anesthesia may be of value in selected parturients with acute or chronic respiratory insufficiency requiring surgery. Copyright © 2010 Elsevier Ltd. All rights reserved.

Prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: a systematic review and meta-analysis.

PubMed

Jauniaux, Eric; Bhide, Amar

2017-07-01

Women with a history of previous cesarean delivery, presenting with a placenta previa, have become the largest group with the highest risk for placenta previa accreta. The objective of the study was to evaluate the accuracy of ultrasound imaging in the prenatal diagnosis of placenta accreta and the impact of the depth of villous invasion on management in women presenting with placenta previa or low-lying placenta and with 1 or more prior cesarean deliveries. We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE for studies published between 1982 and November 2016. Criteria for the study were cohort studies that provided data on previous mode of delivery, placenta previa, or low-lying placenta on prenatal ultrasound imaging and pregnancy outcome. The initial search identified 171 records, of which 5 retrospective and 9 prospective cohort studies were eligible for inclusion in the quantitative analysis. The studies were scored on methodological quality using the Quality Assessment of Diagnostic Accuracy Studies tool. The 14 cohort studies included 3889 pregnancies presenting with placenta previa or low-lying placenta and 1 or more prior cesarean deliveries screened for placenta accreta. There were 328 cases of placenta previa accreta (8.4%), of which 298 (90.9%) were diagnosed prenatally by ultrasound. The incidence of placenta previa accreta was 4.1% in women with 1 prior cesarean and 13.3% in women with ≥2 previous cesarean deliveries. The pooled performance of ultrasound for the antenatal detection of placenta previa accreta was higher in prospective than retrospective studies, with a diagnostic odds ratios of 228.5 (95% confidence interval, 67.2-776.9) and 80.8 (95% confidence interval, 13.0-501.4), respectively. Only 2 studies provided detailed data on the relationship between the depth of villous invasion and the number of previous cesarean deliveries, independently of the depth of the villous invasion. A cesarean hysterectomy was performed in

Transecting versus avoiding incision of the anterior placenta previa during cesarean delivery.

PubMed

Verspyck, Eric; Douysset, Xavier; Roman, Horace; Marret, Stephane; Marpeau, Loïc

2015-01-01

To compare maternal outcomes after transection and after avoiding incision of the anterior placenta previa during cesarean delivery. In a retrospective study, records were reviewed for women who had anterior placenta previa and delivered by cesarean after 24 weeks of pregnancy at a tertiary center in Rouen, France. During period A (January 2000 to December 2006), the protocol was to systematically transect the placenta when it was unavoidable. During period B (January 2007 to December 2010), the technique was to avoid incision by circumventing the placenta and passing a hand around its margin. Logistic regression was used to identify independent risk factors associated with maternal transfusion of packed red blood cells. Eighty-four women were included (period A: n=43; period B: n=41). During period B, there was a reduction in frequency of intraoperative hemorrhage (>1000 mL) (P=0.02), intraoperative hemoglobin loss (P=0.005), and frequency of blood transfusion (P=0.02) as compared with period A. In multivariable analysis, period B was associated with a reduced risk of maternal transfusion (odds ratio 0.27; 95% confidence interval 0.09-0.82; P=0.02). Avoiding incision of the anterior placenta previa was found to reduce frequency of maternal blood transfusion during or after cesarean delivery. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Additive effect between IL-13 polymorphism and cesarean section delivery/prenatal antibiotics use on atopic dermatitis: a birth cohort study (COCOA).

PubMed

Lee, So-Yeon; Yu, Jinho; Ahn, Kang-Mo; Kim, Kyung Won; Shin, Youn Ho; Lee, Kyung-Shin; Hong, Seo Ah; Jung, Young-Ho; Lee, Eun; Yang, Song-I; Seo, Ju-Hee; Kwon, Ji-Won; Kim, Byoung-Ju; Kim, Hyo-Bin; Kim, Woo-Kyung; Song, Dae Jin; Jang, Gwang Cheon; Shim, Jung Yeon; Lee, Soo-Young; Kwon, Ja-Young; Choi, Suk-Joo; Lee, Kyung-Ju; Park, Hee Jin; Won, Hye-Sung; Yoo, Ho-Sung; Kang, Mi-Jin; Kim, Hyung-Young; Hong, Soo-Jong

2014-01-01

Although cesarean delivery and prenatal exposure to antibiotics are likely to affect the gut microbiome in infancy, their effect on the development of atopic dermatitis (AD) in infancy is unclear. The influence of individual genotypes on these relationships is also unclear. To evaluate with a prospective birth cohort study whether cesarean section, prenatal exposure to antibiotics, and susceptible genotypes act additively to promote the development of AD in infancy. The Cohort for Childhood of Asthma and Allergic Diseases (COCOA) was selected from the general Korean population. A pediatric allergist assessed 412 infants for the presence of AD at 1 year of age. Their cord blood DNA was subjected to interleukin (IL)-13 (rs20541) and cluster-of-differentiation (CD)14 (rs2569190) genotype analysis. The combination of cesarean delivery and prenatal exposure to antibiotics associated significantly and positively with AD (adjusted odds ratio, 5.70; 95% CI, 1.19-27.3). The association between cesarean delivery and AD was significantly modified by parental history of allergic diseases or risk-associated IL-13 (rs20541) and CD14 (rs2569190) genotypes. There was a trend of interaction between IL-13 (rs20541) and delivery mode with respect to the subsequent risk of AD. (P for interaction = 0.039) Infants who were exposed prenatally to antibiotics and were born by cesarean delivery had a lower total microbiota diversity in stool samples at 6 months of age than the control group. As the number of these risk factors increased, the AD risk rose (trend p<0.05). Cesarean delivery and prenatal antibiotic exposure may affect the gut microbiota, which may in turn influence the risk of AD in infants. These relationships may be shaped by the genetic predisposition.

Skin Preparation for Prevention of Surgical Site Infection After Cesarean Delivery: A Randomized Controlled Trial.

PubMed

Ngai, Ivan M; Van Arsdale, Anne; Govindappagari, Shravya; Judge, Nancy E; Neto, Nicole K; Bernstein, Jeffrey; Bernstein, Peter S; Garry, David J

2015-12-01

To compare chlorhexidine with alcohol, povidone-iodine with alcohol, and both applied sequentially to estimate their relative effectiveness in prevention of surgical site infections after cesarean delivery. Women undergoing nonemergent cesarean birth at greater than 37 0/7 weeks of gestation were randomly allocated to one of three antiseptic skin preparations: povidone-iodine with alcohol, chlorhexidine with alcohol, or the sequential combination of both solutions. The primary outcome was surgical site infection reported within the first 30 days postpartum. Based on a surgical site infection rate of 12%, an anticipated 50% reduction for the combination group relative to either single skin preparation group, with a power of 0.90 and an α of 0.05, 430 women per group were needed to detect a difference. From January 2013 to July 2014, 1,404 women were randomly assigned to one of three groups: povidone-iodine with alcohol (n=463), chlorhexidine with alcohol (n=474), or both (n=467). The groups were similar with respect to demographics, medical disorders, indication for cesarean delivery, operative time, and blood loss. The overall rate of surgical site infection-4.3%-was lower than anticipated. The skin preparation groups had similar surgical site infection rates: povidone-iodine 4.6%, chlorhexidine with alcohol 4.5%, and sequential 3.9% (P=.85). The skin preparation techniques resulted in similar rates of surgical site infections. Our study provides no support for any particular method of skin preparation before cesarean delivery. ClinicalTrials.gov, www.clinicaltrials.gov, NCT01870583. I.

Transvaginal ultrasonographic cervical measurement in predicting failed labor induction and cesarean delivery for failure to progress in nulliparous women.

PubMed

Park, Kyo Hoon

2007-08-01

The aim of this study was to evaluate the value of transvaginal sonographic cervical measurement in predicting failed labor induction and cesarean delivery for failure to progress in nulliparous women. One hundred and sixty-one women scheduled for labor induction underwent transvaginal ultrasonography and digital cervical examinations. Logistic regression demonstrated that cervical length and gestational age at induction, but not the Bishop score, significantly and independently predicted failed labor induction. According to the receiver operating characteristic curves analysis, the best cut-off value of cervical length for predicting failed labor induction was 28 mm, with a sensitivity of 62% and a specificity of 60%. In terms of the likelihood of a cesarean delivery for failure to progress as the outcome variable, logistic regression indicated that maternal height and birth weight, but not cervical length or Bishop score, were significantly and independently associated with an increased risk of cesarean delivery for failure to progress. Transvaginal sonographic measurements of cervical length thus independently predicted failed labor induction in nulliparous women. However, the relatively poor predictive performance of this test undermines its clinical usefulness as a predictor of failed labor induction. Moreover, cervical length appears to have a poor predictive value for the likelihood of a cesarean delivery for failure to progress.

Patterns of Recovery from Pain after Cesarean Delivery.

PubMed

Booth, Jessica L; Sharpe, Emily E; Houle, Timothy T; Harris, Lynnette; Curry, Regina S; Aschenbrenner, Carol A; Eisenach, James C

2018-06-13

We know very little about the change in pain in the first 2 months after surgery. To address this gap, we studied 530 women scheduled for elective cesarean delivery who completed daily pain diaries for two months after surgery via text messaging. Over 82% of subjects missed fewer than 10 diary entries and were included in the analysis. Completers were more likely to be Caucasian, non-smokers, and with fewer previous pregnancies than non-completers. Daily worst pain intensity ratings for the previous 24 hours were fit to a log(time) function and allowed to change to a different function up to 3 times according to a Bayesian criterion. All women had at least one change point, occurring 22 ± 9 days postoperatively, and 81% of women had only one change, most commonly to a linear function at 0 pain. Approximately 9% of women were predicted to have pain 2 months after surgery, similar to previous observations. Cluster analysis revealed 6 trajectories of recovery from pain. Predictors of cluster membership included severity of acute pain, perceived stress, surgical factors, and smoking status. These data demonstrate feasibility but considerable challenges to this approach to data acquisition. The form of the initial process of recovery from pain is common to all women, with divergence of patterns at 2-4 weeks after cesarean delivery. The change point model accurately predicts recovery from pain, its parameters can be used to assess predictors of speed of recovery, and it may be useful for future observational, forecasting, and interventional trials.

Systematic review of the risk of uterine rupture with the use of amnioinfusion after previous cesarean delivery.

PubMed

Hicks, Paul

2005-04-01

Amnioinfusion is commonly used for the intrapartum treatment of women with pregnancy complicated by thick meconium or oligohydramnios with deep variable fetal heart rate decelerations. Its benefit in women with previous cesarean deliveries is less known. Theoretically, rapid increases in intrauterine volume would lead to a higher risk of uterine rupture. Searches of the Cochrane Library from inception to the third quarter of 2001 and MEDLINE, 1966 to November 2001, were performed by using keywords "cesarean" and "amnioinfusion." Search terms were expanded to maximize results. All languages were included. Review articles, editorials, and data previously published in other sites were not analyzed. Four studies were retrieved having unduplicated data describing amnioinfusion in women who were attempting a trial of labor after previous cesarean section. As the studies were of disparate types, meta-analysis was not possible. The use of amnioinfusion in women with previous cesarean delivery who are undergoing a trial of labor may be a safe procedure, but confirmatory large, controlled prospective studies are needed before definitive recommendations can be made.

Dystocia as a cause of untimely cesarean section.

PubMed

Djurić, Janko; Arsenijević, Slobodan; Banković, Dragic; Protrka, Zoran; Sorak, Marija; Dimitrijević, Aleksandra; Tanasković, Irena

2012-07-01

One of the most frequent indications for cesarean section is dystocia. It is impossible to predict, difficult to identify and coincident with the rapid expiry of the expected time, so it is important to point out some mistakes in expecting vaginal delivery. The aim of this study was to examine the frequency and the length of dystocia-related cesarean delivery, as well as the vitality of the newborn immediately after birth. A prospective 3-year study was conducted including a total number of 6470 deliveries regardless of whether they were completed using cesarean section after an unsuccessful attempt of spontaneous vaginal delivery or not. The Apgar score, a proved useful tool for the assessment of the vitality of newborn children in the first minute, was used. On the basis of the established indications, 653 (10.10%) of deliveries were completed using cesarean section. Dystocia was the third most common indication for cesarean section (16.38%). Deliveries in which dystocia was established as a diagnosis lasted much longer (p = 0.030) which resulted in weaker vitality of newborn children (p = 0.000) compared to the deliveries ended by spontaneous vaginal delivery. This study shows that deliveries caused by dystocia last much longer and newborn children are of weaker vitality compared to other deliveries caused not by dystocia. Decisions concerning cesarean section must be made in a timely fashion.

Lessons learned from a single institution's retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia.

PubMed

Ainsworth, A; Sviggum, H P; Tolcher, M C; Weaver, A L; Holman, M A; Arendt, K W

2017-05-01

To evaluate the risk of emergent cesarean delivery with the use of neuraxial anesthesia for external cephalic version in a single practice. Randomized trials have shown increased external cephalic version success when neuraxial anesthesia is used, without additional risk. We hypothesized that in our actual clinical practice, outside the confines of randomized trials, neuraxial anesthesia could be associated with an increased risk of emergent cesarean delivery. This retrospective cohort study included all women who underwent external cephalic version at a single institution with and without neuraxial anesthesia. The primary outcome was the incidence of emergent cesarean delivery (defined as delivery within 4hours of version). Secondary outcomes were version success and ultimate mode of delivery. A total of 135 women underwent external cephalic version procedures; 58 with neuraxial anesthesia (43.0%) and 77 without (57.0%). Location of the procedure, tocolytic therapy, and gestational age were different between groups. An increased rate of emergent cesarean delivery was found in procedures with neuraxial anesthesia compared to procedures without (5/58 (8.6%) compared to 0/77 (0.0%); 95% CI for difference, 1.4 to 15.8%; P=0.013). In this single hospital's practice, patients who may be at higher risk of complications and have a lesser likelihood of success were provided NA for ECV. As a result, the use of neuraxial anesthesia for external cephalic version was associated with a higher rate of emergent cesarean delivery. Obstetric and anesthetic practices should evaluate their patient selection and procedure protocol for external cephalic version under neuraxial anesthesia. Copyright © 2017 Elsevier Ltd. All rights reserved.

Amniocentesis compared with antenatal corticosteroids prior to early term scheduled cesarean delivery.

PubMed

Zafman, Kelly B; Fox, Nathan S

2018-05-06

There are a variety of maternal or fetal conditions that require late preterm or early term delivery. In cases where early delivery is indicated, optimal management is not always clear. Historically, obstetricians used amniocentesis to document fetal lung maturity, but recently, many have transitioned to administration of antenatal corticosteroids (ACS). The objective of this study was to compare neonatal outcomes between women undergoing amniocentesis or receiving ACS prior to scheduled cesarean delivery (CD) less than 39 weeks. This was a retrospective cohort study of women undergoing scheduled CD by one maternal-fetal medicine practice between 36 and 38 6/7 weeks, from 2005 to 2017. We identified women who underwent amniocentesis or received ACS within 2 weeks prior to delivery. Neonatal outcomes were compared between the two groups, with the primary outcome being neonatal intensive care unit (NICU) admission. A total of 502 women were included, of whom 313 (62.4%) underwent amniocentesis and 189 (37.6%) received ACS. Overall, 55 (11.0%) of neonates were admitted to the NICU. NICU admission was not significantly different between groups (11.8 versus 9.5%, p=.46). This held true after adjusting for gestational age and other differences in baseline characteristics. There were no significant differences between groups for all other neonatal outcomes, including NICU admission for respiratory indications, respiratory support, neonatal greater than maternal length of stay, low Apgar scores, and neonatal death. Rates of hypoglycemia were low and not significantly different between groups (2.2% in the amniocentesis group versus 0.5% in the ACS group, p=.27). Diabetes was the only covariate significantly associated with NICU admission (aOR 3.19, 95% CI 1.35, 7.54). In women undergoing scheduled CD between 36 and 38 6/7 weeks, administration of ACS is associated with similar neonatal outcomes compared to amniocentesis. This supports the current notion that outcomes are

Obstetricians' perspective towards cesarean section delivery based on professional level: experience from Egypt.

PubMed

Shaaban, Mohamed M; Sayed Ahmed, Waleed Ali; Ahmed, Waleed S; Khadr, Zeinab; El-Sayed, Hesham F

2012-08-01

(1) To investigate Egyptian obstetricians' views towards cesarean delivery on maternal request, (2) to investigate Egyptian obstetricians' views towards some of the "potentially neglected" or controversial obstetrical skills or maneuvers as external cephalic version (ECV), fetal scalp pH measurement or tubal ligation during CS and (3) to examine the effect of professional level on the above factors. This is a descriptive study performed at the 8th annual Obstetrics and Gynecology conference of Suez Canal University held at Ismailia city in Egypt in June 2011 via a structured self administered questionnaire. Questionnaire was distributed to 223 conference attendants from the three professional levels (consultants, specialists and registrars) working at the two major institutions in Egypt: University and Ministry of Health. The structured questionnaire was based on informed opinion and professional guidelines. In total, 167 (75%) completed the questionnaire. Cesarean delivery on maternal request was accepted by 66% of the studied group and acceptance was significantly higher among consultants. There was no difference in all physicians' practices of cesarean section in both private and public settings. Limited access to medical equipment such as cardiotocogram (CTG) was shown in consultant group reflecting improper private sector preparations. The study revealed that 59% of obstetricians accepted vaginal breech delivery, and only 14% would consider ECV. Fetal scalp pH taking in cases of abnormal CTG was accepted by only 16.3% and 49% rejected the practice of instrumental delivery. There were significant differences among the three professional and the two institutional groups regarding these attitudes. There were different views regarding tubal sterilization during CS. Lack of knowledge, the need to improve some clinical skills and some professional attitudes may shed light on rising CS rates in Egypt.

Comparison of induction of labor methods for unfavorable cervices in trial of labor after cesarean delivery.

PubMed

Shah, Utsavi; Bellows, Patricia; Drexler, Kathleen; Hawley, Lauren; Davidson, Christina; Sangi-Haghpeykar, Haleh; Gandhi, Manisha

2017-05-01

To compare induction of labor methods in patients attempting a trial of labor after cesarean (TOLAC) with an unfavorable cervix. This is a retrospective cohort study from patients attempting TOLAC from 2009 to 2013. Patients with a simplified Bishop score of three or less where labor was initiated with either a Cook balloon or oxytocin were included. Our primary outcome was mode of delivery. Our secondary outcomes included duration of labor and multiple maternal and neonatal morbidities. Two-hundred and fourteen women met inclusion criteria: 150 received oxytocin and 64 had the Cook balloon placed. The vaginal birth after cesarean delivery rate was significantly higher in the oxytocin group at 70.7% versus 50.0% in the Cook balloon group (p = 0.004). In the multivariable analysis, odds for cesarean delivery were two times higher with the Cook balloon than with oxytocin (Adjusted OR = 2.09, 95% CI = 1.05-4.18, p = 0.036). The duration of labor was longer with the Cook balloon versus oxytocin (21.9 versus 16.3 hours, p = 0.0002). There were no significant differences in maternal and neonatal health outcomes. Oxytocin induction of labor was associated with a higher rate of vaginal delivery and a shorter duration of labor compared to the Cook balloon in women undergoing TOLAC with an unfavorable cervix.

Scheduling the Stork: Media Portrayals of Women's and Physicians' Reasons for Elective Cesarean Delivery.

PubMed

Campo-Engelstein, Lisa; Howland, Lauren E; Parker, Wendy M; Burcher, Paul

2015-06-01

Media interest in cesarean delivery has grown in recent years driven both by rising cesarean delivery rates and the decision by the American College of Obstetrics and Gynecology (ACOG) to permit elective cesarean (EC) delivery. A content analysis of United States newspaper and magazine articles from 2000 to 2013 (n = 131 articles) was completed to understand how the news media portrays ECs. The majority of articles (71.8%) emphasized reasons to support women having an EC, while 38.2 percent of the articles exhibited themes of physician support for ECs. Relatively few articles mentioned reasons against ECs either from the women's perspective (11.5%) or the practitioners' (3.8%). The most common themes given for women choosing ECs were convenience/scheduling (48.9%), avoidance of pain or fear of labor (29.8%), and physical harm to women from vaginal birth (17.6%). Doctors' perspectives were less prevalent in the media than women's perspectives, but when mentioned they were almost exclusively in support of ECs for reasons including avoiding malpractice (28.2%), avoiding physical harm to the woman or baby (16.8%), and timing/scheduling (14.5%). Media coverage suggests ECs are widely accepted by both women and doctors, with women choosing an EC mainly for convenience/scheduling and fear. However, 43 percent of doctors surveyed by ACOG said they were not willing to perform the procedure, and surveys report that mothers rarely request an EC. © 2015 Wiley Periodicals, Inc.

Urinary incontinence after vaginal delivery or cesarean section.

PubMed

Borges, João Bosco Ramos; Guarisi, Telma; Camargo, Ana Carolina Marchesini de; Gollop, Thomaz Rafael; Machado, Rogério Bonassi; Borges, Pítia Cárita de Godoy

2010-06-01

To assess the prevalence of stress urinary incontinence, urge incontinence and mixed urinary incontinence among women residing in the city of Jundiaí (São Paulo, Brazil), and the relation between the type of incontinence and the obstetric history of these women. A cross-sectional community-based study was conducted. A total of 332 women were interviewed; they were seen for whatever reason at the public primary healthcare units of the city of Jundiaí, from March 2005 to April 2006. A pre-tested questionnaire was administered and consisted of questions used in the EPINCONT Study (Epidemiology of Incontinence in the County of Nord-Trondelag). Statistical analysis was carried out using the χ2 test and odds ratio (95%CI). Urinary incontinence was a complaint for 23.5% of the women interviewed. Stress urinary incontinence prevailed (50%), followed by mixed urinary incontinence (35%) and urge incontinence (15%). Being in the age group of 35-64 years, having a body mass index of 30 or greater and having had only vaginal delivery or cesarean section, with uterine contraction, regardless of the number of pregnancies, were factors associated with stress urinary incontinence. However, being in the age group of 55 or older, having a body mass index of 30 or greater and having had three or more pregnancies, only with vaginal deliveries, were factors associated with mixed urinary incontinence. One third of the interviewees complained of some type of urinary incontinence, and half of them presented stress urinary incontinence. Cesarean section, only when not preceded by contractions, was not associated with stress urinary incontinence. The body mass index is only relevant when the stress factor is present.

[Maternal refusal to consent to a cesarean delivery, stillbirth].

PubMed

Defline, A; Obadia, M; El Djerbi, A; Plevy, P; Lepercq, J

2014-01-01

The doctor-lawyer perspective that we discuss is a maternal refusal to consent to a cesarean delivery for a fetal indication in June 2011. Despite repeated information of the risks during a three-week hospitalization for pre-eclampsia, after being assured of the proper understanding of the seriousness of the situation by the patient and spouse, and after consideration to transfer to another hospital, the reiterated refusal led to a late fetal extraction resulting in term stillbirth. Copyright © 2013. Published by Elsevier Masson SAS.. All rights reserved.

Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy.

PubMed

Asztalos, Elizabeth V; Hannah, Mary E; Hutton, Eileen K; Willan, Andrew R; Allen, Alexander C; Armson, B Anthony; Gafni, Amiram; Joseph, K S; Ohlsson, Arne; Ross, Susan; Sanchez, J Johanna; Mangoff, Kathryn; Barrett, Jon F R

2016-03-01

The Twin Birth Study randomized women with uncomplicated pregnancies, between 32(0/7)-38(6/7) weeks' gestation where the first twin was in cephalic presentation, to a policy of either a planned cesarean or planned vaginal delivery. The primary analysis showed that planned cesarean delivery did not increase or decrease the risk of fetal/neonatal death or serious neonatal morbidity as compared with planned vaginal delivery. This study presents the secondary outcome of death or neurodevelopmental delay at 2 years of age. A total of 4603 children from the initial cohort of 5565 fetuses/infants (83%) contributed to the outcome of death or neurodevelopmental delay. Surviving children were screened using the Ages and Stages Questionnaire with abnormal scores validated by a clinical neurodevelopmental assessment. The effect of planned cesarean vs planned vaginal delivery on death or neurodevelopmental delay was quantified using a logistic model to control for stratification variables and using generalized estimating equations to account for the nonindependence of twin births. Baseline maternal, pregnancy, and infant characteristics were similar. Mean age at assessment was 26 months. There was no significant difference in the outcome of death or neurodevelopmental delay: 5.99% in the planned cesarean vs 5.83% in the planned vaginal delivery group (odds ratio, 1.04; 95% confidence interval, 0.77-1.41; P = .79). A policy of planned cesarean delivery provides no benefit to children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 32(0/7)-38(6/7)weeks' gestation where the first twin is in cephalic presentation. Copyright © 2016 Elsevier Inc. All rights reserved.

Infectious morbidity, operative blood loss, and length of the operative procedure after cesarean delivery by method of placental removal and site of uterine repair.

PubMed

Magann, E F; Washburne, J F; Harris, R L; Bass, J D; Duff, W P; Morrison, J C

1995-12-01

This study was done to determine the impact of the method of placental removal and the site of uterine repair on postcesarean infectious morbidity rates in women receiving prophylactic antibiotics at cesarean delivery. This prospective study included 284 women who underwent cesarean delivery and who were randomly assigned to four groups based on the method of placental removal and the site of uterine repair: group 1, spontaneous placental removal and in situ uterine repair; group 2, spontaneous placental removal and exteriorized uterine repair; group 3, manual placental removal and in situ uterine repair; and group 4, manual placental removal with exteriorized uterine repair. Exclusion criteria were repeat cesarean deliveries without labor, active infection at the time of cesarean delivery, and patient refusal to participate. There was no significant difference among the groups in maternal age, race, parity, weight, the length of time from rupture of membranes (ROM) or the number of vaginal examinations from ROM to cesarean delivery, or preoperative hematocrit. Intraoperatively, the type of uterine incision, anesthesia administered, incidence of meconium-stained amniotic fluid, Apgar scores, and cord gases were similar between groups. The incidence of postcesarean endometritis was greater in group 4 (32 [45 percent] of 71, p = 0.003) compared with group 1 (17 [24 percent] of 71), group 2 (12 [30 percent] of 71); and group 3 (13 [18 percent] of 71). Manual placental removal and exteriorization of the uterus for repair of the surgical incision increases the infectious morbidity rate in women receiving prophylactic antibiotics at the time of cesarean delivery and increases the length of hospitalization.

[Pregnancy and delivery in patients with a personal history of cesarean section in Dakar: epidemiological, clinical, therapeutic and prognostic aspects].

PubMed

Koulimaya-Gombet, Cyr Espérance; Diouf, Abdoul Aziz; Diallo, Moussa; Dia, Anna; Sène, Codou; Moreau, Jean Charles; Diouf, Alassane

2017-01-01

The aim of our study was to determine hospitalization rate for vaginal birth after cesarean section in Pikine, to evaluate the quality of the management of pregnant women with previous cesarean section and to determine prognostic factors of the outcome of a trial of scar. We conducted a retrospective study based on medical records and operational protocols of patients who underwent vaginal birth after cesarean section over the period 1 January 2010 - 31 December 2011. We analyzed socio-demographic data, pregnancy follow-up, therapeutic modalities and prognosis. Data were collected and analyzed using Microsoft Office Excel 2007 software and SPSS software 17.0. The frequency of vaginal births after cesarean section was 9.6%. The average age of our patients was 29.4 years. Primiparous women accounted for 54%. Short spacing interval between births was found in 52.6% of cases. Based on the number of cesarean sections, the breakdown was as follows: patients with a history of one previous cesarean section (79.8%), patients with a history of two previous caesarean sections (17.9%) and patients with a history of three previous caesarean sections (2.3%). The number of antenatal consultations performed was greater than or equal to 3 in 79.8% of cases. Patients undergoing evacuation accounted for 54.2% and they were already in labor at the time of admission in 81.7% of cases. Trial of scar was authorized in 177 patients (34.3%) and, at the end of this test, 147 patients (83%) had vaginal birth, of whom 21.7% by vacuum extraction. Cesarean section was performed in 71.4% of cases with 245 emergency cesarean sections and 93 scheduled cesarean sections. A history of vaginal birth was a determining factor in normal delivery (p = 0.0001). There was also a significant relationship between mode of admission and decision to perform a cesarean section (p = 0.0001). Maternal mortality was 0.4%. Perinatal mortality rate was 28.2‰ of live births. We are witnessing a dramatic increase of

Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series.

PubMed

Polin, C M; Hale, B; Mauritz, A A; Habib, A S; Jones, C A; Strouch, Z Y; Dominguez, J E

2015-08-01

Parturients with super-morbid obesity, defined as body mass index greater than 50kg/m(2), represent a growing segment of patients who require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications. The surgical approach for cesarean delivery in these patients may require a supra-umbilical vertical midline incision due to a large pannus. The dense T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be prolonged. Patients also may have respiratory complications in the postoperative period due to pain from the incision. We describe the anesthetic management of three parturients with body mass index ranging from 73 to 95kg/m(2) who had a cesarean delivery via a supra-umbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and postoperative analgesia, respectively. Continuous spinal catheters were dosed with incremental bupivacaine boluses to achieve surgical anesthesia. In one case, the patient required respiratory support with non-invasive positive pressure ventilation. Two cases were complicated by intraoperative hemorrhage. All patients had satisfactory postoperative analgesia with a thoracic epidural infusion. None suffered postoperative respiratory complications or postdural puncture headache. The use of a continuous lumbar spinal catheter and a low thoracic epidural provides several advantages in the anesthetic management of super-morbidly obese parturients for cesarean delivery. Copyright © 2015 Elsevier Ltd. All rights reserved.

Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis.

PubMed

Keag, Oonagh E; Norman, Jane E; Stock, Sarah J

2018-01-01

Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with

Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis

PubMed Central

Keag, Oonagh E.; Stock, Sarah J.

2018-01-01

Background Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. Methods and findings Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean

Neonatal outcome of very preterm twins: policy of planned vaginal or cesarean delivery.

PubMed

Sentilhes, Loïc; Oppenheimer, Anne; Bouhours, Anne-Charlotte; Normand, Estelle; Haddad, Bassam; Descamps, Philippe; Marpeau, Loïc; Goffinet, François; Kayem, Gilles

2015-07-01

The objective of the study was to compare neonatal mortality and morbidity in very preterm twins with the first twin in cephalic presentation in hospitals with a policy of planned vaginal delivery (PVD) and those with a policy of planned cesarean delivery (PCD). Women with preterm cephalic first twins delivered after preterm labor and/or premature preterm rupture of membranes from 26(0/7) to 31(6/7) weeks of gestation were identified from the databases of 6 perinatal centers and classified as PVD or PCD according to the center's management policy from 1999 to 2010. Severe neonatal morbidity was defined as any of the following: intraventricular hemorrhage grades 3-4, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, and hospital death. The independent effect of the planned mode of delivery, defined by the center's management policy, was tested and quantified with a 2-level multivariable logistic regression. The PVD group included 248 women, and the PCD group 63. Maternal characteristics did not differ between the 2 groups. The rate of vaginal delivery was 85.9% (213 of 248) vs 20.6% (13 of 63) (P < .001), and the rate of cesarean delivery for the second twin was 1.6% (4 of 248) vs 4.8% (3 of 63) (P = .13) for PVD and PCD. PVD had no independent effect on either newborn hospital mortality or severe neonatal composite morbidity. A policy of planned vaginal delivery of very preterm twins with the first twin in cephalic presentation does not increase either severe neonatal morbidity or mortality. Copyright © 2015 Elsevier Inc. All rights reserved.

Effects of Intrathecal Opioids Use in Cesarean Section on Breastfeeding and Newborns’ Weight Gaining

PubMed Central

Yousefshahi, Fardin; Davari-Tanha, Fatemeh; Najafi, Atabak; Kaveh, Mahbod; Rezaei Hemami, Mohsen; Khashayar, Patricia; Anbarafshan, Mohammad

2016-01-01

Objective: To assess the association between intrapartum intrathecal opioid use and breastfeeding and weight gain following cesarean section. Materials and methods: The prospective double-blinded study was conducted on term pregnant women, undergoing elective cesarean section under spinal anesthesia. They divided into two groups. In the first group, intrathecal Morphine was used to achieve analgesia during or after the operation. The remainder divided into two subgroups, those who did not receive any opioid or those received systemic opioids. Following labor breastfeeding accessed in a follow-up, two month latter. Results: There was no difference between the demographic variables of the mothers and newborns APGAR score and weight at the time of birth. Breastfeeding rate was similar in intrathecal group in compare with other patents (P value = 0.518). While, the infants’ weight at the end of second month was lower in spinal opioid group (P value = 0.036). Conclusion: The present study was the first to suggest that spinal (intrathecal) opioids do not have any impact on breastfeeding. However the relationship between spinal anesthesia on weight gaining needs more investigation. PMID:28546816

Effects of Intrathecal Opioids Use in Cesarean Section on Breastfeeding and Newborns' Weight Gaining.

PubMed

Yousefshahi, Fardin; Davari-Tanha, Fatemeh; Najafi, Atabak; Kaveh, Mahbod; Rezaei Hemami, Mohsen; Khashayar, Patricia; Anbarafshan, Mohammad

2016-12-01

Objective: To assess the association between intrapartum intrathecal opioid use and breastfeeding and weight gain following cesarean section. Materials and methods: The prospective double-blinded study was conducted on term pregnant women, undergoing elective cesarean section under spinal anesthesia. They divided into two groups. In the first group, intrathecal Morphine was used to achieve analgesia during or after the operation. The remainder divided into two subgroups, those who did not receive any opioid or those received systemic opioids. Following labor breastfeeding accessed in a follow-up, two month latter. Results: There was no difference between the demographic variables of the mothers and newborns APGAR score and weight at the time of birth. Breastfeeding rate was similar in intrathecal group in compare with other patents (P value = 0.518). While, the infants' weight at the end of second month was lower in spinal opioid group (P value = 0.036). Conclusion: The present study was the first to suggest that spinal (intrathecal) opioids do not have any impact on breastfeeding. However the relationship between spinal anesthesia on weight gaining needs more investigation.

Economic evaluation of the DiAMOND randomized trial: cost and outcomes of 2 decision aids for mode of delivery among women with a previous cesarean section.

PubMed

Hollinghurst, Sandra; Emmett, Clare; Peters, Tim J; Watson, Helen; Fahey, Tom; Murphy, Deirdre J; Montgomery, Alan

2010-01-01

Maternal preferences should be considered in decisions about mode of delivery following a previous cesarean, but risks and benefits are unclear. Decision aids can help decision making, although few studies have assessed costs in conjunction with effectiveness. Economic evaluation of 2 decision aids for women with 1 previous cesarean. Cost-consequences analysis. Data sources were self-reported resource use and outcome and published national unit costs. The target population was women with 1 previous cesarean. The time horizon was 37 weeks' gestation and 6 weeks postnatal. The perspective was health care delivery system. The interventions were usual care, usual care plus an information program, and usual care plus a decision analysis program. The outcome measures were costs to the National Health Service (NHS) in the United Kingdom (UK), score on the Decisional Conflict Scale, and mode of delivery. RESULTS OF MAIN ANALYSIS: Cost of delivery represented 84% of the total cost; mode of delivery was the most important determinant of cost differences across the groups. Mean (SD) total cost per mother and baby: 2033 (677) for usual care, 2069 (738) for information program, and 2019 (741) for decision analysis program. Decision aids reduced decisional conflict. Women using the decision analysis program had fewest cesarean deliveries. Applying a cost premium to emergency cesareans over electives had little effect on group comparisons. Conclusions were unaffected. Disparity in timing of outcomes and costs, data completeness, and quality. Decision aids can reduce decisional conflict in women with a previous cesarean section when deciding on mode of delivery. The information program could be implemented at no extra cost to the NHS. The decision analysis program might reduce the rate of cesarean sections without any increase in costs.

Declining Fertility and the Use of Cesarean Delivery: Evidence from a Population-Based Study in Taiwan

PubMed Central

Ma, Ke-Zong M; Norton, Edward C; Lee, Shoou-Yih D

2010-01-01

Objective To test the hypothesis that declining fertility would affect the number of cesarean sections (c-sections) on maternal demand, but not medically indicated c-sections. Data Sources The 1996–2004 National Health Insurance Research Database in Taiwan for all singleton deliveries. Study Design Retrospective population-based, longitudinal study. Estimation was performed using multinomial probit models. Principal Findings Results revealed that declining fertility had a significant positive effect on the probability of having a c-section on maternal request but not medically indicated c-section. Conclusions Our findings offer a precautionary note to countries experiencing a fertility decline. Policies to contain the rise of c-sections should understand the role of women's preferences, especially regarding cesarean deliveries on maternal request. PMID:20545781

The Dose-response of Intrathecal Ropivacaine Co-administered with Sufentanil for Cesarean Delivery under Combined Spinal-epidural Anesthesia in Patients with Scarred Uterus

PubMed Central

Xiao, Fei; Xu, Wen-Ping; Zhang, Yin-Fa; Liu, Lin; Liu, Xia; Wang, Li-Zhong

2015-01-01

Background: Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery. This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia. Methods: Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Patients received 6, 8, 10, 12, or 14 mg intrathecal hyperbaric ropivacaine with 5 μg sufentanil. Successful spinal anesthesia was defined as a T4 sensory level achieved with no need for epidural supplementation. The 50% effective dose (ED50) and 95% effective dose (ED95) were calculated with a logistic regression model. Results: ED50 and ED95 of intrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA) were 8.28 mg (95% confidence interval [CI]: 2.28–9.83 mg) and 12.24 mg (95% CI: 10.53–21.88 mg), respectively. Conclusion: When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery, the ED50 and ED95 of intrathecal hyperbaric ropivacaine along with 5 μg sufentanil were 8.28 mg and 12.24 mg, respectively. In addition, this local anesthetic is unsuitable for emergent cesarean delivery, but it has advantages for ambulatory patients. PMID:26415793

Simple, validated vaginal birth after cesarean delivery prediction model for use at the time of admission.

