Complications of cesarean deliveries: rates and risk factors

Operative delivery in the second stage of labor and preterm birth in a subsequent pregnancy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy.

DATA SOURCES

MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023.

STUDY ELIGIBILITY CRITERIA

All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included.

METHODS

Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool.

RESULTS

After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57-2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries.

CONCLUSION

Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution.

Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series

A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management.

Prevalence and determinants of socioeconomic inequality in caesarean section deliveries in Bangladesh: an analysis of cross-sectional data from Bangladesh Demographic Health Survey, 2017-18

BACKGROUND

Caesarean section deliveries, which involve incisions in the abdomen and uterus of the mother, have been a widespread event among women with obstructed labour. The current study not only estimated the socioeconomic and demographic factors of caesarean deliveries in Bangladesh but also decomposed the existing socioeconomic inequality in caesarean deliveries.

DATA AND METHODS

2017-18 Bangladesh Demographic and Health Survey (BDHS) data was used for this study. The adequate sample size for the analysis was 5,338 women aged 15-49 years who had given birth at a health facility for three years preceding the survey. Explanatory variables included women's age, women's educational level, women's working status, mass media exposure, body mass index (BMI), birth order, Ante Natal Care (ANC) visits, place of delivery, partner's education and occupation, religion, wealth index, place of residence, and divisions. Descriptive statistics along with bivariate and multivariate logistic regression analysis was performed to identify the factors associated with the outcome variable. Concentration index and concentration curve were made to measure the socioeconomic inequality in caesarean births in Bangladesh. Further, Wagstaff decomposition analysis was used to decompose the inequalities in the study.

RESULTS

About one-third of the deliveries in Bangladesh were caesarean. Education of the women and the family's wealth had a positive relationship with caesarean delivery. The likelihood of caesarean delivery was 33% less among working women than those who were not working [AOR: 0.77; CI: 0.62-0.97]. Women who had mass media exposure [AOR: 1.27; CI: 0.97-1.65], overweight/obese [AOR: 1.43; CI: 1.11-1.84], first birth order, received four or more Antenatal check-ups (ANC) [AOR: 2.39; CI: 1.12-5.1], and delivered in a private health facility [AOR: 6.69; CI: 5.38-8.31] had significantly higher likelihood of caesarean delivery compared to their counterparts. About 65% of inequality was explained by place of delivery followed by wealth status of the household (about 13%). ANC visits explained about 5% of the inequality. Furthermore, the BMI status of the women had a significant contribution to caesarean births-related inequality (4%).

CONCLUSION

Socioeconomic inequality prevails in the caesarean deliveries in Bangladesh. The place of delivery, household wealth status, ANC visits, body mass index, women's education and mass media have been the highest contributors to the inequality. The study, through its findings, suggests that the health authorities should intervene, formulate specialized programs and spread awareness about the ill effects of caesarean deliveries amongst the most vulnerable groups of women in Bangladesh.

Proportion and associated factors of maternal complications of cesarean sections among mothers who deliver at Bahir Dar City Public Specialized Hospitals, Bahir Dar, Ethiopia

INTRODUCTION

Cesarean delivery carries both short term and long-term maternal complications. Eventhough it's being a public burden, the proportion of complications and underlying risk factors are not studied well in our setup. This study aimed to assess the proportion and associated factors of complications of cesarean sections among mothers who delivered at Bahir Dar city public specialized hospitals, Bahir Dar, Ethiopia 2021.

METHODS

A cross-sectional study was conducted at two specialized Hospitals in Bahir Dar city, Ethiopia. The sample size was 495 mothers who had cesarean section in the time period from January 1, 2020 to December 30, 2020. Checklist was used to retrieve information from the patient medical document. Study population was selected from the operation registration book. Systematic sampling was used after arranging the study frame based on date of operation. Both bivariable and multivariable logistic regression was done. In multivariable logistic regression variables with p value < 0.05 at 95% confidence interval were significantly associated with outcome variable.

RESULT

Overall maternal complication rate was 44.04% (95% CI: 39.6-48.5). Living in rural setting (AOR = 4.247,95%CI: 2.765-6.522), having one or more obstetric complication (AOR = 1.913,95% CI: 1.214-3.015), cesarean section done at Second stage of labor (AOR = 4.358,95%CI: 1.841-10.317), having previous cesarean section (AOR = 3.540,95%CI: 2.121-5.910), emergency operation (AOR = 2.967,95%CI: 1.492-5.901), duration of surgery taking more than 60 min (AOR = 3.476,95%CI: 1.521-7.947) were found to be significantly associated with maternal complications.

CONCLUSION

The magnitude of maternal complication of cesarean section was higher than most studies. Living in rural setting, having obstetric complications, previous cesarean scar, emergency surgeries, operation done in second stage of labor and prolonged duration of surgery are important predictors of maternal complication. Therefore, we recommend timely and adequate progress of labor evaluation, timely decision for cesarean delivery and vigilant care in post-operative period shall be conducted.

Prolonged operative time of cesarean is a risk marker for subsequent cesarean maternal complications

PURPOSE

Prolonged cesarean operative time (OT) is a well-established proxy for post-operative maternal complications. We aimed to study whether prolonged OT may serve as a proxy for maternal complications in the subsequent cesarean delivery.

METHODS

A retrospective cohort study of women who underwent cesarean delivery between 2005 and 2019. Parturients who had two subsequent cesarean deliveries were included and those with Placenta Accreta Syndrome (PAS) were excluded. Prolonged operative time was defined as the duration of cesarean delivery above 60 min. Univariate analyses were followed by multivariate analysis (adjusted Odds Ratio (aORs); [95% Confidence Interval]).

RESULTS

A total of 5163 women met the inclusion and exclusion criteria of which 360 (7%) had prolonged operative time. Prolonged operative time of a cesarean section in the index pregnancy was significantly associated in the subsequent cesarean delivery with the following: Prolonged operative time, intra-operative blood loss > 1000 ml, postpartum hemorrhage, blood products transfusion, injuries to the urinary system in the subsequent delivery, and hysterectomy. Multivariate analysis revealed that prolonged OT in the index delivery was associated with composite adverse maternal outcome (aOR 1.46 [1.09-1.95]; P = 0.01) and blood products transfusion (aOR 2.93 [1.90-4.52]; P < 0.01) in the subsequent delivery.

CONCLUSION

Prolonged operative may serve as a proxy for adverse maternal outcomes, mostly blood products transfusion, in the subsequent cesarean delivery among women undergoing repeat cesarean delivery.

Time trends in caesarean section rates and associations with perinatal and neonatal health: a population-based cohort study of 1 153 789 births in Norway

OBJECTIVES

To study caesarean section (CS) rates and associations with perinatal and neonatal health in Norway during 1999-2018.

DESIGN

Population-based cohort study.

SETTING

Medical Birth Registry of Norway.

PARTICIPANTS

1 153 789 births and 1 174 066 newborns.

METHODS

CS, intrapartum, perinatal and neonatal mortality rates expressed as percentages (%) or per mille (‰) with 95% CIs.

PRIMARY AND SECONDARY OUTCOME MEASURES

CS rates in the Robson Ten-Group Classification System; intrapartum, perinatal and neonatal mortality rates.

RESULTS

The overall CS rate increased from 12.9% in 1999 to 16.7% in 2008 (p<0.001), and then reduced to 15.8% in 2018 (p<0.001). The largest reductions were observed in Robson groups 2 and 4. In Robson group 2, the planned CS rate decreased from 9.6% in 2007-2008 to 4.6% in 2017-2018, the intrapartum CS rate decreased from 26.6% in 2007-2008 to 22.3% in 2017-2018. In Robson group 4, the planned CS rate decreased from 16.1% in 2007-2008 to 7.6% in 2017-2018, and the intrapartum CS rate decreased from 7.8% in 2007-2008 to 5.2% in 2017-2018.The intrapartum fetal mortality rate decreased from 0.51 per 1000 (‰) in 1999-2000 to 0.14‰ in 2017-2018. Neonatal mortality decreased from 2.52‰ to 1.58‰.

