Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction

INTRODUCTION

Women's sexual health is a vital and important part of life at any age. In particular, pregnancy and childbirth bring biological, psychological, and social changes which may influence sexual health. It has been shown that sexual function declines during pregnancy and does not return to its baseline levels during the postpartum period. Despite the complexity and significance of this subject, health providers often neglect sexual aspects during pregnancy and postpartum.

AIM

We believe that clarifying the risk factors will help open conversations and improvements in sexual function.

METHODS

In this review, we focus on how postpartum sexual function is affected by mode of delivery, perineal trauma during delivery, episiotomy, and lactation.

CONCCLUSIONS

We conclude that the mode of delivery has no significant effect on short- and long-term postpartum sexual function. On the other hand, 3rd and 4th degree tears are strongly associated with postpartum sexual dysfunction. We found that episiotomy does not adversely affect sexual function, and lactation has a slightly negative effect. We believe that shedding light on this topic will lead to a better understanding for pregnant and postpartum women and the obstetrician. Further studies may elucidate more useful treatment approaches. Ola Gutzeit, Gali Levy, Lior Lowenstein. Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction. Sex Med 2019;8:8-13.

Breech deliveries in OLVG, the Netherlands: A retrospective cohort study of seven years

BACKGROUND

The clinical dilemma on the preferred mode of delivery for breech position still exists. Elective caesarean delivery (CD) could be safer for neonates, whereas vaginal breech delivery (VBD) remains a safe option when conducted by an experienced person. Besides successful VBD is beneficial for mothers and subsequent pregnancies.

OBJECTIVES

To evaluate breech deliveries on mode of delivery, maternal and neonatal outcomes.

STUDY DESIGN

A single center, retrospective, cohort study was performed of women who delivered a singleton fetus in breech position from 32 weeks' gestation onwards from January 2011 to December 2017. Primary outcome measure was mode of delivery defined as an elective CD and planned VBD. Secondary outcome measures were neonatal and maternal outcome. For neonatal outcome, we used neonatal mortality and a composite measure neonatal morbidity. Maternal outcome included maternal mortality and maternal morbidity divided in severe and non-severe complications. We subcategorized for preterm (32 weeks to 37 weeks of gestation) and term pregnancies (from 37 weeks of gestation onwards).

RESULTS

1.774 women delivered a child in breech position, 73 % opted for an elective CD. Of the 484 women that had a planned VBD (preterm 38 % (n = 59), term 26 % (n = 425)) 71 % were successful. Neonatal mortality occurred twice in the VBD cohort. Preterm neonatal morbidity occurred in the elective CD and VBD cohort equally (both 66 %), at term significantly more in the VBD cohort (12 % v 4%, OR 3.2, 95 % CI 2.1-4.8). For the total cohort, severe maternal postpartum complications occurred more often in the elective CD compared to successful VBD (2% v 0.3 %, OR 6.0, 95 % CI 0.80-44.3).

CONCLUSION

A high rate of successful VBD after opting for a planned VBD was found in our center. Nevertheless, compromised neonatal outcome at term was more frequent in the planned VBD group compared to the elective CD group. Severe maternal postpartum complications were more frequent in the elective CD group compared to the VBD group. Future research should focus alternations in the management of breech presentation.

Coital resumption after delivery among OASIS patients: differences between instrumental and spontaneous delivery

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are associated with sexual dysfunction and a lower likelihood of sexual activity in the postpartum period. The aim of the present study was to compare coital resumption and the variables influencing this activity after delivery in women with and without a history of obstetric anal sphincter injury (OASIS) and according to the mode of delivery.

METHODS

A prospective, observational, case-control study was performed at 6 months postpartum in 318 women: 140 with a history of primary repaired OASIS and 178 women without OASIS. Demographic and obstetric data, breastfeeding, and symptoms of urinary and anal incontinence were collected. Patients were asked about coital resumption and completed the validated specific Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). Continuous and non-continuous variables were compared using ANOVA and the Fisher exact tests, respectively. A multivariate logistic regression model and a multiple regression analysis were constructed to assess the impact of demographic and clinical variables on the percentage of coital resumption and on the PISQ-12 score, respectively.

RESULTS

After a spontaneous delivery (SD), patients without OASIS showed a higher percentage of coital resumption than those with OASIS (98% vs. 77%; p = 0.003), and the PISQ-12 score was also higher (p < 0.001). PISQ-12 score was better in women with SD compared to those with operative vaginal delivery (OVD)(p < 0.001), independently of the history of OASIS. Current breastfeeding, a higher Wexner score and OVD negatively influenced the PISQ-12 score.