PubMed

Metz, Torri D; Stoddard, Gregory J; Henry, Erick; Jackson, Marc; Holmgren, Calla; Esplin, Sean

2013-09-01

To create a simple tool for predicting the likelihood of successful trial of labor after cesarean delivery (TOLAC) during the pregnancy after a primary cesarean delivery using variables available at the time of admission. Data for all deliveries at 14 regional hospitals over an 8-year period were reviewed. Women with one cesarean delivery and one subsequent delivery were included. Variables associated with successful VBAC were identified using multivariable logistic regression. Points were assigned to these characteristics, with weighting based on the coefficients in the regression model to calculate an integer VBAC score. The VBAC score was correlated with TOLAC success rate and was externally validated in an independent cohort using a logistic regression model. A total of 5,445 women met inclusion criteria. Of those women, 1,170 (21.5%) underwent TOLAC. Of the women who underwent trial of labor, 938 (80%) had a successful VBAC. A VBAC score was generated based on the Bishop score (cervical examination) at the time of admission, with points added for history of vaginal birth, age younger than 35 years, absence of recurrent indication, and body mass index less than 30. Women with a VBAC score less than 10 had a likelihood of TOLAC success less than 50%. Women with a VBAC score more than 16 had a TOLAC success rate more than 85%. The model performed well in an independent cohort with an area under the curve of 0.80 (95% confidence interval 0.76-0.84). Prediction of TOLAC success at the time of admission is highly dependent on the initial cervical examination. This simple VBAC score can be utilized when counseling women considering TOLAC. II.

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.

The Effect of Adequate Gestational Weight Gain among Adolescents Relative to Adults of Equivalent Body Mass Index and the Risk of Preterm Birth, Cesarean Delivery, and Low Birth Weight.

PubMed

Houde, Michele; Dahdouh, Elias M; Mongrain, Vanessa; Dubuc, Elise; Francoeur, Diane; Balayla, Jacques

2015-12-01

To determine whether similar odds of cesarean delivery (C/S), preterm birth (PTB), and low birth weight (LBW) are observed among adolescents compared with body mass index (BMI)-equivalent adults in cases of adequate gestational weight gain. We conducted a retrospective, population-based, cohort study using the Center for Disease Control and Prevention's birth data files from the United States for 2012. We selected from the cohort all singleton, cephalic pregnancies and stratified them according to maternal age, prepregnancy BMI, and gestational weight gain following the 2009 Institute of Medicine (IOM) recommendations. The effect of adequate gestational weight gain among adolescents relative to adults of equivalent BMI on the risk of C/S, PTB, and LBW was estimated using logistic regression analysis, adjusting for relevant confounders. We analyzed a total of 3,960,796 births, of which 1,036,646 (26.1%) met the inclusion criteria. In adolescents and adults, likelihood of achieving ideal gestational weight gain decreased with greater prepregnancy BMI. Relative to adults, the overall odds of C/S in all adolescents were (adjusted odds ratio [95% confidence interval]) 0.61 (0.58 to 0.63). When comparing equivalent BMI categories, these odds were unchanged (P < .0001). The overall adjusted odds ratio of LBW was 1.15 (1.13 to 1.16). These odds were significantly higher when BMI stratification took place, decreasing with advancing BMI categories, from 1.23 (1.14 to 1.33) among the underweight, to nonsignificant differences in the obese classes (P < .05). Finally, when including only those achieving ideal weight gain, the overall odds of premature delivery (1.17 [1.14 to 1.20]) were higher among nonobese adolescents, while they were not found among the obese. When ideal gestational weight gain is attained, only nonobese adolescents exhibit a greater risk of LBW and preterm birth relative to adults of similar BMI, whereas the risk of C/S remains lower for all adolescents

Impella™ Left Ventricular Assist Device for Acute Peripartum Cardiomyopathy After Cesarean Delivery.

PubMed

Padilla, Cesar; Hernandez Conte, Antonio; Ramzy, Danny; Sanchez, Michael; Zhao, Manxu; Park, Donald; Lubin, Lorraine

2016-07-01

Peripartum cardiomyopathy is a rare form of heart failure with significant perioperative implications. In this case report, we describe a 34-year-old gravida 5, parity 3, patient who was admitted for an elective cesarean delivery. During the delivery, the patient developed sudden cardiac arrest and was emergently intubated in the operating room. An emergent transesophageal echocardiogram revealed a left ventricular ejection fraction of 10% with global biventricular hypokinesis. Urgent multidisciplinary consultations led to the rapid implementation of the Impella™ 2.5 for ventricular support. The patient recovered ventricular function within 4 days and recovered to baseline function.

Obstetric outcome associated with trial of labor in women with three prior cesarean delivery and at least one prior vaginal birth in an area with a particularly high rate of cesarean delivery.

PubMed

Vigorito, Roberto; Montemagno, Rodolfo; Saccone, Gabriele; De Stefano, Renato

2016-11-01

The objective of this study is to evaluate maternal and neonatal outcomes associated with trial of labor after cesarean (TOLAC) in women with three prior cesarean delivery (CD) and at least one prior vaginal delivery. This is a retrospective study using data collected from clinical records of women three prior CD and at least one prior vaginal delivery who were referred to our unit. Maternal and perinatal outcomes were compared between women with three prior CD who underwent TOLAC and those who underwent planned repeated CD (i.e. control group). The primary outcome was a composite of maternal complications including at least one of the followings: need for blood transfusion, uterine rupture, hysterectomy, and admission to intensive care unit. Fifty singleton gestations with three prior CD at with at least one prior vaginal birth were analyzed. Of them, 10 accepted to undergo TOLAC. Of the 10 women who underwent TOLAC, nine had vaginal birth and one had CD for non-reassuring pattern. We found no significant differences in the primary outcome, in need for blood transfusion, in the incidence of uterine rupture, hysterectomy, and admission to intensive care unit comparing TOLAC group with controls. TOLAC in women with three prior CD and at least one prior vaginal delivery is a viable option and is not associated with higher risk of adverse maternal or fetal outcomes.

[Risk factors for bladder injuries during cesarean section].

PubMed

Alcocer Urueta, Jaime; Bonilla Mares, Marcela; Gorbea Chávez, Viridiana; Velázquez Valassi, Beatriz

2009-01-01

To identify risk factors for bladder injury during cesarean delivery, to let patients and doctors know them and their importance. We conducted a case-control study of women undergoing cesarean delivery at the Instituto Nacional de PerinatologíaIsidro Espinosa de los Reyes between January 2001 and December 2007. Cases were women with bladder injuries at the time of cesarean section. Two controls per case were selected randomly. Medical records were reviewed for clinical and demographic data to compare them. Twenty-one bladder injuries were identified among 24, 057 cesarean sections, (incidence 0.087%), only 19 were analized. Prior cesarean section was more prevalent among cases than controls (63% vs 42% p 0.134), with an OR of 2.35 (95% CI 0.759-7.319), when we take only patients with one cesarea in contrast with no cesarea the OR is 3.75 (95% CI 1.002- 14.07). Statistically significant differences (P values < .05) between cases and controls were found in gestacional age (38.16 vs 37.35 weeks), prior cesareans (42% vs 18%), adhesions (79% vs 5%), Odds ratio of 67.5 (95% CI 11.14- 408), VBAC (31.5 vs 3%), median skin incisión (16% vs 68%), Pfannenstiel (84% vs 32%), blood loss (744cc vs 509cc) and length of surgery 135 vs 58 minutes). No differences were found among age, BMI, prior surgery, labor, premature rupture of membranes, station, chorioamnioitis, induction, uterine incision, timing of delivery, uterine rupture. Prior cesarean section and adhesions are risk factors for bladder injury at the time of repeat cesarean delivery. Elective cesarean delivery is valid but it is duty of physicians to inform patients the risks of it.

Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal delivery and cesarean section.

PubMed

Kayman-Kose, Seda; Arioz, Dagistan Tolga; Toktas, Hasan; Koken, Gulengul; Kanat-Pektas, Mine; Kose, Mesut; Yilmazer, Mehmet

2014-10-01

The present study aims to determine the efficiency and reliability of transcutaneous electrical nerve stimulation (TENS) in the management of pain related with uterine contractions after vaginal delivery and the pain related with both abdominal incision uterine contractions after cesarean section. A hundred healthy women who underwent cesarean section under general anesthesia were randomly assigned to the placebo group (Group 1) or the TENS group (Group 2), while 100 women who delivered by vaginal route without episiotomy were randomized into the placebo group (Group 3) or the TENS group (Group 4). The patients in Group 2 had statistically lower visual analog scale (VAS) and verbal numerical scale (VNS) scores than the patients in Group 1 (p < 0.001 for both). The patients in Group 4 had statistically lower VAS and VNS scores than the patients in Group 3 (p = 0.022 and p = 0.005, respectively). The analgesic requirement at the eighth hour of cesarean section was significantly lower in the patients who were treated with TENS (p = 0.006). The need for analgesics at the eighth hour of vaginal delivery was statistically similar in the patients who were treated with TENS and the patients who received placebo (p = 0.830). TENS is an effective, reliable, practical and easily available modality of treatment for postpartum pain.

Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section.

PubMed

Yang, Y Tony; Mello, Michelle M; Subramanian, S V; Studdert, David M

2009-02-01

Since the 1990s, nationwide rates of vaginal birth after cesarean section (VBAC) have decreased sharply and rates of cesarean section have increased sharply. Both trends are consistent with clinical behavior aimed at reducing obstetricians' exposure to malpractice litigation. To estimate the effects of malpractice pressure on rates of VBAC and cesarean section. We used state-level longitudinal mixed-effects regression models to examine data from the Natality Detail File on births in the United States (1991-2003). Malpractice pressure was measured by liability insurance premiums and tort reforms. Outcome measures were rates of VBAC, cesarean section, and primary cesarean section. Malpractice premiums were positively associated with rates of cesarean section (beta = 0.15, P = 0.02) and primary cesarean section (beta = 0.16, P = 0.009), and negatively associated with VBAC rates (beta = -0.35, P = 0.01). These estimates imply that a $10,000 decrease in premiums for obstetrician-gynecologists would be associated with an increase of 0.35 percentage points (1.45%) in the VBAC rate and decreases of 0.15 and 0.16 percentage points (0.7% and 1.18%) in the rates of cesarean section and primary cesarean section, respectively; this would correspond to approximately 1600 more VBACs, 6000 fewer cesarean sections, and 3600 fewer primary cesarean sections nationwide in 2003. Two types of tort reform-caps on noneconomic damages and pretrial screening panels-were associated with lower rates of cesarean section and higher rates of VBAC. The liability environment influences choice of delivery method in obstetrics. The effects are not large, but reduced litigation pressure would likely lead to decreases in the total number cesarean sections and total delivery costs.

Validation of the close-to-delivery prediction model for vaginal birth after cesarean delivery in a Middle Eastern cohort.

PubMed

Abdel Aziz, Ahmed; Abd Rabbo, Amal; Sayed Ahmed, Waleed A; Khamees, Rasha E; Atwa, Khaled A

2016-07-01

To validate a prediction model for vaginal birth after cesarean (VBAC) that incorporates variables available at admission for delivery among Middle Eastern women. The present prospective cohort study enrolled women at 37weeks of pregnancy or more with cephalic presentation who were willing to attempt a trial of labor (TOL) after a single prior low transverse cesarean delivery at Al-Jahra Hospital, Kuwait, between June 2013 and June 2014. The predicted success rate of VBAC determined via the close-to-delivery prediction model of Grobman et al. was compared between participants whose TOL was and was not successful. Among 203 enrolled women, 140 (69.0%) had successful VBAC. The predicted VBAC success rate was higher among women with successful TOL (82.4%±13.1%) than among those with failed TOL (67.7%±18.3%; P<0.001). There was a high positive correlation between actual and predicted success rates. For deciles of predicted success rate increasing from >30%-40% to >90%-100%, the actual success rate was 20%, 30.7%, 38.5%, 59.1%, 71.4%, 76%, and 84.5%, respectively (r=0.98, P=0.013). The close-to-delivery prediction model was found to be applicable to Middle Eastern women and might predict VBAC success rates, thereby decreasing morbidities associated with failed TOL. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

PubMed

Haas, David M; Morgan, Sarah; Contreras, Karenrose

2014-12-21

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 December 2014). We included randomized and quasi-randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. We independently assessed eligibility and quality of the studies. Seven trials randomizing 2816 women (2635 analyzed) evaluated the effects of vaginal cleansing (all with povidone-iodine) on post-cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post-cesarean endometritis from 8.3% in control groups to 4.3% in vaginal cleansing groups (average risk ratio (RR) 0.45, 95% confidence interval (CI) 0.25 to 0.81, seven trials, 2635 women). The risk reduction was particularly strong for women who were already in labor at the time of the cesarean delivery (7.4% in the vaginal cleansing group versus 13.0% in the control group; RR 0.56, 95% CI 0.34 to 0.95, three trials, 523 women) and for women with ruptured membranes (4.3% in the vaginal cleansing group versus 17.9% in the control group; RR 0.24, 95% CI 0.10 to 0.55, three trials, 272 women). No other outcomes realized statistically significant

Pharmacokinetics of bupivacaine after bilateral ultrasound-guided transversus abdominis plane block following cesarean delivery under spinal anesthesia.

PubMed

Trabelsi, B; Charfi, R; Bennasr, L; Marzouk, S Ben; Eljebari, H; Jebabli, N; Sassi, M Ben; Trabelsi, S; Maghrebi, H

2017-11-01

Transversus abdominis plane block is an effective method of post-cesarean analgesia. There are no data available about plasma bupivacaine levels after this block in adults. This study aimed to assess bupivacaine pharmacokinetic parameters after ultrasound-guided transversus abdominis plane blocks following cesarean delivery under spinal anesthesia. A prospective observational study in parturients undergoing elective cesarean delivery under hyperbaric bupivacaine spinal anesthesia was conducted. After surgery, patients received bilateral transversus abdominis plane block (50mg bupivacaine each side). Venous blood samples were collected immediately before performing the block and at 10, 20, 30, 45, 60, 90, 120, 180, 240, 720 and 1440minutes. High performance liquid chromatography was used to measure total plasma bupivacaine concentrations. Mean bupivacaine area under the curve (AUC) was calculated from 0 to 24hours. Data were collected from 17 parturients. Mean age and body mass index were 31±6y and 30±4kg/m 2 respectively. Mean plasma bupivacaine concentration before the block was 171ng/mL. Mean peak concentration was 802.36ng/mL (range 231.8 to 3504.5ng/mL). Mean time to peak concentration was 30min and mean area-under-the-curve (0-24h) was 4505.4h.ng/mL. Mean elimination half-life was 8.75h. Three subjects had concentrations above the quoted toxic threshold and mild symptoms suggestive of neurotoxicity were reported by two subjects, but no treatment was required. Single-dose bilateral transversus abdominis plane block using 100mg of bupivacaine, after spinal anesthesia for cesarean delivery, can result in toxic plasma bupivacaine concentrations. Copyright © 2017 Elsevier Ltd. All rights reserved.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

PubMed

Haas, David M; Morgan, Sarah; Contreras, Karenrose

2014-09-09

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 July 2014). We included randomized and quasi-randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. We independently assessed eligibility and quality of the studies. Five trials randomizing 1946 women (1766 analyzed) evaluated the effects of vaginal cleansing (all with povidone-iodine) on post-cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post-cesarean endometritis from 7.2% in control groups to 3.6% in vaginal cleansing groups (average risk ratio (RR) 0.39, 95% confidence interval (CI) 0.16 to 0.97, five trials, 1766 women). The risk reduction was particularly strong for women with ruptured membranes (1.4% in the vaginal cleansing group versus 15.4% in the control group; RR 0.13, 95% CI 0.02 to 0.66, two trials, 148 women). No other outcomes realized statistically significant differences between the vaginal cleansing and control groups. No adverse effects were reported with the povidone-iodine vaginal cleansing.The quality of the evidence using GRADE was low for post-cesarean endometritis

Relationship Between Malpractice Litigation Pressure and Rates of Cesarean Section and Vaginal Birth After Cesarean Section

PubMed Central

Yang, Y. Tony; Mello, Michelle M.; Subramanian, S. V.; Studdert, David M.

2011-01-01

Background Since the 1990s, nationwide rates of vaginal birth after cesarean section (VBAC) have decreased sharply and rates of cesarean section have increased sharply. Both trends are consistent with clinical behavior aimed at reducing obstetricians’ exposure to malpractice litigation. Objective To estimate the effects of malpractice pressure on rates of VBAC and cesarean section. Research Design, Subjects, Measures We used state-level longitudinal mixed-effects regression models to examine data from the Natality Detail File on births in the United States (1991–2003). Malpractice pressure was measured by liability insurance premiums and tort reforms. Outcome measures were rates of VBAC, cesarean section, and primary cesarean section. Results Malpractice premiums were positively associated with rates of cesarean section (β = 0.15, P = 0.02) and primary cesarean section (β = 0.16, P = 0.009), and negatively associated with VBAC rates (β = −0.35, P = 0.01). These estimates imply that a $10,000 decrease in premiums for obstetrician-gynecologists would be associated with an increase of 0.35 percentage points (1.45%) in the VBAC rate and decreases of 0.15 and 0.16 percentage points (0.7% and 1.18%) in the rates of cesarean section and primary cesarean section, respectively; this would correspond to approximately 1600 more VBACs, 6000 fewer cesarean sections, and 3600 fewer primary cesarean sections nationwide in 2003. Two types of tort reform—caps on noneconomic damages and pretrial screening panels—were associated with lower rates of cesarean section and higher rates of VBAC. Conclusions The liability environment influences choice of delivery method in obstetrics. The effects are not large, but reduced litigation pressure would likely lead to decreases in the total number cesarean sections and total delivery costs. PMID:19169125

Coding update of the SMFM definition of low risk for cesarean delivery from ICD-9-CM to ICD-10-CM.

PubMed

Armstrong, Joanne; McDermott, Patricia; Saade, George R; Srinivas, Sindhu K

2017-07-01

In 2015, the Society for Maternal-Fetal Medicine developed a low risk for cesarean delivery definition based on administrative claims-based diagnosis codes described by the International Classification of Diseases, Ninth Revision, Clinical Modification. The Society for Maternal-Fetal Medicine definition is a clinical enrichment of 2 available measures from the Joint Commission and the Agency for Healthcare Research and Quality measures. The Society for Maternal-Fetal Medicine measure excludes diagnosis codes that represent clinically relevant risk factors that are absolute or relative contraindications to vaginal birth while retaining diagnosis codes such as labor disorders that are discretionary risk factors for cesarean delivery. The introduction of the International Statistical Classification of Diseases, 10th Revision, Clinical Modification in October 2015 expanded the number of available diagnosis codes and enabled a greater depth and breadth of clinical description. These coding improvements further enhance the clinical validity of the Society for Maternal-Fetal Medicine definition and its potential utility in tracking progress toward the goal of safely lowering the US cesarean delivery rate. This report updates the Society for Maternal-Fetal Medicine definition of low risk for cesarean delivery using International Statistical Classification of Diseases, 10th Revision, Clinical Modification coding. Copyright © 2017. Published by Elsevier Inc.

Cesarean section delivery and development of food allergy and atopic dermatitis in early childhood.

PubMed

Papathoma, Evangelia; Triga, Maria; Fouzas, Sotirios; Dimitriou, Gabriel

2016-06-01

Delivery by Cesarean section (CS) may predispose to allergic disorders, presumably due to alterations in the establishment of normal gut microbiota in early infancy. In this study, we sought to investigate the association between CS and physician-diagnosed food allergy and atopic dermatitis during the first 3 years of life, using data from a homogeneous, population-based, birth cohort. A total of 459 children born and cared for in the same tertiary maternity unit were examined at birth and followed up at 1, 6, 12, 18, 24, 30 and 36 months of age. Participants with symptoms suggestive of food allergy or atopic dermatitis were evaluated by a pediatric allergy specialist to confirm the diagnosis based on well-defined criteria. The rate of CS was 50.8% (n = 233). Food allergy was diagnosed in 24 participants (5.2%) while atopic dermatitis was diagnosed in 62 children (13.5%). Cesarean section (OR 3.15; 95% CI 1.14-8.70), atopic dermatitis of the child (OR 3.01; 95% CI 1.18-7.80), parental atopy (OR 4.33; 95% CI 1.73-12.1), and gestational age (OR 1.57; 95% CI 1.07-2.37) were significant and independent predictors of food allergy. Children with at least one allergic parent delivered by CS had higher probability of developing food allergy compared with vaginally delivered children of non-allergic parents (OR 10.0; 95% CI 3.06-32.7). Conversely, the effect of CS on atopic dermatitis was not significant (OR 1.35; 95% CI 0.74-2.47). Delivery by CS predisposes to the development of food allergy but not atopic dermatitis in early childhood. Cesarean section delivery seems to upregulate the immune response to food allergens, especially in children with allergic predisposition. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Topical application of recombinant activated factor VII during cesarean delivery for placenta previa.

PubMed

Schjoldager, Birgit T B G; Mikkelsen, Emmeli; Lykke, Malene R; Præst, Jørgen; Hvas, Anne-Mette; Heslet, Lars; Secher, Niels J; Salvig, Jannie D; Uldbjerg, Niels

2017-06-01

During cesarean delivery in patients with placenta previa, hemorrhaging after removal of the placenta is often challenging. In this condition, the extraordinarily high concentration of tissue factor at the placenta site may constitute a principle of treatment as it activates coagulation very effectively. The presumption, however, is that tissue factor is bound to activated factor VII. We hypothesized that topical application of recombinant activated factor VII at the placenta site reduces bleeding without affecting intravascular coagulation. We included 5 cases with planned cesarean delivery for placenta previa. After removal of the placenta, the surgeon applied a swab soaked in recombinant activated factor VII containing saline (1 mg in 246 mL) to the placenta site for 2 minutes; this treatment was repeated once if the bleeding did not decrease sufficiently. We documented the treatment on video recordings and measured blood loss. Furthermore, we determined hemoglobin concentration, platelet count, international normalized ratio, activated partial thrombin time, fibrinogen (functional), factor VII:clot, and thrombin generation in peripheral blood prior to and 15 minutes after removal of the placenta. We also tested these blood coagulation variables in 5 women with cesarean delivery planned for other reasons. Mann-Whitney test was used for unpaired data. In all 5 cases, the uterotomy was closed under practically dry conditions and the median blood loss was 490 (range 300-800) mL. There were no adverse effects of recombinant activated factor VII and we did not measure factor VII to enter the circulation. Neither did we observe changes in thrombin generation, fibrinogen, activated partial thrombin time, international normalized ratio, and platelet count in the peripheral circulation (all P values >.20). This study indicates that in patients with placenta previa, topical recombinant activated factor VII may diminish bleeding from the placenta site without initiation

Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe.

PubMed

Lonnée, Herman A; Madzimbamuto, Farai; Erlandsen, Ole R M; Vassenden, Astrid; Chikumba, Edson; Dimba, Rutenda; Myhre, Arne K; Ray, Sunanda

2018-06-01

Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe. In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization. The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were <5%. The estimated institutional maternal mortality ratio was 573 (provincial), 251 (district), and 211 (mission hospitals) per 100,000 live births. Basic monitoring equipment (oximeters, electrocardiograms, sphygmomanometers) was reported available in theatres. Several unsafe practices continue: general anesthesia without a secure airway, shortage of essential drugs for spinal anesthesia, inconsistent use of recovery area or use of table tilt or wedge, and insufficient blood supplies. Postoperative analgesia management was reported inadequate. This study identified areas

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

Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop.

PubMed

Spong, Catherine Y; Berghella, Vincenzo; Wenstrom, Katharine D; Mercer, Brian M; Saade, George R

2012-11-01

With more than one third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. The available information on maternal and fetal factors, labor management and induction, and nonmedical factors leading to the first cesarean delivery was reviewed as well as the implications of the first cesarean delivery on future reproductive health. Key points were identified to assist with reduction in cesarean delivery rates including that labor induction should be performed primarily for medical indication; if done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress. The diagnosis of "failed induction" should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged. When discussing the first cesarean delivery with a patient, counseling should include its effect on future reproductive health.

Serious adverse neonatal outcomes such as 5-minute Apgar score of zero and seizures or severe neurologic dysfunction are increased in planned home births after cesarean delivery.

PubMed

Grünebaum, Amos; McCullough, Laurence B; Arabin, Birgit; Chervenak, Frank A

2017-01-01

The United States is with 37,451 home births in 2014 the country with the largest absolute number of home births among all developed countries. The purpose of this study was to examine the occurrence and risks of a 5-minute Apgar score of zero and neonatal seizures or serious neurologic dysfunction in women with a history of prior cesarean delivery for planned home vaginal birth after cesarean (VBAC), compared to hospital VBAC and hospital birth cesarean deliveries for term normal weight infants in the United States from 2007-2014. We report in this study outcomes of women who had one or more prior cesarean deliveries and included women who had a successful vaginal birth after a trial of labor after cesarean (TOLAC) at home and in the hospital, and a repeat cesarean delivery in the hospital. We excluded preterm births (<37 weeks) and infants weighing under 2500 g. Hospital VBACS were the reference. Women with a planned home birth VBAC had an approximately 10-fold and higher increase in adverse neonatal outcomes when compared to hospital VBACS and hospital repeat cesarean deliveries, a significantly higher incidence and risk of a 5-minute Apgar score of 0 of 1 in 890 (11.24/10,000, relative risk 9.04, 95% confidence interval 4-20.39, p<.0001) and an incidence of neonatal seizures or severe neurologic dysfunction of 1 in 814 (Incidence: 12.27/10,000, relative risk 11.19, 95% confidence interval 5.13-24.29, p<.0001). Because of the significantly increased neonatal risks, obstetric providers should therefore not offer or perform planned home TOLACs and for those desiring a VBAC should strongly recommend a planned TOLAC in the appropriate hospital setting. We emphasize that this stance should be accompanied by effective efforts to make TOLAC available in the appropriate hospital setting.

Placental location, postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study.

PubMed

Belachew, Johanna; Eurenius, Karin; Mulic-Lutvica, Ajlana; Axelsson, Ove

2017-08-01

Women previously giving birth with cesarean section have an increased risk of postpartum hemorrhage (PPH) and retained placenta. The objective of this study was to determine if anterior placental location increased the risk of PPH and retained placenta in such women. We performed a prospective cohort study on 400 women with cesarean section delivery in a previous pregnancy. Ultrasound examinations were performed at gestational week 28-30, and placental location, myometrial thickness, and three-dimensional vascularization index (VI) were recorded. Data on maternal age, parity, BMI, smoking, gestational week at delivery, induction, delivery mode, oxytocin, preeclampsia, PPH, retained placenta, and birth weight were obtained for all women. Outcome measures were PPH (≥1,000 mL) and retained placenta. The overall incidence of PPH was 11.0% and of retained placenta 3.5%. Twenty-three women (11.8%) with anterior placenta had PPH compared to 12 (6.9%) with posterior or fundal locations. The odds ratio was 1.94, but it did not reach statistical significance. There was no significant risk increase for retained placenta in women with anterior placentae. Seven of eight women with placenta previa had PPH, and four had retained placenta. The overall risk of PPH and retained placenta was high for women with previous cesarean section. Anterior location of the placenta in such women tended to impose an increased risk for PPH but no risk increase of retained placenta. Placenta previa in women with previous cesarean section is associated with a high risk for PPH and retained placenta.

Placental location, postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study

PubMed Central

Belachew, Johanna; Eurenius, Karin; Mulic-Lutvica, Ajlana; Axelsson, Ove

2017-01-01

Objective Women previously giving birth with cesarean section have an increased risk of postpartum hemorrhage (PPH) and retained placenta. The objective of this study was to determine if anterior placental location increased the risk of PPH and retained placenta in such women. Materials and methods We performed a prospective cohort study on 400 women with cesarean section delivery in a previous pregnancy. Ultrasound examinations were performed at gestational week 28–30, and placental location, myometrial thickness, and three-dimensional vascularization index (VI) were recorded. Data on maternal age, parity, BMI, smoking, gestational week at delivery, induction, delivery mode, oxytocin, preeclampsia, PPH, retained placenta, and birth weight were obtained for all women. Outcome measures were PPH (≥1,000 mL) and retained placenta. Results The overall incidence of PPH was 11.0% and of retained placenta 3.5%. Twenty-three women (11.8%) with anterior placenta had PPH compared to 12 (6.9%) with posterior or fundal locations. The odds ratio was 1.94, but it did not reach statistical significance. There was no significant risk increase for retained placenta in women with anterior placentae. Seven of eight women with placenta previa had PPH, and four had retained placenta. Conclusions The overall risk of PPH and retained placenta was high for women with previous cesarean section. Anterior location of the placenta in such women tended to impose an increased risk for PPH but no risk increase of retained placenta. Placenta previa in women with previous cesarean section is associated with a high risk for PPH and retained placenta. PMID:28826360

Pelvic floor dysfunction in the immediate puerperium, and 1 month and 3 months after vaginal or cesarean delivery.

PubMed

Colla, Cássia; L Paiva, Luciana; Ferla, Lia; B Trento, Maria J; M P de Vargas, Isadora; A Dos Santos, Bianca; Ferreira, Charles F; L Ramos, José G

2018-06-07

To identify and assess postpartum pelvic floor dysfunction (PFD) between vaginal delivery, elective cesarean delivery (ECD), and intrapartum cesarean delivery (ICD). The present prospective observational study included women aged at least 18 years with no history of pelvic surgery or lower urinary tract malformation, and who had not undergone pelvic floor muscle (PFM) training in the preceding 12 months, who underwent delivery at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil between August 1, 2016, and May 31, 2017. Participants were assessed at 48 hours (phase 1), 1 month (phase 2), and 3 months (phase 3) after delivery. Assessments included the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF); the Jorge-Wexner anal incontinence scale; a self-rated visual analog scale for pelvic pain; the pelvic organ prolapse quantification (POP-Q) system; and a PFM perineometer. A total of 227 women were assessed in phase 1 (141 vaginal deliveries; 28 ICDs; and 58 ECDs), 79 in phase 2, and 41 in phase 3. The ICIQ-SF, Jorge-Wexner scale, visual analog scale, and perineometer measurements did not identify significant differences in relation to the type of delivery (P>0.05). The type of delivery was not associated with differences in the short-term development of postpartum PFD. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials.

PubMed

Bauer, M E; Kountanis, J A; Tsen, L C; Greenfield, M L; Mhyre, J M

2012-10-01

This systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia. Online scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia. 1450 trials were screened, and 13 trials were included for review (n=8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR=3.2, 95% CI 1.8-5.5), greater urgency for cesarean delivery (OR=40.4, 95% CI 8.8-186), and a non-obstetric anesthesiologist providing care (OR=4.6, 95% CI 1.8-11.5). Insufficient evidence is available to support combined spinal-epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion. The risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery. Copyright © 2012 Elsevier Ltd. All rights reserved.

Direct puncture embolization of the internal iliac artery during cesarean delivery for pernicious placenta previa coexisting with placenta accreta.

PubMed

Chen, Zhenyu; Li, Ju; Shen, Jian; Jin, Jiaxi; Zhang, Wei; Zhong, Wan

2016-12-01

To evaluate direct puncture embolization of the internal iliac artery with hemostatic gelatin sponge particles to treat pernicious placenta previa coexisting with placenta accreta during cesarean delivery. A retrospective study was conducted of data from women with pernicious placenta previa and placenta accreta who underwent direct puncture embolization of the internal iliac artery during cesarean delivery at a center in China between September 1, 2013, and February 28, 2015. Information regarding surgical procedures, operative data, and outcomes during hospitalization were obtained from medical records. The procedure was successful in all 16 cases included. Mean operative time was 78 minutes (range 65-90) and mean estimated blood loss was 1550 mL (range 1000-2500). Complications such as fever, buttock pain, or acute limb ischemia were not observed. The procedure was performed after partial cystectomy for two patients with bladder invasion. Postoperative Doppler imaging indicated uterine recovery and normalized uterine blood flow in all patients. Direct puncture embolization of the internal iliac artery during cesarean delivery was a safe, effective, simple, and rapid method to control hemorrhage among women with pernicious placenta previa and placenta accreta. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Effect of maternal death reviews and training on maternal mortality among cesarean delivery: post-hoc analysis of a cluster-randomized controlled trial.

PubMed

Zongo, Augustin; Dumont, Alexandre; Fournier, Pierre; Traore, Mamadou; Kouanda, Séni; Sondo, Blaise

2015-02-01

To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality between patients with cesarean and vaginal delivery in low-resource settings. We reanalyzed the data from a major cluster-randomized controlled trial, QUARITE (Quality of care, Risk management and technology in obstetrics). These subgroup analyses were not pre-specified and were treated as exploratory. The intervention consisted of an initial interactive workshop and quarterly educational clinically oriented and evidence-based outreach visits focused on maternal death reviews (MDR) and best practices implementation. The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal, between 2007 and 2011. The primary endpoint was hospital-based maternal mortality. Subgroup-specific Odds Ratios (ORs) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups (cesarean: 40,975; and vaginal delivery: 150,192). The test for homogeneity of intervention effects on hospital-based maternal mortality among the two delivery mode subgroups was statistically significant (p-value: 0.0201). Compared to the control, the adjusted OR of maternal mortality was 0.71 (95% CI: 0.58-0.82, p=0.0034) among women with cesarean delivery. The intervention had no significant effect among women with vaginal delivery (adjusted OR 0.87, 95% CI 0.69-1.11, p=0.6213). This differential effect was particularly marked for district hospitals. Maternal deaths reviews and on-site training on emergency obstetric care may be more effective in reducing maternal mortality among high-risk women who need a cesarean section than among low-risk women with vaginal delivery. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Increased rates of cesarean sections and large families: a potentially dangerous combination.

PubMed

Saleh, Ahmed M; Dudenhausen, Joachim W; Ahmed, Badreldeen

2017-07-26

Rates of cesarean sections have been on the rise over the past three decades all over the world, despite the ideal rate of 10-15% that had been set by the World Health Organization (WHO) in 1985, in Fortaleza, Brazil. This epidemic increase in the rate of cesarean delivery is due to many factors which include, cesarean delivery on request, advanced maternal age at first pregnancy, decrease in number of patients who are willing to try vaginal birth after cesarean delivery, virtual disappearance of vaginal breech delivery, perceived increase in the weight of the fetus and increase in the number of women with chronic medical conditions such as Diabetes Mellitus and congenital heart disease in the reproductive age. There is no doubt that cesarean delivery is a safe procedure and it is getting safer and safer for many reasons. However, like all other surgical procedures it is not without risks both to the mother and the new born. There is a substantial increase in the incidence of morbidly adherent placenta and the risk of scar pregnancy. In the Middle East and many African and Asian countries women tend to have large families. The number of previous cesarean section deliveries is directly proportional to the risk of developing morbidly adherent placenta. Morbidly adherent placenta is the most common cause of emergency postpartum hysterectomy, which is often associated with multiple surgical complications, severe maternal morbidity and mortality. The increased rates of cesarean sections lead to increased rates of scar pregnancies, which can have lethal consequences. Cesarean delivery has a negative impact on the infant immune system. This effect on the infant led to the introduction of a new concept called "Vaginal seeding". This refers to the practice of transferring some maternal vaginal fluid to the infant born via cesarean section in an effort to enhance its immune system.

Maternal infection rates after cesarean delivery by Pfannenstiel or Joel-Cohen incision: a multicenter surveillance study.

PubMed

Dumas, Anne Marie; Girard, Raphaële; Ayzac, Louis; Caillat-Vallet, Emmanuelle; Tissot-Guerraz, Françoise; Vincent-Bouletreau, Agnès; Berland, Michel

2009-12-01

Our purpose was to evaluate maternal nosocomial infection rates according to the incision technique used for caesarean delivery, in a routine surveillance study. This was a prospective study of 5123 cesarean deliveries (43.2% Joel-Cohen, 56.8% Pfannenstiel incisions) in 35 maternity units (Mater Sud Est network). Data on routine surveillance variables, operative duration, and three additional variables (manual removal of the placenta, uterine exteriorization, and/or cleaning of the parieto-colic gutter) were collected. Multiple logistic regression analysis was used to identify independent risk factors for infection. The overall nosocomial infection and endometritis rates were higher for the Joel-Cohen than Pfannenstiel incision (4.5% vs. 3.3%, 0.8% vs. 0.3%, respectively). The higher rate of nosocomial infections with the Joel-Cohen incision was due to a greater proportion of patients presenting risk factors (i.e., emergency delivery, primary cesarean, blood loss > or =800 mL, no manual removal of the placenta and no uterine exteriorization). However, the Joel-Cohen technique was an independent risk factor for endometritis. The Joel-Cohen technique is faster than the Pfannenstiel technique but is associated with a higher incidence of endometritis.

Bispectral index values during sevoflurane-nitrous oxide general anesthesia in women undergoing cesarean delivery: a comparison between women with and without prior labor.

PubMed

Yoo, Kyung Y; Jeong, Cheol W; Kang, Myung W; Kim, Seok J; Chung, Sung T; Shin, Min H; Lee, JongUn

2008-06-01

An end-tidal concentration of 1% sevoflurane (1% ET(SEVO)) in 50% nitrous oxide (N(2)O) during elective cesarean delivery has been associated with bispectral index (BIS) values >60, which are associated with an increased risk of awareness. We hypothesized that BIS values during sevoflurane-N(2)O general anesthesia for cesarean delivery would be lower in women with prior labor compared with women without prior labor. Forty patients undergoing cesarean delivery were enrolled in this observational study. One group had urgent surgery after labor (labor group, n = 20) and the other had elective surgery without labor (control group, n = 20). General anesthesia was induced with thiopental 4 mg/kg, followed by succinylcholine 1.5 mg/kg, and maintained with 1% ET(SEVO) and 50% N(2)O in oxygen. BIS values, systolic arterial blood pressure, heart rate, plasma stress hormone concentrations, Apgar scores, and postoperative analgesia variables were assessed and compared between groups. BIS values during the period between intubation and delivery were lower in the labor group than in the control group (P < 0.001). Plasma norepinephrine concentrations increased at delivery compared with baseline in both groups. They were higher in the labor group than in the control group both at baseline and at delivery. Systolic arterial blood pressure, heart rate, Apgar scores, surgical characteristics, and plasma concentrations of vasopressin and cortisol were not different between groups. Postoperative visual analog scale pain scores were similar between groups, while the labor group consumed less analgesics (P < 0.01) during the first 24 h after the operation. Prior labor was associated with lower intraoperative BIS values during sevoflurane/N(2)O general anesthesia and reduced postoperative analgesic consumption in women undergoing cesarean delivery compared with women without prior labor.

The effect of delaying childbirth on primary cesarean section rates.