CONCLUSIONS

CS rates in Norway increased between 1999 and 2008, followed by a significant reduction between 2008 and 2018. At the same time, fetal and neonatal mortality rates decreased. Norwegian obstetricians and midwives have contributed to maintaining a low CS rate under 17%. These findings indicate that restricting the use of CS is a safe option for perinatal health.

Continuous versus disrupted subcutaneous tissue closure in cesarean section: A retrospective cohort study

OBJECTIVES

To compare rates of surgical-site infections following continuous, as compared with interrupted, subcutaneous tissue closure technique during cesarean delivery (CD).

METHODS

A retrospective cohort study during 2008-2018. The study group included women who underwent either elective or emergent CD with continuous subcutaneous tissue closure, while the control group comprised those with interrupted subcutaneous tissue closure. We excluded women with suspected infectious morbidity before CD. The primary outcome was surgical-site infection (SSI) rate.

RESULTS

The final analysis included 6281 women. We performed continuous subcutaneous tissue closure in 37.4% (1867/4988) of scheduled CD, and 45.8% (592/1293) of emergent CD. The rate of SSI was significantly lower following continuous than interrupted subcutaneous tissue closure, in both elective CD (2.7% versus 4.5%, respectively, P = 0.031) and emergent CD (3.2% versus 5.4%, respectively, P = 0.036) in nulliparous and multiparous women. Similarly, secondary outcomes such as re-admission rates, postoperative maternal fever, and need for antibiotic treatment were significantly lower following continuous subcutaneous closure.

CONCLUSIONS

Continuous subcutaneous closure technique during CD yields a lower rate of surgical-site complications compared with the interrupted technique.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Optimal mode of delivery in pregnancy: Individualized predictions using national vital statistics data

Child birth via Cesarean section accounts for approximately 32% of all births each year in the United States. A variety of risk factors and complications can lead caregivers and patients to plan for a Cesarean delivery in advance before onset of labor. However, a non-trivial subset of Cesarean sections (∼25%) are unplanned and occur after an initial trial of labor is attempted. Unfortunately, patients who deliver via unplanned Cesarean sections have increased maternal morbidity and mortality rates and higher rates of neonatal intensive care admissions. In an effort to develop models aimed at improving health outcomes in labor and delivery, this work seeks to explore the use of national vital statistics data to quantify the likelihood of an unplanned Cesarean section based on 22 maternal characteristics. Machine learning techniques are used to ascertain influential features, train and evaluate models, and assess accuracy against available test data. Based on cross-validation results from a large training cohort (n = 6,530,467 births), the gradient-boosted tree algorithm was identified as the best performer and was evaluated on a large test cohort (n = 10,613,877 births) for two prediction scenarios. Area under the receiver operating characteristic curves of 0.77 or higher and recall scores of 0.78 or higher were obtained and the resulting models are well calibrated. Combined with feature importance analysis to explain why certain maternal characteristics lead to a specific prediction in individual patients, the developed analysis pipeline provides additional quantitative information to aid in the decision process on whether to plan for a Cesarean section in advance, a substantially safer option among women at a high risk of unplanned Cesarean delivery during labor.

Iranian women's perception on the determinants of birth experience: a qualitative study

BACKGROUND

The prevalence of cesarean birth in Iran is very high. Having a negative childbirth experience is one of the reasons that primiparous women provide to prefer caesarean birth over a vaginal birth. This study is aimed to understand women's perspective on what determines a positive or negative birth experience for them.

METHODS

This qualitative study is a part a mixed method study that was conducted among primiparous women with a previous vaginal birth experience. The purpose of the main study was to develop a guideline based on Iranian primiparous women's birth experiences. The quantitative phase of the study was a cross-sectional study where women's childbirth experiences was measured in a survey via the Childbirth Experience Questionnaire-2. In the qualitative part of the study, women were invited for an in-depth interview via a random stratified sampling method based on their childbirth mean score (women with 10% of the upper bound score which indicated a positive birth experience and 10% of the lower bound indicating negative birth experience, n = 17). Conventional content analysis was used for data analysis.

RESULTS

We extracted three main themes: (a) "Internal control", (b) "External control", and (c) "Support". Possessing internal control, having a balanced external control to feel cared and feeling supported were the main reasons for women to feel positive about their birth experiences. Whereas, loss of internal control, imbalanced external control and unsupportive environment were related to their negative childbirth experiences.

CONCLUSION

Considering that women's sense of control, the care and support that they receive can influence their childbirth experiences, there is a need for changing maternity policies and practices to highlight the importance of a woman-centred care to create a pleasant, respectful and positive memory for primirparous women who experience normal vaginal births.

Postoperative C-reactive protein as a predictive marker for surgical site infection after cesarean section: Retrospective analysis of 748 patients at a Japanese academic institution

Surgical site infection (SSI) is a common but potentially serious maternal complication of cesarean section (CS). C-reactive protein (CRP) can be used in early detection of SSI. However, its predictive value for post-cesarean SSI has never been investigated. This study aims to evaluate the predictive value of CRP for the development of SSI. This was a hospital-based retrospective cohort study of 748 pregnant women who underwent CS at our university hospital between January 2017 and December 2019. CRP was measured on postoperative days 1, 3, and 6. The predictive values of CRP for SSI were evaluated using receiver operating characteristics analysis. Forty-seven (6.3%) patients developed SSI, of whom 38 (80.9%) underwent emergency CS. Serum CRP levels were significantly higher in the SSI group than in the non-SSI group from postoperative day 1 (64 vs. 81 mg/L, p = 0.001); the difference became more evident on postoperative days 3 and 6. The area under the receiver operating characteristic curve (AUC) for CRP on days 1, 3, and 6 was 0.58 (95% confidence interval [CI], 0.49 to 0.68), 0.70 (0.62 to 0.78) and 0.73 (0.65 to 0.81), respectively. The optimal cutoff value for day 3 and 6 CRP was 66.4 mg/L (sensitivity = 76.1% and specificity = 54.4%) and 22.2 mg/L (sensitivity = 76.5% and specificity = 63.2%), respectively. CRP on postoperative days 3 and 6 can be used as a predictive marker for the development of SSI after CS. Further studies to validate the predictive value in different populations is essential.

Racial-ethnic disparities in potentially preventable complications after cesarean delivery in Maryland: an observational cohort study

Background

Potentially preventable complications are monitored as part of the Maryland Hospital Acquired Conditions Program and are used to adjust hospital reimbursement. Few studies have evaluated racial-ethnic disparities in potentially preventable complications.

Our study objective was to explore whether racial-ethnic disparities in potentially preventable complications after Cesarean delivery exist in Maryland.

Methods

We performed a retrospective observational cohort study using data from the Maryland Health Services Cost Review Commission database. All patients having Cesarean delivery, who had race-ethnicity data between fiscal years 2016 and 2020 were included. Multivariable logistic regression modeling was performed to estimate risk-adjusted odds of having a potentially preventable complication in patients of different race-ethnicity.

Results

There were 101,608 patients who had Cesarean delivery in 33 hospitals during the study period and met study inclusion criteria. Among them, 1,772 patients (1.7%), experienced at least one potentially preventable complication. Patients who had a potentially preventable complication were older, had higher admission severity of illness, and had more government insurance. They also had more chronic hypertension and pre-eclampsia (both P<0.001). Median length of hospital stay was longer in patients who had a potentially preventable complications (4 days vs. 3 days, P<0.001) and median hospital charges were approximately $4,600 dollars higher, (P<0.001). The odds of having a potential preventable complication differed significantly by race-ethnicity group (P=0.05). Hispanic patients and Non-Hispanic Black patients had higher risk-adjusted odds of having a potentially preventable complication compared to Non-Hispanic White patients, OR=1.26 (95% CI=1.05 to 1.52) and OR=1.17 (95% CI=1.03 to 1.33) respectively.

Conclusions

In Maryland a small percentage of patients undergoing Cesarean delivery experienced a potentially preventable complication with Hispanic and Non-Hispanic Black patients disproportionately impacted. Continued efforts are needed to reduce potentially preventable complications and obstetric disparities in Maryland.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04818-5.