CONCLUSIONS

After SD, women with OASIS resumed coital activity later than women without OASIS. Women with OVD resumed coital activity later, and had a lower PISQ-12 score than women with SD.

Comparative study between women born in France and migrant women with regard to their mode of delivery

OBJECTIVE

To compare the mode of delivery between women born in France and migrants.

STUDY DESIGN

The study was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were included. Women with multiple pregnancies and women whose pregnancies ended before 22 weeks of gestational age were excluded. The pre-existing characteristics at the time of pregnancy, mode of delivery and postpartum were collected from the University Hospital's medical and administrative computer database. We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery.

RESULTS

Of the 3038 and 3001 women included in 2008 and 2014 respectively, 272 and 385 women were migrants. We observed a significant decrease in the number of spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-migrants. And we showed a higher risk of cesarean section prior to labor (aOR 1.2 [1.01-1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-0.99]) in 2014 compared to 2008.

CONCLUSION

We observed a significant increase in all types of Cesarean sections among women born abroad compared to those born in France, especially in the subgroup of women born in sub-Saharan Africa.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Benefits and Risks for the Neonate and Child of Planned Vaginal Delivery versus Elective Cesarean Section]

OBJECTIVE

To provide guidelines regarding the benefits and risks for the neonate and the child of planning vaginal delivery versus planning elective cesarean section in case of term breech presentation.

METHODS

MedLine and Cochrane Library databases search and review of the main foreign guidelines.

RESULTS

In case of term breech presentation, planned vaginal delivery might be associated with an increased composite risk of perinatal mortality or occurrence of a combined outcome of serious neonatal morbidity in comparison to elective cesarean section (LE2). In case of planned vaginal delivery of term breech presentation, the risk of perinatal mortality is around 1‰ (LE3). It is potentially less but still exists in case of elective cesarean section (LE2). Risks of neonatal trauma - especially fracture of clavicle and breech hematoma -, Apgar score lower than 7 at 5minutes, and need for neonatal intubation and ventilation, are increased in case of planned vaginal delivery (LE2) and are around 1% (LE3). However, no difference has been demonstrated between planned vaginal and planned cesarean delivery regarding neurodevelopmental outcomes at 2 years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4).

CONCLUSIONS

In case of term breech presentation, risks of severe complications for neonate and child are low in case of planned vaginal delivery or elective cesarean section. Short-term benefit/risk balance for the neonate might favor elective cesarean section but long-term morbidity seems to be similar whatever the delivery route (Professional consensus).

Long interpregnancy interval and mode of delivery

PURPOSE

WHO sets 24 months as the ideal minimum interpregnancy interval (IPI) to minimize maternal and perinatal adverse outcomes. Some studies suggest that an interval longer than 59 months may affect these outcomes, but little is known about its influence on labor. The primary objective of this study was to compare the cesarean delivery rate between primiparous women with a long IPI and, on the one hand, primiparous women with an ideal minimum IPI of 18-24 months and, on the other hand, with nulliparous women.

METHODS

This retrospective cohort study of 17 years included nulliparas and primiparas who gave birth to live singleton fetuses in cephalic presentation after 22 weeks of gestation. Women with an IPI < 18 months or from 24 to 59 months were excluded, as were women with planned cesarean. We analyzed three groups: primiparous women with a long IPI defined as > 59 months, primiparous women with an ideal minimum IPI (18-24 months), and nulliparous women.

RESULTS

The study included 18,503 women: 1342 women in the "long IPI" group, 1388 in the "ideal minimum IPI" group, and 15,773 in the nulliparous women group. The cesarean delivery rate was significantly higher in the long compared to the ideal minimum IPI group [12.2% vs. 6.3%, respectively; aOR = 2.2 (95% CI 1.6-3.1)], but both groups had similar durations of labor, regardless of mode of delivery. Women in the long IPI group had significantly lower cesarean rates than nulliparous women [12.2% and 14.3%, respectively; aOR = 0.5 (95% CI 0.4-0.7)], and the nulliparous women had a significantly longer mean duration of labor.

CONCLUSIONS

Primiparas with a long IPI, compared with ideal minimal IPI have a higher risk of cesarean delivery during labor. Compared with nulliparous women, primiparous women with a long IPI had a lower cesarean rate.