PubMed

Smith, Gordon C S; Cordeaux, Yolande; White, Ian R; Pasupathy, Dharmintra; Missfelder-Lobos, Hannah; Pell, Jill P; Charnock-Jones, D Stephen; Fleming, Michael

2008-07-01

The relationship between population trends in delaying childbirth and rising rates of primary cesarean delivery is unclear. The aims of the present study were (1) to characterize the association between maternal age and the outcome of labor, (2) to determine the proportion of the increase in primary cesarean rates that could be attributed to changes in maternal age distribution, and (3) to determine whether the contractility of uterine smooth muscle (myometrium) varied with maternal age. We utilized nationally collected data from Scotland, from 1980 to 2005, and modeled the risk of emergency cesarean section among women delivering a liveborn infant in a cephalic presentation at term. We also studied isolated myometrial strips obtained from 62 women attending for planned cesarean delivery in Cambridge, England, from 2005 to 2007. Among 583,843 eligible nulliparous women, there was a linear increase in the log odds of cesarean delivery with advancing maternal age from 16 y upwards, and this increase was unaffected by adjustment for a range of maternal characteristics (adjusted odds ratio for a 5-y increase 1.49, 95% confidence interval [CI] 1.48-1.51). Increasing maternal age was also associated with a longer duration of labor (0.49 h longer for a 5-y increase in age, 95% CI 0.46-0.51) and an increased risk of operative vaginal birth (adjusted odds ratio for a 5-y increase 1.49, 95% CI 1.48-1.50). Over the period from 1980 to 2005, the cesarean delivery rate among nulliparous women more than doubled and the proportion of women aged 30-34 y increased 3-fold, the proportion aged 35-39 y increased 7-fold, and the proportion aged > or =40 y increased 10-fold. Modeling indicated that if the age distribution had stayed the same over the period of study, 38% of the additional cesarean deliveries would have been avoided. Similar associations were observed in multiparous women. When studied in vitro, increasing maternal age was associated with reduced spontaneous activity and

Cesarean section using the Misgav Ladach method.

PubMed

Federici, D; Lacelli, B; Muggiasca, L; Agarossi, A; Cipolla, L; Conti, M

1997-06-01

To stress the advantages of the Misgav Ladach method for cesarean section. In this study operative details and the postoperative course of 139 patients who underwent cesarean section according to the Misgav Ladach method in 1995-96 are presented. The Misgav Ladach method reduces operation time, time of child delivery, and time of recovery. The rates of febrile morbidity, wound infection and wound dehiscence are not affected by the new technique. Our study highlights the efficiency and safety of the Misgav Ladach method, and points out the speeded recovery, with early ambulation and resumption of drinking and eating, that makes the cesarean section delivery closer and closer to natural childbirth.

Women's autonomy and scheduled cesarean sections in Brazil: a cautionary tale.

PubMed

Potter, Joseph E; Hopkins, Kristine; Faúndes, Anibal; Perpétuo, Ignez

2008-03-01

In Brazil, one-fourth of all women deliver in the private sector, where the rate of cesarean deliveries is extremely high (70%). Most (64%) private sector cesareans are scheduled, although many women would have preferred a vaginal delivery. The question this study addresses is whether childbearing women were induced to accept the procedure by their physicians, and if so, how? Three face-to-face structured interviews were conducted with 1,612 women (519 private sector and 1,093 public sector) early in pregnancy, approximately 1 month before their due date, and approximately 1 month postpartum. For all private sector patients having a scheduled cesarean section, women's self-reported reasons given for programming surgical delivery were classified into three groups according to obstetrical justification. After loss to follow-up (19.2% of private sector and 34.4% of public sector), our final sample included 1,136 women (419 private sector and 717 public sector). Compared with public sector participants in the final sample, on average, private sector participants were older by 3.4 years (28.7 vs 25.3 yr), had 0.4 fewer previous deliveries (0.6 vs 1.0), and had 3.4 more years of education (11.0 vs 7.6 yr). The final samples also differed slightly with respect to preference for vaginal delivery: 72.3 percent among those in the private sector and 79.6 percent in public sector. The cesarean section rate was 72 percent in the private sector and 31 percent in the public sector. Of the women with reports about the timing of the cesarean decision, 64.4 percent had a scheduled cesarean delivery in the private sector compared with 23.7 percent in the public sector. Many cesarean sections were scheduled for an "unjustified" medical reason, especially among women who, during pregnancy, had declared a preference for a vaginal delivery. Among 96 women in this latter group, the reason reported for the procedure was unjustified in 33 cases. On the other hand, more cesarean deliveries

Carbetocin versus oxytocin for prevention of postpartum hemorrhage in obese nulliparous women undergoing emergency cesarean delivery.

PubMed

El Behery, Manal M; El Sayed, Gamal Abbas; El Hameed, Azza A Abd; Soliman, Badeea S; Abdelsalam, Walid A; Bahaa, Abeer

2016-01-01

To assess and compare the effectiveness and safety of single IV polus dose of carbetocin, versus IV oxytocin infusion in the prevention of PPH in obese nulliparous women undergoing emergency Cesarean Delivery. A double-blinded randomized-controlled trial was conducted on 180 pregnant women with BMI >30. Women were randomized to receive either oxytocin or carbetocin during C.S. The primary outcome measure was major primary PPH >1000 ml within 24 h of delivery as per the definition of PPH by the World Health Organization Secondary outcome measures were hemoglobin and hematocrit changes pre- and post-delivery, use of further ecobolics, uterine tone 2 and 12-h postpartum and adverse effects. A significant difference in the amount of estimated blood loss or the incidence of primary postpartum haemorrhage (>1000 ml) in both groups. Haemoglobin levels before and 24-h postpartum was similar. None from the carbetocin group versus 71.5% in oxytocin group needed additional utrotonics (p < 0.01). The uterine contractility was better in the carbetocin group at 2, and 12-h postpartum (p < 0.05). A single 100-µg IV carbetocin is more effective than IV oxytocin infusion for maintaining adequate uterine tone and preventing postpartum bleeding in obese nulliparous women undergoing emergency cesarean delivery, both has similar safety profile and minor hemodynamic effect.

College students' knowledge and attitudes about cesarean birth.

PubMed

Lampman, C; Phelps, A

1997-09-01

Numerous clinicians and researchers have expressed concern about the necessity and potential adverse consequences of many cesarean births in the United States. The purpose of this study was to explore college students' attitudes and beliefs about cesarean section. One hundred two college students (66% women) completed a 20-item questionnaire that asked if they viewed cesarean delivery as a potentially negative experience, as a normal or acceptable method of childbirth, and as medically necessary, and asked about their beliefs concerning risk and prevention of cesarean birth. The number of "undecided" responses in the study was striking (7.8% to 69.6% across the 20 items). In general, women and men responded similarly, although women were significantly more likely than men to say they would be profoundly disappointed if their babies had to be delivered by cesarean section. Despite expressing cynicism about the cesarean birth rate (40% agreed that many unnecessary cesarean births occurred) and not viewing the procedure as a normal way of giving birth (47%), most respondents (over 70%) disagreed that giving birth by cesarean would be a negative experience or would make a woman feel like a failure. A high level of uncertainty exists about certain aspects of cesarean birth among young women and men, highlighting the need for information for prospective parents. Most college students did not view the cesarean birth experience as either potentially negative or normal. Future research should explore coverage of cesarean birth in childbirth education classes and the roles physicians, nurses, and midwives play in preparing expectant parents for the possibility of cesarean delivery.

Intention for Cesarean Section Versus Vaginal Delivery Among Pregnant Women in Isfahan: Correlates and Determinants

PubMed Central

Shams-Ghahfarokhi, Zahra; Khalajabadi-Farahani, Farideh

2016-01-01

Background: Iran has the second highest rate of cesarean section in the world. the corresponding rate in the third metropolitan city of Iran, Isfahan, is even higher. This paper aimed to assess correlates and determinants of intention for cesarean section versus normal vaginal delivery (NVD) among pregnant women in Isfahan. Methods: A study was conducted among 400 pregnant women aged 18–38 years, with gestational age of 24–40 weeks who attended labor clinics of nine hospitals in Isfahan during June and July 2014. Probability proportional to size was used to estimate the number of cases required to be selected for each hospital. T-test, chi-square and logistic regression analysis were employed to analyze the data. Results: Mean age of women was 26.6±4.4 years. Multivariate analysis identified selected factors as determinants of intention for CS. These were “the role of physician” (OR=1.33, p<0.001), “subjective norms” (OR=1.19, p<0.01) and “body Image” (OR= 1.46, p<0.001) upon control of education, income and intended fertility (number of children intended). Moreover, path analysis showed that “attitude towards cesarean section” and “individualism” influence CS decision through subjective norm. Conclusion: Choosing cesarean section voluntarily is a multifaceted decision which is shaped by various factors; hence, comprehensive interventions are suggested to discourage voluntary cesarean section. These interventions need to encompass changes in physicians’ role, social norms, body image and correcting misperceptions among women towards CS and NVD during prenatal courses. PMID:27921002

Randomized double-blind placebo-controlled trial of buccal misoprostol to reduce the need for additional uterotonic drugs during cesarean delivery.

PubMed

Hernández-Castro, Flavio; López-Serna, Norberto; Treviño-Salinas, Emilio M; Soria-López, Juan A; Sordia-Hernández, Luis H; Cárdenas-Estrada, Eloy

2016-02-01

To determine whether buccal misoprostol during cesarean delivery in conjunction with active management of the third stage of labor reduces the need for additional uterotonic drugs. A double-blind, randomized, placebo-controlled trial was performed in Monterrey, Mexico, between February 2008 and December 2013. Eligible women had risk factors for uterine atony and were to undergo cesarean delivery under epidural block. Using a computer-generated sequence and blocks of six, patients were randomly assigned to receive 400μg misoprostol or 800μg placebo buccally after cord clamping. Both groups received an intravenous oxytocin infusion. The primary outcome was the need for additional uterotonic drugs. Analyses were performed per protocol. Patients, investigators, and data analysts were masked to group assignment. A total of 120 women were included in analyses (60 in each group). At least one additional uterotonic drug was required in 24 (40%) women in the placebo group versus 6 (10%) women in the misoprostol group (relative risk 0.16; 95% confidence interval 0.06-0.44). No adverse effects due to misoprostol were recorded. Buccal misoprostol during cesarean delivery reduced the need for additional uterotonic drugs to treat uterine atony. ClinicalTrials.gov:NCT01733329. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game

PubMed Central

Lothian, Judith A.

2014-01-01

Safe Prevention of the Primary Cesarean Delivery, a joint statement of the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, changes the rules of maternity care management. The statement reviews the research and uses the findings to make practice recommendations. This article discusses the major recommendations and their importance in decreasing risk and increasing safety for mothers and babies. The articles in the current issue of the journal are also reviewed.

The impact of body mass index on the risk of high spinal block in parturients undergoing cesarean delivery: a retrospective cohort study.

PubMed

Lamon, Agnes M; Einhorn, Lisa M; Cooter, Mary; Habib, Ashraf S

2017-08-01

To investigate the hypothesis that the risk of high spinal block is not increased in obese parturients undergoing cesarean delivery compared to non-obese parturients. This is a retrospective study at an academic center. We searched the perioperative database for women who underwent cesarean delivery under spinal or combined spinal epidural anesthesia with hyperbaric bupivacaine ≥10.5 mg. A body mass index (BMI) ≥30 kg/m 2 was defined as obese. We categorized obesity into: obesity class I (BMI = 30-34.9 kg/m 2 ), obesity class II (BMI = 35-39.9 kg/m 2 ), obesity class III (BMI = 40-49.9 kg/m 2 ), and super obese (BMI ≥50 kg/m 2 ). The primary outcome was high spinal block defined as need to convert to general anesthesia within 20 min of spinal placement as a result of altered mental status, weakness, or respiratory distress resulting from the high block, or a recorded block height ≥T1. The analysis included 5015 women. High spinal blocks occurred in 29 patients (0.6%). The risk of high spinal was significantly different according to BMI (p = 0.025). In a multivariate model, BMI (p = 0.008) and cesarean delivery priority (p = 0.009) were associated with high blocks. BMI ≥50 kg/m 2 was associated with greater odds of high block compared to BMI <30 kg/m 2 [odds ratio (95% confidence interval): 6.3 (2.2, 18.5)]. Scheduled cesarean delivery was also associated with greater odds of high block compared with unscheduled delivery. At standard spinal doses of hyperbaric bupivacaine used in our practice (≥10.5 mg), there were greater odds of high block in those with BMI ≥50 kg/m 2 .

Randomized controlled trial of tranexamic acid among parturients at increased risk for postpartum hemorrhage undergoing cesarean delivery.

PubMed

Sujata, Nambiath; Tobin, Raj; Kaur, Ranjeet; Aneja, Anjila; Khanna, Mona; Hanjoora, Vijay M

2016-06-01

To assess the effects of tranexamic acid among patients undergoing cesarean delivery who were at high risk of postpartum hemorrhage. Between August 1, 2012, and April 30, 2013, a randomized controlled trial was performed at a tertiary care center in India. Women undergoing an elective or emergency cesarean delivery who were at high risk for postpartum hemorrhage were enrolled. They were randomly assigned using sealed, opaque envelopes to receive 10mg/kg tranexamic acid or normal saline 10min before skin incision. Anesthesiologists were not masked to group assignment, but patients and obstetricians were. The primary outcome was need for additional uterotonic drugs within 24h after delivery. Analyses were by intention to treat. Thirty patients were assigned to each group. Additional uterotonic drugs were required in 7 (23%) patients assigned to tranexamic acid and 25 (83%) patients in the control group (P<0.001). Intravenous tranexamic acid, administered before skin incision, significantly reduced the requirement for additional uterotonics among women at increased risk for postpartum hemorrhage. Clinical Trials Registry India: CTRI/2015/05/005752. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Safety of cesarean delivery through placental incision in patients with anterior placenta previa.

PubMed

Hong, Deok-Ho; Kim, Eugene; Kyeong, Kyu-Sang; Hong, Seung Hwa; Jeong, Eun-Hwan

2016-03-01

To demonstrate the safety of fetal delivery through placental incision in a placenta previa pregnancy. We examined the medical records of 80 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between May 2010 and May 2015 at the Department of Obstetrics and Gynecology, Chungbuk National University Hospital. Among the women with placenta previa, those who did not have the placenta in the uterine incision site gave birth via conventional uterine incision, while those with anterior placenta previa or had placenta attached to the uterine incision site gave birth via uterine incision plus placental incision. We compared the postoperative hemoglobin level and duration of hospital stay for the mother and newborn of the two groups. There was no difference between the placental incision group and non-incision group in terms of preoperative and postoperative hemoglobin change, the amount of blood transfusions required by the mother, newborns with 1-min or 5-min Apgar scores below 7 points or showing signs of acidosis on umbilical cord blood gas analysis result of pH below 7.20. Moreover, neonatal hemoglobin levels did not differ between the two groups. Fetal delivery through placental incision during cesarean section for placenta previa pregnancy does not negatively influence the prognosis of the mother or the newborn, and therefore, is considered a safe surgical technique.

Safety of cesarean delivery through placental incision in patients with anterior placenta previa

PubMed Central

Hong, Deok-Ho; Kim, Eugene; Kyeong, Kyu-Sang; Hong, Seung Hwa

2016-01-01

Objective To demonstrate the safety of fetal delivery through placental incision in a placenta previa pregnancy. Methods We examined the medical records of 80 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between May 2010 and May 2015 at the Department of Obstetrics and Gynecology, Chungbuk National University Hospital. Among the women with placenta previa, those who did not have the placenta in the uterine incision site gave birth via conventional uterine incision, while those with anterior placenta previa or had placenta attached to the uterine incision site gave birth via uterine incision plus placental incision. We compared the postoperative hemoglobin level and duration of hospital stay for the mother and newborn of the two groups. Results There was no difference between the placental incision group and non-incision group in terms of preoperative and postoperative hemoglobin change, the amount of blood transfusions required by the mother, newborns with 1-min or 5-min Apgar scores below 7 points or showing signs of acidosis on umbilical cord blood gas analysis result of pH below 7.20. Moreover, neonatal hemoglobin levels did not differ between the two groups. Conclusion Fetal delivery through placental incision during cesarean section for placenta previa pregnancy does not negatively influence the prognosis of the mother or the newborn, and therefore, is considered a safe surgical technique. PMID:27004200

The Effect of Delaying Childbirth on Primary Cesarean Section Rates

PubMed Central

Smith, Gordon C. S; Cordeaux, Yolande; White, Ian R; Pasupathy, Dharmintra; Missfelder-Lobos, Hannah; Pell, Jill P; Charnock-Jones, D. Stephen; Fleming, Michael

2008-01-01

Background The relationship between population trends in delaying childbirth and rising rates of primary cesarean delivery is unclear. The aims of the present study were (1) to characterize the association between maternal age and the outcome of labor, (2) to determine the proportion of the increase in primary cesarean rates that could be attributed to changes in maternal age distribution, and (3) to determine whether the contractility of uterine smooth muscle (myometrium) varied with maternal age. Methods and Findings We utilized nationally collected data from Scotland, from 1980 to 2005, and modeled the risk of emergency cesarean section among women delivering a liveborn infant in a cephalic presentation at term. We also studied isolated myometrial strips obtained from 62 women attending for planned cesarean delivery in Cambridge, England, from 2005 to 2007. Among 583,843 eligible nulliparous women, there was a linear increase in the log odds of cesarean delivery with advancing maternal age from 16 y upwards, and this increase was unaffected by adjustment for a range of maternal characteristics (adjusted odds ratio for a 5-y increase 1.49, 95% confidence interval [CI] 1.48–1.51). Increasing maternal age was also associated with a longer duration of labor (0.49 h longer for a 5-y increase in age, 95% CI 0.46–0.51) and an increased risk of operative vaginal birth (adjusted odds ratio for a 5-y increase 1.49, 95% CI 1.48–1.50). Over the period from 1980 to 2005, the cesarean delivery rate among nulliparous women more than doubled and the proportion of women aged 30–34 y increased 3-fold, the proportion aged 35–39 y increased 7-fold, and the proportion aged ≥40 y increased 10-fold. Modeling indicated that if the age distribution had stayed the same over the period of study, 38% of the additional cesarean deliveries would have been avoided. Similar associations were observed in multiparous women. When studied in vitro, increasing maternal age was

Optimal intrathecal hyperbaric bupivacaine dose with opioids for cesarean delivery: a prospective double-blinded randomized trial.

PubMed

Onishi, Eiko; Murakami, Mamoru; Hashimoto, Keiji; Kaneko, Miho

2017-05-01

Single-shot spinal anesthesia is commonly used for cesarean delivery. Achieving adequate anesthesia throughout surgery needs to be balanced with associated complications. We investigated the optimal dose of intrathecal hyperbaric bupivacaine, co-administered with opioids, for anesthesia for cesarean delivery. This prospective, randomized, double-blinded, dose-ranging trial included parturients scheduled to undergo cesarean delivery under spinal anesthesia. An epidural catheter was first inserted at the T11-12 vertebral interspace, followed by spinal anesthesia at the L2-3 or L3-4 vertebral interspace. Subjects were randomly assigned to one of seven doses of intrathecal hyperbaric bupivacaine 0.5% (6, 7, 8, 9, 10, 11 or 12mg), with added 15μg fentanyl and 75μg morphine. Successful induction of anesthesia (success ind ) was defined as achievement of bilateral sensory loss to cold at the T6 dermatome or higher, within 10 minutes. Successful maintenance of anesthesia (success main ) was defined by no epidural supplementation within 60 minutes of intrathecal injection. The effective doses for 50% (ED 50 ) and 95% (ED 95 ) of patients were estimated using logistic regression analysis. The ED 50 and ED 95 for success main were 6.0mg (95% CI: 4.5 to 7.5mg) and 12.6mg (95% CI: 7.9 to 17.2mg), respectively. The incidence of respiratory discomfort and maternal satisfaction scores did not differ significantly between dose groups. Phenylephrine dose and nausea/vomiting incidence increased with increasing doses of bupivacaine. Under study conditions, our results suggest that 12.6mg of intrathecal bupivacaine, administered with fentanyl and morphine, is required to achieve adequate intraoperative analgesia without the need for epidural supplemention. Copyright © 2017 Elsevier Ltd. All rights reserved.

Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery.

PubMed

Ho, Szu-Ying; Chang, Shuenn-Dhy; Liang, Ching-Chung

2010-12-01

Uterine rupture is the primary concern when a patient chooses a trial of labor after a cesarean section. Bladder rupture accompanied by uterine rupture should be taken into consideration if gross hematuria occurs. We report the case of a patient with uterine rupture during a trial of labor after cesarean delivery. She had a normal course of labor and no classic signs of uterine rupture. However, gross hematuria was noted after repair of the episiotomy. The patient began to complain of progressive abdominal pain, gross hematuria and oliguria. Cystoscopy revealed a direct communication between the bladder and the uterus. When opening the bladder peritoneum, rupture sites over the anterior uterus and posterior wall of the bladder were noted. Following primary repair of both wounds, a Foley catheter was left in place for 12 days. The patient had achieved a full recovery by the 2-year follow-up examination. Bladder injury and uterine rupture can occur at any time during labor. Gross hematuria immediately after delivery is the most common presentation. Cystoscopy is a good tool to identify the severity of bladder injury. Copyright © 2010 Elsevier. Published by Elsevier B.V. All rights reserved.

Risk of Autism Associated with General Anesthesia during Cesarean Delivery: A Population-Based Birth-Cohort Analysis

ERIC Educational Resources Information Center

Chien, Li-Nien; Lin, Hsiu-Chen; Shao, Yu-Hsuan Joni; Chiou, Shu-Ti; Chiou, Hung-Yi

2015-01-01

The rates of Cesarean delivery (C-section) have risen to >30 % in numerous countries. Increased risk of autism has been shown in neonates delivered by C-section. This study examined the incidence of autism in neonates delivered vaginally, by C-section with regional anesthesia (RA), and by C-section with general anesthesia (GA) to evaluate the…

Cesarean sections in Alberta from April 1979 to March 1988.

PubMed Central

Saunders, L D; Flowerdew, G

1991-01-01

OBJECTIVES: To determine (a) trends in the cesarean section rate in Alberta from April 1979 to March 1988, (b) the contribution of different primary indications to the overall increase in the cesarean section rate and (c) trends in the cesarean section rate by residence of the mother. DESIGN: Retrospective study. PARTICIPANTS: Women who gave birth in acute care hospitals in Alberta during the study period. Indications for cesarean section were defined by a hierarchic classification system. Geographic regions were identified according to the mother's residence. MAIN RESULTS: The crude cesarean section rate increased from 13.2 to 17.3 per 100 deliveries between 1979-80 and 1987-88. Previous cesarean section accounted for 54% of the increase, breech presentation for 17%, fetal distress for 17% and dystocia for 10%. The contribution of previous cesarean section was due to the substantial increase in the number of women presenting with a previous cesarean section. The cesarean section rate among women who had previously had the procedure decreased from 96.7% in 1979-80 to 84.6% in 1987-88. The crude cesarean section rates by region varied from 10.3 to 22.3 per 100 deliveries. CONCLUSIONS: Further efforts to reduce the rate of cesarean section among women who have previously undergone the procedure are needed to control the rate of cesarean section in Alberta. Decreasing the rate of primary cesarean section is also an important goal. PMID:2025819

Evidence-Based Bundles and Cesarean Delivery Surgical Site Infections: A Systematic Review and Meta-analysis.

PubMed

Carter, Ebony B; Temming, Lorene A; Fowler, Susan; Eppes, Catherine; Gross, Gilad; Srinivas, Sindhu K; Macones, George A; Colditz, Graham A; Tuuli, Methodius G

2017-10-01

To estimate the association of implementation of evidence-based bundles with surgical site infection rates after cesarean delivery. We searched MEDLINE through PubMed, EMBASE, Scopus, the Cochrane Database of Systematic Reviews, Google Scholar, and ClinicalTrials.gov. We searched electronic databases for randomized controlled trials and observational studies comparing evidence-based infection prevention bundles for cesarean delivery, defined as implementation of three or more processes proven to prevent surgical site infection such as chlorhexidine skin preparation, antibiotic prophylaxis, and hair clipping, with usual care. The primary outcome was overall surgical site infection, defined using Centers for Disease Control and Prevention's National Healthcare Safety Network criteria. Secondary outcomes were superficial or deep surgical site infection and endometritis. Quality of studies and heterogeneity were assessed using validated measures. Pooled relative risks (RRs) with 95% CIs were calculated using random-effects models. Numbers needed to treat were estimated for outcomes with significant reduction. We found no randomized controlled trials. Fourteen preintervention and postintervention studies met inclusion criteria. Eight were full-text articles, and six were published abstracts. Quality of most of the primary studies was adequate with regard to the intervention, but modest in terms of implementation. The rate of surgical site infection was significantly lower after implementing an evidence-based bundle (14 studies: pooled rates 6.2% baseline compared with 2.0% intervention, pooled RR 0.33, 95% CI 0.25-0.43, number needed to treat=24). Evidence-based bundles were also associated with a lower rate of superficial or deep surgical site infection (six studies: pooled rate 5.9% baseline compared with 1.1% intervention, pooled RR 0.19, 95% CI 0.12-0.32, number needed to treat=21). The rate of endometritis was low at baseline and not significantly different after

Birth by Cesarean Section, Allergic Rhinitis, and Allergic Sensitization among Children with Parental History of Atopy

PubMed Central

Pistiner, Michael; Gold, Diane R.; Abdulkerim, Hassen; Hoffman, Ellaine; Celedón, Juan C.

2016-01-01

Background Cesarean delivery may alter neonatal immune responses and increase the risk of atopy. Studies of the relation between cesarean delivery and allergic diseases in children not selected on the basis of a family history of atopy have yielded inconsistent findings. Objective To examine the relation between birth by cesarean delivery and atopy and allergic diseases in children at risk for atopy. Methods We examined the relation between mode of delivery and the development of atopy and allergic diseases among 432 children with parental history of atopy followed from birth to age 9 years. Asthma was defined as physician-diagnosed asthma and wheeze in the previous year and allergic rhinitis as physician-diagnosed allergic rhinitis and naso-ocular symptoms apart from colds in the previous year. Atopy was considered present at school age if there was >=1 positive skin test or specific IgE to common allergens. Stepwise logistic regression was used to study the relation between cesarean delivery and the outcomes of interest. Results After adjustment for other covariates, children born by cesarean section had twofold higher odds of atopy than those born by vaginal delivery (OR=2.1, 95% CI=1.1–3.9). In multivariate analyses, birth by cesarean section was significantly associated with increased odds of allergic rhinitis (OR=1.8, 95% CI=1.0–3.1) but not with asthma. Conclusions Our findings suggest that cesarean delivery is associated with allergic rhinitis and atopy among children with parental history of asthma or allergies. This could be explained by lack of contact with the maternal vaginal/fecal flora or reduced/absent labor during cesarean delivery. Clinical Implications Potential development of allergic diseases should be considered as a potential risk of cesarean delivery among children with parental history of atopy. Capsule Summary Cesarean delivery may lead to an increased risk of allergic rhinitis and atopy in children with parental history of atopy. PMID

Prenatal Lipid-Based Nutrient Supplements Do Not Affect Pregnancy or Childbirth Complications or Cesarean Delivery in Bangladesh: A Cluster-Randomized Controlled Effectiveness Trial.

PubMed

Mridha, Malay K; Matias, Susana L; Paul, Rina Rani; Hussain, Sohrab; Sarker, Mostofa; Hossain, Mokbul; Peerson, Janet M; Vosti, Stephen A; Dewey, Kathryn G

2017-09-01

Background: Pregnancy and childbirth complications and cesarean delivery are common in Bangladesh. Objective: We evaluated the effect of lipid-based nutrient supplements for pregnant and lactating women (LNS-PL) on pregnancy and childbirth complications and cesarean delivery. Methods: We conducted the Rang-Din Nutrition Study, a cluster-randomized controlled effectiveness trial within a community health program in rural Bangladesh. We enrolled 4011 pregnant women in early pregnancy. Women in 48 clusters received iron and folic acid (IFA; 60 mg Fe + 400 μg folic acid/d) and women in 16 clusters received LNS-PL (20 g/d, 118 kcal) containing essential fatty acids and 22 vitamins and minerals. Pregnancy and childbirth complications and the cesarean delivery rate were secondary outcomes of the study. Results: Women in the LNS-PL group did not differ significantly from the IFA group with respect to mean systolic blood pressure at 36 wk gestation (113 and 112 mm Hg; P = 0.17), diastolic blood pressure at 36 wk gestation (68.9 and 68.7 mmHg; P = 0.88), or mean total number of pregnancy and childbirth complications (0.32 and 0.31; P = 0.86). They also did not differ significantly with respect to the prevalence of high blood pressure at 36 wk (1.74% and 2.03%; P = 0.62), antepartum hemorrhage (0.83% and 1.39%; P = 0.21), prolonged labor (8.34% and 8.79%; P = 0.68), early rupture of membranes (9.30% and 8.45%; P = 0.43), convulsions (1.57% and 1.08%; P = 0.24), high blood pressure in labor (1.54% and 1.19%; P = 0.46), obstructed labor (2.83% and 2.91%; P = 0.90), any complications during pregnancy or childbirth (35.9% and 37.1%; P = 0.64), episiotomy (6.31% and 6.44%; P = 0.90), or cesarean delivery (15.6% and 14.2%; P = 0.48). Conclusion: Compared with IFA, antenatal LNS-PL did not increase or decrease pregnancy and childbirth complications or cesarean delivery among women in rural Bangladesh. This trial was registered at clinicaltrials.gov as NCT01715038. © 2017 American

Liposomal Bupivacaine Block at the Time of Cesarean Delivery to Decrease Postoperative Pain: A Randomized Controlled Trial.

PubMed

Prabhu, Malavika; Clapp, Mark A; McQuaid-Hanson, Emily; Ona, Samsiya; OʼDonnell, Taylor; James, Kaitlyn; Bateman, Brian T; Wylie, Blair J; Barth, William H

2018-07-01

To evaluate whether a liposomal bupivacaine incisional block decreases postoperative pain and represents an opioid-minimizing strategy after scheduled cesarean delivery. In a single-blind, randomized controlled trial among opioid-naive women undergoing cesarean delivery, liposomal bupivacaine or placebo was infiltrated into the fascia and skin at the surgical site, before fascial closure. Using an 11-point numeric rating scale, the primary outcome was pain score with movement at 48 hours postoperatively. A sample size of 40 women per group was needed to detect a 1.5-point reduction in pain score in the intervention group. Pain scores and opioid consumption, in oral morphine milligram equivalents, at 48 hours postoperatively were summarized as medians (interquartile range) and compared using the Wilcoxon rank-sum test. Between March and September 2017, 249 women were screened, 103 women enrolled, and 80 women were randomized. One woman in the liposomal bupivacaine group was excluded after randomization as a result of a vertical skin incision, leaving 39 patients in the liposomal bupivacaine group and 40 in the placebo group. Baseline characteristics between groups were similar. The median (interquartile range) pain score with movement at 48 hours postoperatively was 4 (2-5) in the liposomal bupivacaine group and 3.5 (2-5.5) in the placebo group (P=.72). The median (interquartile range) opioid use was 37.5 (7.5-60) morphine milligram equivalents in the liposomal bupivacaine group and 37.5 (15-75) morphine milligram equivalents in the placebo group during the first 48 hours postoperatively (P=.44). Compared with placebo, a liposomal bupivacaine incisional block at the time of cesarean delivery resulted in similar postoperative pain scores in the first 48 hours postoperatively. ClinicalTrials.gov, NCT02959996.

The Association of Targeted Cell Salvage Blood Transfusion During Cesarean Delivery With Allogeneic Packed Red Blood Cell Transfusions in a Maternity Hospital in China.

PubMed

Yan, Haiya; Hu, Ling-Qun; Wu, Yun; Fan, Qihui; Wong, Cynthia A; McCarthy, Robert J

2018-03-01

Autologous transfusion of intraoperative cell salvage blood may be a potential method to decrease the need for allogeneic packed red blood cell transfusions after cesarean delivery, although there are limited data on the benefits of this method. This study evaluated the implementation of targeted intraoperative cell salvage during cesarean delivery in women at increased risk for hemorrhage at the Women's and Children's Hospital in Ningbo, China. All women who underwent cesarean delivery >28 weeks of gestation were included in the study. The period before intraoperative cell collection (October 1, 2010, to August 31, 2012, n = 11,322) was compared with the postimplementation period (September 1, 2012, to June 30, 2015, n = 17,456) using an interrupted time series analysis. In the postimplementation period, women suspected to be at increased risk of the need for a blood transfusion (1604, 9.2%) underwent intraoperative cell salvage collection. The primary outcomes were the monthly rate of allogeneic packed red blood cell use and the incidence of clinical manifestation of acute blood transfusion reactions. The mean (standard deviation) estimated monthly allogeneic packed blood cell transfusion rate at the end of the 57-month study was 2.2% ± 0.7% with the implementation compared with 2.7% ± 0.9% without, difference -0.5%, 95% CI, -1.4% to 0.3%; P = .22. The mean number of allogeneic units transfused per patient was 4.1 ± 0.4 units with implementation and 3.9 ± 0.9 units without, difference 0.2, 95% CI, -1.7 to 1.1 units; P = .69. Intraoperative cell salvage blood was reinfused in 757 (47%) and wasted in 847 (53%) cases. The monthly intraoperative allogeneic packed red blood cells use rate was lower after implementation (difference -0.7%, 95% CI, -0.1% to -1.4%; P = .03); however, the monthly postpartum allogeneic packed red blood cell use rate was unchanged (difference -0.2%, 95% CI, -0.4% to 0.7%; P = .56). The clinical manifestation of acute blood transfusion

Financial incentives do not always work: an example of cesarean sections in Taiwan.

PubMed

Lo, Joan C

2008-10-01

To test the hypothesis that cesarean sections are less likely to be performed after equalizing the fees for vaginal births and cesarean sections. Population-based National Health Insurance inpatient claims in Taiwan are used. Pre-periods and post-periods are identified to investigate the impact of the policy changes. Logistic regressions are employed. The cesarean section rates for the first, second and higher-order births are 29, 37.4 and 39.3%, while the primary cesarean section rates are 29, 11.8 and 12.1%, respectively. After taking into consideration the case-mix and birth order, the second and higher-order births were approximately 60% less likely to be cesarean deliveries compared to the first births and the increase in the VBAC fee had an additional negative effect on them. A fee equalization policy was not found to influence the cesarean delivery. The total cesarean section rate was primarily determined by the cesarean section rate for the first birth. Cesarean section rates are greater for the higher-order births because of the practice "once a cesarean section, always a cesarean section". Against the background of a rapidly declining fertility rate, females play a more important role in the mode of delivery than ever before. As such, financial incentives designed specifically for obstetricians do not have the desired impact. Policies that are aimed at altering behavior should be designed within the social context.

Association Between Cesarean Birth and Risk of Obesity in Offspring in Childhood, Adolescence, and Early Adulthood.

PubMed

Yuan, Changzheng; Gaskins, Audrey J; Blaine, Arianna I; Zhang, Cuilin; Gillman, Matthew W; Missmer, Stacey A; Field, Alison E; Chavarro, Jorge E

2016-11-07

Cesarean birth has been associated with higher risk of obesity in offspring, but previous studies have focused primarily on childhood obesity and have been hampered by limited control for confounders. To investigate the association between cesarean birth and risk of obesity in offspring. A prospective cohort study was conducted from September 1, 1996, to December 31, 2012, among participants of the Growing Up Today Study, including 22 068 offspring born to 15 271 women, followed up via questionnaire from ages 9 to 14 through ages 20 to 28 years. Data analysis was conducted from October 10, 2015, to June 14, 2016. Birth by cesarean delivery. Risk of obesity based on International Obesity Task Force or World Health Organization body mass index cutoffs, depending on age. Secondary outcomes included risks of obesity associated with changes in mode of delivery and differences in risk between siblings whose modes of birth were discordant. Of the 22 068 offspring (20 950 white; 9359 male and 12 709 female), 4921 individuals (22.3%) were born by cesarean delivery. The cumulative risk of obesity through the end of follow-up was 13% among all participants. The adjusted risk ratio for obesity among offspring delivered via cesarean birth vs those delivered via vaginal birth was 1.15 (95% CI, 1.06-1.26; P = .002). This association was stronger among women without known indications for cesarean delivery (adjusted risk ratio, 1.30; 95% CI, 1.09-1.54; P = .004). Offspring delivered via vaginal birth among women who had undergone a previous cesarean delivery had a 31% (95% CI, 17%-47%) lower risk of obesity compared with those born to women with repeated cesarean deliveries. In within-family analysis, individuals born by cesarean delivery had 64% (8%-148%) higher odds of obesity than did their siblings born via vaginal delivery. Cesarean birth was associated with offspring obesity after accounting for major confounding factors. Although additional research is

A Rare Case of Transvesical Cesarean Section

PubMed Central

Juneja, Sunil Kumar; Tandon, Pooja; Kochhar, Bakul; Singh, Harman Deep; Sharma, Bhanupriya

2017-01-01

Cesarean section, also commonly known as C-section, is a surgical procedure in which incision is made through a mother's abdomen and uterus to deliver one or more babies. According to urgency, they are classified either as elective or emergency. According to technique, they have been classified as classical, lower uterine segment and cesarean hysterectomy. Intentional transvesical cesarean though not a routinely practiced technique is used for delivery in women born with imperforate anus, ectopic intravaginal urethra, vaginal and urethral strictures, and bladder adherent completely over the uterus. Since such cases are very rare, we are reporting one such case of transvesical cesarean section. PMID:28904925

Sufentanil and Bupivacaine Combination versus Bupivacaine Alone for Spinal Anesthesia during Cesarean Delivery: A Meta-Analysis of Randomized Trials.