Static and dynamic postural control of postpartum women of different delivery methods

OBJECTIVE

The aim of this study was to determine whether there is a difference in postural control between nulligravida women and women who have given birth by vaginal or cesarean section.

METHODS

Women who had only vaginal delivery in the previous 1-3 years were included in the vaginal delivery group (n = 27), those who had only cesarean delivery in the previous 1-3 years were included in the cesarean section group (n = 28), and those who had never given birth were included in the control group (n = 32). Evaluations were administered 6-8 days after the ovulation phase. Postural control of the participants was evaluated with the computerized dynamic posturography device.

RESULTS

A total of 87 women with a mean age of 29.4 ± 4 years and a mean body mass index of 24.1 ± 3.1 kg/m² were included in the study. Antero-posterior somatosensory organization test values of the vaginal delivery group were lower than the control group (p = 0.0016). The cesarean delivery group had statistically lower antero-posterior somatosensory (p < 0.001 and p = 0.0013) and medio-lateral somatosensory (p = 0.002 and p = 0.017, respectively) test scores compared to the control group and the vaginal delivery group.

CONCLUSIONS

It was observed that women who birthed with vaginal or cesarean delivery had impaired somatosensory postural control. There is definitely a need for further studies with a long-term follow-up examining the effects of postural control during pregnancy and the postpartum period.

Geographic and socioeconomic inequalities in cesarean birth rates in Peru: A comparison between 2009 and 2018

BACKGROUND

There is a global concern about the high rates of cesarean birth (CB). This study aimed to investigate the geographic and socioeconomic inequalities in CB rates in the Peruvian population.

METHODS

We conducted a population-based study using the Peruvian Demographic and Family Health Surveys (ENDES, the Spanish acronym for Encuesta Demográfica y de Salud Familiar) between 2009 and 2018. ENDES reported data from births registered in the five years preceding survey execution. For the years 2009 (n = 10 289) and 2018 (n = 23 077), we calculated the weighted rates of CB among variables such as natural geographic domain (Coast, Andean, or Amazon), area of residence (rural or urban), wealth index quintile (quintile 1 is poorest, and quintile 5 is richest), and educational level. To assess inequalities, we calculated the concentration index (CIs), the slope index of inequality (SII), and the relative index of inequality (RII).

RESULTS

The CB rates by year were 21.4% (95% confidence interval [CI]: 20.0-22.9) in 2009 and 34.5% (95% CI: 33.4-35.5) in 2018. Women living in urban and coastal regions and with a higher education level had the highest CB rates. All the CIs were positive, reflecting a prowealthy inequality in CB rates, and both SII and RII were positive, indicating a gap between the use of cesarean in women in the higher wealth quintile compared with those in the lower quintile.

CONCLUSIONS

Cesarean birth rates have increased by 60% during the last decade in Peru. The richest wealth quintiles had the highest CB rates during the study years, which were well above global recommendations.

Maternal education and racial/ethnic disparities in nulliparous, term, singleton, vertex cesarean deliveries in the United States

BACKGROUND

Racial and ethnic disparities in obstetrical and neonatal outcomes are prevalent in the United States. Such racial or ethnic disparities have also been documented in the prevalence of cesarean deliveries.

OBJECTIVE

We aimed to evaluate the impact of maternal education on racial or ethnic disparities in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States.

STUDY DESIGN

This is a retrospective analysis of the Centers for Disease Control and Prevention live births database (2016–2019). Nulliparous, term, singleton, vertex births from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. Pregnancies complicated by gestational or pregestational diabetes mellitus and hypertensive disorders were excluded. Data were analyzed on the basis of the level of maternal education (less than high school graduate, high school graduate, college graduate, and advanced degree). We compared the prevalence of cesarean deliveries among the different racial or ethnic groups within each education level using Pearson chi-square test with Bonferroni adjustment. Multivariate logistic regression was performed to assess the association between cesarean deliveries and maternal race/ethnicity, maternal education, and the interaction between maternal race or ethnicity and education level, while controlling for potential confounders. To demonstrate the effect of the interaction, separate logistic regression models with similar covariates were performed for each education level and for each race/ethnicity group. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios with 95% confidence intervals.

RESULTS

The overall prevalence of cesarean deliveries during the study period was 23.4% (695,214 of 2,969,207 births). All racial or ethnic minority groups had higher rates of cesarean deliveries than non-Hispanic White women (non-Hispanic Black, 27.4%; non-Hispanic Asian, 25.6%; Hispanic, 23.0%; and non-Hispanic White, 22.4%; [P<.001 for all comparisons]). Similar racial or ethnic differences in cesarean delivery rates were detected among all education levels. Higher levels of education were associated with a lower likelihood of cesarean delivery (adjusted odds ratio, 0.88; [95% confidence interval, 0.87–0.89]) in women with advanced degrees than in women who did not graduate from high school. However, although maternal education was associated with a protective effect in non-Hispanic White and non-Hispanic Asian women (adjusted odds ratio, 0.83 [95% confidence interval, 0.81–0.85] and adjusted odds ratio, 0.81 [95% confidence interval, 0.77–0.86], respectively, for women with advanced degrees), it had a smaller protective effect in non-Hispanic Black women (adjusted odds ratio, 0.93 [95% confidence interval, 0.89–0.97]) and no protective effect in Hispanic women (adjusted odds ratio, 0.98 [95% confidence interval, 0.96–1.01]).

CONCLUSION

We document a significant racial/ethnic disparity in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. Furthermore, our findings suggest that although a higher level of maternal education is associated with a lower likelihood of cesarean delivery, this protective effect varies among racial or ethnic groups. Further research is needed to investigate the underlying causes for this racial/ethnic disparity.

Laparoscopic Isthmocele Repair: Efficacy and Benefits before and after Subsequent Cesarean Section

OBJECTIVE

To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated.

DESIGN

Retrospective, case series.

SETTING

Public university hospital.

POPULATION

Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified.

METHODS

Women's complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section.

MAIN OUTCOME MEASURES

Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures.

RESULTS

Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery.

CONCLUSION

Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding.

Length of stay in health facilities after childbirth and associated maternal and neonatal factors in Ethiopia: a cross-sectional study from a national survey

OBJECTIVE

This study aimed to assess the length of stay in health facilities after childbirth and associated maternal and neonatal factors in Ethiopia.

DESIGN

A cross-sectional study.

SETTING

Ethiopia.

PARTICIPANTS

2260 mothers who participated in the 2016 Ethiopian Demographic and Health Survey were included in the study.

OUTCOME

Length of stay in health facilities after childbirth was the outcome variable of the study.

RESULT

In Ethiopia, the mean duration of postpartum stay for mothers in health facilities was 21.96 (19.97-23.94) hours. Nine hundred and sixty-eight (34.80%) women remained in health institutions for ≥24 hours after delivery. Gestational age, birth weight and mode of delivery were significantly associated with length of stay. Gestational age was found to be inversely associated with length of stay. Mothers who had a vaginal delivery were 8.89% (adjusted HR (AHR) 8.89, 95% CI (4.28 to 18.46), p<0.001) more likely to discharge earlier from health facilities after delivery, compared with those who had a caesarian section. Women with larger size neonates during birth were 19% (AHR=0.81, 95% CI (0.67 to 0.96), p=0.019) more likely to stay longer in health facilities than women with average size neonates. Women with a smaller size neonate during birth were 16% (AHR=0.84, 95% CI (0.70 to 0.99), p=0.040) more likely to stay longer at a health facility, compared with those with an average size neonate.

CONCLUSION

A small percentage of Ethiopian mothers stayed in health facilities for 24 hours or more after delivery. Encouraging mothers to stay in health facilities for the recommended period after childbirth can play a significant role in reducing maternal and neonatal deaths.