Mode of delivery among nulliparous women with single, cephalic, term pregnancies: The WHO global survey on maternal and perinatal health, 2004-2008

OBJECTIVE

To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1).

METHODS

Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008.

RESULTS

Among 82 280 women in Robson group 1, 67 698 (82.3%) had vaginal and 14 578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18 years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01).

CONCLUSION

The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - External Cephalic Version and other Interventions to turn Breech Babies to Cephalic Presentation]

OBJECTIVES

To provide guidelines regarding efficiency and safety of external cephalic version (ECV) attempt and alternatives methods to turn breech babies to cephalic presentation.

METHODS

MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019.

RESULTS

ECV is associated with a decreasing rate of breech presentation at birth (LE2), and potentially with a lower rate of cesarean section (LE3) without an increase of severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV should be attempt (Professional consensus). ECV attempt should be performed with immediate access to an operating room for emergency cesarean (Professional consensus). The ECV attempt before 37 weeks, compared to ECV attempt after 37 weeks, increases the rate of cephalic presentation at birth (LE2) but with a small increase risk of moderate prematurity (LE2). ECV attempt should be performed from 36SA (Professional consensus). The main factors associated with successful ECV attempt are multiparity (LE3) and no maternal obesity (LE3). Parenteral tocolysis (β mimetic or atosiban), for ECV attempt at term is associated with a higher success rate (LE2), higher rate of achieved cephalic presentation in labor (LE2) and a lower cesarean section rate (LE2). It is recommended to use parenteral tocolysis for ECV attempt at term in order to increase its success rate (grade B). The ECV attempt is associated with an increase in transient FHR abnormalities (LE3), it is therefore recommended that cardiotocography should be performed prior and during 30minutes after the procedure (Professional consensus). There is no argument for recommending the practice of delayed cardiotocography after ECV attempt (Professional consensus). The risk of significant positivity (>30mL) of the Kleihauer test after ECV attempt is low (<0.1%) (LE3), it is not recommended to systematically perform a Kleihauer test after ECV attempt (professional consensus). In case of RH-1 negative women, it is recommended to ensure systematic RH-1 prophylaxis (Professional consensus). In case of breech presentation at term, acupuncture, moxibustion and postural methods are not effective in reducing breech presentation at birth (LE2), and are therefore not recommended (Grade B).

CONCLUSION

According to the clear benefits and the low risks of ECV attempt, all women with a breech presentation at term should be informed that ECV should be attempted to decrease breech presentation at birth and cesarean section.

Adiponectin levels in maternal serum and umbilical cord blood at birth by mode of delivery: relationship to anthropometric measurements and fetal sex

Background

The rate of cesarean section is increasing worldwide. Adiponectin is a hormone related to anti-inflammatory and anti-atherogenic effects; and it′s concentrations may change in response to inflammatory situations including surgical intervention. The aim of the current study was to investigate serum adiponectin levels in maternal and umbilical cord blood according to different modes of delivery and their relationship with anthropometric measurements and fetal sex.

Methods

The study population initially comprised 90 healthy pregnant women referred to the teaching hospital. Eventually, 40 participants in the vaginal delivery group and 35 subjects in the cesarean delivery group were recruited in to the study. Umbilical cord blood and maternal serum samples were analyzed according to the standard protocol from the manufacturer. The collected data were analyzed using SPSS-16 software. P-value < 0.05 was considered as the significance level for all tests.

Results

Our results indicated a significant association between maternal adiponectin and the mode of delivery, with adiponectin levels significantly higher in vaginal delivery compared to cesarean section (P < 0.001). However, no difference was found in umbilical cord blood adiponectin between the two groups (P = 0.51). A significant positive correlation was found between maternal serum adiponectin in the first day after birth and umbilical cord blood adiponectin in the vaginal delivery group (P = 0.007). Nevertheless, this correlation was not statistically significant in the cesarean delivery group (P = 0.62). There was also no significant correlation between fetal sex and anthropometric measurements with maternal adiponectin (P = 0.44) and umbilical cord blood adiponectin (P = 0.86).

Conclusions

The result of the current study revealed that maternal adiponectin concentration was significantly higher in vaginal delivery compared to cesarean section, which might be due to the increased levels of maternal adiponectin release during labor.