PubMed

Hu, Jiajia; Zhang, Chengliang; Yan, Jianqin; Wang, Ruike; Wang, Ying; Xu, Mu

2016-01-01

The addition of lipophilic opioids to local anesthetics for spinal anesthesia has become a widely used strategy for cesarean anesthesia. A meta-analysis to quantify the benefits and risks of combining sufentanil with bupivacaine for patients undergoing cesarean delivery was conducted. A comprehensive literature search without language or date limitation was performed to identify clinical trials that compared the addition of sufentanil to bupivacaine with bupivacaine alone for spinal anesthesia in healthy parturients choosing cesarean delivery. The Q and I2 tests were used to assess heterogeneity of the data. Data from each trial were combined using relative ratios (RRs) for dichotomous data or weighted mean differences (WMDs) for continuous data and corresponding 95% confidence intervals (95% CIs) for each trial. Sensitivity analysis was conducted by removing one study a time to assess the quality and consistency of the results. Begg's funnel plots and Egger's linear regression test were used to detect any publication bias. This study included 9 trials containing 578 patients in the final meta-analysis. Sufentanil addition provided a better analgesia quality with less breakthrough pain during surgery than bupivacaine alone (RR = 0.10, 95% CI 0.06 to 0.18, P < 0.001). Sensory block onset time was shorter and first analgesic request time was longer in sufentanil added group compared with the bupivacaine-alone group (WMD = -1.0 min, 95% CI -1.5 to -0.58, P < 0.001 and WMD = 133 min, 95% CI 75 to 213, P < 192, respectively). There was no significant difference in the risk of hypotension and vomiting between these two groups. But pruritus was more frequentely reported in the group with sufentanil added (RR = 7.63, 95% CI 3.85 to 15.12, P < 0.001). Bupivacaine and sufentanil combination is superior to that of bupivacaine alone for spinal anesthesia for cesarean delivery in analgesia quality. Women receiving the combined two drugs had less breakthrough pain, shorter

Association of Cesarean Delivery and Formula Supplementation With the Intestinal Microbiome of 6-Week-Old Infants.

PubMed

Madan, Juliette C; Hoen, Anne G; Lundgren, Sara N; Farzan, Shohreh F; Cottingham, Kathryn L; Morrison, Hilary G; Sogin, Mitchell L; Li, Hongzhe; Moore, Jason H; Karagas, Margaret R

2016-03-01

The intestinal microbiome plays a critical role in infant development, and delivery mode and feeding method (breast milk vs formula) are determinants of its composition. However, the importance of delivery mode beyond the first days of life is unknown, and studies of associations between infant feeding and microbiome composition have been generally limited to comparisons between exclusively breastfed and formula-fed infants, with little consideration given to combination feeding of both breast milk and formula. To examine the associations of delivery mode and feeding method with infant intestinal microbiome composition at approximately 6 weeks of life. Prospective observational study of 102 infants followed up as part of a US pregnancy cohort study. Delivery mode was abstracted from delivery medical records, and feeding method prior to the time of stool collection was ascertained through detailed questionnaires. Stool microbiome composition was characterized using next-generation sequencing of the 16S rRNA gene. There were 102 infants (mean gestational age, 39.7 weeks; range, 37.1-41.9 weeks) included in this study, of whom 70 were delivered vaginally and 32 by cesarean delivery. In the first 6 weeks of life, 70 were exclusively breastfed, 26 received combination feeding, and 6 were exclusively formula fed. We identified independent associations between microbial community composition and both delivery mode (P< .001; Q < .001) and feeding method (P = .01; Q < .001). Differences in microbial community composition between vaginally delivered infants and infants delivered by cesarean birth were equivalent to or significantly larger than those between feeding groups (P = .003). Bacterial communities associated with combination feeding were more similar to those associated with exclusive formula feeding than exclusive breastfeeding (P = .002). We identified 6 individual bacterial genera that were differentially abundant between delivery mode and feeding groups

Efficacy and tolerability of intravenous morphine patient-controlled analgesia (PCA) in women undergoing cesarean delivery.

PubMed

Andziak, Marta; Beta, Jarosław; Barwijuk, Michal; Issat, Tadeusz; Jakimiuk, Artur J

2015-06-01

The aim of the study was to evaluate analgesic efficacy and tolerability of patient-controlled analgesia (PCA) with intravenous morphine. Our observational study included 50 women who underwent a Misgav-Ladach or modified Misgav-Ladach cesarean section. Automated PCA infusion device (Medima S-PCA Syringe Pump, Medima, Krakow, Poland) was used for postoperative pain control. Time of morphine administration or initiation of intravenous patient-controlled analgesia (IV PCA) with morphine was recorded, as well as post-operative pain at rest assessed by a visual analogue scale (VAS). All patients were followed up for 24 hours after discharge from the operating room, taking into account patient records, worst pain score at rest, number of IV PCA attempts, and drug consumption. Median of total morphine doses used during the postoperative period was 42.9mg (IQR 35.6-48.5), with median infusion time of 687.0 min. (IQR 531.0-757.5). Pain severity and total drug consumption improved after the first 3 hours following cesarean delivery (p < 0.01). Mean number of PCA attempts per patient was 33 (IQR: 24-37), with median of 11 placebo attempts (IQR: 3-27). Patient-controlled analgesia with morphine is an efficient and acceptable analgesic method in women undergoing cesarean section.

Women's knowledge and attitude towards mode of delivery and frequency of cesarean section on mother's request in six public and private hospitals in Tehran, Iran, 2012.

PubMed

Ghotbi, Fatemeh; Akbari Sene, Azadeh; Azargashb, Eznollah; Shiva, Farideh; Mohtadi, Mina; Zadehmodares, Shahrzad; Farzaneh, Farah; Yasai, Fakhr-al-Molouk

2014-05-01

The rate of cesarean section (CS) has been reported to be as high as 40% among Iranian women in the year 2009. The aim of this study was to determine the rate of cesarean delivery on mother's request (CDMR) and to determine maternal attitude and knowledge about various modes of delivery in private and public (university) hospitals in Tehran. All primiparous mothers delivering in six selected hospitals between April 2010 and March 2011 were included. Trained investigators handed a predesigned questionnaire to mothers 1 day after delivery to be filled out in the presence of the investigator. From 600 deliveries, 501 (83.5%) were CS and 99 (16.5%) were normal vaginal delivery. The CS rates in university hospitals versus private hospitals were 78.5% and 91.9%, respectively. In total, mothers' knowledge scores were poor, intermediate, and good in 55.6%, 37.9%, and 6.5% of cases, respectively, and no significant difference in knowledge was observed between mothers attending private or public hospitals. The overall rate of CDMR was 20.8%; and the most frequent reason was fear of pain. Women with CDMR were at higher marital age, education, insurance coverage, and socioeconomic status compared with the women with vaginal delivery. Prompt action is needed to reduce the unacceptably high rate of unwarranted cesarean deliveries. Improving women's knowledge about the risks and benefits of different modes of delivery can lead to a positive maternal attitude towards vaginal delivery. © 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.

Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial.

PubMed

Tawfik, Mohamed Mohamed; Mohamed, Yaser Mohamed; Elbadrawi, Rania Elmohamadi; Abdelkhalek, Mostafa; Mogahed, Maiseloon Mostafa; Ezz, Hanaa Mohamed

2017-04-01

Transversus abdominis plane (TAP) block and local anesthetic wound infiltration provide analgesia after cesarean delivery. Studies comparing the 2 techniques are scarce, with conflicting results. This double-blind, randomized controlled trial aimed to compare bilateral ultrasound-guided TAP block with single-shot local anesthetic wound infiltration for analgesia after cesarean delivery performed under spinal anesthesia. We hypothesized that the TAP block would decrease postoperative cumulative fentanyl consumption at 24 hours. Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies undergoing elective cesarean delivery under spinal anesthesia. Exclusion criteria were: <19 years of age or >40 years of age; height <150 cm, weight <60 kg, body mass index ≥40 kg/m; contraindications to spinal anesthesia; history of recent opioid exposure; hypersensitivity to any of the drugs used in the study; significant cardiovascular, renal, or hepatic disease; and known fetal abnormalities. Eighty subjects were randomly allocated to 2 equal groups. In the infiltration group, participants received 15 mL of bupivacaine 0.25% in each side of the surgical wound (total 30 mL); and in the TAP group, participants received 20 mL of bupivacaine 0.25% bilaterally in the TAP block (total 40 mL). The TAP block and wound infiltration were performed by the primary investigator and the operating obstetrician, respectively. All participants received postoperative standard analgesia (ketorolac and paracetamol) and intravenous fentanyl via patient-controlled analgesia. Patients and outcome assessors were blinded to the study group. The primary outcome was the cumulative fentanyl consumption at 24 hours. Secondary outcomes were the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of

Temporal Trends in Anesthesia-related Adverse Events in Cesarean Deliveries, New York State, 2003-2012.

PubMed

Guglielminotti, Jean; Wong, Cynthia A; Landau, Ruth; Li, Guohua

2015-11-01

Cesarean delivery (CD) is associated with significantly increased risks of anesthesia-related adverse events (ARAEs) and nonanesthetic perioperative morbidity compared with vaginal delivery. Temporal trends in these adverse outcomes remain unknown despite efforts to improve maternal safety. This study examines temporal trends in ARAEs and nonanesthetic perioperative complications in CDs in New York hospitals. Data are from the State Inpatient Database for New York, 2003-2012. ARAEs, including minor and major ARAEs, and nonanesthetic perioperative complications were identified through International Classification of Diseases, Ninth Revision, Clinical Modification codes. Statistical significance in time trends was assessed using the Cochran-Armitage test and multivariable logistic regression. Of the 785,854 CDs studied, 5,715 (730 per 100,000; 95% CI, 710 to 750) had at least one ARAE and 7,040 had at least one perioperative complication (890 per 100,000; 95% CI, 870 to 920). The overall annual rate of ARAEs decreased from 890 per 100,000 in 2003 to 660 in 2012 (25% decrease; 95% CI, 16 to 34; P < 0.0001). The rate of minor ARAEs decreased 23% (95% CI, 13 to 32) and of major ARAEs decreased 43% (95% CI, 23 to 63). No decrease was observed in the rate of ARAEs for CDs performed under general anesthesia. The rate of nonanesthetic complications increased 47% (95% CI, 31 to 63; P < 0.0001). Anesthesia-related outcomes in cesarean deliveries appear to have improved significantly across hospitals in New York in the past decade. Perioperative nonanesthetic complications remain a serious healthcare issue.

Could Revision of the Embryology Influence Our Cesarean Delivery Technique: Towards an Optimized Cesarean Delivery for Universal Use

PubMed Central

Stark, Michael; Mynbaev, Ospan; Vassilevski, Yuri; Rozenberg, Patrick

2016-01-01

Until today, there is no standardized Cesarean Section method and many variations exist. The main variations concern the type of abdominal incision, usage of abdominal packs, suturing the uterus in one or two layers, and suturing the peritoneal layers or leaving them open. One of the questions is the optimal location of opening the uterus. Recently, omission of the bladder flap was recommended. The anatomy and histology as results from the embryological knowledge might help to solve this question. The working thesis is that the higher the incision is done, the more damage to muscle tissue can take place contrary to incision in the lower segment, where fibrous tissue prevails. In this perspective, a call for participation in a two-armed prospective study is included, which could result in an optimal, evidence-based Cesarean Section for universal use. PMID:28078171

Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop

PubMed Central

Spong, Catherine Y.; Berghella, Vincenzo; Wenstrom, Katharine D.; Mercer, Brian M.; Saade, George R.

2012-01-01

With over one-third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean. The available information on maternal and fetal factors, labor management and induction, and non-medical factors leading to the first cesarean were reviewed as well as the implications of the first cesarean on future reproductive health. Key points were identified to assist with reduction in cesarean rates including that labor induction should be performed primarily for medical indication; if done for non-medical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress. The diagnosis of “failed induction” should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed, as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated, and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery is facilitated and encouraged. When discussing the first cesarean with a patient, counseling should include its effect on future reproductive health. PMID:23090537

Cervical dilation at the time of cesarean section for dystocia -- effect on subsequent trial of labor.

PubMed

Abildgaard, Helle; Ingerslev, Marie Diness; Nickelsen, Carsten; Secher, Niels Joergen

2013-02-01

To investigate the effect of cervical dilation at the time of cesarean section due to dystocia and success in a subsequent pregnancy of attempted vaginal delivery. Retrospective study. University hospital in Copenhagen capital area. All women with a prior cesarean section due to dystocia who had undergone a subsequent pregnancy with a singleton delivery during 2006-2010. Medical records were reviewed for prior vaginal birth, cervical dilation reached before cesarean section and induction of labor, gestational age, use of oxytocin, epidural anesthesia and mode of birth was collected. A total of 889 women were included; 373 had had a trial of labor. The success rate for vaginal birth among women with prior cesarean section for dystocia at 4-8 cm dilation was 39%, but 59% for women in whom prior cesarean section had been done at a fully or almost fully dilated cervix (9-10 cm) (p < 0.001). Among the women with a previous vaginal delivery prior to their cesarean section, the success rate for vaginal birth was 76.2%, in contrast to 48.9% in the group without a previous vaginal delivery (p < 0.01). Women who had a trial of labor after a prior cesarean section for dystocia done late in labor and women with a vaginal delivery prior to their cesarean section had a greater chance of a successful vaginal birth during a subsequent delivery. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

[Comparison of two cesarean techniques: classic versus Misgav Ladach cesarean].

PubMed

Moreira, P; Moreau, J C; Faye, M E; Ka, S; Kane Guèye, S M; Faye, E O; Dieng, T; Diadhiou, F

2002-10-01

The aim of the study was to compare two cesarean section techniques Methodology. A prospective study was conducted UB 400 cesareans performed at the Gynecological and Obstetric Clinic of the Dakar Teaching Hospital between March 2000 and August 2000. Two hundred patients underwent the classical procedure (CL group) and the other 200 the Misgav Ladach procedure (ML group). Per- and post-operative data were compared between the two groups with Student's test and the Chi(2) test. A p-value less than 0.05 was considered statistically significant. The two groups were similar for socio-demographic and clinical data. The delay between the skin incision and infant delivery was significantly shorter in the ML group (5 minutes 26 seconds versus 6 minutes 20 seconds). The same trend was found for the length of operation (36 minutes 36 seconds versus 54 minutes 38 seconds). Fewer sutures were used in the ML group (2.92 versus 4.14). There is no significant difference for dose of analgesia, post-operative complications and hospital discharge. Cost analysis demonstrated that the Misgav Ladach procedure was 10000 FCFA (15 euros) less costly. Misgav Ladach method is simple, rapid, cost-effective cesarean procedure which appears to be an attractive alternative to traditional cesarean section.

Improvements in Cesarean Section Techniques: Arad's Obstetrics Department Experience on Adapting the Vejnovic Cesarean Section Technique

PubMed Central

FURAU, Cristian; FURAU, Gheorghe; DASCAU, Voicu; CIOBANU, Gheorghe; ONEL, Cristina; STANESCU, Casiana

2013-01-01

ABSTRACT Objectives: Cesarean section has become recently the first choice for delivery in many clinics in Romania and worldwide. The purpose of our study is to assess the benefits of introducing the adapted Vejnovic uterine suture technique into daily practice. Material and Methods: A total of 1703 out of the 1776 cesarean section performed in the period January, 2012 - March, 2013 in the Obstetric Department of the Emergency Clinical County Hospital of Arad were retrospectively analyzed based on the cesarean section registries, birth registries and patient's personal medical records. We compared results between the group of patients undergoing adapted Vejnovic cesarean section technique and the group of patients operated in a classic manner. Outcomes: The cesarean section rate in the studied period was 56.48%. Adapted Vejnovic cesarean section technique was performed in 548 cases (30.86% of the cases), furthermore in the last 3 months studied it reached 57.27%. Mean APGAR score was better in the adapted Vejnovic cesarean section group (8.43) compared with the reference group (8.34). No significant differences were seen between the two groups regarding maternal age, gestation, weeks of gestation, newborn weight, anesthesia and indications for cesarean section. Exteriorizing the uterus helped the incidental diagnosis of 35 uterine myoma, 22 adnexal masses and 13 uterine malformations. Conclusion: In a society with a constant growth of cesarean rate, the adapted Vejnovic cesarean section technique is becoming popular amongst clinicians for its advantages, but further studies need to be developed for its standardization. PMID:24371494

Failed Operative Vaginal Delivery

PubMed Central

Alexander, James M.; Leveno, Kenneth J.; Hauth, John C.; Landon, Mark B.; Gilbert, Sharon; Spong, Catherine Y.; Varner, Michael W.; Caritis, Steve N.; Meis, Paul; Wapner, Ronald J.; Sorokin, Yoram; Miodovnik, Menachem; O'Sullivan, Mary J.; Sibai, Baha M.; Langer, Oded; Gabbe, Steven G.

2010-01-01

Objective To compare maternal and neonatal outcomes in women undergoing a second stage cesarean after a trial of operative vaginal delivery with women undergoing a second stage cesarean without such an attempt. Methods This study is a secondary analysis of the women who underwent second stage cesarean. .The maternal outcomes examined included blood transfusion, endometritis, wound complication, anesthesia use, and maternal death. Infant outcomes examined included umbilical artery pH < 7.0, Apgar of 3 or less at 5 minutes, seizures within 24 hours of birth, hypoxic ischemic encephalopathy (HIE), stillbirth, skull fracture, and neonatal death. Results Of 3189 women who underwent second stage cesarean, operative vaginal delivery was attempted in 640. Labor characteristics were similar in the two groups with the exception of the admission to delivery time and cesarean indication. Those with an attempted operative vaginal delivery were more likely to undergo cesarean delivery for a non-reassuring fetal heart rate tracing (18.0% vs 13.9%, p=.01), have a wound complication (2.7% vs 1.0%; OR 2.65 95% CI 1.43–4.91), and require general anesthesia (8.0% vs 4.1%, OR 2.05 95% CI 1.44–2.91). Neonatal outcomes including umbilical artery pH less than 7.0, Apgar at or below 3 at 5 minutes, and hypoxic ischemic encephalopathy were more common for those with an attempted operative vaginal delivery. This was not significant when cases with a non-reassuring fetal heart rate tracing were removed. Conclusion Cesarean delivery after an attempt at operative vaginal delivery was not associated with adverse neonatal outcomes in the absence of a non-reassuring fetal heart rate tracing. PMID:20168101

Route of delivery following successful external cephalic version.

PubMed

Policiano, Catarina; Costa, Ana; Valentim-Lourenço, Alexandre; Clode, Nuno; Graça, Luís M

2014-09-01

To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV). A retrospective matched case-control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status. Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63). Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Sufentanil and Bupivacaine Combination versus Bupivacaine Alone for Spinal Anesthesia during Cesarean Delivery: A Meta-Analysis of Randomized Trials

PubMed Central

Yan, Jianqin; Wang, Ruike; Wang, Ying; Xu, Mu

2016-01-01

Objective The addition of lipophilic opioids to local anesthetics for spinal anesthesia has become a widely used strategy for cesarean anesthesia. A meta-analysis to quantify the benefits and risks of combining sufentanil with bupivacaine for patients undergoing cesarean delivery was conducted. Methods A comprehensive literature search without language or date limitation was performed to identify clinical trials that compared the addition of sufentanil to bupivacaine with bupivacaine alone for spinal anesthesia in healthy parturients choosing cesarean delivery. The Q and I2 tests were used to assess heterogeneity of the data. Data from each trial were combined using relative ratios (RRs) for dichotomous data or weighted mean differences (WMDs) for continuous data and corresponding 95% confidence intervals (95% CIs) for each trial. Sensitivity analysis was conducted by removing one study a time to assess the quality and consistency of the results. Begg’s funnel plots and Egger’s linear regression test were used to detect any publication bias. Results This study included 9 trials containing 578 patients in the final meta-analysis. Sufentanil addition provided a better analgesia quality with less breakthrough pain during surgery than bupivacaine alone (RR = 0.10, 95% CI 0.06 to 0.18, P < 0.001). Sensory block onset time was shorter and first analgesic request time was longer in sufentanil added group compared with the bupivacaine-alone group (WMD = −1.0 min, 95% CI −1.5 to −0.58, P < 0.001 and WMD = 133 min, 95% CI 75 to 213, P < 192, respectively). There was no significant difference in the risk of hypotension and vomiting between these two groups. But pruritus was more frequentely reported in the group with sufentanil added (RR = 7.63, 95% CI 3.85 to 15.12, P < 0.001). Conclusion Bupivacaine and sufentanil combination is superior to that of bupivacaine alone for spinal anesthesia for cesarean delivery in analgesia quality. Women receiving the combined two

2009 IOM guidelines for gestational weight gain: how well do they predict outcomes across ethnic groups?

PubMed

Khanolkar, Amal R; Hanley, Gillian E; Koupil, Ilona; Janssen, Patricia A

2017-11-13

To determine whether the Institute Of Medicine's (IOM) 2009 guidelines for weight-gain during pregnancy are predictive of maternal and infant outcomes in ethnic minority populations. We designed a population-based study using administrative data on 181,948 women who delivered live singleton births in Washington State between 2006-2008. We examined risks of gestational hypertension, preeclampsia/eclampsia, cesarean delivery, and extended hospital stay in White, Black, Native-American, East-Asian, Hispanic, South-Asian and Hawaiian/Pacific islander women according to whether they gained more or less weight during pregnancy than recommended by IOM guidelines. We also examined risks of neonatal outcomes including Apgar score <7 at 5 min, admission to NICU, requirement for ventilation, and a diagnosis of small or large for gestational age at birth. Gaining too much weight was associated with increased odds for gestational hypertension (adjusted OR (aOR) ranged between 1.53-2.22), preeclampsia/eclampsia (aOR 1.44-1.81), cesarean delivery (aOR 1.07-1.38) and extended hospital stay (aOR 1.06-1.28) in all ethnic groups. Gaining too little weight was associated with decreased odds for gestational hypertension and delivery by cesarean section in Whites, Blacks and Hispanics. Gaining less weight or more weight than recommended was associated with increased odds for small for gestational age and large for gestational age infants respectively, in all ethnic groups. Adherence to the 2009 IOM guidelines for weight gain during pregnancy reduces risk for various adverse maternal outcomes in all ethnic groups studied. However, the guidelines were less predictive of infant outcomes with the exception of small and large for gestational age. GWG: Gestational weight gain; IOM/NRC; Institute of Medicine and National Research Council; NICU: Neonatal intensive care need for ventilation; SGA: Small for gestational age; LGA: Large for gestational age; BERD: Birth Events Records Database

Maternal and neonatal outcomes among obese women with weight gain below the new Institute of Medicine recommendations.

PubMed

Blomberg, Marie

2011-05-01

To estimate whether weight loss or low gestational weight gain in class I-III obese women is associated with adverse maternal and neonatal outcomes compared with gestational weight gain within the new Institute of Medicine recommendations. This was a population-based cohort study, which included 32,991 obesity class I, 10,068 obesity class II, and 3,536 obesity class III women who were divided into four gestational weight gain categories. Women with low (0-4.9 kg) or no gestational weight gain were compared with women gaining the recommended 5-9 kg concerning obstetric and neonatal outcome after suitable adjustments. Women in obesity class III who lost weight during pregnancy had a decreased risk of cesarean delivery (24.4%; odds ratio [OR] 0.77, 95% confidence interval [CI] 0.60-0.99), large-for-gestational-age births (11.2%, OR 0.64, 95% CI 0.46-0.90), and no significantly increased risk for pre-eclampsia, excessive bleeding during delivery, instrumental delivery, low Apgar score, or fetal distress compared with obese (class III) women gaining within the Institute of Medicine recommendations. There was an increased risk for small for gestational age, 3.7% (OR 2.34, 95% CI 1.15-4.76) among women in obesity class III losing weight, but there was no significantly increased risk of small for gestational age in the same group with low weight gain. Obese women (class II and III) who lose weight during pregnancy seem to have a decreased or unaffected risk for cesarean delivery, large for gestational age, pre-eclampsia, excessive postpartum bleeding, instrumental delivery, low Apgar score, and fetal distress. The twofold increased risk of small for gestational age in obesity class III and weight loss (3.7%) is slightly above the overall prevalence of small-for-gestational-age births in Sweden (3.6%).

Health maintenance organizations, independent practice associations, and cesarean section rates.

PubMed

Tussing, A D; Wojtowycz, M A

1994-04-01

This study tests two hypotheses: that a given delivery is less likely to be by cesarean section (c-section) in an HMO (closed-panel health maintenance organization) or IPA (independent practice association), than in other settings; and that where HMO and IPA penetration is high, the probability of a c-section will be reduced for all deliveries, whether in prepaid groups or not. A data set consisting of 104,595 obstetric deliveries in New York state in 1986 is analyzed. A series of probit regressions is estimated, in which the dependent variable is either the probability that a given delivery is by c-section, or that a given delivery will result in a c-section for dystocia or fetal distress. The Live Birth File is linked with SPARCS hospital discharge data and other variables. HMO setting reduces the probability of a cesarean section by 2.5 to 3.0 percentage points. However, this result is likely to be partly an artifact of offsetting diagnostic labeling and of choice of method of delivery, given diagnosis; a better estimate of the effect of HMO setting is -1.3 percentage points. IPA setting appears to affect the probability of a cesarean section even less, perhaps not at all. And HMO and IPA penetration in a region, as measured by HMO and IPA deliveries, respectively, as a percent of all deliveries, has relatively large depressing effects on the probability of a cesarean section. Ceteris paribus, the probability of a c-section is lower for an HMO delivery than for a fee-for-service delivery; however, HMO effects are smaller than previously reported in the literature for other types of inpatient care. For IPA deliveries, the effects are still smaller, perhaps nil. However, HMO and IPA penetration, possibly measuring the degree of competition in obstetrics markets, have important effects on c-section rates, not only in HMO/IPA settings, but throughout an area. These results appear to have important implications for public policy.

The preference of Iranian women to have normal vaginal or cesarean deliveries

PubMed Central

Maharlouei, Najmeh; Rezaianzadeh, Abbas; Hesami, Elham; Moradi, Fariba; Mazloomi, Ezat; Joulaei, Hassan; Khodayari, Mohammad; Lankarani, Kamran B.

2013-01-01

Background: The cesarean section (C-section) has higher risk compared to normal vaginal delivery (NVD). The aim of this population-based study was to evaluate the frequency of mothers’ tendency toward the mode of delivery and the factors that can affect this inclination. Materials and Methods: This cross-sectional study was conducted from August 2011 to June 2012 in Fars Province, Iran, and comprised mothers in their 20th to 30th weeks of pregnancy. A questionnaire was designed to include, sociodemographic information, maternal knowledge, main sources of knowledge, attitude of the mother, husband, parents, close friends, and gynecologist, regarding the route of delivery, convenience factors, and barriers to choosing NVD, and mother's preference for the route of delivery. Results: Of 6921 participants, 2197 (31.7%) preferred C-section and 4308 (62.2%) favored NVD while 416 (6%) had no idea regarding the preferred route of delivery. Score of knowledge in 904 (13.1%) participants was zero, and 1261 women (18.2%) achieved an acceptable level of knowledge. Using binary logistic regression, positive history of previous abortion and/or infertility, higher education level of mother and husband, mother's unacceptable level of knowledge regarding complications of C-section, and mother's and husband's positive attitude toward C-section were determinant factors in choosing C-section as a preferred route of delivery. Conclusion: Appropriate measures should be taken to raise awareness and knowledge of mothers and all families about complications of the C-section. Establishment of clinics for painless NVD and assuring mothers of benefits and lower complications of NVD can reduce the tendency for C-sections. PMID:24523780

Microperforated Hymen Presenting Spontaneous Pregnancy with Cesarean Delivery and Hymenotomy Surgery: A Case Report

PubMed Central

Elshani, Brikene; Arifi, Heroid; Daci, Armond

2018-01-01

BACKGROUND: Female genital tract anomalies including imperforate hymen affect sexual life and fertility. CASE PRESENTATION: In the present case, we describe a pregnant woman diagnosed with imperforate hymen which never had penetrative vaginal sex. A 27–year-old married patient with 2 months of amenorrhea presented in a clinic without any other complications. Her history of difficult intercourse and prolonged menstrual flow were reported, and subsequent vaginal examination confirmed the diagnosis of imperforate hymen even though she claims to made pinhole surgery in hymen during puberty. Her urine pregnancy test was positive, and an ultrasound examination revealed 8.3 weeks pregnant. The pregnancy was followed up to 39.5 weeks when she entered in cesarean delivery in urgency. Due to perioperative complications in our study, a concomitant hymenotomy was successfully performed. The patient was discharged with the baby, and vaginal anatomy was restored. CONCLUSIONS: This case study suggests that even though as microperforated hymen surgery in puberty can permit pregnancy and intervention with cesarean section and hymenotomy is a good option to reduce the resulting perioperative complications which indirectly affect the increase of the fertilisation and improvement of later sexual life. PMID:29610613

Microperforated Hymen Presenting Spontaneous Pregnancy with Cesarean Delivery and Hymenotomy Surgery: A Case Report.

PubMed

Elshani, Brikene; Arifi, Heroid; Daci, Armond

2018-03-15

Female genital tract anomalies including imperforate hymen affect sexual life and fertility. In the present case, we describe a pregnant woman diagnosed with imperforate hymen which never had penetrative vaginal sex. A 27-year-old married patient with 2 months of amenorrhea presented in a clinic without any other complications. Her history of difficult intercourse and prolonged menstrual flow were reported, and subsequent vaginal examination confirmed the diagnosis of imperforate hymen even though she claims to made pinhole surgery in hymen during puberty. Her urine pregnancy test was positive, and an ultrasound examination revealed 8.3 weeks pregnant. The pregnancy was followed up to 39.5 weeks when she entered in cesarean delivery in urgency. Due to perioperative complications in our study, a concomitant hymenotomy was successfully performed. The patient was discharged with the baby, and vaginal anatomy was restored. This case study suggests that even though as microperforated hymen surgery in puberty can permit pregnancy and intervention with cesarean section and hymenotomy is a good option to reduce the resulting perioperative complications which indirectly affect the increase of the fertilisation and improvement of later sexual life.

Racial and Ethnic Disparities in Mode of Anesthesia for Cesarean Delivery

PubMed Central

Butwick, Alexander J; Blumenfeld, Yair J; Brookfield, Kathleen F.; Nelson, Lorene M; Weiniger, Carolyn F

2015-01-01

Background Racial and ethnic disparities have been identified in the provision of neuraxial labor analgesia. These disparities may exist in other key aspects of obstetric anesthesia care. We sought to determine if racial/ethnic disparities exist in mode of anesthesia for cesarean delivery (CD). Methods Women who underwent CD between 1999 and 2002 at 19 different obstetric centers in the United States were identified from the Maternal-Fetal Medicine Units Network Cesarean Registry. Race/ethnicity was categorized as: Caucasian, African-American, Hispanic, Non-Hispanic Others (NHOs). Mode of anesthesia was classified as neuraxial anesthesia (spinal, epidural or combined spinal-epidural anesthesia) or general anesthesia. To account for obstetric and nonobstetric covariates that may have influenced mode of anesthesia, multiple logistic regression analyses were performed using sequential sets of covariates. Results The study cohort comprised 50,974 women who underwent CD. Rates of general anesthesia among racial/ethnic groups were: 5.2% for Caucasians, 11.3% for African Americans, 5.8% for Hispanics and 6.6% for NHOs. After adjustment for obstetric and nonobstetric covariates, African Americans had the highest odds of receiving general anesthesia compared to Caucasians (adjusted odds ratio (aOR) = 1.7; 95% CI: 1.5 – 1.8; P<0.001). The odds of receiving general anesthesia were also higher among Hispanics (aOR = 1.1; 95% CI: 1.0 – 1.3; P=0.02) and NHOs (aOR = 1.2; 95% CI: 1.0 – 1.4; P=0.03) compared to Caucasians, respectively. In our sensitivity analysis, we reconstructed the models after excluding women who underwent neuraxial anesthesia prior to general anesthesia. The adjusted odds of receiving general anesthesia were similar to those in the main analysis: African-Americans (aOR=1.7; 95% CI=1.5 – 1.9; P<0.001; Hispanics (aOR=1.2; 95% CI=1.1 – 1.4; P=0.006); and NHOs (aOR=1.2; 95% CI=1.0 – 1.5; P=0.05). Conclusion Based on data from the Cesarean Registry

Compliance with regulations on weight gain 6 months after delivery in active duty military women.

PubMed

Chauhan, Suneet P; Johnson, Traci L; Magann, Everett F; Woods, Janine Y; Chen, Han-Yang; Sheldon, Ingrid V; Morrison, John C

2013-04-01

To determine factors associated with active duty military women being within Navy weight standards 6 months following childbirth. Inclusion criteria for this study were active duty women who delivered a nonanomalous fetus at a Naval Hospital and who remained in the area and their weight was recorded 6 months following childbirth. Multivariate logistic regressions, adjusted for 14 covariates, determined the factors for achieving acceptable weight. Among 1,009 women who participated in this prospective cohort study, 68% began within Navy body weight standards and 52% had a normal body mass index (BMI) (<25). Six months after childbirth, 48% were within Navy body weight standards and 32% had a BMI <25. Only 2 factors, BMI at first visit and cesarean delivery, significantly influenced the percentage of women who met the weight standards at 6 months. Lowering the prepregnancy BMI and avoiding a cesarean delivery may improve the percentage of active duty women who meet weight standards 6 months after childbirth. Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.

Prophylactic ampicillin versus cefazolin for the prevention of post-cesarean infectious morbidity in Rwanda.

PubMed

Mivumbi, Victor N; Little, Sarah E; Rulisa, Stephen; Greenberg, James A

2014-03-01

To evaluate the efficacy of ampicillin versus cefazolin as prophylactic antibiotics prior to cesarean delivery in Rwanda. In a prospective, randomized, open-label, single-site study conducted between March and May 2012, the effects of prophylactic ampicillin versus cefazolin were compared among women undergoing cesarean delivery at the Centre Hospitalier Universitaire de Kigali, Rwanda. Postoperatively, participants were evaluated daily for infectious morbidity while in the hospital. Follow-up was done by phone and by appointment at the hospital within 2 weeks of delivery. During the study period, there were 578 total deliveries and 234 cesarean deliveries (40.4%). Overall, 132 women were enrolled in the study and randomized to receive either ampicillin (n=66) or cefazolin (n=66). No women were lost to follow-up. The overall infection rate was 15.9% (21/132). The infection rate in the ampicillin group and the cefazolin group was 25.8% (17/66) and 6.1% (4/66), respectively. Implementing a universal protocol in Rwanda of prophylactic cefazolin prior to cesarean delivery might reduce postoperative febrile morbidity, use of postoperative antibiotics, and number of postoperative days in hospital. Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Gestational Weight Gain: Association with Adverse Pregnancy Outcomes.

PubMed

Hannaford, Karen E; Tuuli, Methodius G; Odibo, Linda; Macones, George A; Odibo, Anthony O

2017-01-01

Background  It is unclear how adherence to the Institute of Medicine's (IOM) guidelines for weight gain affects pregnancy outcomes. Objective  We investigated how weight gain outside the IOM's recommendations affects the risks of adverse pregnancy outcomes. Study Design  We performed a secondary analysis of a prospective cohort study including singleton, nonanomalous fetuses. The risks of small for gestational age (SGA), macrosomia, preeclampsia, cesarean delivery, gestational diabetes, or preterm birth were calculated for patients who gained weight below or above the IOM's recommendations based on body mass index category. A time-to-event analysis was performed to account for gestational age at delivery. A Cox proportional model was fit to estimate hazard ratios accounting for possible confounders. Results  Women who gained weight below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm. Normal-weight patients who gained below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm. Obese patients who gained inadequate weight were 2.5 times more likely to deliver SGA. Conclusion  Among normal-weight patients, adhering to IOM recommendations may prevent growth abnormalities and preterm delivery. Among obese patients, a minimum weight gain requirement may prevent SGA infants. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Analgesic Efficacy of Nonsteroidal Anti-inflammatory Agents (NSAIDs) in Patients Undergoing Cesarean Deliveries: A Meta-Analysis.

PubMed

Zeng, Angela M; Nami, Nina F; Wu, Christopher L; Murphy, Jamie D

Postoperative pain after cesarean delivery, which accounts for approximately 1 in 3 live births in the United States, can be severe in many patients. Nonsteroidal anti-inflammatory agents (NSAIDs) are potent analgesics that are effective in the treatment of postoperative pain. In this meta-analysis, we assessed the analgesic efficacy of NSAIDs in postoperative cesarean delivery patients. An electronic literature search of the Library of Medicine's PubMed, Cochrane CENTRAL, Scopus, and EMBASE databases was conducted in May 2013 and updated in January 2015 (Appendix, Supplemental Digital Content 1, http://links.lww.com/AAP/A174). Searches were limited to randomized controlled trials. The primary outcome variable was visual analog scale or numerical rating scale pain scores. Secondary outcomes included cumulative postoperative opioid consumption and opioid-related adverse effects (drowsiness/sedation, nausea, and vomiting). Data extraction was performed independently by 2 reviewers. Extracted data were input into Review Manager. Twenty-two randomized controlled trials compared a NSAID (n = 639) to a control (n = 674). Patients in the NSAID group versus control reported lower pain scores at 12 hours (P = 0.003) and at 24 hours (P < 0.001). Subgroup analysis showed a significant difference in pain scores at 24 hours, with patients receiving NSAIDs via intravenous/intramuscular (P < 0.001) route, but not the oral (P = 0.39) or rectal routes (P = 0.99). Significantly lower average pain scores were reported for pain with movement at 24 hours in the NSAID group (P = 0.001). Patients in the NSAID group versus controls consumed significantly less opioids (P < 0.001) and had significantly less drowsiness/sedation (P = 0.03), but there was no significant difference between the groups with regard to nausea or vomiting (P = 0.48 and P = 0.17, respectively). The perioperative use of NSAIDs in cesarean delivery patients will result in a significantly lower pain scores, less opioid

Cesarean section among immigrants in Norway.

PubMed

Vangen, S; Stoltenberg, C; Skrondal, A; Magnus, P; Stray-Pedersen, B

2000-07-01

We studied prevalences and risk factors for cesarean section among different groups of immigrants from countries outside Western Europe and North America in comparison to ethnic Norwegians. The study is population based using data from the Medical Birth Registry of Norway. A total of 553,491 live births during the period 1986-1995 were studied, including 17,891 births to immigrant mothers. The prevalences of cesarean section ranged from 10.1% among women from Vietnam to 25.8% in the group of Filipino origin. The use of abdominal delivery was also high in the groups from Sri Lanka/India (21.3%), Somalia/Eritrea/Ethiopia (20.5%) and Chile/Brazil (24.3%), while the frequency among women from Turkey/Morocco (12.6%) and Pakistan (13.2%) was approximately the same as among ethnic Norwegians (12.4%). Feto-pelvic disproportion, fetal distress and prolonged labor were the most important diagnoses associated with the high prevalences, but the significance of these diagnoses differed among the groups. Other unknown factors come into play, particularly among women from Somalia/Eritrea/Ethiopia and Chile/Brazil. There was substantial variation in the use of cesarean section among ethnic groups in Norway. The diagnoses feto-pelvic disproportion, fetal distress and prolonged labor may be confounded by a number of factors including maternal request for cesarean section and difficulties in handling the delivery. Further research is needed to explain the observed differences.