Caesarean delivery in a migration context: the role of prior delivery in the host country

Migrant women in industrialised countries experience high caesarean section (CS) rates but little is known about the effect of a previous delivery in the host country. This study set out to investigate this effect among migrant women in France, using data from the DSAFHIR study on healthcare access of migrant women living in emergency housing hotels, collected in the Paris Metropolitan area in 2017. Respondents reported life-long history of deliveries. We focused on deliveries occurring in France in 2000–2017: 370 deliveries reported by 242 respondents. We conducted chi-square tests and multivariate logistic regressions, adjusting for the clustering of deliveries among respondents by computing standard errors allowing for intragroup correlation. Mode of delivery was associated with duration of residence among multiparous women with no prior CS, with a higher CS rate with shorter duration of residence (16% vs. 7%, p = 0.04). In this group, a previous delivery in France was associated with a lower CS rate (5% vs. 16%, p = 0.008). In multivariate analysis, compared with women with previous birth in France, women giving birth in France for the first time had a higher risk of CS, regardless of duration of residence (aOR = 4.0, 95% CI = 1.3–12.1 for respondents with short duration of residence, aOR = 4.7, 95% CI = 1.2–18.0 for respondents with longer duration of residence). Efforts directed at decreasing the CS rate among migrant women should target women giving birth in the host country for the first time.

Walking to a better future? Postoperative ambulation after cesarean delivery and complications: A prospective study

OBJECTIVE

To assess the correlation between maternal mobility after cesarean delivery and postoperative morbidity.

METHODS

A prospective study was conducted in a tertiary hospital among patients after cesarean delivery. The women were recruited after surgery and before ambulation. Each participant received an accelerometer and routine instructions for mobilization. The patients were asked to wear the accelerometer constantly. It was collected at discharge. Electronic files were reviewed and patients' outcomes were analyzed. The Mann-Whitney U test was used to compare groups and a receiver operating characteristic curve was calculated for the threshold of number of steps.

RESULTS

Data were analyzed for 199 patients, among which 107 (54.4%) deliveries were urgent and 90 (45.6%) were elective. The median number of steps was higher for multiparous women compared to nulliparous women (P = 0.035). Patients who developed complications after discharge walked significantly less during their hospitalization compared to those who did not. There was a trend toward increased risk for in-hospitalization complications among patients who walked less while hospitalized. A threshold of more than 9716 steps per hospitalization was found to be associated with fewer post-discharge complications.

CONCLUSION

There is a significant correlation between the extent of ambulation after cesarean delivery and fewer postoperative complications.

Morbidity associated with planned cesarean deliveries performed before the scheduled date: A cohort study

OBJECTIVE

Women with planned cesareans can require delivery before the scheduled date. However, data describing the morbidity associated with planned cesarean deliveries performed before the originally scheduled date is lacking. The objective of this study was to compare the morbidity associated with planned cesarean delivery performed before compared with on the scheduled date.

STUDY DESIGN

This retrospective single-center cohort study included all 3595 women with singleton pregnancies and cesarean deliveries after 36⁺⁶ weeks. All cases were reviewed individually to identify the initial intended mode of delivery, determined before 37 weeks. We excluded the 2145 (59.7%) unplanned cesareans initially planned as vaginal deliveries. Finally, the analysis included 1450 women with planned cesareans: 1232 (85.0%) performed as scheduled, and 218 (15.0%) before that date. The composite outcomes of maternal morbidity was one or more of the morbidity measures, including surgical complications, postpartum hemorrhage, infection and thrombo-embolism. Neonatal morbidity measures included 5 min Apgar score < 7, arterial cord blood pH < 7.00, and admission to the neonatal intensive care unit (NICU).

RESULTS

Reasons for performing planned cesarean delivery before the scheduled date were as follows: onset of labor (n = 109; 50.0%), rupture of membranes (n = 85; 39.0%), preeclampsia (n = 9; 4.1%), scar pain in women with a previous cesarean (n = 6; 2.8%), unexplained vaginal bleeding (n = 5; 2.3%), and nonreassuring fetal heart rate (n = 4; 1.8%). Mean gestational age for planned cesarean deliveries before the scheduled date was 38.7 weeks ± 0.8 versus 39.2 weeks ± 0.7 for those performed when scheduled (P < 0.0001). The maternal morbidity composite outcome rate was significantly higher among planned cesareans performed early compared with those on the scheduled date: 18.3% vs 9.7%, respectively, P = 0.0002. It was still higher in the multivariable analysis: aOR 2.17, 95% CI 1.46-3.21, P = 0.0001. The neonatal composite outcome did not differ significantly between the two groups.

CONCLUSION

In planned cesarean deliveries, maternal morbidity is higher for cesareans performed before rather than on the scheduled date. Studies without accurate intent-to-treat analyses underestimate the morbidity associated with planned cesareans. Accordingly, medical records must make it possible to distinguish planned cesarean deliveries performed before the scheduled date from those performed as planned.

Magnesium sulfate reduces postoperative pain in women with cesarean section: A meta-analysis of randomized controlled trials

OBJECTIVES

The use of magnesium sulfate (MgSO₄ ) as an adjunct in different anesthetic regimens for cesarean section (CS) delivery often reports conflicting results. This study aimed to review the effectiveness of MgSO₄ on improving postoperative analgesia after CS systematically.

METHODS

PubMed, Embase, and the Cochrane library were searched for randomized controlled trials (RCTs) published from inception to February 2020.

RESULTS

A total of 880 women were included (440 in each group). MgSO₄ had a statistically significant effect compared to the control group on the highest VAS (weighted mean difference [WMD] = -0.74, 95% confidence interval [CI] = -1.03 to -0.46, p < 0.001, I²  = 91.7%, p_{heterogeneity}  < 0.001) and the last VAS (WMD = -0.47, 95% CI = -0.71 to -0.23, p < 0.001, I²  = 95.0%, p_{heterogeneity}  < 0.001). MgSO₄ prolonged the time to the first use of analgesia compared to the control group (standardized mean difference [SMD] = -3.03 min, 95% CI = -4.32 to -1.74, p < 0.001, I²  = 96.3%, p_{heterogeneity}  < 0.001). MgSO₄ decreased the consumption of analgesia compared to the control group (SMD = -3.20 mg of IV morphine equivalent, 95% CI: -5.45 to -0.95, p = 0.005, I²  = 97.6%, p_{heterogeneity}  < 0.001).

DISCUSSION

MgSO₄ decreases the highest VAS in women who underwent general anesthesia, spinal anesthesia, or epidural for CS (all p < 0.05). Additional MgSO₄ significantly reduces postoperative pain in women undergoing CS.

Female genital mutilation/cutting, timing of deinfibulation, and risk of cesarean section

INTRODUCTION

The impact of female genital mutilation/cutting on obstetric outcomes in high-income countries is not clear. In general, women with female genital mutilation/cutting type 3 (infibulation) seem to be most at risk of adverse outcomes such as cesarean section. Deinfibulation is recommended to prevent obstetric complications. Whether the timing of this procedure affects the complication risk is not known. The aims of this study were, first, to examine the association between female genital mutilation/cutting and the risk of cesarean section in Norway, and, second, whether the timing of deinfibulation affected the cesarean section risk.

MATERIAL AND METHODS

This was a historical cohort study of nulliparous Somali-born women who gave birth in Norway between 1990 and 2014. The Medical Birth Registry of Norway identified the women. Data were collected from medical records at 11 participating birth units. The exposures were female genital mutilation/cutting status and deinfibulation before pregnancy, during pregnancy, or no deinfibulation before labor onset. The main outcome was odds ratio (OR) of cesarean section. Type of cesarean section, primary indications, and neonatal outcomes were secondary outcomes.

RESULTS

Women with female genital mutilation/cutting type 3 had lower risk of cesarean section compared with women with no female genital mutilation/cutting (OR 0.54, 95% CI 0.33-0.89 P = .02). Among the 1504 included women, the cesarean section rate was 28.0% and the proportion of emergency operations was 92.9%. Fetal distress was the primary indication in approximately 50% of cases, across the groups with different female genital mutilation/cutting status. Women who had no deinfibulation before labor onset had lower risk of cesarean section compared with those who underwent deinfibulation before or during pregnancy (OR 0.64, 95% CI 0.46-0.88 P = .01).