Type of delivery is not associated with maternal depression

Although many women experience depressive symptoms during the first year after childbirth, the relationship between type of delivery and maternal depression is not clear. The purpose of this study is to evaluate relationship between type of delivery and maternal depression, between 6 to 16 months after childbirth. We performed a prospective cohort study of 558 low-socioeconomic status pregnant women without depression. All participants were recruited from primary care clinics of the public sector in three administrative districts in the Western area of the city of São Paulo, Brazil. Depressive symptoms were assessed using the Self-Report Questionnaire (SRQ-20). Type of delivery was classified as uncomplicated spontaneous vaginal delivery (UVD) (no episiotomy and no more than a first-degree perineal laceration), complicated vaginal delivery (CVD) (episiotomy or more than a second-degree perineal laceration), and cesarean delivery (CD). Data about type of delivery were extracted from medical charts. Crude and adjusted risk ratios with 95% confidence intervals were estimated using Poisson regression with robust variance estimates to examine the association between type of delivery with maternal depression. Among 482 women reassessed during 6 to 16 months after delivery, 18% had symptoms of depression. According to the type of delivery, 250 (51.8%), 85 (21.7%), and 147 (30.5%) were UVD, CVD, and CD, respectively. There was no association between type of delivery and maternal depression. In comparison with women submitted to uncomplicated vaginal, women who had a cesarean or perineal trauma/episiotomy did not show greater risk of maternal depression, in the medium to long term after delivery.

Shared decision-making for delivery mode: An OPTION scale observer-based evaluation

OBJECTIVE

Shared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION¹² scale to obstetric consultations.

METHODS

Fifty-eight outpatient consultations were rated; statistical associations between OPTION¹² scores and sociodemographic data of both patient and physicians were determined.

RESULTS

The OPTION¹² total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION¹² items never reached the minimum skill level.

CONCLUSION

A low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested.

PRACTICE IMPLICATIONS

The OPTION¹² scale may prove useful for testing the extent of pregnant women's involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.

The Development of the Human Microbiome: Why Moms Matter

The human body is cohabitated with trillions of commensal bacteria that are essential for our health. However, certain bacteria can also cause diseases in the human host. Before the microbiome can be attributed to disease risk and pathogenesis, normal acquisition and development of the microbiome must be understood. Here, we explore the evidence surrounding in utero microbial exposures and the significant of this exposure in the proper development of the fetal and neonatal microbiome. We further explore the development of the fetal and neonatal microbiome and its relationship to preterm birth, feeding practices, and mode of delivery, and maternal diet.

Are overweight and obesity associated with increased risk of cesarean delivery in Mexico? A cross-sectional study from the National Survey of Health and Nutrition

Background

In Mexico, obesity is a major public health problem; 71% of adults are overweight or obese. The proportion of deliveries by cesarean is also very high (45%). Women of reproductive age with overweight or obesity may be at higher risk of cesarean.

Methods

We conducted a cross-sectional study to test the association between overweight and obesity (using body mass index, BMI) and cesarean delivery in Mexico using data from the 2012 National Survey of Health and Nutrition (ENSANUT). Our sample included women of reproductive age at the time of survey who reported a live birth between 2006 and 2012. We used bivariate statistics and a multivariate logistic regression model to test the association between measured BMI and self-reported cesarean delivery. We included individual, clinical, and household level confounders and used survey weights to produce population estimates.

Results

Our sample consisted of 4,570 women (population N = 7,447,541). Overall, 44% of the women reported a cesarean at last delivery. We found differences in the proportion of cesarean delivery by BMI group (normal = 39%; 95% CI [35–43]; overweight = 42%; 95% CI [38–45]; obesity = 52%; 95% CI [48–57]; p < 0.001). In multivariable models controlling for socio-demographic and clinical characteristics, we found a strong and independent association between obesity and cesarean delivery among multiparous women, compared with multiparous women with normal BMI (obesity aOR: 1.60; 95% CI [1.21–2.12]).

Conclusions

We provide new evidence about the proportion of women with overweight and obesity who deliver in Mexico. Multiparous women with obesity are at higher risk of cesarean delivery in Mexico than multiparous women with normal body mass index. Given the high prevalence of both obesity and cesarean delivery in Mexico, this relationship is salient for women, health care providers, and the health system.

Efforts to reduce the cesarean deliveries rate need to take the obesity epidemic into account.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2393-5) contains supplementary material, which is available to authorized users.

Vaginal delivery in women with HIV in Italy: results of 5 years of implementation of the national SIGO-HIV protocol

PURPOSE

To evaluate the maternal and neonatal safety of vaginal delivery in women with HIV following the implementation of a national protocol in Italy.