Evidence-Based Cesarean Delivery for the Nonobstetrician

PubMed Central

Dahlke, Joshua D.; Mendez-Figueroa, Hector; Sperling, Jeffrey D.; Maggio, Lindsay; Connealy, Brendan D.; Chauhan, Suneet P.

2016-01-01

Cesarean delivery (CD) is one of the most common major surgeries performed in the United States and worldwide. Surgical techniques evaluated in well-designed randomized controlled trials (RCTs) that demonstrate maternal benefit should be incorporated into practice. The objective of this review is to provide a summary of surgical techniques of the procedure and review the evidence basis for them for the nonobstetrician. The following techniques with the strongest evidence should be commonly performed, when feasible: (1) prophylactic antibiotics with a single dose of ampicillin or first-generation cephalosporin prior to skin incision; (2) postpartum hemorrhage prevention with oxytocin infusion of 10 to 40 IU in 1 L crystalloid over 4 to 8 hours; (3) low transverse skin incision; (4) blunt or sharp subcutaneous and fascial expansion; (5) blunt, cephalad–caudad uterine incision expansion; (6) spontaneous placental removal; (7) blunt-tip needle usage during closure; (8) subcutaneous suture closure (running or interrupted) if thickness is ≥2 cm; and (9) skin closure with suture. Although the number of RCTs designed to optimize maternal and neonatal outcomes of this common procedure is encouraging, further work is needed to minimize surgical morbidity. Optimal methods for postpartum hemorrhage prevention, adhesion prevention, and venous thromboembolism prophylaxis remain ongoing areas of active research, with outcomes that could markedly improve maternal morbidity and mortality. If evidence of a surgical technique appears preferred over another, clinicians should be comfortable adopting the evidence-based technique when performing and teaching CD. PMID:28824974

Impact of delivery mode on the colostrum microbiota composition.

PubMed

Toscano, Marco; De Grandi, Roberta; Peroni, Diego Giampietro; Grossi, Enzo; Facchin, Valentina; Comberiati, Pasquale; Drago, Lorenzo

2017-09-25

Breast milk is a rich nutrient with a temporally dynamic nature. In particular, numerous alterations in the nutritional, immunological and microbiological content occur during the transition from colostrum to mature milk. The objective of our study was to evaluate the potential impact of delivery mode on the microbiota of colostrum, at both the quantitative and qualitative levels (bacterial abundance and microbiota network). Twenty-nine Italian mothers (15 vaginal deliveries vs 14 Cesarean sections) were enrolled in the study. The microbiota of colostrum samples was analyzed by next generation sequencing (Ion Torrent Personal Genome Machine). The colostrum microbiota network associated with Cesarean section and vaginal delivery was evaluated by means of the Auto Contractive Map (AutoCM), a mathematical methodology based on Artificial Neural Network (ANN) architecture. Numerous differences between Cesarean section and vaginal delivery colostrum were observed. Vaginal delivery colostrum had a significant lower abundance of Pseudomonas spp., Staphylococcus spp. and Prevotella spp. when compared to Cesarean section colostrum samples. Furthermore, the mode of delivery had a strong influence on the microbiota network, as Cesarean section colostrum showed a higher number of bacterial hubs if compared to vaginal delivery, sharing only 5 hubs. Interestingly, the colostrum of mothers who had a Cesarean section was richer in environmental bacteria than mothers who underwent vaginal delivery. Finally, both Cesarean section and vaginal delivery colostrum contained a greater number of anaerobic bacteria genera. The mode of delivery had a large impact on the microbiota composition of colostrum. Further studies are needed to better define the meaning of the differences we observed between Cesarean section and vaginal delivery colostrum microbiota.

Applying Lean Six Sigma methodology to reduce cesarean section rate.

PubMed

Chai, Ze-Ying; Hu, Hua-Min; Ren, Xiu-Ling; Zeng, Bao-Jin; Zheng, Ling-Zhi; Qi, Feng

2017-06-01

This study aims to reduce cesarean section rate and increase rate of vaginal delivery. By using Lean Six Sigma (LSS) methodology, the cesarean section rate was investigated and analyzed through a 5-phase roadmap consisting of Define, Measure, Analyze, Improve, and Control. The principal causes of cesarean section were identified, improvement measures were implemented, and the rate of cesarean section before and after intervention was compared. After patients with a valid medical reason for cesarean were excluded, the main causes of cesarean section were maternal request, labor pain, parturient women assessment, and labor observation. A series of measures was implemented, including an improved parturient women assessment system, strengthened pregnancy nutrition guidance, implementation of painless labor techniques, enhanced midwifery team building, and promotion of childbirth-assist skills. Ten months after introduction of the improvement measures, the cesarean section rate decreased from 41.83% to 32.00%, and the Six Sigma score (ie, Z value) increased from 1.706 to 1.967 (P < .001). LSS is an effective way to reduce the rate of cesarean section. © 2016 John Wiley & Sons, Ltd.

Obstetrician gender and the likelihood of performing a maternal request for a cesarean delivery.

PubMed

Liu, Tsai-Ching; Lin, Herng-Ching; Chen, Chin-Shyan; Lee, Hsin-Chien

2008-01-01

To examine the relationship between obstetrician gender and the likelihood of maternal request for cesarean section (CS) within different healthcare institutions (medical centers, regional hospitals, district hospitals, and obstetric and gynecology clinics). Five years of population-based data from Taiwan covering 857,920 singleton deliveries without a clinical indication for a CS were subjected to a multiple logistic regression to examine the association between obstetrician gender and the likelihood of maternal request for a CS. After adjusting for physician and institutional characteristics, it was found that male obstetricians were more likely to perform a requested CS than female obstetricians in district hospitals (OR=1.53) and clinics (OR=2.26), while obstetrician gender had no discernible associations with the likelihood of a CS upon maternal request in medical centers and regional hospitals. While obstetrician gender had the greatest association with delivery mode decisions in the lowest obstetric care units, those associations were diluted in higher-level healthcare institutions.

Further evidence of psychological factors underlying choice of elective cesarean delivery (ECD) by primigravidae.

PubMed

Matinnia, Nasrin; Haghighi, Mohammad; Jahangard, Leila; Ibrahim, Faisal B; Rahman, Hejar A; Ghaleiha, Ali; Holsboer-Trachsler, Edith; Brand, Serge

2018-01-01

Requests for elective cesarean delivery (ECD) have increased in Iran. While some sociodemographic and fear-related factors have been linked with this choice, psychological factors such as self-esteem, stress, and health beliefs are under-researched. A total of 342 primigravidae (mean age = 25 years) completed questionnaires covering psychological dimensions such as self-esteem, perceived stress, marital relationship quality, perceived social support, and relevant health-related beliefs. Of the sample, 214 (62.6%) chose to undergo ECD rather than vaginal delivery (VD). This choice was associated with lower self-esteem, greater perceived stress, belief in higher susceptibility to problematic birth and barriers to an easy birth, along with lower perceived severity of ECD, fewer perceived benefits from VD, lower self-efficacy and a lower feeling of preparedness. No differences were found for marital relationship quality or perceived social support. The pattern suggests that various psychological factors such as self-esteem, self-efficacy, and perceived stress underpin the decision by primigravidae to have an ECD.

Maternal brain response to own baby-cry is affected by cesarean section delivery

PubMed Central

Swain, James E.; Tasgin, Esra; Mayes, Linda C.; Feldman, Ruth; Constable, R. Todd; Leckman, James F.

2011-01-01

A range of early circumstances surrounding the birth of a child affects peripartum hormones, parental behavior and infant wellbeing. One of these factors, which may lead to postpartum depression, is the mode of delivery: vaginal delivery (VD) or cesarean section delivery (CSD). To test the hypothesis that CSD mothers would be less responsive to own baby-cry stimuli than VD mothers in the immediate postpartum period, we conducted functional magnetic resonance imaging, 2–4 weeks after delivery, of the brains of six mothers who delivered vaginally and six who had an elective CSD. VD mothers’ brains were significantly more responsive than CSD mothers’ brains to their own baby-cry in the superior and middle temporal gyri, superior frontal gyrus, medial fusiform gyrus, superior parietal lobe, as well as regions of the caudate, thalamus, hypothalamus, amygdala and pons. Also, within preferentially active regions of VD brains, there were correlations across all 12 mothers with out-of-magnet variables. These include correlations between own baby-cry responses in the left and right lenticular nuclei and parental preoccupations (r = .64, p < .05 and .67, p < .05 respectively), as well as in the superior frontal cortex and Beck depression inventory (r = .78, p < .01). First this suggests that VD mothers are more sensitive to own baby-cry than CSD mothers in the early postpartum in sensory processing, empathy, arousal, motivation, reward and habit-regulation circuits. Second, independent of mode of delivery, parental worries and mood are related to specific brain activations in response to own baby-cry. PMID:18771508

Indications for mode of delivery in pregnant women with inflammatory bowel disease

PubMed Central

Burke, Kristin E.; Haviland, Miriam J.; Hacker, Michele R.; Shainker, Scott A.; Cheifetz, Adam S.

2017-01-01

Background Reasons for the increased incidence of cesarean delivery among women with inflammatory bowel disease remain unclear. We assessed cesarean delivery incidence and factors influencing mode of delivery in women with inflammatory bowel disease. Methods We performed a 10-year retrospective cohort study of nulliparous women who delivered a singleton infant at our institution. We compared risk for each mode of delivery in women with Crohn's disease and ulcerative colitis to women without inflammatory bowel disease. We assessed mode of delivery indications for patients with inflammatory bowel disease and whether cesarean deliveries were planned. Results The overall incidence of cesarean delivery among women with Crohn's disease (24/59; 40.7%) was similar to women without inflammatory bowel disease (7868/21805; 36.1%) (RR 1.1 [95% CI: 0.83,1.5]; p=0.46), but was increased in the subgroups with active and inactive perianal disease (RR 2.3; p<0.01). Women with ulcerative colitis had a 1.8-fold increased relative risk of cesarean delivery (41/65; 63.1%) (95% CI 1.5, 2.1; p<0.01), with highest incidence in patients with ileal pouch-anal anastomosis. Forty-nine percent of ulcerative colitis and 66.7% of Crohn's disease cesarean deliveries were unplanned, with only one unplanned delivery performed for active inflammatory bowel disease. Most unplanned deliveries were for arrest of descent/dilation and non-reassuring fetal heart tracings. Seventy-five percent of planned cesarean deliveries were for inflammatory bowel disease-related indications. Conclusions Women with ulcerative colitis and perianal Crohn's disease have an increased incidence of cesarean delivery. At least half of cesarean deliveries are unplanned. PMID:28426453

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

PubMed

Stourac, Petr; Adamus, Milan; Seidlova, Dagmar; Pavlik, Tomas; Janku, Petr; Krikava, Ivo; Mrozek, Zdenek; Prochazka, Martin; Klucka, Jozef; Stoudek, Roman; Bartikova, Ivana; Kosinova, Martina; Harazim, Hana; Robotkova, Hana; Hejduk, Karel; Hodicka, Zuzana; Kirchnerova, Martina; Francakova, Jana; Obare Pyszkova, Lenka; Hlozkova, Jarmila; Sevcik, Pavel

2016-05-01

Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial.

PubMed

Chaillet, N; Bujold, E; Masse, B; Grobman, W A; Rozenberg, P; Pasquier, J C; Shorten, A; Johri, M; Beaudoin, F; Abenhaim, H; Demers, S; Fraser, W; Dugas, M; Blouin, S; Dubé, E; Gauthier, R

2017-09-20

Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean. The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis. The intervention is designed to facilitate: (1) women's decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine

The impact of payment source and hospital type on rising cesarean section rates in Brazil, 1998 to 2008.

PubMed

Hopkins, Kristine; de Lima Amaral, Ernesto Friedrich; Mourão, Aline Nogueira Menezes

2014-06-01

High cesarean section rates in Brazilian public hospitals and higher rates in private hospitals are well established. Less is known about the relationship between payment source and cesarean section rates within public and private hospitals. We analyzed the 1998, 2003, and 2008 rounds of a nationally representative household survey (PNAD), which includes type of delivery, where it took place, and who paid for it. We construct cesarean section rates for various categories, and perform logistic regression to determine the relative importance of independent variables on cesarean section rates for all births and first births only. Brazilian cesarean section rates were 42 percent in 1998 and 53 percent in 2008. Women who delivered publicly funded births in either public or private hospitals had lower cesarean section rates than those who delivered privately financed deliveries in public or private hospitals. Multivariate models suggest that older age, higher education, and living outside the Northeast region all positively affect the odds of delivering by cesarean section; effects are attenuated by the payment source-hospital type variable for all women and even more so among first births. Cesarean section rates have risen substantially in Brazil. It is important to distinguish payment source for the delivery to have a better understanding of those rates. © 2014 Wiley Periodicals, Inc.

The Impact of Payment Source and Hospital Type on Rising Cesarean Section Rates in Brazil, 1998 to 2008

PubMed Central

Hopkins, Kristine; de Lima Amaral, Ernesto Friedrich; Mourão, Aline Nogueira Menezes

2015-01-01

Background High cesarean section rates in Brazilian public hospitals and higher rates in private hospitals are well established. Less is known about the relationship between payment source and cesarean section rates within public and private hospitals. Methods We analyzed the 1998, 2003, and 2008 rounds of a nationally representative household survey (PNAD), which includes type of delivery, where it took place, and who paid for it. We construct cesarean section rates for various categories, and perform logistic regression to determine the relative importance of independent variables on cesarean section rates for all births and first births only. Results Brazilian cesarean section rates were 42 percent in 1998 and 53 percent in 2008. Women who delivered publicly funded births in either public or private hospitals had lower cesarean section rates than those who delivered privately financed deliveries in public or private hospitals. Multivariate models suggest that older age, higher education, and living outside the Northeast region all positively affect the odds of delivering by cesarean section; effects are attenuated by the payment source–hospital type variable for all women and even more so among first births. Conclusions Cesarean section rates have risen substantially in Brazil. It is important to distinguish payment source for the delivery to have a better understanding of those rates. PMID:24684250

Cesarean section and interferon-induced helicase gene polymorphisms combine to increase childhood type 1 diabetes risk.

PubMed

Bonifacio, Ezio; Warncke, Katharina; Winkler, Christiane; Wallner, Maike; Ziegler, Anette-G

2011-12-01

The incidence of type 1 diabetes is increasing. Delivery by cesarean section is also more prevalent, and it is suggested that cesarean section is associated with type 1 diabetes risk. We examine associations between cesarean delivery, islet autoimmunity and type 1 diabetes, and genes involved in type 1 diabetes susceptibility. Cesarean section was examined as a risk factor in 1,650 children born to a parent with type 1 diabetes and followed from birth for the development of islet autoantibodies and type 1 diabetes. Children delivered by cesarean section (n = 495) had more than twofold higher risk for type 1 diabetes than children born by vaginal delivery (hazard ratio [HR] 2.5; 95% CI 1.4-4.3; P = 0.001). Cesarean section did not increase the risk for islet autoantibodies (P = 0.6) but was associated with a faster progression to diabetes after the appearance of autoimmunity (P = 0.015). Cesarean section-associated risk was independent of potential confounder variables (adjusted HR 2.7;1.5-5.0; P = 0.001) and observed in children with and without high-risk HLA genotypes. Interestingly, cesarean section appeared to interact with immune response genes, including CD25 and in particular the interferon-induced helicase 1 gene, where increased risk for type 1 diabetes was only seen in children who were delivered by cesarean section and had type 1 diabetes-susceptible IFIH1 genotypes (12-year risk, 9.1 vs. <3% for all other combinations; P < 0.0001). These findings suggest that type 1 diabetes risk modification by cesarean section may be linked to viral responses in the preclinical autoantibody-positive disease phase.

Evaluation of delivery options for second stage events

PubMed Central

Bailit, Jennifer L.; Grobman, William A.; Rice, Madeline Murguia; Wapner, Ronald J.; Reddy, Uma M.; Varner, Michael W.; Thorp, John M.; Caritis, Steve N.; Iams, Jay D.; Saade, George; Rouse, Dwight J.; Tolosa, Jorge E.

2015-01-01

Background Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery in the second stage versus cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean versus operative vaginal delivery. Objective Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps versus cesarean delivery) in patients needing second stage assistance at a fetal station of +2 or below. Study Design Secondary analysis of an observational obstetric cohort in 25 academically-affiliated U.S. hospitals over a three-year period. A subset of ≥37 weeks, non-anomalous, vertex, singletons, with no prior vaginal delivery who reached a station of +2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, non-reassuring fetal status, labor dystocia or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother’s, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third and fourth degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the three attempted modes of delivery. Odds ratios were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified. Results 2531 women met inclusion criteria. Vacuum attempt was

Anesthesia for cesarean delivery in an achondroplastic dwarf: a case report.

PubMed

Huang, Jeffrey; Babins, Noah

2008-12-01

There are more than 100 different types of dwarfism. Achondroplasia is the most common form of this rare condition. The incidence of achondroplasia in the United States is about 15 per 1 million births. Although inherited as an autosomal dominant condition, 80% of cases result from spontaneous mutation. Underdevelopment and premature ossification of bones result in characteristic craniofacial and spinal abnormalities. Limited neck extension, foramen magnum stenosis, a large tongue, large mandible, and atlanto-axial instability can lead to increased difficulty of airway management. Severe kyphosis, scoliosis, spinal stenosis, and unpredictable spread of local anesthetics in the epidural space and subarachnoid space lead to reluctance to apply regional anesthesia in this patient group. In addition, pregnancy in a person with achondroplasis poses more problems for anesthetic selection. These problems include potential hypoxia, severely decreased functional residual capacity, risk of gastric aspiration, and supine hypotension. In this case report, we describe the anesthetic management of an achondroplastic dwarf who underwent cesarean delivery.

Impact of clinical audits on cesarean section rate.

PubMed

Peng, Fu-Shiang; Lin, Hsien-Ming; Lin, Ho-Hsiung; Tu, Fung-Chao; Hsiao, Chin-Fen; Hsiao, Sheng-Mou

2016-08-01

Many countries have noted a substantial increase in the cesarean section rate (CSR). Several methods for lowering the CSR have been described. Understanding the impact of clinical audits on the CSR may aid in lowering CSR. Thus, our aim is to elucidate the effect of clinical audits on the CSR. We retrospectively analyzed 3781 pregnant women who gave birth in a medical center between January 2008 and January 2011. Pregnant women who delivered between January 2008 and July 2009 were enrolled as the pre-audit group (n = 1592). After August 2009, all cesarean section cases that were audited were enrolled in the audit group (n = 2189). The CSR was compared between groups. The overall CSR (34.5% vs. 31.1%, adjusted odds ratio [OR] = 0.83, p = 0.008) and the cesarean section rate due to dystocia (9.6% vs. 6.2%, p < 0.001) were significantly lower in the audit group than the pre-audit group. However, there was no significant difference in the rate of operative vaginal delivery between groups. Consensus on the unnecessity for cesarean section was achieved in 16 (8.2%) of 195 audit cases in the monthly audit conference. In nulliparous pregnant women (n = 2148), multivariate analysis revealed that clinical audit (OR = 0.78), maternal age (OR = 1.10), gestational age at delivery (OR = 0.80), and fetal body weight at birth (OR = 1.0005) were independent predictors of cesarean section (all p < 0.05). Most variables of maternal and perinatal morbidity and mortality did not differ before and after audits were implemented. Clinical audits appear to be an effective strategy for reducing the CSR. Therefore, we recommend strict monitoring of the indications in dystocia for cesarean section to reduce the CSR. Copyright © 2016. Published by Elsevier B.V.

Outcomes of Term Induction in Trial of Labor After Cesarean Delivery: Analysis of a Modern Obstetric Cohort.

PubMed

Lappen, Justin R; Hackney, David N; Bailit, Jennifer L

2015-07-01

To evaluate outcomes of induction of labor, compared with expectant management, in women attempting trial of labor after cesarean delivery (TOLAC) in a large obstetric cohort. We performed a secondary analysis of data from the Consortium on Safe Labor that included women with term (37 weeks of gestation or greater) singleton gestations and a history of one prior cesarean delivery who attempted TOLAC. Induction of labor was compared with expectant management by week of gestation from 37 to 40 weeks in both high- and low-risk cohorts. The primary outcome was failed TOLAC. Secondary outcomes included composite maternal morbidity (hysterectomy, transfusion, intensive care unit (ICU) transfer, venous thromboembolism, death), composite neonatal morbidity (5-minute Apgar score less than 5, cord pH less than 7.0, asphyxia, hypoxic ischemic encephalopathy, neonatal death), and neonatal ICU admission. Multivariate logistic regression was performed with adjustment for confounding factors. We identified 6,033 women attempting TOLAC of whom 1,626 (27.0%) underwent induction of labor and 4,407 (73.0%) did not. Compared with expectant management, induction was associated with an increased risk of failed TOLAC at 37-39 weeks of gestation but not at 40 weeks of gestation (37 weeks of gestation, 48.5% compared with 34.3%, adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.02-2.28]; 38 weeks of gestation, 47.0% compared with 33.0%, adjusted OR 1.74, 95% CI 1.29-2.34; 39 weeks of gestation, 45.6% compared with 29.8%, adjusted OR 2.16, 95% CI 1.76-2.67; 40 weeks of gestation, 37.9% compared with 29.4%, adjusted OR 1.21, 95% CI 0.90-1.66). Induction was associated with an increased risk of composite maternal morbidity at 39 weeks of gestation (adjusted OR 1.87, 95% CI 1.22-2.87) and neonatal ICU admission at 37 weeks of gestation (adjusted OR 2.51, 95% CI 1.62-3.90). Induction was not associated with an increased risk of neonatal morbidity. Induction of labor in women with

Delivery at Term: When, How, and Why.

PubMed

Walker, Kate F; Thornton, Jim G

2018-06-01

There is growing evidence from randomized trials that induction of labor at or near term does not increase cesarean delivery; observational data show that the optimal gestation for spontaneous delivery for the baby is 39 weeks. Elective cesarean at these gestations is also sometimes considered, but evaluating the associated risks is complex. For the baby, although cesarean obviates the risks of labor, it carries a risk of respiratory problems, which may be severe. For the mother, cesarean is more dangerous than vaginal and emergency cesarean is more dangerous than elective. The authors consider the evidence base for near-term induction of labor and cesarean for a range of scenarios. Copyright © 2018 Elsevier Inc. All rights reserved.

Cesarean Section and Interferon-Induced Helicase Gene Polymorphisms Combine to Increase Childhood Type 1 Diabetes Risk

PubMed Central

Bonifacio, Ezio; Warncke, Katharina; Winkler, Christiane; Wallner, Maike; Ziegler, Anette-G.

2011-01-01

OBJECTIVE The incidence of type 1 diabetes is increasing. Delivery by cesarean section is also more prevalent, and it is suggested that cesarean section is associated with type 1 diabetes risk. We examine associations between cesarean delivery, islet autoimmunity and type 1 diabetes, and genes involved in type 1 diabetes susceptibility. RESEARCH DESIGN AND METHODS Cesarean section was examined as a risk factor in 1,650 children born to a parent with type 1 diabetes and followed from birth for the development of islet autoantibodies and type 1 diabetes. RESULTS Children delivered by cesarean section (n = 495) had more than twofold higher risk for type 1 diabetes than children born by vaginal delivery (hazard ratio [HR] 2.5; 95% CI 1.4–4.3; P = 0.001). Cesarean section did not increase the risk for islet autoantibodies (P = 0.6) but was associated with a faster progression to diabetes after the appearance of autoimmunity (P = 0.015). Cesarean section–associated risk was independent of potential confounder variables (adjusted HR 2.7;1.5–5.0; P = 0.001) and observed in children with and without high-risk HLA genotypes. Interestingly, cesarean section appeared to interact with immune response genes, including CD25 and in particular the interferon-induced helicase 1 gene, where increased risk for type 1 diabetes was only seen in children who were delivered by cesarean section and had type 1 diabetes–susceptible IFIH1 genotypes (12-year risk, 9.1 vs. <3% for all other combinations; P < 0.0001). CONCLUSIONS These findings suggest that type 1 diabetes risk modification by cesarean section may be linked to viral responses in the preclinical autoantibody-positive disease phase. PMID:22110093

Delivery by Cesarean Section is not Associated With Decreased at-Birth Fracture Rates in Osteogenesis Imperfecta

PubMed Central

Bellur, S; Jain, M; Cuthbertson, D; Krakow, D; Shapiro, JR; Steiner, RD; Smith, PA; Bober, MB; Hart, T; Krischer, J; Mullins, M; Byers, PH; Pepin, M; Durigova, M; Glorieux, FH; Rauch, F; Sutton, VR; Lee, B; Nagamani, SC

2015-01-01

Purpose Osteogenesis imperfecta (OI) predisposes to recurrent fractures. The moderate-to-severe forms of OI present with antenatal fractures and the mode of delivery that would be safest for the fetus is not known. Methods We conducted systematic analyses on the largest cohort of individuals (n=540) with OI enrolled to-date in the OI Linked Clinical Research Centers. Self-reported at-birth fracture rates were compared in individuals with OI types I, III, and IV. Multivariate analyses utilizing backward-elimination logistic regression model building were performed to assess the effect of multiple covariates including method of delivery on fracture-related outcomes. Results When accounting for other covariates, at-birth fracture rates did not differ based on whether delivery was by vaginal route or by cesarean section (CS). Increased birth weight conferred higher risk for fractures irrespective of the delivery method. In utero fracture, maternal history of OI, and breech presentation were strong predictors for choosing CS for delivery. Conclusion Our study, the largest to analyze the effect of various factors on at-birth fracture rates in OI shows that delivery by CS is not associated with decreased fracture rate. With the limitation that the fracture data were self-reported in this cohort, these results suggest that CS should be performed only for other maternal or fetal indications, but not for the sole purpose of fracture prevention in OI. PMID:26426884

Weight loss in exclusively breastfed infants delivered by cesarean birth.

PubMed

Preer, Genevieve L; Newby, P K; Philipp, Barbara L

2012-05-01

Rates of exclusive breastfeeding during the postpartum hospital stay are a key measure of quality maternity care. Often, however, concern for excessive in-hospital weight loss leads to formula supplementation of breastfed infants. The American Academy of Pediatrics defines 7% weight loss as acceptable for breastfed newborns regardless of mode of delivery. Typical weight loss in exclusively breastfed infants delivered by cesarean birth has not been studied nor have possible correlates of greater weight loss in this population. To determine average weight loss in a cohort of exclusively breastfed infants delivered by cesarean birth and to identify correlates of greater than expected weight loss. We performed a retrospective chart review of exclusively breastfed infants delivered via cesarean birth at a Baby-Friendly hospital between 2005 and 2007. Average weight loss was calculated, and multivariate regression analysis was performed. Average weight loss during the hospital stay in our cohort of 200 infants was 7.2% ± 2.1% of birth weight, slightly greater than the American Academy of Pediatrics guideline of 7%. Absence of labor prior to delivery was significantly associated with a greater percentage of weight loss (P = .0004), as were lower gestational age (P = .0004) and higher birth weight (P < .0001). Maternal age, gravity, parity, infant sex, Apgar scores, and prior cesarean birth were not significantly associated. We conclude that for exclusively breastfed infants delivered by cesarean birth in a Baby-Friendly hospital, absence of labor prior to cesarean birth may be a previously unreported risk factor for greater than expected weight loss.

Evaluation of delivery options for second-stage events.

PubMed

Bailit, Jennifer L; Grobman, William A; Rice, Madeline Murguia; Wapner, Ronald J; Reddy, Uma M; Varner, Michael W; Thorp, John M; Caritis, Steve N; Iams, Jay D; Saade, George; Rouse, Dwight J; Tolosa, Jorge E

2016-05-01

Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery vs cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean vs operative vaginal delivery. Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps vs cesarean delivery) in patients needing second-stage assistance at a fetal station of +2 or below. We conducted secondary analysis of an observational obstetric cohort in 25 academically affiliated US hospitals over a 3-year period. A subset of ≥37 weeks, nonanomalous, vertex, singletons, with no prior vaginal delivery who reached a station of +2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, nonreassuring fetal status, labor dystocia, or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother's, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third- and fourth-degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the 3 attempted modes of delivery. Odds ratios (OR) were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified. In all, 2531 women met inclusion criteria. No difference in the neonatal composite outcome was observed between groups. Vacuum

The Costs and Their Determinant of Cesarean Section and Vaginal Delivery: An Exploratory Study in Chongqing Municipality, China

PubMed Central

He, Zhifei; Cheng, Zhaohui; Wu, Tailai; Zhou, Yan; Chen, Junguo; Fu, Qian

2016-01-01

Objectives. This study aims to analyze the cesarean section (CS) rates and vaginal delivery rates in tertiary hospitals of China, explore the costs of two different deliveries, and examine the relative influencing factors of the costs in both CS and vaginal deliveries. Methods. 30,168 anonymized obstetric medical cases were selected from three sample tertiary hospitals in Chongqing Municipality from 2011 to 2013. Chi-square test was used to compare the distributions of CS and vaginal deliveries under different indicators. Mann–Whitney test and Kruskal-Wallis test were adopted to analyze the differences under different items. Multiple linear regression was used to determine the influencing factors of the costs of different delivery modes. Results. (1) The rates of CS were 69%, 65.5%, and 59.2% in the three sample tertiary hospitals in Chongqing from 2011 to 2013. (2) The costs and the length of stay of CS were greater than those of vaginal delivery, which had significant differences (P < 0.005). (3) The areas, length of stay, age, medical insurance, and modes of delivery were the influencing factors of both CS and vaginal delivery costs. Discussion. The high CS rates in China must be paid significant attention. The indicators of two modes of delivery should be regulated strictly. CS rate reduction and saving medical resources will be the benefits if vaginal delivery is chosen by pregnant women. PMID:27995142

Association of Gestational Weight Gain With Maternal and Infant Outcomes

PubMed Central

Goldstein, Rebecca F.; Abell, Sally K.; Ranasinha, Sanjeeva; Misso, Marie; Boyle, Jacqueline A.; Black, Mary Helen; Li, Nan; Hu, Gang; Corrado, Francesco; Rode, Line; Kim, Young Ju; Haugen, Margaretha; Song, Won O.; Kim, Min Hyoung; Bogaerts, Annick; Devlieger, Roland; Chung, Judith H.

2017-01-01

Importance Body mass index (BMI) and gestational weight gain are increasing globally. In 2009, the Institute of Medicine (IOM) provided specific recommendations regarding the ideal gestational weight gain. However, the association between gestational weight gain consistent with theIOM guidelines and pregnancy outcomes is unclear. Objective To perform a systematic review, meta-analysis, and metaregression to evaluate associations between gestational weight gain above or below the IOM guidelines (gain of 12.5-18 kg for underweight women [BMI <18.5]; 11.5-16 kg for normal-weight women [BMI 18.5-24.9]; 7-11 kg for overweight women [BMI 25-29.9]; and 5-9 kg for obese women [BMI ≥30]) and maternal and infant outcomes. Data Sources and Study Selection Search of EMBASE, Evidence-Based Medicine Reviews, MEDLINE, and MEDLINE In-Process between January 1, 1999, and February 7, 2017, for observational studies stratified by prepregnancy BMI category and total gestational weight gain. Data Extraction and Synthesis Data were extracted by 2 independent reviewers. Odds ratios (ORs) and absolute risk differences (ARDs) per live birth were calculated using a random-effects model based on a subset of studies with available data. Main Outcomes and Measures Primary outcomes were small for gestational age (SGA), preterm birth, and large for gestational age (LGA). Secondary outcomes were macrosomia, cesarean delivery, and gestational diabetes mellitus. Results Of 5354 identified studies, 23 (n = 1 309 136 women) met inclusion criteria. Gestational weight gain was below or above guidelines in 23% and 47% of pregnancies, respectively. Gestational weight gain below the recommendations was associated with higher risk of SGA (OR, 1.53 [95% CI, 1.44-1.64]; ARD, 5% [95% CI, 4%-6%]) and preterm birth (OR, 1.70 [1.32-2.20]; ARD, 5% [3%-8%]) and lower risk of LGA (OR, 0.59 [0.55-0.64]; ARD, −2% [−10% to −6%]) and macrosomia (OR, 0.60 [0.52-0.68]; ARD, −2% [−3% to −1

Dose-response study of spinal hyperbaric ropivacaine for cesarean section

PubMed Central

Chen, Xin-zhong; Chen, Hong; Lou, Ai-fei; Lü, Chang-cheng

2006-01-01

Background: Spinal hyperbaric ropivacaine may produce more predictable and reliable anesthesia than plain ropivacaine for cesarean section. The dose-response relation for spinal hyperbaric ropivacaine is undetermined. This double-blind, randomized, dose-response study determined the ED50 (50% effective dose) and ED95 (95% effective dose) of spinal hyperbaric ropivacaine for cesarean section anesthesia. Methods: Sixty parturients undergoing elective cesarean section delivery with use of combined spinal-epidural anesthesia were enrolled in this study. An epidural catheter was placed at the L1~L2 vertebral interspace, then lumbar puncture was performed at the L3~L4 vertebral interspace, and parturients were randomized to receive spinal hyperbaric ropivacaine in doses of 10.5 mg, 12 mg, 13.5 mg, or 15 mg in equal volumes of 3 ml. Sensory levels (pinprick) were assessed every 2.5 min until a T7 level was achieved and motor changes were assessed by modified Bromage Score. A dose was considered effective if an upper sensory level to pin prick of T7 or above was achieved and no intraoperative epidural supplement was required. ED50 and ED95 were determined with use of a logistic regression model. Results: ED50 (95% confidence interval) of spinal hyperbaric ropivacaine was determined to be 10.37 (5.23~11.59) mg and ED95 (95% confidence interval) to be 15.39 (13.81~23.59) mg. The maximum sensory block levels and the duration of motor block and the rate of hypotension, but not onset of anesthesia, were significantly related to the ropivacaine dose. Conclusion: The ED50 and ED95 of spinal hyperbaric ropivacaine for cesarean delivery under the conditions of this study were 10.37 mg and 15.39 mg, respectively. Ropivacaine is suitable for spinal anesthesia in cesarean delivery. PMID:17111469

Mode of delivery preferences in a diverse population of pregnant women.

PubMed

Yee, Lynn M; Kaimal, Anjali J; Houston, Kathryn A; Wu, Erica; Thiet, Mari-Paule; Nakagawa, Sanae; Caughey, Aaron B; Firouzian, Atoosa; Kuppermann, Miriam

2015-03-01

The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean. This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches. Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity. Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach. Copyright © 2015 Elsevier Inc. All rights reserved.

[Comparative trial between traditional cesarean section and Misgav-Ladach technique].

PubMed

Gutiérrez, José Gabriel Tamayo; Coló, José Antonio Sereno; Arreola, María Sandra Huape

2008-02-01

The cesarean section was designed to extract to the neoborn, when the childbirth becomes difficult by the natural routes. The institutional obstetrical work demands long surgical time and high raw materials; therefore, simpler procedures must be implemented. To compare traditional cesarean section vs Misgav-Ladach technique to assess surgical time, and hospital stay and costs. Forty-eight pregnant patients at term with obstetrical indication for cesarean delivery were randomized in two groups: 24 were submitted to traditional cesarean and 24 to Misgav-Ladach technique. The outcomes included surgical time, bleeding, amount of sutures employed, pain intensity and some others adverse effects. The surgical time with Misgav-Ladach technique was shorter compared with traditional cesarean section, bleeding was consistently lesser and pain was also low. None adverse effects were registered in both groups. Although short follow-up showed significant operative time reduction and less bleeding, longer follow-up should be desirable in order to confirm no abdominal adhesions.

Grouping Parturients by Parity, Previous-Cesarean, and Mode of Delivery (P-C-MoD Classification) Better Identifies Groups at Risk for Postpartum Hemorrhage.

PubMed

Reichman, Orna; Gal, Micahel; Sela, Hen Y; Khayyat, Izzat; Emanuel, Michael; Samueloff, Arnon

2016-10-01

Objective We aimed to create a clinical classification to better identify parturients at risk for postpartum hemorrhage (PPH). Method A retrospective cohort, including all women who delivered at a single tertiary care medical center, between 2006 and 2014. Parturients were grouped by parity and history of cesarean delivery (CD): primiparas, multipara, and multipara with previous CD. Each were further subgrouped by mode of delivery (spontaneous vaginal delivery [SVD], operative vaginal delivery [OVD], emergency or elective CD). In all, 12 subgroups, based on parity, previous cesarean, and mode of delivery, formed the P-C-MoD classification. PPH was defined as a decrease of ≥3 gram% hemoglobin from admission and/or transfusion of blood products. Univariate analysis followed by multivariate analysis was performed to assess risk for PPH, controlling for confounders. Results The crude rate of PPH among 126,693 parturients was 7%. The prevalence differed significantly among independent risk factors: primiparity, 14%; multiparity, 4%; OVD, 22%; and CD, 15%. The P-C-MoD classification, segregated better between parturients at risk for PPH. The prevalence of PPH was highest for primiparous undergoing OVD (27%) compared with multiparous with SVD (3%), odds ratio [OR] = 12.8 (95% confidence interval [CI],11.9-13.9). These finding were consistent in the multivariate analysis OR = 13.1 (95% CI,12.1-14.3). Conclusion Employing the P-C-MoD classification more readily identifies parturients at risk for PPH and is superior to estimations based on single risk factors. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Sublingual misoprostol as an adjunct to oxytocin during cesarean delivery in women at risk of postpartum hemorrhage.

PubMed

Chaudhuri, Picklu; Majumdar, Arindam

2015-01-01

To evaluate whether a combination of misoprostol and oxytocin more effectively reduces blood loss during and after cesarean delivery than does oxytocin alone among women with known risk factors for postpartum hemorrhage (PPH). A prospective, randomized, double-blind, placebo-controlled trial was performed at a tertiary care center in Kolkata, India, between October 2012 and December 2013. Women were eligible if they were undergoing emergency cesarean under spinal anesthesia and were at high risk for PPH. Participants were randomly assigned (1:1) to receive 400 μg misoprostol or matched placebo sublingually after delivery of the newborn using a computer-generated random number sequence (block size eight). Participants and providers were masked to assignment. All participants received 20 IU oxytocin. The primary outcomes were intraoperative and postoperative blood loss. Both groups contained 198 women. Mean intraoperative blood loss was significantly lower in the misoprostol group (505.4±215.5 mL) than in the placebo group (587.3±201.5 mL; P<0.001). Mean postoperative blood loss was slightly lower in the misoprostol group (96.9±57.3 mL) than in the placebo group (103.4±58.4 mL; P=0.07). Shivering and pyrexia were more frequently associated with misoprostol (P<0.05 for both). Misoprostol as an adjunct to oxytocin seemed to more effectively reduce blood loss than did oxytocin alone. Clinical Trial Registry India:CTRI/2013/05/003645. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Outcomes of Spontaneous Labor in Women Undergoing Trial of Labor after Cesarean as Compared with Nulliparous Women: A Retrospective Cohort Study.