CONCLUSIONS

High risk of cesarean section in Somali nulliparous women was not related to the type of female genital mutilation/cutting in the present study. Deinfibulation before labor did not protect against cesarean section. Our findings indicate that nulliparous Somali women are at high risk of intrapartum complications. Future research should focus on measures to reduce maternal morbidity and on how timing of deinfibulation affects the outcomes of vaginal births.

How do women interpret abortion information they find online?

OBJECTIVE

We sought to assess how women interpret the information they find online about the overall safety and risk of infertility associated with abortion and cesarean delivery (CD).

METHODS

We conducted an exploratory, prospective study tracking the internet searches of 100 reproductive-aged individuals who identify as women. We directed participants to search for information about either (1) whether surgical abortion or CD is safe or (2) the risk of infertility following surgical abortion or CD. Our data collection had 3 phases: baseline survey, directed internet search, and a postsearch survey. We analyzed participants' pre- and postsurvey responses using bivariate tests and analyzed within-subject changes. We evaluated the sites they visited based on expert ratings of site content based on trustworthiness and slant.

RESULTS

Women perceived abortion as safer and less likely to cause infertility after their web searches than before (70% perceived abortion in the United States as very/completely safe presearch vs 92% postsearch; p < 0.02). Women's perceptions about CD did not change. Participants sought information from web pages that experts largely deemed trustworthy and lacking in slant.

CONCLUSIONS

Women's perceptions about abortion safety and risk can be influenced by information they find online; perceptions about CD safety and risk may be less influenced by online information.

IMPLICATIONS

Disseminating high quality, user-friendly abortion information on highly ranked and easily findable websites can help women find evidence-based information and influence knowledge about abortion.

Clarithromycin use for adjunct surgical prophylaxis before non-elective cesarean deliveries to adapt to azithromycin shortages in COVID-19 pandemic

OBJECTIVE

This study aimed to evaluate safety and effectiveness of clarithromycin as adjunctive antibiotic prophylaxis for patients undergoing non-elective cesarean delivery in comparison with no macrolides, to adapt to azithromycin shortages in COVID-19 pandemic.

STUDY DESIGN

We conducted a multi-center, prospective observational cohort study from March 23, 2020 through June 1, 2020. We followed all women receiving either clarithromycin or no macrolide antibiotic for adjunct surgical prophylaxis for non-elective cesarean deliveries. The primary outcome was development of postpartum endometritis. Secondary outcomes included meconium-stained amniotic fluid at time of cesarean delivery, neonatal sepsis, neonatal intensive care unit admission, and neonatal acute respiratory distress syndrome. All patients in this study were tested for SARS-CoV-2 infection and resulted negative.

RESULTS

This study included 240 patients, with 133 patients receiving clarithromycin and 107 patients receiving no adjunct macrolide prophylaxis. Patients receiving clarithromycin were noted to have significantly lower rates of postpartum endometritis as compared to those who did not receive adjunct prophylaxis (4.5% versus 11.2%, p = 0.025). In crude (unadjusted) analysis, a significantly lower risk of developing endometritis was noted in the clarithromycin group as compared to the control group (66% decreased risk, 95% CI 0.12 to 0.95, p = 0.040). When adjusted for perceived confounders, a significant difference was again noted (67% decreased risk, 95% CI 0.11 to 0.97, p = 0.034). Stratified analysis of significantly different demographic factors including Black race, BMI, and age was performed. A significantly decreased risk of development of endometritis when taking clarithromycin versus no adjunct macrolide was noted for Black race women in crude and adjusted models (crude: 87% decreased risk, 95% CI 0.08 to 0.83, p = 0.032; adjusted: 91% decreased risk, 95% CI 0.06 to 0.79, p = 0.026). This was also noted for women aged 18-29 years in crude and adjusted models (crude: model, 79% decreased risk, 95% CI 0.06 to 0.80, p = 0.014; adjusted model: 75% decreased risk, 95% CI 0.06 to 0.94, p = 0.028). All other stratified analyses did not yield significant differences in endometritis risk.

CONCLUSION

Our study suggests that administration of clarithromycin for adjunctive surgical prophylaxis for non-elective cesarean deliveries may be a safe option that may provide suitable endometritis prophylaxis in cases where azithromycin is unavailable, as was the case during the start of COVID-19 pandemic, most especially for Black race women and women ages 18-29 years.

Incidence and Risk Factors of Wound Infection in Women Who Underwent Cesarean Section in 2014 at King Abdulaziz Medical City, Jeddah

Introduction

Cesarean section (C/S) is considered one of the most commonly performed procedures among women. The maternal morbidity due to infection post-C/S reaches eight-fold higher than that of vaginal delivery. Our aim is to identify the incidence and risk factors of surgical site infection (SSI) among patients at King Abdul Aziz Medical City (KAMC), Jeddah, Saudi Arabia, in order to develop a strong strategy to reduce its occurrence.

Methods

This retrospective cohort study was conducted at KAMC, Jeddah. The study included a total of 387 women who underwent cesarean sections from January 2014 to December 2014. The data were collected consecutively by reviewing medical records of pregnant patients who underwent elective or emergency C/S. The risk factors studied included age, presence of underlying diseases, BMI, hemoglobin level, prophylactic antibiotics, pre-labor rupture of membrane, duration of induction of labor, type of C/S, type of uterine incision, duration of operation, type of anesthesia, estimated blood loss, type of organism, and the duration of hospital stay postoperatively. 

Results

The incidence rate of wound infections (WI) was 3.4% (13/387). The mean age score was 31.1±5.6 years, and the mean score of BMI was 32.7±6.2, where the majority were obese (255, 65.9%). More than half of the participants (205, 53.0%) had elective C/S, with mean hospitalization duration 2.5±1.3 days, and operation duration mean score 59.5±22.0 minutes. The majority (378, 97.7%) received antibiotics before the operation, where cefazolin was the main antibiotic (376, 97.2%). Only 38 (10%) cases had intra-operative complications, where the main complication was postpartum hemorrhage (18, 44.0%). The majority of WI were superficial (11 cases), the main organism was E. coli in four (36.4%) cases, followed by Staphylococcus aureus in three (27.3%) cases. There was a significant association between WI post-C/S and BMI, type of uterine incision, and induction of labor (P=006, P=0.003, respectively). 

Conclusions

This study showed that WI post-C/S is associated with high BMI, prolonged induction of labor, and Pfannenstiel incision. Reducing the rate of SSI will help to reduce its morbidity by identifying the risk factors pre-pregnancy and encouraging the implementation of preconception counseling clinics and antenatal classes to educate and increase awareness among patients.

Effectiveness of the fetal pillow to prevent adverse maternal and fetal outcomes at full dilatation cesarean section in routine practice

INTRODUCTION

The fetal pillow has been suggested to reduce maternal trauma and fetal adverse outcomes when used to disimpact the fetal head at full dilatation cesarean section.

MATERIAL AND METHODS

We performed a retrospective cohort study of the use of the fetal pillow device at full dilatation cesarean section between September 2014 and March 2018 at Liverpool Women's Hospital, a large UK teaching hospital.

RESULTS

There were 471 cases of full dilatation cesarean section during the study period and 391 were included for the analysis; 170 used the fetal pillow and 221 were delivered without. We did not demonstrate any benefit in the significant maternal outcomes of estimated blood loss >1000 mL or >1500 mL, need for blood transfusion, or duration of hospital stay, from the use of the fetal pillow. We did not demonstrate any improvement in fetal outcome following use of the fetal pillow for arterial pH <7.1, Apgar score <7 at 5 minutes or admission to the neonatal unit. For deliveries undertaken at or below the level of the ischial spines there was likewise no benefit from fetal pillow use, except in a reduced risk of an arterial pH <7.1 (relative risk 0.39, 95% CI 0.20-0.80, P = .01); however, admission to the neonatal unit was unaffected.