METHODS

Vaginal delivery was offered to all eligible women who presented antenatally at twelve participating clinical sites. Data collection and definition of outcomes followed the procedures of the National Program on Surveillance on Antiretroviral Treatment in Pregnancy. Pregnancy outcomes were compared according to the mode of delivery, classified as vaginal, elective cesarean (ECS) and non-elective cesarean section (NECS).

RESULTS

Among 580 women who delivered between January 2012 and September 2017, 142 (24.5%) had a vaginal delivery, 323 (55.7%) had an ECS and 115 (19.8%) had an NECS. The proportion of vaginal deliveries increased significantly over time, from 18.9% in 2012 to 35.3% in 2017 (p < 0.001). Women who delivered vaginally were younger, more commonly nulliparous, diagnosed with HIV during current pregnancy, and antiretroviral-naïve, but had a slightly longer duration of pregnancy, with significantly higher birthweight of newborns. NECS was associated with adverse pregnancy outcomes. The rate of HIV transmission was minimal (0.4%). There were no differences between vaginal and ECS about delivery complications, while NECS was more commonly associated with complications compared to ECS.

CONCLUSIONS

Vaginal delivery in HIV-infected women with suppressed viral load appears to be safe for mother and children. No cases of HIV transmission were observed. Despite an ongoing significant increase, the rate of vaginal delivery remains relatively low compared to other countries, and further progress is needed to promote this mode of delivery in clinical practice.

Investigation of the impact of birth by cesarean section on fetal and maternal metabolism

PURPOSE

Elective cesarean section (CS) was related to long-term adverse health effects in the offspring, but little is known about underlying mechanisms. Our study investigates the metabolic changes in both maternal and cord blood associated with CS in comparison to vaginal delivery (VD) to explore potential causal pathways.

METHODS

Samples obtained from PREOBE study participants were subjected to LC-MS/MS-targeted metabolomics comprising > 200 metabolites.

RESULTS

Elective CS showed an impact on both maternal and cord blood metabolomes. In maternal blood, the CS group showed lower levels of phospholipids (PL), principally ether-linked phosphatidylcholines (aaPC), pyruvic acid, branched chain keto-acids (BCKA), and other gluconeogenic substrates, but since the CS group showed different HDL levels in comparison to the VD group, we could not exclude contribution of the latter in the findings. In cord blood, the most remarkable finding in the CS group was the high levels of Cys; conversely, the lower levels of non-esterified fatty acids (NEFA), some tricarboxylic acid (TCA) cycle metabolites, gluconeogenic substrates, markers of β-oxidation, and the sum of hexoses were lower in CS-born babies in addition to tendentially lower levels of PL.

CONCLUSIONS

We speculate that lower levels of maternal and fetal corticosteroids in CS, due to less stressful condition, cause metabolic perturbations at birth initiating future negative health outcomes. This further supports the early programming hypothesis.

Predictors of patient preference for mode of delivery following an obstetric anal sphincter injury

OBJECTIVES

Patients who sustain an Obstetric Anal Sphincter Injury (OASI) have the opportunity to select an elective caesarean section over a vaginal delivery in subsequent pregnancies. It remains unclear whether there are identifiable factors which predict expectant mothers' choices. The primary aim of our study was to explore this issue further in a consecutive group of patients who had suffered OASI.

STUDY DESIGN

Data were retrospectively collected for patients attending a specialist OASIS clinic between July 2016 and February 2018. Information routinely collected in clinical practice was considered including mode of previous delivery, severity of OASI, combined with anal incontinence symptoms and endoanal ultrasound results. Logistic regression analysis was used to explore the relationship between these variables and the preferred mode of delivery.

RESULTS

A total of 188 patients were identified of whom 153 had complete data for analysis. Approximately 30% (n = 45) of patients preferred to have a caesarean section in their subsequent pregnancy. Bivariate analysis revealed significant associations between choosing a caesarean section in subsequent pregnancy and individuals with major tears (p = 0.001), high anal incontinence scores (p = 0.001) and defects on endoanal ultrasound (p < 0.001). Logistic regression analysis showed statistically significant associations between Caucasian ethnicity (Odds ratio (OR) 12.6, 95% CI 2.4-69.9) and endoanal ultrasound results (OR 2.3, 95% CI 1.7-3.2) with preference for caesarean section.

CONCLUSION

Our data suggests that emphasis is placed by patients on endoanal ultrasound results when making their decision about mode of delivery in a subsequent pregnancy, suggesting a useful application of this tool. Ethnicity is a strong predictor of choice of delivery after OASI and may be potentially useful in forecasting maternity unit services.