PubMed

Lassey, Sarah C; Robinson, Julian N; Kaimal, Anjali J; Little, Sarah E

2018-01-24

 The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women.  A 4-year retrospective cohort. We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator.  Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p  < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p  = 0.02) and uterine rupture (1.9 vs. 0.0%; p  < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p  = 0.51), maternal, or immediate neonatal complications.  Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography.

PubMed

Murad-Regadas, Sthela M; Regadas, Francisco Sérgio P; Rodrigues, Lusmar V; Oliveira, Leticia; Barreto, Rosilma G L; de Souza, Marcellus H L P; Silva, Flavio Roberto S

2009-10-01

This study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD). Three hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I-105 nulliparous, Group II-165 had at least one vaginal delivery, and Group III-comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions. No statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively. The distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

[Delivery after a previous cesarean in the Gyneco-Obsteric Hospital Garza Garcia, N.L].

PubMed

de la Garza Quintanilla, C; Celaya Juárez, J A; Hernández Escobar, C

1997-04-01

One hundred and four patients who delivered after a previous cesarean section, at Hospital de Ginecoobstetricia de Garza García, N.L., from February 1, 1994 to January 31, 1995, were reviewed. The objective for this study was to know materno-fetal morbi-mortality at our hospital. Age, parity weeks of gestation, cause for previous section, delivery culmination, weight and Apgar of products, as well as, materno-fetal morbi-mortality, were analyzed. Average age group was 21 to 30 years with 68.5%. As to parity nulliparae predominated with 48.1%. As to weeks of gestation, the most frequent was 37 to 40 weeks, 85.5%. Previous section indication was: 1. Pelvic presentation, 2. Fetal stress, 3. Cefalo-pelvic disproportion, 4. Premature rupture of membranes, 5. Toxemia. As to deliveries outcome, there was dystocia in 86.5%, by profilactic low forceps application in 81.7%; and mid low in 4.8%. Eutocic delivery, 13.5%. Product weight was 3,000 to 3,500 g, with 51%. Apgar in 94 products was 8 and 9 at one minute. Maternal morbidity was 15.3% being most frequent vaginal tears. There was one case of uterine atonia, and one case of dura mater adverted puncture. There were no uterine dehiscence nor rupture. Perinatal morbidity was 5.6%. There was no perinatal death.

The utility of midtrimester ultrasound assessment of the subcutaneous space in predicting cesarean wound complications

PubMed Central

Shainker, Scott A.; Raghuraman, Nandini; Modest, Anna M.; Schnettler, William T.; Hacker, Michele R.; Ralston, Steven J.

2016-01-01

Objective To evaluate the association between cesarean wound complications and thickness of the subcutaneous space within the anterior abdomen at the midtrimester fetal anatomical survey. Methods In this case-control study, cases were identified using an ICD9 code for wound complications of cesarean delivery. For each case, we identified the woman with the next consecutive midtrimester ultrasound who had a cesarean delivery without a wound complication, matched on age and race, as the control. A blinded investigator measured subcutaneous space at three distinct suprapubic levels in the midsagital plane. Results Of 7228 women with a cesarean delivery, 123 (1.7%) had a wound complication. Seventy-nine cases were eligible. Midline suprapubic subcutaneous thickness did not differ between cases and controls at the superior, middle or inferior locations (p ≥ 0.35). Body mass index was moderately correlated with ultrasound-derived measurements (r≥ 0.63; p<0.001). The incidence of vertical skin incision, stapled skin closure and classical hysterotomy differed between groups (p≤ 0.046). There was no significant increase in wound complication risk with increasing subcutaneous space thickness, even after adjustment (p≥ 0.34). Conclusion Prenatal ultrasound can quantify the subcutaneous space. Vertical skin incision, stapled wound closure, and a classical hysterotomy were associated with cesarean wound complication, but midtrimester subcutaneous thickness was not. PMID:25302863

New Views on Cesarean Section, its Possible Complications and Long-Term Consequences for Children’s Health

PubMed Central

Kulas, Tomislav; Bursac, Danijel; Zegarac, Zana; Planinic-Rados, Gordana; Hrgovic, Zlatko

2013-01-01

Historical developments and advancements in cesarean section techniques and logistics have reduced the maternal and neonatal risks associated with the procedure, while increasing the number of operatively completed pregnancies for medically unjustifiable reasons. The uncritical attitude towards cesarean section and the fast emergence of ‘modern’ diseases such as obesity at a young age, asthma, type 1 diabetes mellitus and various forms of dermatitis have stimulated researches associating cesarean section with these diseases. Intestinal flora of the children born by cesarean section contains less bifidobacteria, i.e. their intestinal flora is similar to the intestinal flora in diabetic individuals. In children born by cesarean section, the ‘good’ maternal bacterial that are normally found in the maternal birth canal and rectum are lacking, while the ‘bad’ bacteria that may endanger the child’s immune system are frequently present. In children born by vaginal delivery, the ‘good’ maternal bacteria stimulate the newborn’s white blood cells and other components of the immune system, which has been taken as a basis for the hypotheses explaining the evident association of the above morbidities and delivery by cesarean section. PMID:25568522

Vaginal breech delivery: results of a prospective registration study

PubMed Central

2013-01-01

Background Most countries recommend planned cesarean section in breech deliveries, which is considered safer than vaginal delivery. As one of few countries in the western world Norway has continued to practice planned vaginal delivery in selected women. The aim of this study is to evaluate prospectively registered neonatal and maternal outcomes in term singleton breech deliveries in a Norwegian hospital during a ten years period. We aim to compare maternal and neonatal outcomes in term breech pregnancies subjected either to planned vaginal or elective cesarean section. Methods A prospective registration study including 568 women with term breech deliveries (>37 weeks) consecutively registered at Sorlandet Hospital Kristiansand between 2001 and 2011. Fetal and maternal outcomes were compared according to delivery method; planned vaginal delivery versus planned cesarean section. Results Of 568 women, elective cesarean section was planned in 279 (49%) cases and vaginal delivery was planned in 289 (51%) cases. Acute cesarean section was performed in 104 of the planned vaginal deliveries (36.3%). There were no neonatal deaths. Two cases of serious neonatal morbidity were reported in the planned vaginal group. One infant had seizures, brachial plexus injury, and cephalhematoma. The other infant had 5-minutes Apgar < 4. Twenty-nine in the planned vaginal group (10.0%) and eight in the planned cesarean section group (2.9%) (p < 0.001) were transferred to the neonatal intensive care unit. However, only one infant was admitted for ≥4 days. According to follow-up data (median six years) none of these infants had long-term sequelae. Regarding maternal morbidity, blood loss was the only variable that was significantly higher in the planned cesarean section group versus in the vaginal delivery group (p < 0.001). Conclusions Strict guidelines were followed in all cases. There were no neonatal deaths. Two infants had serious neonatal morbidity in the planned

Trends in the delivery route of twin pregnancies in the United States, 2006-2013.

PubMed

Bateni, Zhoobin H; Clark, Steven L; Sangi-Haghpeykar, Haleh; Aagaard, Kjersti M; Blumenfeld, Yair J; Ramin, Susan M; Lee, Henry C; Fox, Karin A; Moaddab, Amirhossein; Shamshirsaz, Amir A; Salmanian, Bahram; Hosseinzadeh, Pardis; Racusin, Diana A; Erfani, Hadi; Espinoza, Jimmy; Dildy, Gary A; Belfort, Michael A; Shamshirsaz, Alireza A

2016-10-01

To determine the trends of cesarean delivery rate among twin pregnancies from 2006 to 2013. This is a population-based, cross-sectional analysis of twin live births from United State birth data files of the National Center for Health Statistics for calendar years 2006 through 2013. We stratified the population based on the gestational age groups, maternal race/ethnicity, advanced maternal age (AMA) which was defined by age more than 35 years and within the standard birth weight groups (group 1: birth weight 500-1499g, group 2: birth weight 1500-2499g and group 3: birth weight >2500g). We also analyzed the effect of different risk factors for cesarean delivery in twins. There were 1,079,102 infants born of twin gestations in the U.S. from 2006 to 2013, representing a small but significant increase in the proportion of twin births among all births (3.2% in 2006 versus 3.4% in 2013). The rate of cesarean delivery in twin live births peaked at 75.3% in 2009, and was significantly lower (74.8%) in 2013. The rate of the twin live birth with the breech presentation increased steadily from 26.3% in 2006 to 29.1% in 2013. For the fetus of the twin pregnancy presented as breech, the cesarean delivery rate peaked at 92.2% in 2010, falling slightly but significantly in the ensuing 3 years. The results demonstrated that the decrease in cesarean delivery rate was due to fewer cesareans in non-Hispanic white patients; all other ethnic subgroups showed increasing rates of cesarean delivery throughout the study. Gestational diabetes, gestational hypertension, previous cesarean delivery and breech presentation were all significant risk factors for cesarean delivery during the entire study period. Induction of labor and premature rupture of the membranes were associated with lower rates of cesarean delivery in twins. The recent decrease in the cesarean delivery rate in twin gestation appears to be largely attributable to a decline in cesarean among pregnancies complicated by breech

Effects of Cesarean delivery and formula supplementation on the intestinal microbiome of six-week old infants

PubMed Central

Madan, Juliette C.; Hoen, Anne G.; Lundgren, Sara N.; Farzan, Shohreh F.; Cottingham, Kathryn L.; Morrison, Hilary G.; Sogin, Mitchell L.; Li, Hongzhe; Moore, Jason H.; Karagas, Margaret R.

2016-01-01

Importance The intestinal microbiome plays a critical role in infant development, and delivery mode and feeding method (breastmilk vs. formula) are determinants of its composition. However, the importance of delivery mode beyond the first days of life is unknown, and studies of associations between infant feeding and microbiome composition have been generally limited to comparisons between exclusively breastfed and formula fed infants, with little consideration given to combination feeding of both breastmilk and formula. Objectives To examine the relative effects of delivery mode and feeding method on infant intestinal microbiome composition at approximately six weeks of life. Design, Setting and Participants Prospective observational study of 102 infants followed as part of a US pregnancy cohort study. Exposures Delivery mode was abstracted from delivery medical records and feeding method prior to the time of stool collection was ascertained through detailed questionnaires. Main Outcomes and Measures Stool microbiome composition was characterized using next-generation sequencing of the 16S rRNA gene. Results We identified independent associations between microbial community composition and both delivery mode and feeding method. Differences in microbial community composition between vaginally and infants delivered by Cesarean section were equivalent to or significantly larger than those between feeding groups. Bacterial communities associated with combination feeding were more similar to those associated with exclusive formula feeding than exclusive breastfeeding. We identified individual bacterial genera that were differentially abundant between delivery mode and feeding groups. Conclusions and Relevance The infant intestinal microbiome at approximately six weeks of age is significantly associated with both delivery mode and feeding method, and the supplementation of breastmilk feeding with formula is associated with a microbiome composition that resembles that of

"Informed" Consent: An Audit of Informed Consent of Cesarean Section Evaluating Patient Education and Awareness.

PubMed

Kirane, Akhilesh G; Gaikwad, Nandkishor B; Bhingare, Prashant E; Mule, Vidya D

2015-12-01

Better diagnosis and early referral due to increased health care coverage have increased the cesarean deliveries at tertiary-care hospitals of India. Improvements in the health care system raise many concerns and need of cross-checking system in place to counter the problems pertaining to patient education and participation of patient. While most of the cesarean sections are done in good faith for the patient, it does not escape the purview of consumer awareness and protection. This cross-sectional study was undertaken at a tertiary level government institution to understand the level of awareness of 220 patients regarding the various aspects of cesarean delivery which are essential for women to know before giving an informed consent. 71 % of the women had knowledge about the indication and need to do cesarean delivery. Of these, only one-third (25 % of total women) were properly explained about procedure and complications. Other demographic and social characteristics were also evaluated. While the health care schemes have had their improved results, the onus lies upon the caregivers to improve and maintain the quality of health care in these tertiary-care government hospitals in proportion to the increase in patient load. The results of this study highlight the need for proper counseling of patients regarding complications of cesarean section. The fact that only 25 % of total cases were explained proper procedure and complication as opposed to 71 % of patients having proper knowledge about the indication of cesarean section points out the lack of information in seemingly "informed" consent. To bring about awareness about the risks and complications of cesarean section, there is a need that patients be counseled during the antenatal visits, specifically when patients visit near term for antenatal check up.

Effects of Reiki on Post-cesarean Delivery Pain, Anxiety, and Hemodynamic Parameters: A Randomized, Controlled Clinical Trial.

PubMed

Midilli, Tulay Sagkal; Eser, Ismet

2015-06-01

The aim of this study was to investigate the effect of Reiki on pain, anxiety, and hemodynamic parameters on postoperative days 1 and 2 in patients who had undergone cesarean delivery. The design of this study was a randomized, controlled clinical trial. The study took place between February and July 2011 in the Obstetrical Unit at Odemis Public Hospital in Izmir, Turkey. Ninety patients equalized by age and number of births were randomly assigned to either a Reiki group or a control group (a rest without treatment). Treatment applied to both groups in the first 24 and 48 hours after delivery for a total of 30 minutes to 10 identified regions of the body for 3 minutes each. Reiki was applied for 2 days once a day (in the first 24 and 48 hours) within 4-8 hours of the administration of standard analgesic, which was administered intravenously by a nurse. A visual analog scale and the State Anxiety Inventory were used to measure pain and anxiety. Hemodynamic parameters, including blood pressure (systolic and diastolic), pulse and breathing rates, and analgesic requirements also were recorded. Statistically significant differences in pain intensity (p = .000), anxiety value (p = .000), and breathing rate (p = .000) measured over time were found between the two groups. There was a statistically significant difference between the two groups in the time (p = .000) and number (p = .000) of analgesics needed after Reiki application and a rest without treatment. Results showed that Reiki application reduced the intensity of pain, the value of anxiety, and the breathing rate, as well as the need for and number of analgesics. However, it did not affect blood pressure or pulse rate. Reiki application as a nursing intervention is recommended as a pain and anxiety-relieving method in women after cesarean delivery. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Effect of Primary Elective Cesarean Delivery on Placenta Accreta: A Case-Control Study.

PubMed

Shi, Xiao-Ming; Wang, Yan; Zhang, Yan; Wei, Yuan; Chen, Lian; Zhao, Yang-Yu

2018-03-20

Cesarean section (CS) is an independent risk factor for placenta accreta. Some researchers think that the timing of primary cesarean delivery is associated with placenta accreta in subsequent pregnancies. The aim of this study was to investigate the risk of placenta accreta following primary CS without labor, also called primary elective CS, in a pregnancy complicated with placenta previa. A retrospective, single-center, case-control study was conducted at Peking University Third Hospital. Relevant clinical data of singleton pregnancies between January 2010 and September 2017 were recorded. The case group included women with placenta accreta who had placenta previa and one previous CS. Control group included women with one previous CS that was complicated with placenta previa. Maternal age, body mass index, gestational age, fetal birth weight, gravity, parity, induced abortion, the rate of women received assisted reproductive technology, other uterine surgery, and primary elective CS were analyzed between the two groups. The rate of primary elective CS (90.1% vs. 69.9%, P < 0.001) was higher, and maternal age was younger (32.7 ± 4.7 years vs. 34.6 ± 4.0 years, P < 0.001) in case group, compared with control group. Case group also had higher gravity and induced abortions compared with the control group (both P < 0.05). Primary CS without labor was associated with significantly increased risk of placenta accreta in a subsequent pregnancy complicated with placenta previa (odds ratio: 3.32; 95% confidential interval: 1.68-6.58). Women with a primary elective CS without labor have a higher chance of developing an accreta in a subsequent pregnancy that is complicated with placenta previa.

Effect of Primary Elective Cesarean Delivery on Placenta Accreta: A Case-Control Study

PubMed Central

Shi, Xiao-Ming; Wang, Yan; Zhang, Yan; Wei, Yuan; Chen, Lian; Zhao, Yang-Yu

2018-01-01

Background: Cesarean section (CS) is an independent risk factor for placenta accreta. Some researchers think that the timing of primary cesarean delivery is associated with placenta accreta in subsequent pregnancies. The aim of this study was to investigate the risk of placenta accreta following primary CS without labor, also called primary elective CS, in a pregnancy complicated with placenta previa. Methods: A retrospective, single-center, case-control study was conducted at Peking University Third Hospital. Relevant clinical data of singleton pregnancies between January 2010 and September 2017 were recorded. The case group included women with placenta accreta who had placenta previa and one previous CS. Control group included women with one previous CS that was complicated with placenta previa. Maternal age, body mass index, gestational age, fetal birth weight, gravity, parity, induced abortion, the rate of women received assisted reproductive technology, other uterine surgery, and primary elective CS were analyzed between the two groups. Results: The rate of primary elective CS (90.1% vs. 69.9%, P < 0.001) was higher, and maternal age was younger (32.7 ± 4.7 years vs. 34.6 ± 4.0 years, P < 0.001) in case group, compared with control group. Case group also had higher gravity and induced abortions compared with the control group (both P < 0.05). Primary CS without labor was associated with significantly increased risk of placenta accreta in a subsequent pregnancy complicated with placenta previa (odds ratio: 3.32; 95% confidential interval: 1.68–6.58). Conclusion: Women with a primary elective CS without labor have a higher chance of developing an accreta in a subsequent pregnancy that is complicated with placenta previa. PMID:29521289

Factors associated with successful vaginal birth after cesarean section and outcomes in rural area of Anatolia

PubMed Central

Senturk, Mehmet Baki; Cakmak, Yusuf; Atac, Halit; Budak, Mehmet Sukru

2015-01-01

Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation. This study attempts to evaluate factors associated with success of vaginal birth after cesarean section and to compare the maternal and perinatal outcomes between vaginal birth after cesarean section and intrapartum cesarean section in patients who were admitted to hospital during the active or second stage of labor. A retrospective evaluation was made from the results of 127 patients. Cesarean section was performed in 57 patients; 70 attempted trial of labor. The factors associated with success of vaginal birth after cesarean section were investigated. Maternal and neonatal outcomes were compared between the groups. Vaginal birth after cesarean section was successful in 55% of cases. Advanced cervical opening, effacement, gravidity, parity, and prior vaginal delivery were factors associated with successful vaginal birth. The vaginal birth group had more complications (P<0.01), but these were minor. The rate of blood transfusion and prevalence of changes in hemoglobin level were similar in both groups (P>0.05). In this study, cervical opening, effacement, gravidity, parity, and prior vaginal delivery were important factors for successful vaginal birth after cesarean section. The patients’ requests influenced outcome. Trial of labor should take into consideration the patient’s preference, together with the proper setting. PMID:26203286

Emergency cesarean section and the 30-minute rule: definitions.

PubMed

Schauberger, Charles W; Chauhan, Suneet P

2009-03-01

We explored the role that lack of a standard definition and heterogeneity in patient selection criteria in the literature might have on the apparent inability to routinely begin an emergency cesarean section in less than 30 minutes. A review of the literature on emergency cesarean delivery was performed. Although there are some similarities in definitions and the criteria used for patient selection in multiple studies, the variability in the definitions could be responsible for some of the apparent timeliness performance deficiency in the literature. A standard definition and directions for future research are suggested.

Complications of Delivery Among Mothers with Spina Bifida.

PubMed

Shepard, Courtney L; Yan, Phyllis L; Kielb, Stephanie J; Wittmann, Daniela A; Quint, Elisabeth H; Kraft, Kate H; Hollingsworth, John M

2018-06-13

To determine rates and types of peripartum morbidity among delivering women with spina bifida (SB) compared to those without SB. The rates of pregnancy and delivery among women with SB have been significantly increasing. Current knowledge of peripartum outcomes for these women is limited. Using 2004-2013 National Inpatient Sample data, we identified all hospitalizations for delivery, distinguishing between women with and without SB. Using a code-based algorithm, we determined whether a complication occurred during the hospitalization. We then fit a series of multivariable logistic models to examine for associations between a complication occurrence during vaginal or cesarean delivery and a woman's SB status. We identified 38,319,814 weighted admissions for delivery, 9,516 of which were made by women with SB. Women with SB had a significantly higher rate of cesarean delivery than women without this diagnosis (53% v 32%, p<0.001). The 46.7% of women with SB who delivered vaginally did not have significantly increased odds of a complication associated with their delivery compared to women without SB [odds ratio (OR) 1.15, 95% confidence interval (CI) 0.99 to 1.34, p=0.066]. However, women with SB who underwent a cesarean delivery did have higher odds of morbidity compared to those without (OR 1.49, 95% CI 1.25 to 1.78, p<0.001). Common complications included preterm delivery, urinary tract infection, hematologic event, and blood transfusion. Compared to women without SB, those with SB deliver more frequently by cesarean section and have higher odds of morbidity associated with cesarean delivery, but not vaginal delivery. Copyright © 2018. Published by Elsevier Inc.

Complications and outcomes of repeat cesarean section in adolescent women

PubMed Central

Kaplanoglu, Mustafa; Karateke, Atilla; Un, Burak; Akgor, Utku; Baloğlu, Ali

2014-01-01

Aim: The evaluation of the effect of repeat cesarean sections in adolescent pregnancies on the morbidity, obstetric and perinatal results. Materials and methods: We reviewed the patient file and hospital records of patients who underwent at least one cesarean section among adolescent age group pregnant women who gave birth at our clinic between January 2010 and May 2013. The patients were divided into two groups as the patients who underwent the second cesarean section (116 patients) and those who underwent the third cesarean section (36 patients). The demographic data, maternal data and obstetric and perinatal results of the patients were evaluated. Results: A significant difference was present between the patients in the evaluation of the total number of examinations during pregnancy (P = 0.001), total maternal weight gain during pregnancy (P = 0.006), and the first examination gestational age (P = 0.006) and all values were less favorable in the third cesarean group. The gestational week at birth (P < 0.001), birth weight (P < 0.001), and APGAR score (P < 0.001) in the group with the third cesarean section were statistically significantly lower than the second cesarean section. The third cesarean cesarean was found to cause a significant risk increase for placenta accreta risk in adolescent pregnancies (P = 0.042). Conclusion: The increasing number of cesarean sections in the adolescent group is seen to be a significant risk factor for low gestational week of birth, low birth weight and related morbidities. The most important reason for the increased morbidity with increasing cesarean sections in the adolescent age has been defined as placenta accreta. PMID:25664081

Prevention of cesarean section. Does intracervical dinoprostone work?

PubMed Central

Gilson, G J; Izquierdo, L A; Chatterjee, M S; Curet, L B; Qualls, C R

1993-01-01

We investigated the effect of preinduction cervical ripening with the intracervical instillation of dinoprostone (prostaglandin E2 gel, 0.5 mg) on the results of labor induced with intravenous oxytocin. We randomly allocated 79 pregnant women to receive either the intracervial application of dinoprostone gel or placebo gel. Compared with control subjects, the group who received dinoprostone had no difference in induction-to-delivery interval or in cesarean section rate. The dinoprostone group had fewer failed inductions, but there was no difference between the two groups in the number who delivered spontaneously within 24 hours. From review of the literature and a meta-analysis, it was likewise revealed that dinoprostone did not favorably affect the cesarean section rate. Contrary to current opinion, intracervical dinoprostone gel does not appreciably lower the cesarean section rate when used at this dose and route before labor is induced. PMID:8212680

Obstetrician call schedule and obstetric outcomes among women eligible for a trial of labor after cesarean.

PubMed

Yee, Lynn M; Liu, Lilly Y; Grobman, William A

2017-01-01

Reducing cesarean deliveries is a major public health goal. The low rate of vaginal birth after cesarean has been attributed largely to a decrease in the likelihood of choosing a trial of labor after cesarean, despite evidence suggesting a majority of women with 1 prior low transverse cesarean are trial of labor after cesarean candidates. Although a number of reasons for this decrease have been explored, it remains unclear how systems issues such as physician call schedules influence delivery approach and mode in this context. The objective of the study was to investigate the relationship between obstetricians' call schedule and obstetric outcomes among women eligible for a trial of labor after cesarean. This is a retrospective cohort study of the likelihood of attempting a trial of labor after cesarean and achieving vaginal birth after cesarean among women with 1 prior low transverse cesarean delivery and a term, cephalic singleton gestation based on the delivering provider's call schedule. Attending obstetrician call schedules were classified as traditional or night float call. Night float call was defined as a schedule in which the provider had clinical responsibilities only for a day or night shift, without other clinical responsibilities before or after the period of responsibility for laboring patients. Call schedules are determined by individual provider groups. Bivariable analyses and random-effects logistic regression were used to examine the relationship between obstetricians' call schedule and the frequency of trial of labor after cesarean. Secondary outcomes including frequency of vaginal birth after cesarean and maternal and neonatal outcomes also were assessed. Of 1502 eligible patients, 556 (37%) were delivered by physicians in a night float call system. A total of 22.6% underwent a trial of labor after cesarean and 12.8% achieved vaginal birth after cesarean; the vaginal birth after cesarean rate for women attempting a trial of labor after cesarean

Malpractice premiums and primary cesarean section rates in New York and Illinois.

PubMed Central

Rock, S M

1988-01-01

The fear of malpractice liability is mentioned frequently as a cause of increased cesarean section rates, but without quantitative investigations. This perception may be studied at an aggregate level by comparing malpractice insurance premiums, a proxy for liability risk, with primary cesarean section rates. Both New York and Illinois are divided into territories for insurance rates; the premium was uniform within each territory over the period studied for each specialty. Premiums for obstetricians were linked to birth and procedure data from New York and Illinois hospitals for 1981 and 1983, respectively, to determine whether there was a correlation between premium levels and the primary cesarean section rate. A statistically significant difference was found between mean cesarean rates by insurance premium territories in each State. A correlation was observed between increased insurance rates among territories and increased cesarean section rates. Based on these results, a substantial impact was found on delivery decisions resulting from the fear of malpractice suits. PMID:3140270

Quality assurance: The 10-Group Classification System (Robson classification), induction of labor, and cesarean delivery.

PubMed

Robson, Michael; Murphy, Martina; Byrne, Fionnuala

2015-10-01

Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables. The 10-Group Classification System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland. Interpretation of the classification can be easily taught. The standard table can provide much insight into the philosophy of care in the population of women studied and also provide information on data quality. With standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes can be explained only by poor data collection, significant epidemiological variables, or differences in practice. In April 2015, WHO proposed that the TGCS (also known as the Robson classification) is used as a global standard for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities. Copyright © 2015. Published by Elsevier Ireland Ltd.

Induction of labor before 40 weeks is associated with lower rate of cesarean delivery in women with gestational diabetes mellitus.

PubMed

Melamed, Nir; Ray, Joel G; Geary, Michael; Bedard, Daniel; Yang, Cathy; Sprague, Ann; Murray-Davis, Beth; Barrett, Jon; Berger, Howard

2016-03-01

In women with gestational diabetes mellitus, it is not clear whether routine induction of labor at <40 weeks of gestation is beneficial to mother and newborn infant. The purpose of this study was to compare outcomes among women with gestational diabetes mellitus who had induction of labor at either 38 or 39 weeks with those whose pregnancy was managed expectantly. We included all women in Ontario, Canada, with diagnosed gestational diabetes mellitus who had a singleton hospital birth at ≥38 + 0 weeks of gestation between April 2012 and March 2014. Data were obtained from the Better Outcomes Registry & Network Ontario, which is a province-wide registry of all births in Ontario, Canada. Women who underwent induction of labor at 38 + 0 to 38 + 6 weeks of gestation (38-IOL; n = 1188) were compared with those who remained undelivered until 39 + 0 weeks of gestation (38-Expectant; n = 5229). Separately, those women who underwent induction of labor at 39 + 0 to 39 + 6 weeks of gestation (39-IOL; n = 1036) were compared with women who remained undelivered until 40 + 0 weeks of gestation (39-Expectant; n = 2162). Odds ratios and 95% confidence intervals were adjusted for maternal age, parity, insulin treatment, and prepregnancy body mass index. Of 281,480 women who gave birth during the study period, 14,600 women (5.2%) had gestational diabetes mellitus; of these, 8392 women (57.5%) met all inclusion criteria. Compared with the 38-Expectant group, those women in the 38-IOL group had lower odds for cesarean delivery (adjusted odds ratio, 0.73; 95% confidence interval, 0.52-0.90), higher odds for neonatal intensive care unit admission (adjusted odds ratio, 1.36; 95% confidence interval, 1.09-1.69), and no difference in other maternal-newborn infant outcomes. Compared with the 39-Expectant group, women in the 39-IOL group likewise had lower odds for cesarean delivery (adjusted odds ratio, 0.73; 95% confidence interval, 0.58-0.93) but no difference in neonatal intensive care

Fear of Childbirth and Preference for Cesarean Delivery Among Young American Women Before Childbirth: A Survey Study.

PubMed

Stoll, Kathrin; Edmonds, Joyce Katherine; Hall, Wendy A

2015-09-01

Fear of birth and mode of delivery preferences are similar among pregnant and nonpregnant women, suggesting that attitudes toward birth are formed in young adulthood or earlier. Understanding why some young women fear birth and prefer obstetric interventions can inform public health initiatives aimed at reducing fear and promoting birth as a normal life event. We conducted an online survey with 752 American nulliparous young women to assess their preferences and attitudes toward childbirth. We identified explanatory variables associated with reported fear of childbirth and cesarean delivery (CD) preferences. A preference for CD was reported by 14 percent of young women and 27 percent had scores indicating elevated fear of birth. Fear of birth increased the likelihood of cesarean preference (adjusted relative risk (ARR) 3.84 [95% CI 2.49-5.95]) as did a family history of CD (ARR 1.65 [95% CI 1.13-2.42]). The likelihood of reporting elevated childbirth fear was increased among young women who reported concerns about the physical changes pregnancy and birth have on women's bodies (ARR 2.04 [95% CI 1.50-2.78]). Young women who reported a high degree of confidence in their knowledge about childbirth were significantly less likely to report childbirth fear (ARR 0.61 [95% CI 0.42-0.87]). Access to childbirth information was also associated with a decreased likelihood of fear of birth (ARR 0.75 [95% CI 0.59-0.95]). Young women reporting high levels of childbirth fear are nearly four times more likely to prefer a CD. Specific fears, such as worries over the influence of pregnancy and birth on the female body, need to be addressed before pregnancy. © 2015 Wiley Periodicals, Inc.

The effect of increased number of cesarean on maternal and fetal outcomes.

PubMed

Çintesun, Ersin; Al, Ragıp Atakan

2017-01-01

The aim of this study was to evaluate the effects of multiple cesarean deliveries (CDs) on maternal-fetal mor-bidity and mortality rates. This retrospective study included a total of 1,506 patients who underwent multiple CDs between January 2006 and May 2014. The patients were divided into two groups. One group consisted of patients with four or more CDs (n = 444) and a control group of patients with three CDs (n=1,062). Both groups were analyzed for demographics, complications from multiple cesarean deliveries and perinatal outcomes. The mean age was higher in the study group (p < 0.001). Dense adhesion (p < 0.001), demand for tubal ligation (p < 0.001), the requirement of pelvic drainage (p < 0.001), duration of hospitalization (p < 0.001) and the requirement for blood transfusion (p=0.03) was also significantly higher in the study group. Hemoglobin levels (p = 0.002) were signifi-cantly higher in the control group on the second postoperative day. Regarding perinatal morbidity; umbilical artery pH results (p = 0.003) were significantly lower in the study group. There was no significant difference in the maternal and fetal mortality rates between both groups. According to our study results, an increase in the number of cesarean sections increases maternal and fetal morbidity rates significantly. Therefore, we recommend decreasing the rate of primary cesarean deliveries by encouraging vaginal birth after CD. We also advocate the use of permanent contraceptive methods in patients with a high number of CD's. Further large-scale prospective results are required to establish a definitive conclusion.

Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China.

PubMed

Wang, Eileen

2017-01-01

Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China's maternal-services system. Copyright © 2016 Elsevier Ltd. All rights reserved.

Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status.

PubMed

Attanasio, Laura B; Hardeman, Rachel R; Kozhimannil, Katy B; Kjerulff, Kristen H

2017-12-01

Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status. Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms. Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured. There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth. © 2017 Wiley Periodicals, Inc.

Association of Gestational Weight Gain With Maternal and Infant Outcomes: A Systematic Review and Meta-analysis.

PubMed

Goldstein, Rebecca F; Abell, Sally K; Ranasinha, Sanjeeva; Misso, Marie; Boyle, Jacqueline A; Black, Mary Helen; Li, Nan; Hu, Gang; Corrado, Francesco; Rode, Line; Kim, Young Ju; Haugen, Margaretha; Song, Won O; Kim, Min Hyoung; Bogaerts, Annick; Devlieger, Roland; Chung, Judith H; Teede, Helena J

2017-06-06

Body mass index (BMI) and gestational weight gain are increasing globally. In 2009, the Institute of Medicine (IOM) provided specific recommendations regarding the ideal gestational weight gain. However, the association between gestational weight gain consistent with theIOM guidelines and pregnancy outcomes is unclear. To perform a systematic review, meta-analysis, and metaregression to evaluate associations between gestational weight gain above or below the IOM guidelines (gain of 12.5-18 kg for underweight women [BMI <18.5]; 11.5-16 kg for normal-weight women [BMI 18.5-24.9]; 7-11 kg for overweight women [BMI 25-29.9]; and 5-9 kg for obese women [BMI ≥30]) and maternal and infant outcomes. Search of EMBASE, Evidence-Based Medicine Reviews, MEDLINE, and MEDLINE In-Process between January 1, 1999, and February 7, 2017, for observational studies stratified by prepregnancy BMI category and total gestational weight gain. Data were extracted by 2 independent reviewers. Odds ratios (ORs) and absolute risk differences (ARDs) per live birth were calculated using a random-effects model based on a subset of studies with available data. Primary outcomes were small for gestational age (SGA), preterm birth, and large for gestational age (LGA). Secondary outcomes were macrosomia, cesarean delivery, and gestational diabetes mellitus. Of 5354 identified studies, 23 (n = 1 309 136 women) met inclusion criteria. Gestational weight gain was below or above guidelines in 23% and 47% of pregnancies, respectively. Gestational weight gain below the recommendations was associated with higher risk of SGA (OR, 1.53 [95% CI, 1.44-1.64]; ARD, 5% [95% CI, 4%-6%]) and preterm birth (OR, 1.70 [1.32-2.20]; ARD, 5% [3%-8%]) and lower risk of LGA (OR, 0.59 [0.55-0.64]; ARD, -2% [-10% to -6%]) and macrosomia (OR, 0.60 [0.52-0.68]; ARD, -2% [-3% to -1%]); cesarean delivery showed no significant difference (OR, 0.98 [0.96-1.02]; ARD, 0% [-2% to 1%]). Gestational weight gain above the

Increase in Cesarean Operative Time Following Institution of the 80-Hour Workweek

PubMed Central

Smrtka, Michael P.; Gunatilake, Ravindu P.; Harris, Benjamin; Yu, Miao; Lan, Lan; Brancazio, Leo R.; Valea, Fidel A.; Grotegut, Chad A.; Brown, Haywood L.

2015-01-01

Background  In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours per week. More than a decade later, the effect of the limits on resident clinical competence is not fully understood. Objective  We sought to assess the effect of duty hour restrictions on resident performance of an uncomplicated cesarean delivery. Methods  We reviewed unlabored primary cesarean deliveries at Duke University Hospital after 34 weeks gestation, between 2003 and 2011. Descriptive statistics and linear regression were used to compare total operative time with incision to delivery time as a function of years since institution of the 80-hour workweek. Resident training level, subject body mass index, estimated blood loss, and skin closure method were controlled for in the regression model. Results  We identified 444 deliveries that met study criteria. The mean (SD) total operative time in 2003–2004 was 43.3 (14.3) minutes and 59.6 (10.7) minutes in 2010–2011 (P < .001). Multivariable regression demonstrated an increase in total operative time of 1.9 min/y (P < .001) but no change in incision to delivery time (P = .05). The magnitude of increased operative time was seen among junior residents (2.0 min/y, P < .001) compared to that of senior residents (1.2 min/y, P = .06). Conclusions  Since introduction of the 2003 duty hour limits, there has been an increase of nearly 20 minutes in the time required for a routine cesarean delivery. It is unclear if the findings are due to a change in residency duty hours or to another aspect of residency training. PMID:26457141

[Experience with combined spinal and epidural anesthesia at cesarean section].

PubMed

Levinzon, A S; Taran, O I; Pura, K R; Mishchenko, G S; Mamaeva, N V

2006-01-01

The paper analyzes some experience gained in using various modes of regional anesthesia as an anesthetic appliance at cesarean sections and comparatively characterizes various types of central segmental blocks. The results of 213 cases of cesarean section performed under spinal or combined spinal and epidural anesthesia (CSEA) were generalized by the following parameters: block onset, maternal and fetal action, the quality of anesthesia and postoperative analgesia, which leads to the conclusion that CSEA is the method of choice.

Impact of a diagnosis-related group payment system on cesarean section in Korea.

PubMed

Kim, Seung Ju; Han, Kyu-Tae; Kim, Sun Jung; Park, Eun-Cheol; Park, Hye Ki

2016-06-01

Cesarean sections (CSs) are the most expensive method of delivery, which may affect the physician's choice of treatment when providing health services to patients. We investigated the effects of the diagnosis-related group (DRG)-based payment system on CSs in Korea. We used National Health Insurance claim data from 2011 to 2014, which included 1,289,989 delivery cases at 674 hospitals. We used a generalized estimating equation model to evaluate the association between the likelihood of cesarean delivery and the length of the DRG adoption period. A total of 477,309 (37.0%) delivery cases were performed by CSs. We found that a longer DRG adoption period was associated with a lower odds ratio of CSs (odds ratio [OR]: 0.997, 95% CI: 0.996-0.998). In addition, a longer DRG adoption period was associated with a lower odds ratio for CSs in hospitals that had voluntarily adopted the DRG system. Similar results were also observed for urban hospitals, primiparas, and those under 28 years old and over 33 years old. Our results suggest that the change in the reimbursement system was associated with a low likelihood of CSs. The impact of DRG adoption on cesarean delivery can also be expected to increase with time, as our finding provides evidence that the reimbursement system is associated with the health provider's decision to provide health services for patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Placenta previa and it's relation with maternal age, gravidity and cesarean section.