CONCLUSIONS

This is the largest study to date on the use of the fetal pillow at full dilatation cesarean section. We did not demonstrate any statistically significant benefit from the use of the fetal pillow to prevent any maternal or fetal adverse outcomes at full dilatation cesarean section in routine clinical use. Further randomized studies are required to prove clinical benefit from this device before more widespread use.

Passive management of labour may predispose to anal sphincter injury

INTRODUCTION AND HYPOTHESIS

To compare anal sphincter damage in two groups of primigravid women in Sydney: one passively managed in public hospitals, the other more actively managed in adjacent private hospitals. Data from actively managed labours at the National Women's Hospital, Dublin, served as an independent control.

METHODS

We carried out a comparative study of third and fourth degree anal sphincter tears in all primiparas delivering at term in the years 2010-2015 in six Sydney public teaching hospitals with data from patients delivered in six adjacent Sydney private hospitals. A second comparator was published data from the National Women's Hospital, Dublin, where active management is still performed under the direction of midwives. All data was publicly available from www.health.nsw.gov.au/hsnsw . The difference between the two groups: public hospitals were under MANDATORY (NSW DG's upper case emphasis) direction from the Director General of NSW Health (PD 2010-045 File no 09/638-3) for labour to proceed without any augmentation.

RESULTS

The study comprised 130,000 women. The mean third and fourth degree anal sphincter tear rate was 8.17% for the public hospitals and 1.52% for the private hospitals in the same period (p < 0.0003). Dublin's rate was 2.6%. There was no significant difference in the emergency Caesarean section rate 2010-2015 (13.7% private vs 12.7% public, 7.9% in National Women's Hospital Dublin) as well as an increase in epidurals, forceps/ventouse and lower Apgar scores.

CONCLUSION

Passive management of labour instituted in Sydney public hospitals by government directive seems to be associated with a higher rate of obstetric anal sphincter injuries than was observed with active management. In addition, there were more epidurals, forceps/ventouse, and lower Apgar scores. Our hypothesis of deflexion of the head causing deficient powers is logically appealing, but needs further proof.

Just choice: a Danielsian analysis of the aims and scope of prenatal screening for fetal abnormalities

Developments in Non-Invasive Prenatal Testing (NIPT) and cell-free fetal DNA analysis raise the possibility that antenatal services may soon be able to support couples in non-invasively testing for, and diagnosing, an unprecedented range of genetic disorders and traits coded within their unborn child's genome. Inevitably, this has prompted debate within the bioethics literature about what screening options should be offered to couples for the purpose of reproductive choice. In relation to this problem, the European Society of Human Genetics (ESHG) and American Society of Human Genetics (ASHG) tentatively recommend that any expansion of this type of screening, as facilitated by NIPT, should be limited to serious congenital and childhood disorders. In support of this recommendation, the ESHG and ASHG cite considerations of distribution justice. Notably, however, an account of justice in the organization and provision of this type of screening which might substantiate this recommendation has yet to be developed. This paper attempts to redress this oversight through an investigation of Norman Daniels' theory of Just health: meeting health needs fairly. In line with this aim, the paper examines what special moral importance (for Just health) screening for the purpose of reproductive choice might have where concerning serious congenital and childhood disorders in particular. The paper concludes that screening for reproductive choice where concerning serious congenital and childhood disorders may be important for providing women with fair opportunity to protect their health (by either having or not having an affected child).

Effect of Low-Dose Intravenous Ketamine on Prevention of Headache After Spinal Anesthesia in Patients Undergoing Elective Cesarean Section: A Double-Blind Clinical Trial Study

Background

Spinal anesthesia is the most commonly used method for elective cesarean section, which is a popular technique due to its simplicity, reliability, and speed to achieve adequate anesthesia. Headache following dura perforation is the most important delayed complication following spinal and epidural anesthesia.

Objectives

To evaluate the impact of low-dose intravenous ketamine in patients undergoing cesarean section under spinal anesthesia on the prevention of dura perforation headache (PDPH).

Methods

This clinical trial study was performed on 64 pregnant women undergoing cesarean section at Vali-e-Asr Hospital. The patients were divided into two groups. In the case group, 0.15 mg/kg body weight ketamine was injected intravenously and in the control group, normal saline was used as the placebo. The incidence of headache and its severity at one, 4, 12, and 24 hours postoperatively, nausea and its severity were also measured and compared. Independent t-test, Mann-Whitney U and chi-square tests were used. A P value < 0.05 was considered statistically significant.

Results

The data revealed that low dose intravenous ketamine significantly decreased patients’ headaches (P = 0.001), the sensation of pruritus (P = 0.009), and the need for analgesic (P = 0.001). Furthermore, the sensation of postoperative nausea was less in the case group. The patients in the case and control groups had no significant difference in terms of hypertension or bradycardia (P = 0.717 and 0.939, respectively).

Conclusions

The injection of ketamine as a premedication in the cesarean section can reduce the severity of postoperative headache in mothers. Therefore, it is recommended to use ketamine as an anti-headache drug in pregnant women.

The majority of early term elective cesarean sections can be postponed

INTRODUCTION

To minimize the risk of neonatal respiratory morbidity it is recommended that elective cesarean sections should not be done before 39-week gestation unless medically indicated. However, elective cesarean sections are still being performed at early term (at 37⁰-38⁶ weeks gestation) without sound medical indications. In this study, we evaluated the indications for elective cesarean sections performed at early term to assess the proportion of procedures that could possibly have been postponed until ≥39 weeks to avoid neonatal respiratory morbidity.

MATERIAL AND METHODS

Maternal and neonatal information was collected from medical records on all elective cesarean sections performed in singleton pregnancies at ≥37⁰ weeks gestation over a 20-year period in a population with secure ultrasound gestational age assignment. Indications were grouped and uterine scar, breech, or transverse presentation and maternal request classified as nonurgent.

RESULTS

There were 3411 elective cesarean sections performed at ≥37-week gestation, of which 790 (23.2%) were at 37⁰-38⁶ weeks. Medical indications were present for 34% (272/790), but 65.6% (518/790) could possibly have been postponed until ≥39⁰ weeks. Of the neonates 5.7% developed respiratory morbidity if delivery was at 37⁰-38⁶ weeks gestation compared to 2.4% at 39⁰-42¹ weeks gestation (p < .001).

CONCLUSION

Of elective cesarean sections before 39-week gestation two-thirds were done without a clear medical indication, thereby exposing the newborn to an increased risk of respiratory morbidity. Scheduling elective cesarean sections at ≥39-week gestation is important to minimize the risk of neonatal respiratory morbidity, unless a clear medical indication dictates earlier delivery.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Maternal Benefits and Risks of Planned Cesarean Delivery compared to Planned Vaginal Delivery]

OBJECTIVE

To evaluate maternal risks and benefits associated with planned mode of delivery in case of breech presentation at term.

METHODS

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

RESULTS

To analyze maternal complications according to the planned mode of delivery for breech singleton at term, only one study of high quality is available, a randomized controlled trial- the Term Breech Trial, having found a similar maternal morbidity rate with planned cesarean delivery compared to planned vaginal delivery (LE2). This trial found at 3 months postpartum a decreased risk of urinary incontinence and perineal pain, and an increased risk of abdominal pain in case of planned cesarean delivery compared to planned vaginal delivery (LE2). This trial found at 2 years postpartum, a similar rate of maternal morbidity according to planned mode of delivery, in the absence of subsequent pregnancy (LE2). In studies with fetus in cephalic presentation, previous cesarean delivery exposes women in subsequent pregnancies at serious risk of uterine rupture, abnormalities of placental insertion and hysterectomy (LE2).

CONCLUSION

For breech singleton at term, short and long term maternal complications appear similar in case of planned vaginal delivery compared to planned cesarean delivery without subsequent pregnancy. In subsequent pregnancies, women with previous cesarean section are at risk for serious complications (uterine rupture, abnormalities of placental insertion).