The Effect of Mode of Delivery on Newborn Hearing Screening Results

Objective

Congenital hearing loss is one of the most important public health problems with a frequency of about 1-6 per 1000 live births all over the world. Although neonatal hearing screening tests are important for the timely detection and rehabilitation of hearing loss, determining the factors that may affect the screening results will contribute greatly to the development of screening programs. In this study, the effects of the modes of delivery on the results of tests in the screening program was investigated.

Methods

In this study, the results of 10.575 newborns who were screened according to the National Neonatal Hearing Screening Protocol between January 2013 and May 2017 were evaluated. The screening test results of 2.653 newborns were examined retrospectively according to the type of delivery after candidates were excluded according to the exclusion criteria and risk factors for hearing loss. Of these newborns, 1.571 (59.2%) were born by normal delivery and 1.082 (40.8%) by cesarean section. Screening test results were analyzed using Pearson's Chi-square test.

Results

No statistically significant difference was observed among the 2.653 neonatal hearing screening test results in terms of mode of delivery (p>0.05). In both delivery modes, the rate of false positive was found to be high (81.9%) in the first hearing screening test of newborns, and this rate decreased in the second screening test (14.5%).

Conclusion

The mode of delivery has no significant effect on the neonatal hearing screening results; however, the observation that neonates had been more successful in the second screening test in both groups suggests that the test protocol should be re-evaluated in terms of timing.

Effect of Delivery Mode and Nutrition on Gut Microbiota in Neonates

BACKGROUND/AIMS

The mode of delivery (vaginal or cesarean section) and feeding type (breastfeeding or formula feeding) of neonates are considered the most influential factors in the development of gut microbiota.

OBJECTIVES

This study investigated the effect of prebiotic-rich breast milk on overcoming gut microbiota dysbiosis.

METHOD

Stool samples from 36 healthy Japanese neonates were obtained at 4 days and 1 month of age, and divided into 4 groups based on mode of delivery and feeding type. The gut microbiota composition and bacterial diversity were assessed using 16S rRNA sequencing.

RESULTS

At 4 days old, vaginally delivered neonates had a significantly higher diversity of bacteria than those born by cesarean section. Bacteroidales and Enterobacteriales were overrepresented in vaginally delivered neonates (p = 0.0031 and p = 0.011), while Bacillales and Lactobacillales were overrepresented in caesarean section delivered neonates (p = 0.012 and p = 0.0016). However, there was little difference in bacterial diversity and bacterial relative abundance at 1 month of age between groups.

CONCLUSIONS

Cesarean section delivery appeared to reduce the diversity of neonate gut microbiota, resulting in dysbiosis, but this improved to the equivalent level seen in vaginally delivered infants by 1 month of age. Breastfeeding, even for short periods, may therefore improve neonate gut dysbiosis.

Relations between mode of birth delivery and timing of developmental milestones and adiposity in preadolescence: A retrospective study

BACKGROUND

Cesarean delivery (CS) is an increasingly common mode of delivery comprising over 30% of all deliveries in the U.S. The long-term impact of this delivery mode on child development remains unclear.

AIMS

We investigated the relationship between mode of delivery (vaginal vs. CS) and timing of developmental milestones and adiposity in preadolescence, as well as additional milestones beyond motor/language development including toilet training, dressing, and feeding self.

STUDY DESIGN

This study utilized a retrospective survey given to a parent/guardian and dual energy x-ray absorptiometry in preadolescence, respectively. A composite z-score was calculated based on nine questions pertaining to developmental milestones i.e., parent-reported age for supporting head by self, rolling over, sitting up, standing, walking, talking, toilet-training, dressing, and feeding self.

SUBJECTS

7-10-year-old (N = 104) children in East-Central Illinois.

OUTCOME MEASURES

Composite z-score for timing of attainment of developmental milestones, mode of delivery, and preadolescent adiposity.

RESULTS

Vaginally-born children had a lower composite z-score, signifying earlier attainment of developmental milestones, relative to both emergency and planned CS-born children. Further, elective CS-born children had greater adiposity in preadolescence, relative to vaginal and emergency cesarean-section born children.

CONCLUSIONS

These findings suggest relationships between delivery mode, developmental milestones, and obesity in preadolescence. Additionally, they provide novel insights into the differential impact of elective versus emergency CS.