PubMed

Hossain, G A; Islam, S M; Mahmood, S; Chakraborty, R K; Akhter, N; Sultana, S

2004-07-01

The placenta provides the essential connection between the mother and the developing fetus. Placental position were routinely mentioned in an ultrasound report starting from early second trimester to the end of third trimester when asked for pregnancy evaluation. The aim of this study was to see the prevalence of lower segment placenta (placenta previa) and its relations with previous cesarean section delivery, parity and maternal age. The study conducted in Centre for Nuclear Medicine and Ultrasound (CNMU) Mymensingh in a period from January 2001 to December 2002. About 2536 pregnant women (those included in this study) underwent ultrasound examination during pregnancy at third trimester. The prevalence of lower segment placenta was 1.34%. The highest prevalence of placenta previa (2.58%) was seen in 3rd and higher gravida group. Also the highest prevalence were seen 30 yr. and above age group in compare to below 30 yr. age group. No increased prevalence of placenta previa were seen in previous cesarean section (C / S) delivery group (0.65%) in compare to normal delivery group (1.97%). From our study it was seen that development of lower segment placenta has relation with increased number of gravidity and maternal age but no increased prevalence were seen in subjects with previously done cesarean section

Increased cesarean section rates and emerging patterns of health insurance in Shanghai, China.

PubMed Central

Cai, W W; Marks, J S; Chen, C H; Zhuang, Y X; Morris, L; Harris, J R

1998-01-01

OBJECTIVES: This study examined the trend in cesarean section deliveries and the factors associated with it in the Minhang District of Shanghai, China. METHODS: A representative sample of the members of 2716 households in the district were interviewed in the fall of 1993. This study analyzed the data from 1959 married women of reproductive age with at least one live birth. RESULTS: During the past 3 decades, the proportion of infants born by cesarean section increased from 4.7% to 22.5%. Logistic regression analysis revealed that the highest cesarean section rate, which occurred in the most recent period of 1988 through 1993, was associated with form of medical payment, self-reported complications during pregnancy, higher birthweight, and maternal age. Government insurance pays all costs of cesarean sections and accounted for the highest proportion of the cesarean section rate. CONCLUSIONS: The high rates of cesarean sections in China are surprising given the lack of the factors that usually lead to cesarean sections. The increasing cesarean section rates may be an early indication that emerging forms of health insurance and fee-for-service payments to physicians will lead to an excessive emphasis on costly, high-technology medical care in China. PMID:9585744

Surgical Techniques at Cesarean Delivery: A U.S. Survey

PubMed Central

Lyell, Deirdre J.; Power, Michael; Murtough, Katie; Ness, Amen; Anderson, Britta; Erickson, Kristine; Schulkin, Jay

2016-01-01

Objective  To assess the frequency of surgical techniques at cesarean delivery (CD) among U.S. obstetricians. Methods  Members of the American College of Obstetrician Gynecologists were randomly selected and e-mailed an online survey that assessed surgical closure techniques, demographics, and reasons. Data were analyzed using SPSS (IBM Corp., Armonk, New York, United States), descriptive statistics, and analysis of variance. Results  Our response rate was 53%, and 247 surveys were analyzed. A similar number of respondents either “always or usually” versus “rarely or never” reapproximate the rectus muscles (38.4% versus 43.3%, p  = 0.39), and close parietal peritoneum (42.5% versus 46.9%, p  = 0.46). The most frequently used techniques were double-layer hysterotomy closure among women planning future children (73.3%) and suturing versus stapling skin (67.6%); the least frequent technique was closure of visceral peritoneum (12.2%). Surgeons who perform double-layer hysterotomy closure had fewer years in practice (15.0 versus 18.7 years, p  = 0.021); surgeons who close visceral peritoneum were older (55.5 versus 46.4 years old, p  < 0.001) and had more years in practice (23.8 versus 13.8 years practice; p  < 0.001). Conclusion  Similar numbers of obstetricians either reapproximate or leave open the rectus muscles and parietal peritoneum at CD, suggesting that wide variation in practice exists. Surgeon demographics and safety concerns play a role in some techniques. PMID:28825004

The Relationship between Rostral Retraction of the Pannus and Outcomes at Cesarean Section.

PubMed

Turan, Ozhan M; Rosenbloom, Joshua; Galey, Jessica L; Kahntroff, Stephanie L; Bharadwaj, Shobana; Turner, Shafonya M; Malinow, Andrew M

2016-08-01

Objective Maternal obesity presents several challenges at cesarean section. In an effort to routinely employ a transverse suprapubic skin incision, we often retract the pannus in a rostral direction using adhesive tape placed after induction of anesthesia and before surgical preparation of the skin. We sought to understand the association between taping and neonatal cord blood gases, Apgar scores, and time from skin incision to delivery of the neonate. Study Design This is a retrospective study, performed using prospectively collected anesthesiology records with data supplemented from the patients' medical records. Singleton pregnancies with morbid obesity (body mass index [BMI] > 40 kg/m(2)) between 37 and 42 weeks of gestation who delivered via nonurgent, scheduled cesarean delivery under regional (spinal, combined spinal-epidural, or epidural) anesthesia between March 2007 and March 2013 were identified. Maternal demographics including BMI, comorbidities, type of anesthesia, time intervals during the surgery, cord gas results, and Apgar scores were collected. The relationship between taping and blood acid-base status, Apgar scores, and interval from skin incision to delivery was investigated using appropriate statistical tests. Results There were 2,525 (27.5%) cesarean deliveries out of 9,189 total deliveries. Applying the described inclusion/exclusion criteria, 141 patients were identified (33 taped and 108 nontaped). There was no significant difference in BMI between the taped (51.9 kg/m(2)) and nontaped groups (47.4 kg/m(2)), p > 0.05. There was no difference in type of anesthesia (p > 0.05). The only significant difference between the taped and not-taped groups was the presence of chronic hypertension in the taped group (p = 0.03). There were no significant differences in cord blood gas values, Apgar scores, or skin incision to delivery interval (p > 0.05 for all outcomes). Conclusions Taping of the pannus at cesarean section is a

Does information available at admission for delivery improve prediction of vaginal birth after cesarean?

PubMed Central

Grobman, William A.; Lai, Yinglei; Landon, Mark B.; Spong, Catherine Y.; Leveno, Kenneth J.; Rouse, Dwight J.; Varner, Michael W.; Moawad, Atef H.; Simhan, Hyagriv N.; Harper, Margaret; Wapner, Ronald J.; Sorokin, Yoram; Miodovnik, Menachem; Carpenter, Marshall; O'sullivan, Mary J.; Sibai, Baha M.; Langer, Oded; Thorp, John M.; Ramin, Susan M.; Mercer, Brian M.

2010-01-01

Objective To construct a predictive model for vaginal birth after cesarean (VBAC) that combines factors that can be ascertained only as the pregnancy progresses with those known at initiation of prenatal care. Study design Using multivariable modeling, we constructed a predictive model for VBAC that included patient factors known at the initial prenatal visit as well as those that only became evident as the pregancy progressed to the admission for delivery. Results 9616 women were analyzed. The regression equation for VBAC success included multiple factors that could not be known at the first prenatal visit. The area under the curve for this model was significantly greater (P < .001) than that of a model that included only factors available at the first prenatal visit. Conclusion A prediction model for VBAC success that incorporates factors that can be ascertained only as the pregnancy progresses adds to the predictive accuracy of a model that uses only factors available at a first prenatal visit. PMID:19813165

Cesarean Section - Multiple Languages

MedlinePlus

... Translations Your Recovery After Cesarean Birth (Part 1) - English PDF Your Recovery After Cesarean Birth (Part 1) - ... Media Your Recovery After Cesarean Birth (Part 2) - English PDF Your Recovery After Cesarean Birth (Part 2) - ...

Financial incentives and use of Cesarean delivery: Taiwan birth data 2003 to 2007.

PubMed

Hong, Yi-Chen; Linn, George Chinhung

2012-01-01

The Cesarean section (CS) rate in Taiwan has exceeded 30% since 2000. To lower the CS rate, the Bureau of National Health Insurance in Taiwan raised the payment for vaginal delivery (VD) in May 2005, and also increased the insured's copayment for elective CS in May 2006. This study clarifies the influences of these financial incentives, and explores whether the 2 policies lowered the CS rate. The materials used are birth cases obtained from a systematic sampling of the original inpatient claim data in the National Health Insurance research database between 2003 and 2007. The empirical analysis of this study groups the birth data into 4 types: VD, unplanned CS, planned CS, and elective CS. The 4 delivery types represent the dependent variable. A multinomial logistic regression model was adopted as the empirical method. The policy changes, hospital attributes, and insured status were considered independent variables. Results indicate that the supply-side policy change in May 2005 reduced the number of CS cases. However, the policy effect was not very significant, and the CS rate decreased mainly because of planned CS cases. The demand-side policy change in May 2006 did not lower the rate of elective CS. The results imply that the financial incentives were not the main consideration for both the demand and supply sides. To encourage more VDs and lower the CS rate, the authorities could consider mechanisms other than adjusting the payment or changing the copayment.

Case report: Anesthesia management for emergency cesarean section in a patient with dwarfism.

PubMed

Li, Xiaoxi; Duan, Hongjun; Zuo, Mingzhang

2015-04-28

Dwarfism is characterized by short stature. Pregnancy in women with dwarfism is uncommon and cesarean section is generally indicated for delivery. Patients with dwarfism are high-risk population for both general and regional anesthesia, let alone in an emergency surgery. In this case report we present a 27-year-old Chinese puerpera with dwarfism who underwent emergency cesarean section under combined spinal and epidural anesthesia. It is an original case report, which provides instructive significance for anesthesia management especially combined spinal and epidural anesthesia in this rare condition. There was only one former article that reported a puerpera who underwent combined spinal and epidural anesthesia for a selective cesarean section.

Upcoming strategies in obstetrics: how the technology of clinical audit may reduce cesarean birth.

PubMed

Paracchini, Sara; Masturzo, Bianca; Tangolo, Domenico; Roletti, Enrica; Piazzese, Annalisa; Attini, Rossella; Rolfo, Alessandro; Todros, Tullia

2017-12-01

The rate of cesarean delivery is currently increasing all over Europe. In Italy it reaches 38% of all child births. Therefore, it is important to identify the clinical and organizational variables that determine the appropriateness of elective cesarean delivery. With this aim we chose the technology of clinical audit, a process that promotes improvement in clinical practice through systematic review of clinical care in relation with explicit standards derived from scientific literature. This is a prospective audit: in the period March 2014-July 2014 we analyzed the medical records of 150 women who underwent elective cesarean delivery at Gynecological and Obstetrical University Hospital Sant'Anna, Turin. We collected data related to five quality criteria derived from scientific literature. Each criterion was stratified by indicators and matched with respective standards of adequate care. Criteria and indicators are: 1) cesarean section (CS) rate in twin pregnancies with both cephalic fetal presentation (stratified by dichorionic diamniotic and monochorionic diamniotic); 2) CS rates in preterm births (stratified by gestational age ≤32, ≤34 and ≤37 week); 3) CS rates on maternal request due to tokophobia in patients who received a psychological support during pregnancy; 4) repeated CS rates; 5) multidisciplinary evaluation of the indication to CS for non-obstetric reasons (orthopedic, ophthalmologic, psychiatric and neurological). The rate of CSs found in each criterion was compared with the respective standard in literature. The value obtained for each indicator was tested for statistical significance (CI 95%). We considered performing indicators whose final rate was found to be better or equal to the reference standard. The majority of the indicators result to be performant. CS rate for previous CS was 84% (73/86), far more frequent than the standard of optimal care fixed at ≤30% (P<0.05). Repeated CSs were analyzed in steps IV and V of audit because of the

Prevalence of and risk factors associated with cesarean section in Lebanon - A retrospective study based on a sample of 29,270 women.

PubMed

Zgheib, Sandy M; Kacim, Mohammad; Kostev, Karel

2017-12-01

During the last decades, there has been an alarming and dramatic increase in the number of cesarean births in both developed and undeveloped countries. This increase has not been clinically justified but, nevertheless, has raised an important number of issues. The aim of this study was to determine the risk factors associated with the high cesarean section rates in Lebanon. This study is based on a sample of 29,270 Lebanese women who were pregnant between 2000 and 2015. Among these, 14,327 gave birth by cesarean section and 14,943 gave birth vaginally. To identify the risk factors of cesarean section, logistic regression was applied as a statistical method using the SPSS statistical package. Of the 29,270 pregnant women included in the study, 49% had cesarean sections while 51% gave birth vaginally. Repeat cesarean section accounted for 23% while vaginal birth after cesarean accounted for only 0.2% of deliveries. In addition, weekdays were associated with a preference of providers to carry out more cesarean sections. According to an analysis of our data using logistic regression, the risk factors associated with the increase in cesarean section rates were advanced maternal age, elective cesarean section, malpresentation of fetus, multiple birth, prolonged pregnancy, prolonged labor, and fetal distress. Based on these results, it is recommended that a new health policy be implemented to reduce the number of unnecessary cesarean deliveries in Lebanon. Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Attitudes of midwives in Sweden toward a woman's refusal of an emergency cesarean section or a cesarean section on request.

PubMed

Danerek, Margaretha; Maršál, Karel; Cuttini, Marina; Lingman, Göran; Nilstun, Tore; Dykes, Anna-Karin

2011-03-01

A woman's refusal or request for a cesarean section can be a problem for midwives and obstetricians working in maternity units. The objective of this study was to describe the attitudes of midwives in Sweden toward the obstetrician's decision making in relation to a woman's refusal of an emergency cesarean section and to a woman's request for a cesarean section without a medical indication. The study has a cross-sectional multicenter design and used an anonymous, structured, and standardized questionnaire for data collection. The study group comprised midwives who had experience working at a delivery ward at 13 maternity units with neonatal intensive care units in Sweden (n = 259). In the case of a woman's refusal to undergo an emergency cesarean section for fetal reasons, most midwives (89%) thought that the obstetrician should try to persuade the woman to agree. Concerning a woman's request for a cesarean section without any medical indications, most midwives thought that the obstetrician should agree if the woman had previous maternal or fetal complications. The reason was to support the woman's decision out of respect for her autonomy; the midwives at six university hospitals were less willing to accept the woman's autonomy in this situation. If the only reason was "her own choice," 77 percent of the midwives responded that the obstetrician should not comply. The main focus of midwives seems to be the baby's health, and therefore they do not always agree with respect to a woman's refusal or request for a cesarean section. The midwives prefer to continue to explain the situation and persuade the woman to agree with the recommendation of the obstetrician. © 2010, Copyright the Authors. Journal compilation © 2010, Wiley Periodicals, Inc.

A modified fetal heart rate tracing interpretation system for prediction of cesarean section

PubMed Central

Schnettler, William T.; Rogers, Jennifer; Barber, Rachel E.; Hacker, Michele R.

2013-01-01

Objective To investigate whether a modified version of the 2008 National Institute of Child Health and Human Development (NICHD) interpretation system upon admission decreases cesarean delivery risk. Methods This retrospective cohort study ascribed a modified category to the first 30 min of fetal heart rate (FHR) tracings in labor. Category I was divided into two subsets (Ia and Ib) by the presence of accelerations. Category II was divided into four subsets (IIa–IId) based on baseline FHR, variability, response to stimulation and decelerations. Log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI). Results A category was ascribed to 910 women. Most FHR tracings were Category Ia (65.8%), Ib (7.7%), IIb (11.8%) and IId (14.0%). Category Ib tracings (fewer than two accelerations) were 2.26 (95% CI: 1.13–4.52) times more likely to result in cesarean delivery for abnormal FHR tracing than Category Ia tracings. A similar increase in risk was seen when comparing Category IIb and Category IId with Category Ia. Conclusion Application of a modified version of the 2008 NICHD FHR interpretation system to the initial 30 min of labor can identify women at increased risk of cesarean delivery for abnormal FHR tracing. PMID:21942513

A Prospective Randomized Clinical Trial of Single vs. Double Layer Closure of Hysterotomy at the Time of Cesarean Delivery: The Effect on Uterine Scar Thickness.

PubMed

Bamberg, Christian; Dudenhausen, Joachim W; Bujak, Verena; Rodekamp, Elke; Brauer, Martin; Hinkson, Larry; Kalache, Karim; Henrich, Wolfgang

2018-06-01

 We undertook a randomized clinical trial to examine the outcome of a single vs. a double layer uterine closure using ultrasound to assess uterine scar thickness.  Participating women were allocated to one of three uterotomy suture techniques: continuous single layer unlocked suturing, continuous locked single layer suturing, or double layer suturing. Transvaginal ultrasound of uterine scar thickness was performed 6 weeks and 6 - 24 months after Cesarean delivery. Sonographers were blinded to the closure technique.  An "intent-to-treat" and "as treated" ANOVA analysis included 435 patients (n = 149 single layer unlocked suturing, n = 157 single layer locked suturing, and n = 129 double layer suturing). 6 weeks postpartum, the median scar thickness did not differ among the three groups: 10.0 (8.5 - 12.3 mm) single layer unlocked vs. 10.1 (8.2 - 12.7 mm) single layer locked vs. 10.8 (8.1 - 12.8 mm) double layer; (p = 0.84). At the time of the second follow-up, the uterine scar was not significantly (p = 0.06) thicker if the uterus had been closed with a double layer closure 7.3 (5.7 - 9.1 mm), compared to single layer unlocked 6.4 (5.0 - 8.8 mm) or locked suturing techniques 6.8 (5.2 - 8.7 mm). Women who underwent primary or elective Cesarean delivery showed a significantly (p = 0.03, p = 0.02, "as treated") increased median scar thickness after double layer closure vs. single layer unlocked suture.  A double layer closure of the hysterotomy is associated with a thicker myometrium scar only in primary or elective Cesarean delivery patients. © Georg Thieme Verlag KG Stuttgart · New York.

Route of delivery and neonatal birth trauma.

PubMed

Moczygemba, Charmaine K; Paramsothy, Pangaja; Meikle, Susan; Kourtis, Athena P; Barfield, Wanda D; Kuklina, Elena; Posner, Samuel F; Whiteman, Maura K; Jamieson, Denise J

2010-04-01

We sought to examine rates of birth trauma in 2 groupings (all International Classification of Diseases, Ninth Revision codes for birth trauma, and as defined by the Agency for Healthcare Research and Quality Patient Safety Indicator [PSI]) among infants born by vaginal and cesarean delivery. Data on singleton infants were obtained from the 2004-2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. The rates of Agency for Healthcare Research and Quality PSI and all birth trauma were 2.45 and 25.85 per 1000 births, respectively. Compared with vaginal, cesarean delivery was associated with increased odds of PSI birth trauma (odds ratio [OR], 1.71), primarily due to an increased risk for "other specified birth trauma" (OR, 2.61). Conversely, cesarean delivery was associated with decreased odds of all birth trauma (OR, 0.55), due to decreased odds of clavicle fractures (OR, 0.07), brachial plexus (OR, 0.10), and scalp injuries (OR, 0.55). Infants delivered by cesarean are at risk for different types of birth trauma from infants delivered vaginally. Copyright 2010 Mosby, Inc. All rights reserved.

The maternal childbirth experience more than a decade after delivery.

PubMed

Bossano, Carla M; Townsend, Kelly M; Walton, Alexandra C; Blomquist, Joan L; Handa, Victoria L

2017-09-01

Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period. This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery. This was a planned, supplementary analysis of data collected for the Mothers' Outcomes after Delivery study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to Mothers' Outcomes after Delivery study participants >10 years from their first delivery. This validated questionnaire yields 3 scores: fulfillment, distress, and difficulty. These 3 scores were compared by mode of delivery (cesarean prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined. Among 576 women, 10.1-17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differed between women delivering by cesarean and those delivering vaginally: women delivering vaginally reported greater fulfillment (0.40 [-0.37 to 0.92] vs 0.15 [-0.88 to 0.66], P < .001) and less distress (-0.34 [-0.88 to 0.38] vs 0.20 [-0.70 to 0.93], P < .001) than those who delivered by cesarean. Women who delivered by cesarean prior to labor reported the greatest median fulfillment scores and the lowest median difficulty scores. Median distress scores were lowest among those who delivered by spontaneous vaginal birth. Among women who

Adverse obstetric outcomes in women with previous cesarean for dystocia in second stage of labor.

PubMed

Jastrow, Nicole; Demers, Suzanne; Gauthier, Robert J; Chaillet, Nils; Brassard, Normand; Bujold, Emmanuel

2013-03-01

To evaluate obstetric outcomes in women undergoing a trial of labor (TOL) after a previous cesarean for dystocia in second stage of labor. A retrospective cohort study of women with one previous low transverse cesarean undergoing a first TOL was performed. Women with previous cesarean for dystocia in first stage and those with previous dystocia in second stage were compared with those with previous cesarean for nonrecurrent reasons (controls). Multivariable regressions analyses were performed. Of 1655 women, those with previous dystocia in second stage of labor (n = 204) had greater risks than controls (n = 880) to have an operative delivery [odds ratio (OR): 1.5; 95% confidence intervals (CI) 1.1 to 2.2], shoulder dystocia (OR: 2.9; 95% CI 1.1 to 8.0), and uterine rupture in the second stage of labor (OR: 4.9; 95% CI 1.1 to 23), and especially in case of fetal macrosomia (OR: 29.6; 95% CI 4.4 to 202). The median second stage of labor duration before uterine rupture was 2.5 hours (interquartile range: 1.5 to 3.2 hours) in these women. Previous cesarean for dystocia in the second stage of labor is associated with second-stage uterine rupture at next delivery, especially in cases of suspected fetal macrosomia and prolonged second stage of labor. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cohort study of the depression, anxiety, and anhedonia components of the Edinburgh Postnatal Depression Scale after delivery.

PubMed

Zanardo, Vincenzo; Giliberti, Lara; Volpe, Francesca; Parotto, Matteo; de Luca, Federico; Straface, Gianluca

2017-06-01

To investigate the applicability of the Edinburgh Postnatal Depression Scale (EPDS) for identifying depressive symptoms following vaginal or cesarean delivery. The present observational study included consecutive Italian-speaking women who underwent vaginal or cesarean deliveries of uncomplicated singleton pregnancies at term at Policlinico Abano Terme, Abano Terme, Italy, between February 1, 2014, and May 31, 2015, who completed the EPDS 2 days after delivery. EPDS scores and the depression, anxiety, and anhedonia subscale items were compared between delivery methods to identify factors predictive of high EPDS scores. There were 950 patients included in the analysis; 694 (73.1%) and 256 (26.9%) patients underwent vaginal and cesarean deliveries, respectively. Total EPDS scores were higher among patients who had cesarean deliveries compared with vaginal deliveries (6.95±4.80 vs 6.05±4.20; P=0.007); the depression (0.53±0.72 vs 0.37±0.65; P=0.007), anxiety (1.07±0.88 vs 1.16±0.93; P=0.021), and anhedonia (0.32±0.59 vs 0.19±0.48; P=0.009) subscale scores were all higher among patients who underwent cesarean deliveries. Women who underwent cesarean deliveries demonstrated higher EPDS scores and could be at increased risk of developing early postpartum depressive symptomatology, particularly anhedonia, anxiety, and depression. © 2017 International Federation of Gynecology and Obstetrics.

Cesarean section trends in the Nordic Countries - a comparative analysis with the Robson classification.

PubMed

Pyykönen, Aura; Gissler, Mika; Løkkegaard, Ellen; Bergholt, Thomas; Rasmussen, Steen C; Smárason, Alexander; Bjarnadóttir, Ragnheiður I; Másdóttir, Birna B; Källén, Karin; Klungsoyr, Kari; Albrechtsen, Susanne; Skjeldestad, Finn E; Tapper, Anna-Maija

2017-05-01

The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates. Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate. Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates. The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates. © 2017 Nordic Federation of Societies of Obstetrics and Gynecology.

Cesarean Section Rate in Singleton Primiparae and Related Factors in Beijing, China.

PubMed

Song, Geng; Wei, Yu-Mei; Zhu, Wei-Wei; Yang, Hui-Xia

2017-10-20

The cesarean section rate (CSR) has been a main concern worldwide. The present study aimed to investigate the CSR in Beijing, China, and to analyze the related factors of CS delivery. An observational study was conducted in 15 medical centers in Beijing using a systemic cluster sampling method. In total, 15,194 pregnancies were enrolled in the study between June 20, 2013 and November 30, 2013. Independent t-tests and Pearson's Chi-square test were used to examine differences between two groups, and related factors of the CSR were examined by multivariable logistic regression. The CSR was 41.9% (4471/10,671) in singleton primiparae. Women who were more than 35 years old had a 7.4-fold increased risk of CS delivery compared with women <25 years old (odd ratio [OR] = 7.388, 95% confidence interval [CI] = 5.561-9.816, P < 0.001). Prepregnancy obese women had a 2-fold increased risk of CS delivery compared with prepregnancy normal weight women (OR = 2.058, 95% CI = 1.640-2.584, P < 0.001). The excessive weight gain group had a 1.4-fold increased risk of CS delivery compared with the adequate weight gain group (OR = 1.422, 95% CI = 1.289-1.568, P < 0.001). Gestational diabetes mellitus (GDM) women and DM women had an increased risk of CS delivery (1.2- and 1.7-fold, respectively) compared with normal blood glucose women. Women who were born in rural areas had a lower risk of CS delivery than did those who were born in urban areas (OR = 0.696, 95% CI = 0.625-0.775, P < 0.001). The risk of CS delivery gradually increased with a decreasing education level. Neonates weighing 3000-3499 g had the lowest CSR (36.2%). Neonates weighing <2500 g had a 2-fold increased risk of CS delivery compared with neonates weighing 3000-3499 g (OR = 2.020, 95% CI = 1.537-2.656, P < 0.001). Neonates weighing ≥4500 g had an 8.3-fold increased risk of CS delivery compared with neonates weighing 3000-3499 g (OR = 8.313, 95% CI = 4.436-15.579, P < 0.001). Maternal age, prepregnancy body mass

Cesarean Section Rate in Singleton Primiparae and Related Factors in Beijing, China

PubMed Central

Song, Geng; Wei, Yu-Mei; Zhu, Wei-Wei; Yang, Hui-Xia

2017-01-01

Background: The cesarean section rate (CSR) has been a main concern worldwide. The present study aimed to investigate the CSR in Beijing, China, and to analyze the related factors of CS delivery. Methods: An observational study was conducted in 15 medical centers in Beijing using a systemic cluster sampling method. In total, 15,194 pregnancies were enrolled in the study between June 20, 2013 and November 30, 2013. Independent t-tests and Pearson's Chi-square test were used to examine differences between two groups, and related factors of the CSR were examined by multivariable logistic regression. Results: The CSR was 41.9% (4471/10,671) in singleton primiparae. Women who were more than 35 years old had a 7.4-fold increased risk of CS delivery compared with women <25 years old (odd ratio [OR] = 7.388, 95% confidence interval [CI] = 5.561–9.816, P < 0.001). Prepregnancy obese women had a 2-fold increased risk of CS delivery compared with prepregnancy normal weight women (OR = 2.058, 95% CI = 1.640–2.584, P < 0.001). The excessive weight gain group had a 1.4-fold increased risk of CS delivery compared with the adequate weight gain group (OR = 1.422, 95% CI = 1.289–1.568, P < 0.001). Gestational diabetes mellitus (GDM) women and DM women had an increased risk of CS delivery (1.2- and 1.7-fold, respectively) compared with normal blood glucose women. Women who were born in rural areas had a lower risk of CS delivery than did those who were born in urban areas (OR = 0.696, 95% CI = 0.625–0.775, P < 0.001). The risk of CS delivery gradually increased with a decreasing education level. Neonates weighing 3000–3499 g had the lowest CSR (36.2%). Neonates weighing <2500 g had a 2-fold increased risk of CS delivery compared with neonates weighing 3000–3499 g (OR = 2.020, 95% CI = 1.537–2.656, P < 0.001). Neonates weighing ≥4500 g had an 8.3-fold increased risk of CS delivery compared with neonates weighing 3000–3499 g (OR = 8.313, 95% CI = 4.436–15.579, P < 0

The Effect of Prophylactic Phenylephrine and Ephedrine Infusions on Umbilical Artery Blood pH in Women With Preeclampsia Undergoing Cesarean Delivery With Spinal Anesthesia: A Randomized, Double-Blind Trial.

PubMed

Higgins, Nicole; Fitzgerald, Paul C; van Dyk, Dominique; Dyer, Robert A; Rodriguez, Natalie; McCarthy, Robert J; Wong, Cynthia A

2018-06-01

Spinal anesthesia for cesarean delivery is associated with a high incidence of hypotension. Phenylephrine results in higher umbilical artery pH than ephedrine when used to prevent or treat hypotension in healthy women. We hypothesized that phenylephrine compared to ephedrine would result in higher umbilical artery pH in women with preeclampsia undergoing cesarean delivery with spinal anesthesia. This study was a randomized double-blind clinical trial. Nonlaboring women with preeclampsia scheduled for cesarean delivery with spinal anesthesia at Prentice Women's Hospital of Northwestern Medicine were randomized to receive prophylactic infusions of phenylephrine or ephedrine titrated to maintain systolic blood pressure >80% of baseline. Spinal anesthesia consisted of hyperbaric 0.75% bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg. The primary outcome was umbilical arterial blood pH and the secondary outcome was umbilical artery base excess. One hundred ten women were enrolled in the study and 54 per group were included in the analysis. There were 74 and 72 infants delivered in the ephedrine and phenylephrine groups, respectively. The phenylephrine:ephedrine ratio for umbilical artery pH was 1.002 (95% confidence interval [CI], 0.997-1.007). Mean [standard deviation] umbilical artery pH was not different between the ephedrine 7.20 [0.10] and phenylephrine 7.22 [0.07] groups (mean difference -0.02, 95% CI of the difference -0.06 to 0.07; P = .38). Median (first, third quartiles) umbilical artery base excess was -3.4 mEq/L (-5.7 to -2.0 mEq/L) in the ephedrine group and -2.8 mEq/L (-4.6 to -2.2mEq/L) in the phenylephrine group (difference -0.6 mEq/L, 95% CI of the difference -1.6 to 0.3 mEq/L; P = .10). When adjusted for gestational age and infant gender, umbilical artery pH did not differ between groups. There were also no differences in the umbilical artery pH stratified by magnesium therapy or by the severity of preeclampsia. We were unable to demonstrate a

Delivery by Cesarean Section

MedlinePlus

... relatively few side effects, and allows you to witness the delivery. But sometimes, especially for an emergency ... 2009 Source Caring for Your Baby and Young Child: Birth to Age 5 (Copyright © 2009 American Academy ...

External cephalic version among women with a previous cesarean delivery: report on 36 cases and review of the literature.

PubMed

Abenhaim, Haim A; Varin, Jocelyne; Boucher, Marc

2009-01-01

Whether or not women with a previous cesarean section should be considered for an external cephalic version remains unclear. In our study, we sought to examine the relationship between a history of previous cesarean section and outcomes of external cephalic version for pregnancies at 36 completed weeks of gestation or more. Data on obstetrical history and on external cephalic version outcomes was obtained from the C.H.U. Sainte-Justine External Cephalic Version Database. Baseline clinical characteristics were compared among women with and without a history of previous cesarean section. We used logistic regression analysis to evaluate the effect of previous cesarean section on success of external cephalic version while adjusting for parity, maternal body mass index, gestational age, estimated fetal weight, and amniotic fluid index. Over a 15-year period, 1425 external cephalic versions were attempted of which 36 (2.5%) were performed on women with a previous cesarean section. Although women with a history of previous cesarean section were more likely to be older and para >2 (38.93% vs. 15.0%), there were no difference in gestational age, estimated fetal weight, and amniotic fluid index. Women with a prior cesarean section had a success rate similar to women without [50.0% vs. 51.6%, adjusted OR: 1.31 (0.48-3.59)]. Women with a previous cesarean section who undergo an external cephalic version have similar success rates than do women without. Concern about procedural success in women with a previous cesarean section is unwarranted and should not deter attempting an external cephalic version.

[How to reduce the number of cesarean sections?].

PubMed

Guzmán Sánchez, A; González Moreno, J; González Guzmán, M; Villa Villagran, F

1997-07-01

The cesarean section (C) frequency has increased dramatically as high as 62%. This situation has been producing a real preoccupation in all the world as well as in México. Documented bibliography about this subject, is unquestionable. We feel that at this time there is a lack of punctuals strategies in order to reduce the high frequency of C. Our communication analyzes this problem in relation to antecedents, evolution and integrated general strategies in order to reduce the C rates. Special analysis and comments involve amnioinfusion, trials for vaginal deliveries in case of previous cesarean section, prostaglandins, and external version. With these actions, at the Antiguo Hospital Civil de Guadalajara we have achieved 10.8% of C. rates, without any increase in fetomaternal morbility and/or mortality.

Cesarean section may increase the risk of both overweight and obesity in preschool children.

PubMed

Rutayisire, Erigene; Wu, Xiaoyan; Huang, Kun; Tao, Shuman; Chen, Yunxiao; Tao, Fangbiao

2016-11-03

The increase rates of cesarean section (CS) occurred at the same period as the dramatic increase of childhood overweight/obesity. In China, cesarean section rates have exponentially increased in the last 20 years and they now exceed World Health Organization (WHO) recommendation. Such high rates demand an understanding to the long-term consequences on child health. We aim to examine the association between CS and risk of overweight and obesity among preschool children. We recruited 9103 children from 35 kindergartens in 4 cities located in East China. Children anthropometric measurements were taken in person by trained personnel. The mode of delivery was classified as vaginal or CS, in sub-analyses we divided cesarean delivery into elective or non-elective. The mode of delivery and other parental information were self-reported by parents. Multivariate logistic regression analysis was used to examine the associations. In our cross-sectional study of 8900 preschool children aged 3-6 years, 67.3 % were born via CS, of whom 15.7 % were obese. Cesarean delivery was significantly associated with the risk of overweight [OR 1.24; (95 % CI 1.07-1.44); p = 0.003], and the risk of obesity [OR 1.29; (95 % CI 1.13-1.49); p < 0.001] in preschool children. After adjusted for child characteristics, parental factors and family income, the odd of overweight was 1.35 and of obesity was 1.25 in children delivered by elective CS. The associations between CS and overweight/obesity in preschool children are influenced by potential confounders. Both children delivered by elective or non-elective CS are at increased risk of overweight/obesity. Potential consequences of CS on the health of the children should be discussed among both health care professionals and childbearing women.

Rectus Muscle Reapproximation at Cesarean Delivery and Postoperative Pain: A Randomized Controlled Trial

PubMed Central

Lyell, Deirdre J.; Naqvi, Mariam; Wong, Amy; Urban, Renata; Carvalho, Brendan

2017-01-01

Objective  Rectus muscle reapproximation at cesarean delivery (CD) is performed frequently by some obstetricians; however, the effect on postoperative pain is unclear. To this end, we investigated whether rectus muscle reapproximation increases postoperative pain. Materials and Methods  This is a prospective, double-blind, randomized controlled trial of women undergoing primary CD with singleton or twin pregnancy at >35 weeks' gestation. Women were randomized to rectus muscle reapproximation with three interrupted sutures or no reapproximation. Exclusion criteria were prior cesarean, prior laparotomy, vertical skin incision, active labor, chronic analgesia use, allergy to opioid or nonsteroidal anti-inflammatory drugs, and body mass index ≥ 40. Intra- and postoperative pain management was standardized within the study protocol. The primary outcome was a combined movement pain and opioid use score averaged over the 72-hour study period, called the Silverman integrated assessment. Movement pain scores were assessed at 24, 48, and 72 postoperative hours. Results  In total, 63 women were randomized, of whom 35 underwent rectus muscle reapproximation and 28 did not. Demographic and obstetric variables were similar between groups. Silverman integrated assessment scores during the 72-hour postoperative period were higher in the rectus muscle reapproximation group (15 ± 100% vs. –31 ± 78% difference from the mean; p  = 0.04). Operative times were similar between groups (63 ± 15 vs. 65 ± 15 minutes; p  = 0.61), and there were no surgical complications in either group. Maternal satisfaction with analgesia at 72 hours was high in both groups (85% [73–90] rectus muscle reapproximation vs. 90% [75–100]; p  = 0.16). Conclusion  Rectus muscle reapproximation increased immediate postoperative pain without differences in operative time, surgical complications, or maternal satisfaction. Benefits of rectus muscle reapproximation

Mode of delivery after successful external cephalic version: a systematic review and meta-analysis.

PubMed

de Hundt, Marcella; Velzel, Joost; de Groot, Christianne J; Mol, Ben W; Kok, Marjolein

2014-06-01

To assess the mode of delivery in women after a successful external cephalic version by performing a systematic review and meta-analysis. We searched MEDLINE, Embase, ClinicalTrials.gov, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library for studies reporting on the mode of delivery in women after successful external cephalic version at term and women with a spontaneous cephalic-presenting fetus. Two reviewers independently selected studies, extracted data, and assessed study quality. The association between mode of delivery and successful external cephalic version was expressed as a common odds ratio with a 95% confidence interval (CI). We identified three cohort studies and eight case-control studies, reporting on 46,641 women. The average cesarean delivery rate for women with a successful external cephalic version was 21%. Women after successful external cephalic version were at increased risk for cesarean delivery for dystocia (odds ratio [OR] 2.2, 95% CI 1.6-3.0), cesarean delivery for fetal distress (OR 2.2, 95% CI 1.6-2.9), and instrumental vaginal delivery (OR 1.4, 95% CI 1.1-1.7). Women who have had a successful external cephalic version for breech presentation are at increased risk for cesarean delivery and instrumental vaginal delivery as compared with women with a spontaneous cephalic presentation. Nevertheless, with a number needed to treat of three, external cephalic version still remains a very efficient procedure to prevent a cesarean delivery.

Does the baricity of bupivacaine influence intrathecal spread in the prolonged sitting position before elective cesarean delivery? A prospective randomized controlled study.