Comparison of maternal and perinatal morbidity between elective and emergency caesarean section in singleton-term breech presentation

The objective of the study was to compare maternal and neonatal adverse outcomes between elective caesarean section (ElCS) and emergency caesarean section (EmCS) for singleton-term breech presentation. This study included women with singleton breech presentation who underwent ElCS or EmCS at term during 2007-2015 at Siriraj Hospital (Thailand). Complete data were collected for 2178 pregnant women. Of those, 1322 (60.7%) women underwent EmCS, and 856 (39.3%) delivered by ElCS. Maternal and perinatal morbidity were compared. There was no maternal or perinatal death in either group. Maternal morbidity was comparable between groups, except for longer hospital stay in the EmCS group (p = .047). One-minute Apgar score was significantly lower in the EmCS group (p = .040). There was no significant difference in 5-min Apgar score between groups. No significant difference was observed for serious maternal and neonatal morbidity between women who underwent ElCS versus those who underwent EmCS for singleton-term breech presentation.IMPACT STATEMENTWhat is already known on this subject? Emergency caesarean section (EmCS) is generally known to be associated with a higher risk of maternal and neonatal complications than elective caesarean section (ElCS).What do the results of this study add? In singleton-term breech presentation, EmCS in tertiary care setting was not associated with an increase in serious maternal and neonatal morbidity compared with EICS. Cord prolapse as an indication for emergency caesarean section was significantly associated with adverse outcomes while advanced cervical dilation ≥7 cm or low foetal station ≥+1 did not have an impact on maternal and neonatal complications.What are the implications of these findings for clinical practice and/or further research? Mean gestational age in both the ElCS and EmCS groups was approximately 38 weeks and 5 d; there were no neonatal cases with respiratory distress syndrome. Our findings suggest further prospective study in planned caesarean section scheduled for 38-39 weeks in patients with term breech presentation. The results of such a study could yield lower rates of both EmCS and potential adverse outcomes.

Canine dystocia in 50 UK first-opinion emergency care veterinary practices: clinical management and outcomes

Canine dystocia is a relatively common veterinary presentation. First opinion emergency care clinical data from 50 Vets Now clinics across the UK were used to explore dystocia management and outcomes in bitches. Caesarean section (CS) was performed on 341/701 (48.6 per cent (95 per cent CI 44.9 to 52.4)) of dystocia cases. The bulldog (OR 7.60, 95 per cent CI 1.51 to 38.26, P=0.014), Border terrier (OR 4.89, 95 per cent CI 0.92 to 25.97, P=0.063) and golden retriever (OR 4.07, 95 per cent CI 0.97 to 17.07, P=0.055) had the highest odds of CS among dystocic bitches compared with crossbreds. Brachycephalic dystocic bitches had 1.54 (95 per cent CI 1.05 to 2.28, P=0.028) times the odds of CS compared with non-brachycephalics. Oxytocin was administered to 380/701 (54.2 per cent) and calcium gluconate was administered to 82/701 (11.7 per cent) of dystocic bitches. 12 of 701 dystocia cases (1.7 per cent) died during emergency care. These results can help veterinary surgeons to provide better evidence on the risks to owners who may be contemplating breeding from their bitches. In addition, the results on the management and clinical trajectory of dystocia can facilitate clinical benchmarking and encourage clinical audit within primary care veterinary practice.

Increased rate of acute caesarean sections in women with epilepsy: results from the Oppland Perinatal Database in Norway

Background and purpose

Studies in women with epilepsy (WWE) regarding pregnancy and labour complications have disclosed contradictory results. Our purpose was to investigate whether WWE have a higher risk of acute caesarean section (CS) or pregnancy complications than women without epilepsy or women with other chronic diseases and, if we found a higher risk, to explore potential explanations.

Methods

The study used prospectively registered obstetric data from the Oppland Perinatal Database in the period 2001–2011, containing information on 18 244 births, including 110 singleton pregnancies in mothers with validated epilepsy. Data regarding epilepsy were collected retrospectively from medical records.

Results

Epilepsy was a significant risk factor for acute CS, breech presentation and low birth weight in offspring [odds ratio (OR), 1.93, 95% confidence interval (CI), 1.2–3.1; OR, 2.29, 95% CI, 1.2–4.6 and OR, 2.10, 95% CI, 1.0–4.2, respectively]. In multivariate logistic regression analysis, antiepileptic drug exposure was an independent risk factor for acute CS (OR, 2.00; 95% CI, 1.06–3.77) and polytherapy was a significant risk factor for breech presentation (OR, 5.37; 95% CI, 1.13–25.57). Seizure frequency during pregnancy had no influence on the complication rate.

Conclusions

We found that WWE using antiepileptic drugs during pregnancy had increased rates of acute CS, breech presentation and low birth weight, and that seizure frequency during pregnancy did not influence the complication rate.

Obstetrical outcomes after vaginal repair of caesarean scar diverticula in reproductive-aged women

Background

Although vaginal repair has been conducted to manage caesarean scar diverticula, most studies evaluated only the gynaecological outcomes post-surgery, and their obstetrical outcomes were unknown. This study aimed to evaluate the obstetrical outcomes in vaginal repair-treated caesarean scar diverticula patients.

Methods

A series of 51 symptomatic women with caesarean scar defects or a thickness of the remaining muscular layer of less than 3 mm according to transvaginal ultrasound were included. We retrospectively evaluated the gynaecological and obstetrical outcomes after vaginal repair and histologically analysed the defect.

Results

Transvaginal ultrasound revealed that the thickness of the remaining muscular layer significantly increased from 2.24 ± 0.81 mm to 6.10 ± 1.43 mm 3 months after vaginal repair. The duration of menstruation significantly decreased from 14.29 ± 3.13 days to 8.31 ± 2.14 days post-vaginal repair. Notably, 26 of the 51 (50.98%) women who were followed for more than 15.04 months post-surgery achieved pregnancy. A total of 6 of the 26 pregnancies (23.08%) resulted in miscarriages, including 5 early miscarriages and 1 late miscarriage. Among the 20 women who achieved pregnancy without miscarriage, 18 had term deliveries, 2 had preterm birth, and none reported uterine rupture. Histological analysis was performed in all 51 cases. Muscle fibre density was significantly lower in the scar than in the myometrium adjacent to the scar and collagen expression was markedly increased in the scar tissue.

Conclusion

Satisfactory gynaecological and subsequent obstetrical outcomes can be achieved in vaginal repair-treated caesarean scar diverticula patients.

Impact of eating disorders on obstetric outcomes in a large clinical sample: A comparison with the HUNT study

OBJECTIVE

Current evidence from clinical studies suggests that having an active eating disorder (ED) during pregnancy is associated with unfavorable obstetric outcomes. However, the role of a lifetime diagnosis of ED is not fully understood. Variations in findings suggest a need for additional studies of maternal ED. This study aims to identify associations between a lifetime ED and obstetric outcomes.

METHOD

Data from a hospital patient register and a population-based study (The HUNT Study) were linked to the Medical Birth Registry in Norway. Register based information of obstetric complications (preeclampsia, preterm birth, perinatal deaths, small for gestational age (SGA), large for gestational age (LGA), Caesarean sections, and 5-min Apgar score) were acquired for 532 births of women with ED and 43,657 births of non-ED women. Multivariable regression in generalized estimating equations was used to account for clusters within women as they contributed multiple births to the dataset.

RESULTS

After adjusting for parity, maternal age, marital status, and year of delivery, lifetime history of anorexia nervosa was associated with increased odds of having offspring who were SGA (Odds ratio (OR) 2.7, 95% Confidence Interval (CI) 1.4-5.2). Women with a lifetime history of bulimia nervosa had higher odds of having a Caesarian section (OR 1.7 95% CI 1.1-2.5). Women with EDNOS/sub-threshold ED had a higher likelihood of having a low Apgar score at 5 min (OR 3.1, 95% CI 1.1-8.8).

CONCLUSION

Our study corroborates available evidence on the associations between maternal ED and adverse obstetric outcomes.

Determinants of caesarean section in Bangladesh: Cross-sectional analysis of Bangladesh Demographic and Health Survey 2014 Data

BACKGROUND

Caesarean section (CS) has been on the rise worldwide and Bangladesh is no exception. In Bangladesh, the CS rate, which includes both institutional and community-based deliveries, has increased from about 3% in 2000 to about 24% in 2014. This study examines the association of reported complications around delivery and socio-demographic, healthcare and spatial characteristics of mothers with CS, using data from the latest Bangladesh Demographic and Health Survey (BDHS).