Mode of delivery and mortality and morbidity for very preterm singleton infants in a breech position: A European cohort study

OBJECTIVE

Caesarean section (CS) may reduce mortality and morbidity for very preterm breech infants, but evidence is inconclusive. We evaluated neonatal outcomes for singleton breech infants by mode of delivery in a European cohort.

STUDY DESIGN

Data come from the EPICE population-based cohort of very preterm births in 19 regions in 11 European countries (7770 live births). The study population was singleton spontaneous-onset breech births at 24-31 weeks gestational age (GA) without antenatal medical complications requiring caesarean delivery (N = 572). Mixed-effects regression models adjusting for maternal and pregnancy covariates and propensity score matching was used to examine the effect of (1) CS and (2) a unit policy of systematic CS for breech presentation by GA. The primary outcome was a composite of in-hospital mortality, intraventricular haemorrhage grades III & IV or cystic periventricular leukomalacia. Secondary outcomes were each component separately, five minute Apgar score below seven and mortality within six hours of delivery.

RESULTS

64.4% of infants were delivered by CS with a range across regions from 41% to 100%; these infants had higher GA and were more likely to be small for gestational age, receive antenatal steroids, and have mothers who were hospitalised for more than one day before delivery compared to those delivered vaginally. CS was associated with lower risks of all outcomes in mixed-effects adjusted models (odds ratio (OR) for the composite outcome: 0.50, 95% confidence interval (CI): 0.30-0.81), but not in propensity score matched models (OR: 0.72, 95% CI: 0.41; 1.29). A systematic CS policy was associated with lower mortality and morbidity in unadjusted, but not adjusted models (OR for composite outcome: 0.76, 95% CI: 0.44; 1.28). 35% of births 24-25 weeks were delivered by CS and protective effects were consistently stronger, but not statistically significant.

CONCLUSIONS

Point estimates indicated protective effects of caesarean delivery for very preterm breech infants in conventional statistical models. However, analyses using propensity scores and based on unit policies did not confirm statistically significant associations. Prospective large-scale studies are needed to establish best practice and could be implemented in European regions where vaginal delivery remains an option.

The impact of mode of delivery on the outcome in very preterm twins

Objective: Studies on the optimal mode of delivery in women with a twin pregnancy <32 weeks are scarce. We studied the effects of the mode of delivery on perinatal and maternal outcomes in very preterm twin pregnancy.Study Design: Population-based cohort study including all women with twin pregnancy who delivered very preterm (26-32 weeks of gestation) in the Netherlands between January 2000 and December 2010. We compared perinatal mortality and neonatal and maternal morbidity according to the intended mode of delivery as well as to the actual mode of delivery. Perinatal outcomes were paired taking into account the dependency between the children of the same twin pregnancy and were also analysed for each child separately. We used logistic regression to correct for possible confounding factors.Results: We studied 1,655 women with a very preterm delivery of a twin pregnancy. A planned caesarean section (n = 212) was associated with a significantly higher perinatal mortality compared to a planned vaginal delivery (n = 1.443) (10% compared to 6.5%; adjusted odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2). The same applied for perinatal morbidity (66% compared to 63%; adjusted OR 1.5, 95% CI 1.1-2.0), maternal morbidity (17% compared to 4.9%; adjusted OR 4.0, 95% CI 2.6-6.3) and for perinatal mortality for the second twin (7.1% compared to 3.5% adjusted OR 2.9, 95% CI 1.7-5.2).Conclusion: In very preterm delivery of twins a vaginal delivery is the preferred mode of delivery.

Elective cesarean delivery at term and the long-term risk for respiratory morbidity of the offspring