PubMed

Loubert, Christian; Hallworth, Stephen; Fernando, Roshan; Columb, Malachy; Patel, Nisa; Sarang, Kavita; Sodhi, Vinnie

2011-10-01

Difficulties in inserting an epidural catheter while performing combined spinal-epidural anesthesia for cesarean delivery may lead to undue delays between the spinal injection of the local anesthetic mixture and the adoption of the supine position with lateral tilt. We hypothesized that this delay may affect the intrathecal distribution of local anesthetic of different baricities such that hypobaric local anesthetic would lead to a higher sensory block level. Healthy parturients with uncomplicated pregnancies undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this prospective double-blind randomized controlled trial. The subjects were allocated to receive hyperbaric (hyperbaric group), isobaric (isobaric group), or hypobaric (hypobaric group) spinal bupivacaine 10 mg. After the spinal injection, the subjects remained in the sitting position for 5 minutes (to simulate difficulty in inserting the epidural catheter) before being helped into the supine lateral tilt position. The primary outcome was the sensory block level during the 25 minutes after the spinal injection. Other end points included motor block score, maternal hypotension, and vasopressor requirements. Data from 89 patients were analyzed. Patient characteristics were similar in all groups. The median [interquartile range] (95% confidence interval) sensory levels after spinal injection were significantly higher with decreasing baricity: hyperbaric T10 [T11-8] (T10-9), isobaric T9 [T10-7] (T9-7), and hypobaric T6 [T8-4] (T8-5) (P < 0.001, Cuzick trend). All patients in the hypobaric group reached a sensory block level of T4 at 25 minutes after spinal injection compared with 80% of the patients in both the isobaric and hyperbaric groups (P = 0.04; difference 20%, 95% confidence interval of difference 4%-33%). Significantly more patients in the hypobaric group had complete lower limb motor block (Bromage score = 4) (hyperbaric 43%, isobaric 63%, and hypobaric 90

Patients' attitudes vs. physicians' determination: implications for cesarean sections.

PubMed

Lo, Joan C

2003-07-01

Most research studies identifying non-clinical factors that influence the choice of Cesarean Section as a method of obstetric delivery assume that the physician makes the decision. This paper arguably shows the role played by the mother. Owing to the fact that Chinese people generally believe that choosing the right days for certain life events, such as marriage, can change a person's fate into a better one, the hypothesis is tested that the probability of Cesarean Sections being performed is significantly higher on auspicious days and significantly lower on inauspicious days. By employing a logistic model and utilizing 1998 birth certificate data for Taiwan, we are able to show that the hypothesis is accepted.

[Development of a scale to measure the self concept of cesarean section mothers].

PubMed

Lee, M L; Cho, J H

1990-08-01

Recently, the rate of cesarean section in Korea has been increasing. The results of several previous studies in foreign countries on the emotional responses of cesarean section mothers showed that they might experience difficulties in the mother-infant interaction due to fatigue, lack of early mother-infant interaction, disappointments, anger, feelings of loss of control, and other factors. Human behavior is said to be determined by one's self concept, and self concept is influenced by both internal and external environmental factors. A scale to measure the self concept of cesarean section mothers was needed in order to identify those who might have difficulties in the mother-infant interactions in future. The purposes of this study were to develop a measuring scale, and to test its reliability and validity. The process of this study was as follows. A structured interview was done with 50 cesarean section and vaginal delivery mothers to find their state of emotional reaction after giving birth to their babies. Based on the results of the interviews, a 50 items Likert scale was developed. The self concept of 268 cesarean section and vaginal delivery mothers who were hospitalized at six hospital in seoul were measured, during the period between Feb. 1 and April 30. Reviewing the discriminating power of each item by means of crosstabulation, ten items were selected for the final scale. The reliability and validity of this ten item scale were tested by Cronbach's alpha and t-test, using spss pc + package. The results of this study and recommendation are as follows. 1. The ten selected items were as follows. I feel pains in my breast. (-) I have a good appetite now. (+) I feel pains in my flank. (-) I feel fine now. (+) My body seems to have returned to its prepregnant state. (+) Thinking of the delivery process, I feel sorry. (-) I want to hold my baby in my arms. (+) I want to keep my own life, even if I became a mother. (-) I want to delegate the care of the baby to

Cesarean Birth

MedlinePlus

... after the procedure? • What should I expect during recovery? • Glossary What is cesarean birth? Cesarean birth is ... right away. You will be taken to a recovery room or directly to your room. Your blood ...

Male fetuses are associated with increased risk for cesarean delivery in Malaysian nulliparae.

PubMed

Viegas, Osborn A C; Lee, Pei Sue; Lim, Keng Joo; Ravichandran, Jeganathan

2008-01-01

The association between fetal sex and outcome of pregnancy and labor has been well documented in western populations. However, no studies in Malaysia or other developing countries have examined the effect of fetal sex on such outcomes.The main objective of this study was to determine the influence of fetal sex on the outcome of labor at term in a cohort of Malaysian nulliparae.A retrospective observational study was designed using data from 4644 Malaysian nulliparae who gave birth consecutively to singleton male babies at Hospital Sultanah Aminah, Johor Bahru, after normal full-term pregnancies.The results of this study indicate that mothers giving birth to male infants have a greater risk of requiring cesarean delivery because male babies are heavier and have statistically significantly greater head circumference (P < .001). These findings concur with those obtained in western populations and suggest that the differences in outcome observed are biological, not dictated by race, ethnicity, or environmental conditions. Such information could help in the antenatal assessment of Malaysian patients and stimulate more comprehensive studies of the mechanisms involved in this sex-based difference in outcomes. Reasons for such differences are proposed.

Anticoagulant and antithrombotic drugs in pregnancy: what are the anesthetic implications for labor and cesarean delivery?

PubMed

Butwick, A J; Carvalho, B

2011-02-01

Neuraxial anesthetic techniques are commonly used during the peripartum period to provide effective pain relief for labor and anesthesia during cesarean delivery. Major neurologic complications are rare after neuraxial anesthesia; however, spinal hematoma is associated with catastrophic neurologic outcomes (including lower-limb paralysis). Anticoagulant and antithrombotic drugs can increase the risk of spinal hematoma after neuraxial anesthesia, and better understanding of the pharmacokinetics and pharmacodynamics of anticoagulants has led to greater appreciation for withholding anticoagulation before and after neuraxial anesthesia. A number of national anesthetic societies have produced guidelines for performing neuraxial anesthesia in patients receiving anticoagulation. However, there is limited information about anesthetic implications of anticoagulation during the peripartum period. This article will review the risks of spinal hematoma after neuraxial anesthesia in pregnant patients; current guidelines for neuraxial anesthesia for anticoagulated patients; and relevant pharmacological data of specific anticoagulant and antithrombotic drugs in pregnancy.

Delivery route determines the presence of immune complexes on umbilical cord erythrocytes.

PubMed

de Lima, Andrés; Franco, Luis C; Sarmiento, Andrés; González, John M

2017-11-01

Umbilical cord blood offers a unique opportunity to study the basal level of immunoglobulin complexes. This study aims to determine the presence of immune complexes and complement deposition on erythrocytes from umbilical cord blood from normal, full-term pregnancies. In vitro pre-formed IgA, IgG, and IgM complexes were used as positive control for flow cytometry detection, and for C3d deposition. Blood samples (34) of umbilical cord blood taken from vaginal and cesarean deliveries were tested for the presence of immunoglobulin complexes. Fourteen samples from vaginal deliveries and 20 samples from cesarean deliveries were assessed. IgG and IgM complexes were detected on erythrocytes, whereas no IgA complexes or complement deposition was observed. Interestingly, the percentage of IgG complexes was higher on erythrocytes from vaginal delivery samples compared to those from cesarean deliveries. No other associations between immune complexes and other maternal or newborn variables were found. IgG and IgM complexes seem to be normally present on umbilical cord erythrocytes. Erythrocytes from vaginal deliveries have a higher percentage of IgG complexes present compared to that from cesarean deliveries. Since no C3d activity was detected, these complexes are non-pathological and should be part of the newborn's initial innate immune response.

Delivery modes and pregnancy outcomes of low birth weight infants in China.

PubMed

Chen, Y; Wu, L; Zhang, W; Zou, L; Li, G; Fan, L

2016-01-01

To investigate and analyze the perinatal outcomes of low birth weight (LBW) infants, thereby selecting the appropriate mode and suitable time of delivery to improve the adverse pregnancy outcomes. A retrospective analysis of 112,441 deliveries (from 39 hospitals of different levels in 14 provinces and autonomous regions in China throughout 2011) were performed in this study to further evaluate the modes of delivery and pregnancy outcomes of LBW infants. The rate of cesarean section, stillbirth, neonatal asphyxia and mortality of LBW were significantly higher than those of normal birth weight (NBW) infants (odds ratio, 1.24, 56.56, 57.27 and 10.40 times higher, respectively). Stratified analysis showed that adverse events were reduced with the increase in gestational weeks, especially at 34 to 36(+6) weeks. However, LBW infants still had higher risks of adverse events as compared with NBW infants. In particular, full-term LBW babies had a 23.81- and 26.06-fold higher risk of stillbirth and neonatal death as compared with term babies with NBW. In addition, the cesarean delivery rate was 1.24-fold higher for LBW babies than for NBW babies. With an increase in gestational age in LBW infants, the rate of cesarean section was also increased. The rates of stillbirth and neonatal mortality of full-term LBW infants who were delivered via cesarean section (0.5% and 1.0%, respectively) were significantly lower than in the vaginal-delivery group (5.2% and 6.9%, respectively). LBW is one of the causes of perinatal death and other adverse pregnancy outcomes and increases the rate of cesarean section. Individualized analysis according to gestational age and intrauterine fetal condition should be performed to extend the gestational age to at least 34 weeks before delivery, cesarean section is a relatively safe mode of delivery, but cannot completely eliminate complications. The key to improving mother and child outcomes is to strengthen pregnancy care and reduce low birth weight

Managed care market share and cesarean section rates in the United States: is there a link?

PubMed

Hueston, W J; Sutton, A

2000-11-01

After peaking during the early 1980s, cesarean section rates in the United States have been falling for the last decade. At the same time, managed care enrollment has increased dramatically. This study examines whether managed care penetration in local markets is associated with lower cesarean section rates in those geographic area. A cross-sectional comparison of cesarean section rates and health maintenance organization (HMO) market penetration in 61 selected metropolitan areas in the United States was conducted. National birth certificate data for 1996 were used to calculate crude and race-adjusted cesarean section rates for residents in each area. No relationship between overall cesarean section rates in the metropolitan areas and managed care penetration was observed. Subanalyses of racial groups demonstrated the existence of a weak association between managed care penetration and cesarean section rates for white women (21.2% for the highest quartile of HMO penetration, compared with 19.1% for the lowest quartile; P = .03), but not for African-Americans or other minorities. Managed care penetration in a market may have an association with cesarean section rates for white women, but the strength of this relationship is small. Even if managed care delivery systems reduce cesarean section rates in their own populations, this change is likely to have only a small impact on overall cesarean rates. HMO penetration is unlikely to influence national cesarean section rates, nor does it appear to explain state variations in these rates.

Safety of vaginal delivery among dichorionic diamniotic twins over 10 years in a UK teaching hospital.

PubMed

Rzyska, Ewelina; Ajay, Bini; Chandraharan, Edwin

2017-01-01

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK. A retrospective study was conducted using data for women with dichorionic diamniotic twin pregnancies who attended a teaching hospital in London, UK, for delivery between January 4, 2000, and December 23, 2010. Among 892 women, 474 (53.1%) attempted vaginal delivery, 220 (46.4%) of whom achieved spontaneous vaginal delivery of both twins. Instrumental vaginal delivery was performed among 89 women (18.8%), and 165 (34.8%) women underwent emergency cesarean delivery. Delivery of the second twin by emergency cesarean (n=31) was predominantly for fetal distress (13 [41.9%]) or abnormal lie (10 [32.3%]). A 5-minute Apgar score of 9 or 10 was recorded for 384 (83.7%) of 459 first twins and 369 (82.9%) of 445 second twins, irrespective of the mode of delivery. Vaginal delivery among dichorionic diamniotic twins had a good success rate and a low intrapartum emergency cesarean delivery rate. Training in cardiotocography and intrapartum procedures might further reduce the need for emergency cesarean delivery. © 2016 International Federation of Gynecology and Obstetrics.

[Umbilical blood-gas status at cesarean section for breech presentation: a comparison with vertex presentation].

PubMed

Haruta, M; Saeki, N; Naka, Y; Funato, T; Ohtsuki, Y

1989-10-01

Umbilical blood-gas status at elective cesarean section with oxygen inhalation for breech presentation (25 cases) was compared with that for vertex presentation (25 cases), so as to confirm the security of full-term breech fetuses delivered by cesarean section under spinal anesthesia. Umbilical arterial oxygen levels were significantly lower in the breech group (Mean PO2:18.9 mmHg; SO2:37.3%; Oxygen content:7.6 ml/dl). The number of hypoxemic fetuses was significantly higher in the breech group (the breech: 7; the vertex; 0). The other umbilical blood-gas values revealed no significant differences between the breech and vertex groups, and were within normal limits in both groups. Oxygen extraction in the breech (Mean: 49.0%) was higher than that in the vertex (32.9%). Therefore decreased umbilical blood flow in the breech was suggested. The incidence of depression at 1 minute after delivery in the breech infants (24%) was significantly higher than that in the vertex infants (0%). It became obvious in the breech that as the interval between the uterine incision and delivery increased, umbilical arterial blood tended to acidosis and the 1 minute Apgar score decreased. Cesarean section for breech presentation requires sufficient and optimal incisions of the abdominal wall and uterus as well as a skillful manual delivery technique, because the fetus or neonate should be protected against asphyxia resulting from umbilical compression and prolonged delivery interval.

Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography.

PubMed

Thurmond, A S; Harvey, W J; Smith, S A

1999-01-01

A previously undescribed cause of abnormal uterine bleeding is presented. Nine of 310 women evaluated by sonohysterography for abnormal bleeding demonstrated an 8 to 17 mm gap in the anterior lower uterine segment myometrium at the site of prior cesarean deliveries. All women were premenopausal and had a history of 2 to 12 days of postmenstrual spotting. Presumably a lack of coordinated muscular contractions occurs around the cesarean scar, allowing the defect to collect menstrual debris. Subsequently, the debris leaches out through the cervix for several days after the majority of menstrual flow has ceased.

Obstetric Care and Method of Delivery in Mexico: Results from the 2012 National Health and Nutrition Survey

PubMed Central

Heredia-Pi, Ileana; Servan-Mori, Edson E.; Wirtz, Veronika J.; Avila-Burgos, Leticia; Lozano, Rafael

2014-01-01

Objective To identify the current clinical, socio-demographic and obstetric factors associated with the various types of delivery strategies in Mexico. Materials and Methods This is a cross-sectional study based on the 2012 National Health and Nutrition Survey (ENSANUT) of 6,736 women aged 12 to 49 years. Delivery types discussed in this paper include vaginal delivery, emergency cesarean section and planned cesarean section. Using bivariate analyses, sub-population group differences were identified. Logistic regression models were applied, including both binary and multinomial outcome variables from the survey. The logistic regression results identify those covariates associated with the type of delivery. Results 53.1% of institutional births in the period 2006 through 2012 were vaginal deliveries, 46.9% were either a planned or emergency cesarean sections. The highest rates of this procedure were among women who reported a complication during delivery (OR: 4.21; 95%CI: 3.66–4.84), between the ages of 35 and 49 at the time of their last child birth (OR: 2.54; 95%CI: 2.02–3.20) and women receiving care through private healthcare providers during delivery (OR: 2.36; 95%CI: 1.84–3.03). Conclusions The existence of different socio-demographic and obstetric profiles among women who receive care for vaginal or cesarean delivery, are supported by the findings of the present study. The frequency of vaginal delivery is higher in indigenous women, when the care provider is public and, in women with two or more children at time of the most recent child birth. Planned cesarean deliveries are positively associated with years of schooling, a higher socioeconomic level, and higher age. The occurrence of emergency cesarean sections is elevated in women with a diagnosis of a health issue during pregnancy or delivery, and it is reduced in highly marginalized settings. PMID:25101781

Predicting acute pain after cesarean delivery using three simple questions.

PubMed

Pan, Peter H; Tonidandel, Ashley M; Aschenbrenner, Carol A; Houle, Timothy T; Harris, Lynne C; Eisenach, James C

2013-05-01

Interindividual variability in postoperative pain presents a clinical challenge. Preoperative quantitative sensory testing is useful but time consuming in predicting postoperative pain intensity. The current study was conducted to develop and validate a predictive model of acute postcesarean pain using a simple three-item preoperative questionnaire. A total of 200 women scheduled for elective cesarean delivery under subarachnoid anesthesia were enrolled (192 subjects analyzed). Patients were asked to rate the intensity of loudness of audio tones, their level of anxiety and anticipated pain, and analgesic need from surgery. Postoperatively, patients reported the intensity of evoked pain. Regression analysis was performed to generate a predictive model for pain from these measures. A validation cohort of 151 women was enrolled to test the reliability of the model (131 subjects analyzed). Responses from each of the three preoperative questions correlated moderately with 24-h evoked pain intensity (r = 0.24-0.33, P < 0.001). Audio tone rating added uniquely, but minimally, to the model and was not included in the predictive model. The multiple regression analysis yielded a statistically significant model (R = 0.20, P < 0.001), whereas the validation cohort showed reliably a very similar regression line (R = 0.18). In predicting the upper 20th percentile of evoked pain scores, the optimal cut point was 46.9 (z =0.24) such that sensitivity of 0.68 and specificity of 0.67 were as balanced as possible. This simple three-item questionnaire is useful to help predict postcesarean evoked pain intensity, and could be applied to further research and clinical application to tailor analgesic therapy to those who need it most.

Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery.

PubMed

Kozhimannil, Katy B; Hardeman, Rachel R; Alarid-Escudero, Fernando; Vogelsang, Carrie A; Blauer-Peterson, Cori; Howell, Elizabeth A

2016-03-01

One in nine US infants is born before 37 weeks' gestation, incurring medical costs 10 times higher than full-term infants. One in three infants is born by cesarean; cesarean births cost twice as much as vaginal births. We compared rates of preterm and cesarean birth among Medicaid recipients with prenatal access to doula care (nonmedical maternal support) with similar women regionally. We used data on this association to mathematically model the potential cost-effectiveness of Medicaid coverage of doula services. Data came from two sources: all Medicaid-funded, singleton births at hospitals in the West North Central and East North Central US (n = 65,147) in the 2012 Nationwide Inpatient Sample, and all Medicaid-funded singleton births (n = 1,935) supported by a community-based doula organization in the Upper Midwest from 2010 to 2014. We analyzed routinely collected, de-identified administrative data. Multivariable regression analysis was used to estimate associations between doula care and outcomes. A probabilistic decision-analytic model was used for cost-effectiveness estimates. Women who received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries regionally (4.7 vs 6.3%, and 20.4 vs 34.2%). After adjustment for covariates, women with doula care had 22 percent lower odds of preterm birth (AOR 0.77 [95% CI 0.61-0.96]). Cost-effectiveness analyses indicate potential savings associated with doula support reimbursed at an average of $986 (ranging from $929 to $1,047 across states). Based on associations between doula care and preterm and cesarean birth, coverage reimbursement for doula services would likely be cost saving or cost-effective for state Medicaid programs. © 2016 Wiley Periodicals, Inc.

Modeling the cost effectiveness of doula care associated with reductions in preterm birth and cesarean delivery

PubMed Central

Kozhimannil, Katy B; Hardeman, Rachel R.; Alarid-Escudero, Fernando; Vogelsang, Carrie; Blauer-Peterson, Cori; Howell, Elizabeth A.

2017-01-01

Background One in nine US infants is born before 37 weeks gestation, incurring medical costs 10 times higher than full-term infants. One in three infants is born by cesarean; cesarean births cost twice as much as vaginal births. We compared rates of preterm and cesarean birth among Medicaid recipients with prenatal access to doula care (non-medical maternal support) with similar women regionally. We used data on this association to mathematically model the potential cost effectiveness of Medicaid coverage of doula services. Methods Data came from two sources: all Medicaid-funded, singleton births at hospitals in the West North Central and East North Central US (n=65,147) in the 2012 Nationwide Inpatient Sample, and all Medicaid-funded singleton births (n=1,935) supported by a community-based doula organization in the Upper Midwest from 2010–2014. We analyzed routinely collected, de-identified administrative data. Multivariable regression analysis was used to estimate associations between doula care and outcomes. A probabilistic decision-analytic model was used for cost-effectiveness estimates. Results Women who received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries regionally (4.7% vs. 6.3%, and 20.4% vs. 34.2%). After adjustment for covariates, women with doula care had 22% lower odds of preterm birth (AOR=0.77, 95% CI[0.61–0.96]). Cost-effectiveness analyses indicate potential savings associated with doula support reimbursed at an average of $986, (ranging from $929 to $1,047 across states). Conclusions Based on associations between doula care and preterm and cesarean birth, coverage reimbursement for doula services would likely be cost saving or cost effective for state Medicaid programs. PMID:26762249

Indications for Emergency Intervention, Mode of Delivery, and the Childbirth Experience.

PubMed

Handelzalts, Jonathan E; Waldman Peyser, Avigail; Krissi, Haim; Levy, Sigal; Wiznitzer, Arnon; Peled, Yoav

2017-01-01

Although the impact of emergency procedures on the childbirth experience has been studied extensively, a possible association of childbirth experience with indications for emergency interventions has not been reported. To compare the impacts on childbirth experience of 'planned' delivery (elective cesarean section and vaginal delivery) versus 'unplanned' delivery (vacuum extraction or emergency cesarean section); the intervention itself (vacuum extraction versus emergency cesarean section); and indications for intervention (arrest of labor versus risk to the mother or fetus). A total of 469 women, up to 72 hours post-partum, in the maternity ward of one tertiary health care institute completed the Subjective Childbirth Experience Questionnaire (score: 0-4, a higher score indicated a more negative experience) and a Personal Information Questionnaire. Intra-partum information was retrieved from the medical records. One-way analysis of variance and two-way analysis of variance, followed by analysis of covariance, to test the unique contribution of variables, were used to examine differences between groups in outcome. Tukey's Post-Hoc analysis was used when appropriate. Planned delivery, either vaginal or elective cesarean section, was associated with a more positive experience than unplanned delivery, either vacuum or emergency cesarean section (mean respective Subjective Childbirth Experience scores: 1.58 and 1.49 vs. 2.02 and 2.07, P <0.01). The difference in mean Subjective Childbirth Experience scores following elective cesarean section and vaginal delivery was not significant; nor was the difference following vacuum extraction and emergency cesarean section. Interventions due to immediate risk to mother or fetus resulted in a more positive birth experience than interventions due to arrest of labor (Subjective Childbirth Experience: 1.9 vs. 2.2, P <0.01). Compared to planned interventions, unplanned interventions were shown to be associated with a more negative

Factors affecting the choice of type of delivery with breast feeding in Iranian mothers.

PubMed

Sharifi, Farangis; Nouraei, Soheila; Sharifi, Nader

2017-09-01

This study assessed the factors affecting the choice of type of delivery with breast feeding in Iranian mothers. This Cross section descriptive analytic study was performed using a random sampling technique, using data from 400 pregnant women who attended the maternity centers in Borazjan and Kazerun in Iran in 2014. A questionnaire covering demographic characteristics, mode of delivery and postpartum conditions was completed for each mother. Descriptive analysis and Chi square test were used along with SPSS 23 software to statistically analyze the data and p-value less than 0.05 was considered for statistical significance. In this study, the rate of normal delivery and cesarean operation are considered equal. In the main factors influencing the choice of delivery, mothers' education level (p=0.028) and pregnancy status (p=0.041) showed a significant relationship. Although no significant association between child nutrition with the type of delivery was found, duration of breastfeeding with the type of delivery showed significant association (p=0.046). Although cesarean delivery in many cases is life-saving for mother and fetus; in addition to medical indications, parents with higher education and pregnancy status are also important factors in increasing the rate of cesarean section compared to vaginal delivery. Babies of mothers with normal delivery had a longer time of breastfeeding. Further studies in Iran are necessary, regarding the reasons for high cesarean section and their outcomes.

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.

The Green Bay cesarean section study. III. Falling cesarean birth rates without a formal curtailment program.

PubMed

Sandmire, H F; DeMott, R K

1994-06-01

We observed decreases in cesarean birth rates at two Green Bay hospitals after the 1990 publication of our first cesarean section study. The purpose of this study was to determine the causes of those decreases and to see whether any outcome changes occurred with lower rates. An additional objective was to determine the perceptions of the 10 physicians regarding the determinants of cesarean birth rates. We compared recent cesarean birth rates (1990 to 1992) to former rates (1986 to 1988) for 10 of the 11 physicians analyzed in our previous studies. Newborn outcomes were analyzed to determine whether variations occur in comparing low to high cesarean rate physician groups. The total, primary, and repeat cesarean birth rates declined from 13.3% to 10.2%, 8.6% to 6.8%, and 4.7% to 3.4%, respectively, between 1986 to 1988 and 1990 to 1992. Variations in cesarean rates occurred among physicians and groups of physicians. Higher cesarean rates did not result in better perinatal outcome. Literature reports, residency training, continuing medical education attendance, and liability risks were the major determinants of cesarean birth as perceived by the 10 physicians in the study. The least important determinant, rated fifteenth of 15, was the national cesarean birth rate.

Timing of Delivery and Pregnancy Outcomes Among Laboring Nulliparous Women

PubMed Central

Tita, Alan Thevenet N.; Lai, Yinglei; Bloom, Steven L.; Spong, Catherine Y.; Varner, Michael W.; Ramin, Susan M.; Caritis, Steve N.; Grobman, William A; Sorokin, Yoram; Sciscione, Anthony; Carpenter, Marshall W.; Mercer, Brian M.; Thorp, John M.; Malone, Fergal D.; Harper, Margaret; Iams, Jay D.

2011-01-01

OBJECTIVE To compare pregnancy outcomes by completed week of gestation after 39 weeks with outcomes at 39 weeks. STUDY DESIGN Secondary analysis of a multicenter trial of fetal pulse oximetry in spontaneously laboring or induced nulliparous women ≥36 weeks’ gestation. Maternal outcomes included a composite (treated uterine atony, blood transfusion and peripartum infections) and cesarean delivery. Neonatal outcomes included a composite of death, neonatal respiratory and other morbidities and neonatal ICU admission. RESULTS Among the 4086 women studied, the risks of the composite maternal outcome (p-value for trend<0.001), cesarean delivery (p<0.001) and composite neonatal outcome (p=0.047) increased with increasing gestational age from 39 to ≥41 completed weeks. Adjusted odds ratios (95% CI) for 40 and ≥41 weeks respectively compared with 39 weeks were 1.29 (1.03–1.64) and 2.05 (1.60–2.64) for composite maternal outcome, 1.28 (1.05–1.57) and 1.75 (1.41–2.16) for cesarean delivery and 1.25 (0.86–1.83) and 1.37 (0.90–2.09) for composite neonatal outcome. CONCLUSIONS Risks of maternal morbidity and cesarean delivery but not neonatal morbidity increased significantly beyond 39 weeks. PMID:22244471

Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy.

PubMed

Stankiewicz Karita, Helen C; Moss, Nicholas J; Laschansky, Ellen; Drolette, Linda; Magaret, Amalia S; Selke, Stacey; Gardella, Carolyn; Wald, Anna

2017-01-01

Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive. To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed. From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using suppressive antiviral therapy were less likely

Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy

PubMed Central

Moss, Nicholas J; Laschansky, Ellen; Drolette, Linda; Magaret, Amalia S; Selke, Stacey; Gardella, Carolyn; Wald, Anna

2017-01-01

Abstract Background Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive. Methods To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed. Results From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using

[Breech presentation and vaginal delivery: evolution of acceptability by obstetricians and patients].

PubMed

Lagrange, E; Ab der Halden, M; Ughetto, S; Boda, C; Accoceberry, M; Neyrat, C; Houlle, C; Vendittelli, F; Laurichesse-Delmas, H; Jacquetin, B; Lémery, D; Gallot, D

2007-09-01

To investigate the influence of obstetrician and patient respectively on mode of delivery in case of breech presentation at term. This retrospective study included all women with a singleton pregnancy in a breech presentation delivered at term in a tertiary care maternity unit from January 1998 to December 2004. Mode of delivery was suggested by a score based on maternal age, parity, obstetrical past history, radiopelvimetry and cephalopelvic confrontation. The obstetrician was free to follow or not the score indication and patient's informed consent was required concerning the mode of delivery. Our main outcome measurements were mode of delivery and neonatal parameters. Two hundred cases were identified. Elective cesarean section increased progressively (from 52% in 1998 to 80% in 2004 [P=0,002]). Neonatal status and proportion of score in favour of vaginal birth remained stable during the study period. The rise in cesarean section rate was mainly due to patient's request (P=0,001) whereas the trend of obstetrician in favour of cesarean did not reach significance (P=0,3). The rise of elective cesarean section for term breech delivery in a maternity unit using a predefinite score is mainly induced by patient's request. This evolution has no effect on neonatal status.

Efficacy of Intrauterine Bakri Balloon Tamponade in Cesarean Section for Placenta Previa Patients.

PubMed

Cho, Hee Young; Park, Yong Won; Kim, Young Han; Jung, Inkyung; Kwon, Ja-Young

2015-01-01

The aims of this study were to analyze the predictive factors for the use of intrauterine balloon insertion and to evaluate the efficacy and factors affecting failure of uterine tamponade with a Bakri balloon during cesarean section for abnormal placentation. We reviewed the medical records of 137 patients who underwent elective cesarean section for placenta previa between July 2009 and March 2014. Cesarean section and Bakri balloon insertion were performed by a single qualified surgeon. The Bakri balloon was applied when blood loss during cesarean delivery exceeded 1,000 mL. Sixty-four patients (46.7%) required uterine balloon tamponade during cesarean section due to postpartum bleeding from the lower uterine segment, of whom 50 (78.1%) had placenta previa totalis. The overall success rate was 75% (48/64) for placenta previa patients. Previous cesarean section history, anterior placenta, peripartum platelet count, and disseminated intravascular coagulopathy all significantly differed according to balloon success or failure (all p<0.05). The drainage amount over 1 hour was 500 mL (20-1200 mL) in the balloon failure group and 60 mL (5-500 mL) in the balloon success group (p<0.01). Intrauterine tamponade with a Bakri balloon is an adequate adjunct management for postpartum hemorrhage following cesarean section for placenta previa to preserve the uterus. This method is simple to apply, non-invasive, and inexpensive. However, possible factors related to failure of Bakri balloon tamponade for placenta previa patients such as prior cesarean section history, anterior placentation, thrombocytopenia, presence of DIC at the time of catheter insertion, and catheter drainage volume more than 500 mL within 1 hour of catheter placement should be recognized, and the next-line management should be prepared in advance.

Efficacy of Intrauterine Bakri Balloon Tamponade in Cesarean Section for Placenta Previa Patients

PubMed Central

Cho, Hee Young; Park, Yong Won; Kim, Young Han; Jung, Inkyung; Kwon, Ja-Young

2015-01-01

Purpose The aims of this study were to analyze the predictive factors for the use of intrauterine balloon insertion and to evaluate the efficacy and factors affecting failure of uterine tamponade with a Bakri balloon during cesarean section for abnormal placentation. Methods We reviewed the medical records of 137 patients who underwent elective cesarean section for placenta previa between July 2009 and March 2014. Cesarean section and Bakri balloon insertion were performed by a single qualified surgeon. The Bakri balloon was applied when blood loss during cesarean delivery exceeded 1,000 mL. Results Sixty-four patients (46.7%) required uterine balloon tamponade during cesarean section due to postpartum bleeding from the lower uterine segment, of whom 50 (78.1%) had placenta previa totalis. The overall success rate was 75% (48/64) for placenta previa patients. Previous cesarean section history, anterior placenta, peripartum platelet count, and disseminated intravascular coagulopathy all significantly differed according to balloon success or failure (all p<0.05). The drainage amount over 1 hour was 500 mL (20–1200 mL) in the balloon failure group and 60 mL (5–500 mL) in the balloon success group (p<0.01). Conclusion Intrauterine tamponade with a Bakri balloon is an adequate adjunct management for postpartum hemorrhage following cesarean section for placenta previa to preserve the uterus. This method is simple to apply, non-invasive, and inexpensive. However, possible factors related to failure of Bakri balloon tamponade for placenta previa patients such as prior cesarean section history, anterior placentation, thrombocytopenia, presence of DIC at the time of catheter insertion, and catheter drainage volume more than 500 mL within 1 hour of catheter placement should be recognized, and the next-line management should be prepared in advance. PMID:26263014

Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise.

PubMed

Hankins, Gary D V; Clark, Shannon M; Munn, Mary B

2006-10-01

The purpose of this analysis was to determine the impact on specific forms of neonatal morbidity and mortality by allowing women to opt for delivery by elective cesarean section at 39 weeks of gestation (EGA). According to the National Vital Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational ages>or=39 weeks EGA. Estimating that over 4 million deliveries occur annually in the United States, this would yield approximately 3 million pregnancies wherein the woman may exercise her choice for either primary or repeat cesarean section at 39 weeks EGA or at the point when labor is established. A search was conducted using Ovid Medline spanning the past 10 years using the following key words: fetal trauma, shoulder dystocia, brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal encephalopathy. Using this search technique, over 2100 articles were identified. The abstracts were reviewed and pertinent articles were chosen for further consideration. The identified articles and their applicable references were obtained for inclusion in this review. Preference was given to publications on or after the year 2000 with the exception of classical or sentinel articles, which were included without regard to year of publication. Four major categories of neonatal morbidity and mortality are discussed: Shoulder dystocia: Accepting that we do not have a successful method for the prediction or prevention of shoulder dystocia, the question becomes, "What is the chance that a baby will sustain a permanent brachial plexus injury at delivery?" Additionally, is there a significant protective effect of cesarean section in reducing the risk of such injury? Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a composite estimate of the risk of 0

Transversus abdominis plane block reduces postoperative pain intensity and analgesic consumption in elective cesarean delivery under general anesthesia.

PubMed

Eslamian, Laleh; Jalili, Zorvan; Jamal, Ashraf; Marsoosi, Vajiheh; Movafegh, Ali

2012-06-01

It is reported that following abdominal surgery, transversus abdominis plane (TAP) block can reduce postoperative pain. The primary outcome of this study was the evaluation of the efficacy of TAP block on pain intensity following cesarean delivery with Pfannenstiel incision. Fifty pregnant women were randomized blindly to receive either a TAP block with 15 ml 0.25% bupivacaine in both sides (group T, n = 25) or no blockade (group C, n = 25) at the end of the surgery, which was performed with a Pfannenstiel incision under general anesthesia. The pain intensity in the patients was assessed by a blinded investigator at the time of discharge from recovery and at 6, 12, and 24 h postoperatively, with a visual analogue scale (VAS) for pain. The women in the TAP block group had significantly lower VAS pain scores at rest and during coughing and consumed significantly less tramadol than the women in group C [50 mg (0-150) vs. 250 mg (0-400), P = 0.001]. There was a significantly longer time to the first request for analgesic in the TAP block group [210 min (0-300) vs. 30 min (10-180) in group C, P = 0.0001]. Two-sided TAP block with 0.25% bupivacaine in parturients who undergo cesarean section with a Pfannenstiel incision under general anesthesia can decrease postoperative pain and analgesic consumption. The time to the first analgesic rescue was longer in the parturients who received the TAP block.

[Delivery management for the prevention of shoulder dystocia in case of identified risk factors].

PubMed

Schmitz, T

2015-12-01

To determine the impact of (i) computed tomographic (CT) pelvimetry for the choice of the mode of delivery, (ii) cesarean, (iii) induction of labor, and of (iv) various delivery managements on the risk of shoulder dystocia in case of fetal macrosomia, with or without maternal diabetes, and in women with previous history of shoulder dystocia. The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. In case of clinically suspected macrosomia, a sonography should be performed to increase diagnostic performances and to assist in decision-making (Professional consensus). Because CT pelvimetry is associated with high false positive rates and increases cesarean deliveries, its use is not recommended to prevent shoulder dystocia in case of fetal macrosomia (Professional consensus). To avoid the neonatal complications of shoulder dystocia, mainly permanent brachial plexus palsy, cesarean delivery is recommended in case of estimated fetal weight (EFW) greater than 4500 g if associated with maternal diabetes (grade C), and greater than 5000 g in the absence of maternal diabetes (grade C). The published data do not provide definitive evidences to recommend systematic labor induction in case of impending fetal macrosomia (Professional consensus). In case of favourable cervix and gestational age greater than 39 weeks of gestation, labor induction should be promoted (Professional consensus). Prophylactic McRoberts maneuver is not recommended to prevent shoulder dystocia in case of fetal macrosomia (grade C). Because data are lacking, no recommendation is possible regarding the use of episiotomy. In case of fetal macrosomia and failure to progress in the second stage of labor, midpelvic and higher instrumental deliveries are not recommended and a cesarean delivery should be preferred (grade C), if the fetal head is at or lower than a +2 station, cesarean delivery is not recommended and an

Elective Cesarean Section: It’s Impact on Neonatal Respiratory Outcome

PubMed Central

Ramachandrappa, Ashwin; Jain, Lucky

2008-01-01

The transition from a fluid filled lung to one filled with air in a very short period of time is one of the biggest challenges a newborn faces after birth. Respiratory morbidity as a result of failure to clear fetal lung fluid is not uncommon, and can be particularly problematic in some infants delivered by elective cesarean section (ECS) without being exposed to labor. The increasing rates of cesarean deliveries in the United States and worldwide, have the potential for a significant impact on public health and health care costs due to the morbidity associated with this subgroup. Whereas the occurrence of birth asphyxia, trauma, and meconium aspiration is reduced by elective cesarean delivery, the risk of respiratory distress secondary to transient tachypnea of the newborn, surfactant deficiency, and pulmonary hypertension is increased. It is clear that physiologic events in the last few weeks of pregnancy coupled with the onset of spontaneous labor are accompanied by changes in the hormonal milieu of the fetus and its mother, resulting in preparation of the fetus for neonatal transition. Rapid clearance of fetal lung fluid is a key part of these changes, and is mediated in large part by transepithelial sodium reabsorption through amiloride-sensitive sodium channels in the alveolar epithelial cells, with only a limited contribution from mechanical factors and Starling forces. In this chapter we discuss the respiratory morbidity associated with ECS, the physiologic mechanisms underlying fetal lung fluid absorption and potential strategies for facilitating neonatal transition when infants are delivered by ECS before the onset of spontaneous labor. PMID:18456075

Serotonin receptor antagonists for the prevention and treatment of pruritus, nausea, and vomiting in women undergoing cesarean delivery with intrathecal morphine: a systematic review and meta-analysis.