METHODS

The study is based on data from the 2014 BDHS. BDHS is a nationally representative survey which is conducted periodically and 2014 is the latest of the BDHS conducted. Data collected from 4,627 mothers who gave birth in health care institutions in three years preceding the survey were used in this study.

RESULTS

Average age of the mothers was 24.6 years, while their average years of schooling were 3.2. Factors like mother being older, obese, residing in urban areas, first birth, maternal perception of large newborn size, husband being a professional, had higher number of antenatal care (ANC) visits, seeking ANC from private providers, and delivering in a private facility were statistically associated with higher rates of CS.

CONCLUSIONS

Bangladesh health system urgently needs policy guideline with monitoring of clinical indications of CS deliveries to avoid unnecessary CS. Strict adherence to this guideline, along with enhance knowledge on the unsafe nature of the unnecessary CS can achieve increased institutional normal delivery in future; otherwise, an emergency procedure may end up being a lucrative practice.

Family Planning and Pregnancy Management in Adults with Congenital Heart Disease

With advances in congenital heart disease management, there are an increasing number of women reaching reproductive age. Pregnancy results in a surge of hormones and increased demands on both the cardiovascular (CV) and respiratory systems. Depending on the heart defect and the treatments the mother has undergone, these hemodynamic changes can result in an increased risk of maternal CV events and an increased risk of fetal morbidity and mortality. Thus, it is important to have a comprehensive approach to adult congenital heart disease patients involving pre-pregnancy planning in addition to diligent peri- and post-partum care.

A Case of Pelvic Abscess Caused by Edwardsiella tarda followed by Laparoscopic Resection of a Hematoma Derived from Caesarean Section

Edwardsiella tarda (E. tarda) infections are rare and can be fatal. We report a case of an E. tarda abscess which developed in the hematoma originally derived from a caesarean section. A 24-year-old gravida 1 woman was admitted to our hospital with a complaint of abdominal pain. Approximately one month before her admission, pelvic hematoma had developed derived from caesarean section. Followed by the failure of conservative management, she underwent laparoscopic surgery to remove the hematoma 6 days before her admission. On computed tomography examination, we found that the abscess with a diameter of 9 cm was located in the right pelvic space. We punctured the abscess and identified E. tarda in the abscess. We continued administering antibiotics, but her symptoms, including fever and abdominal pain, became worse, and the abscess enlarged. We performed laparotomy drainage and ileocecal resection on the 10th posthospitalization day. After drainage surgery, the patient's condition improved gradually, and the patient was discharged uneventfully. There are no reports in patients of E. tarda infection during the perinatal period. E. tarda infection can be a life-threatening illness even in immunocompetent patients. In the case of E. tarda infection, intensive care and surgical procedures should be considered.

Factors Associated with Cesarean Section in Tehran, Iran using Multilevel Logistic Regression Model

Objectives

Over the past few decades, the prevalence of cesarean sections (CS) have risen dramatically worldwide, particularly in Iran. The aim of this study was to determine the prevalence of CS in Tehran, and to examine the associated risk factors.

Methods

A cross-sectional study of 4,308 pregnant women with singleton live-births in Tehran, Iran, between July 6–21, 2015 was performed. Multilevel logistic regression analysis was performed using demographic and obstetrical variables at the first level, and hospitals as a variable at the second level.

Results

The incidence of CS was 72.0%. Multivariate analysis showed a significant relationship between CS and the mother’s age, socioeconomic status, body mass index, parity, type of pregnancy, preeclampsia, infant height, and baby’s head circumference. The intra-class correlation using the second level variable, the hospital was 0.292, indicating approximately 29.2% of the total variation in the response variable accounted for by the hospital.

Conclusion

The incidence of CS was substantially higher than other countries. Therefore, educational and psychological interventions are necessary to reduce CS rates amongst pregnant Iranian women.

Women's preference for caesarean section and the actual mode of delivery - Comparing five sites in Norway

OBJECTIVES

The caesarean (CS) section rate varies among hospitals in Norway, and little is known about whether this is influenced by women's preferences. The aim of this study was to investigate the differences in women's preferred mode of delivery during pregnancy between five hospitals in Norway, and to relate this to the actual mode of delivery.

STUDY DESIGN

A prospective cohort study of 2,177 unselected pregnant women in five hospitals in Norway. Women were recruited at their standard ultrasound examinations, and data was collected through questionnaires and electronic patient charts. The exposure was a CS preference and the main outcome measure was the actual mode of delivery.

RESULTS

In total, 3.5% of the primiparous women and 9.6% of the multiparous women reported a preference for CS. This was associated with fear of childbirth and education between 10 and 13 years in both groups, symptoms of depression and an age over 35 years old among the primiparous women, and a previous CS and/or negative birth experience among the multiparous. The multiparous women in Drammen and Tromsø were less likely to prefer a CS, and none of the primiparous women in Tromsø preferred a CS. A total of 67.8% of those who preferred a CS gave birth with this mode of delivery.

CONCLUSION

There were significant differences between the hospitals according to the CS preference. This preference was associated with the previous obstetric history and psychological factors. Therefore, creating good birth experiences and offering women counselling may reduce the CS preference rate.

Association Between Mode of Delivery and Risk of Infection in Early Childhood: A Cohort Study

BACKGROUND

Infections are the leading cause of morbidity and mortality in children. Caesarean section as a potential risk factor for infection has recently gained interest. Delivery by caesarean section has increased greatly, with nonmedical reasons playing an increasing role. We aimed to analyze the association between mode of delivery and hospitalizations because of infection and symptoms of infection at home in early childhood.

METHODS

A cohort study, based on the Odense Child Cohort, following infants from gestation until a mean age of 3.5 years. Data on hospitalization because of infections were collected from the Danish National Patient Registry. Data on symptoms of infection at home were collected via a text message-based questionnaire.

RESULTS

A total of 1921 children were born by vaginal delivery, 283 by elective caesarean section and 227 by acute caesarean section. An adjusted regression model showed an incidence rate ratio for hospitalizations because of infection in children born by elective caesarean section compared with children born by vaginal delivery of 1.45 (95% confidence interval: 1.16-1.80; P = 0.001). The analyses on symptoms of infection at home found no associations between any symptom of infection and mode of delivery. Symptom-specific subanalyses showed contrasting results.

CONCLUSIONS

Mode of delivery showed a strong association to hospitalization because of infectious disease during early childhood. Overall, no association was present between rate of symptoms of infection at home and mode of delivery.

Effect of intra-operative glove changing during cesarean section on post-operative complications: a randomized controlled trial

PURPOSE

To compare the rates of wound-related complications among women undergoing a cesarean section when the surgical team used intra-operative glove changing versus usual care.

METHODS

All women undergoing a cesarean section at a single, county hospital were randomized to usual care or intra-operative glove changing prior to abdominal closure. Participants were randomized at the time of decision for cesarean section; surgeons were not blinded to the randomization arm. The primary outcome was any wound-related complication, including wound hematoma, seroma, skin separation of at least 1 cm, wound infection, or other incisional abnormality requiring treatment within 8 weeks of surgery. To detect a reduction in the primary outcome from 17% in the control group to 9% in the intervention group with 80% power, a total of 554 women (277 per group) were required. Secondary outcomes included other infectious complications including endometritis and other superficial or deep soft tissue infections.

RESULTS

From August 2015 to November 2016, 277 women were randomized to usual care and 276 women were randomized to intra-operative glove changing. The two groups were well balanced in terms of demographic data, comorbid conditions and surgical characteristics. Intra-operative glove changing led to a significant decrease in composite wound complications from 13.6% in the control group to 6.4% in the intervention group (p = 0.008).

CONCLUSION

Intra-operative glove changing prior to abdominal closure during cesarean section significantly reduced the incidence of post-operative wound complications.