Maternal morbidity is associated with cesarean deliveries. However, new evidence suggests that short- and long-term neonatal morbidity is also associated. This includes respiratory morbidity with conflicting results. To determine whether mode of delivery has an impact on the long-term risk for respiratory morbidity in the offspring, a population-based cohort analysis was conducted including all singleton term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via elective cesarean delivery (CD) and those delivered vaginally. Multiple gestations and fetuses with congenital malformations were excluded from the analysis as were all cases of urgent CDs. Pediatric hospitalizations involving respiratory morbidity of offspring up to the age of 18 years were evaluated. A Kaplan-Meier survival curve was used to compare cumulative respiratory morbidity incidence and a Cox regression model to control for confounders. During the study period, 132,054 term deliveries met the inclusion criteria; 8.9% were via elective CDs (n = 11,746) and 91.1% (n = 120,308) were vaginal deliveries. Hospitalizations of the offspring involving respiratory morbidity were significantly more common in offspring delivered by CDs (5.2 vs. 4.3% in vaginal deliveries, p < 0.001). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of respiratory morbidity in the elective CD group (log rank p < 0.001). In a Cox proportional hazards model, while controlling for maternal age, gestational age, and birthweight, CD exhibited a significant and independent association with long-term respiratory morbidity of the offspring (adjusted hazard ratio = 1.22 (CI, 1.12-1.33), p < 0.001).Conclusion: Elective cesarean delivery at term is a significant risk factor for long-term pediatric respiratory morbidity of the offspring. What is Known: • Cesarean delivery is a major surgery with known possible complications. • Cesarean delivery has possible immediate complications for the newborn including respiratory complications. What is New: • Our study shows more long term respiratory morbidity in the CD group including asthma and obstructive sleep apnea. • Different possible explanations have been proposed including exposure to maternal flora during vaginal delivery and the stress hormones secreted during contractions and delivery.

Clinical experience with misoprostol vaginal insert for induction of labor: a prospective clinical observational study

Purpose

To provide real-world evidence using misoprostol vaginal insert (MVI) for induction of labor in nulliparous and parous women at two German Level I Centers in a prospective observational study.

Methods

Between 1 August 2014 and 1 October 2015, eligible pregnant women (≥ 36 + 0 weeks of gestation) requiring labor induction were treated with MVI. Endpoints included time to and mode of delivery rates of tocolysis use, tachysystole, uterine hypertonus or uterine hyperstimulation syndrome and newborn outcomes.

Results

Of the 354 women enrolled, 68.9% (244/354) achieved vaginal delivery (nulliparous, 139/232 [59.9%]; parous 105/122 [86.1%]; p < 0.001). Median time from MVI administration to vaginal delivery was 14.0 h (nulliparous, 14.5 h; parous, 11.9 h; p < 0.001). A total of 205/244 (84.0%) and 228/244 (93.4%) women achieved a vaginal delivery within 24 h and 30 h, respectively. The most common indications for cesarean delivery were pathologic cardiotocography (nulliparous, 41/232 [17.4%]; parous, 13/122 [10.7%]; p = 0.081) and arrested labor (dilation or descent; nulliparous, 45/232 [19.4%], parous, 3/122 [2.5%]; p ≤ 0.001). A total of 24.3% of women experienced uterine tachysystole and 9.6% experienced uterine tachysystole with fetal heart rate involvement, neither of which were significantly different for nulliparous and parous women. In total, 42/345 (12.2%) of the neonates had an arterial pH < 7.15 and 12/345 3.5% had a 5-min Apgar score ≤ 7.

Conclusion

When clinically indicated, MVI was efficient and safe for induction of labor in women with an unfavorable cervix. Women, however, should be counseled regarding the risk of uterine tachysystole prior to labor induction with MVI.

Vaginal birth after prior myomectomy

OBJECTIVE

The aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery.

STUDY DESIGN

We analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed.

RESULTS

469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported.

CONCLUSIONS

A successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option. Obstetricians' attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery.

Lower Apgar scores and Caesarean sections are related to attention-deficit/hyperactivity disorder

AIM

We examined the associations between prenatal, birth-related and newborn risk factors and attention-deficit/hyperactivity disorder (ADHD).

METHODS

In this population-based study, 10 409 subjects diagnosed with ADHD by 31 December 2011 and 39 124 controls, born between 1 January 1991 and 31 December 2005, were identified from Finnish nationwide registers. Perinatal data were obtained from the Birth Register. Conditional logistic regression was used to examine the associations after controlling for confounders.

RESULTS

Lower Apgar scores were associated with a higher risk of ADHD, with odds ratios of 1.12 (95% confidence intervals 1.06-1.19) for one-minute Apgar scores of 7-8, 1.17 (95% CI 1.02-1.35) for scores of 5-6 and 1.41 (95% CI 1.18-1.68) for scores of 0-4, compared to Apgar scores of 9-10. Elective Caesarean sections were associated with an increased risk of ADHD with an adjusted odds ratio of 1.15 (95% CI 1.05-1.26). Other identified risk factors were breech presentation, induced labour and admission to a neonatal intensive care unit. Low umbilical artery pH did not increase the risk of ADHD.

CONCLUSION

Elective Caesareans and perinatal adversities leading to lower Apgar scores increased the risk of ADHD. Future research to identify the mechanisms behind these findings is warranted.