Emergent (crash) cesarean delivery: indications and outcomes

["Red code" C-sections: A new tool developed with Delphi method is enabling analysis of practices]

OBJECTIVE

In France, C-sections are classified through a color code according to their degree of urgency. A red-classified C-section is triggered when life of mother or fetus is immediately threatened These cases happen very rarely and represent less than 1% of total deliveries. Many French maternity hospitals are above this rate. This risky procedure should remain an exception. The main purpose of this study is to develop a new tool enabling to determine the relevance of red C-sections in order to improve obstetrical practices.

METHODS

Eleven national obstetrical experts were submitted with relevant-estimated indications of red C-sections. A two-round Delphi methodology was then used to reach a consensus on a new table of relevance.

RESULTS

Five different groups of indications were proposed to the panel of experts. After two rounds, four groups achieved a consensus by being qualified "very relevant" or "relevant" by more than 80% of the 11 experts.

CONCLUSION

The aim of this new consensual table of relevance is to improve quality of care. It allows to evaluate the relevance of red C-sections and determine when red C-sections are non-relevant but it particularly helps teams to identify ways of improvements. Finally, this tool enables a reproductible analysis that can be further intra- or inter-hospitals developed towards harmonization of practices.

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis

OBJECTIVE

Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR.

STUDY DESIGN

We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY).

RESULTS

In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis.

CONCLUSION

Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources.

KEY POINTS

· Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..

Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes

BACKGROUND

Pregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood.

OBJECTIVE

This study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients.

STUDY DESIGN

This was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity.

RESULTS

Of 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50-6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant.

CONCLUSION

Almost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

BACKGROUND

To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

STUDY DESIGN

An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS).

RESULTS

A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

CONCLUSIONS

A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Examining the effects of second-and third-trimester gestational weight gain rates on the perinatal outcomes among Chinese twin pregnancies: a retrospective cohort study

Background

This paper investigated how second- and third-trimester gestational weight gain relates to perinatal outcomes among normal weight women with twin pregnancies in Fujian, China.

Methods

A retrospective study examining the medical records of 931 normal weight twin-pregnant women was conducted in Fujian Maternity and Child Health Hospital from 2014 to 2018.The 2^nd and 3^rdtrimester weekly weight gain rates were calculated, and women were categorized as gaining below, within, or above the 2009 Institute of Medicine (IOM) recommended rates. The association between the trimester-specific weight gain rate and perinatal outcome was determined by traditional regression analysis among groups.

Results

A total of 25.9%, 19.8% and 54.3% of women had rates of weight gain across the 2^nd and 3^rd trimesters less than, greater than or within the recommended rates respectively. Multivariate logistic regression analysis showed that weight gain greater than the recommended rate in the 2^nd trimester was associated with a decreased risk of preeclampsia (aOR:0.489,95%CI:0.289 ~ 0.974). Weight gain less than the recommended rate of weight gain in the 3^rd trimester was associated with increased risks of premature delivery(aOR:2.079, 95%CI:1.467 ~ 2.968), gestational diabetes mellitus (aOR: 2.048, 95%CI:1.411 ~ 2.971), intrahepatic cholestasis syndrome (aOR:3.015,95%CI: 1.058 ~ 8.587), pre-labour rupture of membrane (aOR: 1.708,95%CI: 1.169 ~ 2.493), average twin birth weight < 2500 g(aOR:1.532,95%CI: 1.125 ~ 2.084) and neonatal respiratory distress syndrome (aOR:4.934,95%CI:1.626 ~ 15.083) and was associated with decreased risks of caesarean section (aOR:0.589,95%CI:0.386 ~ 0.898) and preeclampsia (aOR:0.471, 95%CI:0.274 ~ 0.808). In addition, weight gain greater than the recommended rate of weight gain in the 3^rd trimester was associated with increased risks of premature delivery (aOR:1.589,95%CI:1.428 ~ 2.951) and gestational hypertension (aOR:2.137,95% CI:1.034 ~ 4.415) as well as preeclampsia (aOR:2.246, 95%CI:1.462 ~ 3.452). The stratified analysis of weight gain in the 3^rd trimester showed that there was no significant difference in the incidence of adverse pregnancy outcomes compared to the 2^nd trimester weight gain groups.

Conclusions

While this study showed that a gestational weight gain rate above or below the recommendation in the 3^rd trimester was associated with some adverse maternal and neonatal outcomes, further prospective and multicentre studies are required to explore alternate ranges of gestational weight gain rates in twin pregnancies.

Non-reassuring fetal status and anesthetic impact on cesarean section-delivered very-low-birthweight infants

BACKGROUND

There is limited evidence concerning the impact on neonatal outcomes of different types of anesthesia used for cesarean delivery due to non-reassuring fetal status (NRFS). We aimed to assess the impact of NRFS and general anesthesia (GA) on neonatal outcomes in very-low-birthweight (VLBW) infants delivered by cesarean section.

METHODS

Data were collected relating to VLBW infants admitted to our institution. Infants were grouped into no-NRFS and NRFS groups and further subcategorized into GA and regional anesthesia (RA) subgroups. Neonatal outcomes were evaluated based on the presence of NRFS and the type of anesthesia.

RESULTS

A total of 356 infants were included. The GA subgroup in the no-NRFS group had higher requirements for respiratory support. However, GA was not associated with adverse neonatal outcomes based on the multivariable logistic regression analysis except for 5 min Apgar score <5. On the other hand, NRFS was associated with an increased risk of 5 min Apgar score <5 [adjusted odds ratio (aOR) 2.062, 95% confidence interval (CI) 1.064-3.997], use of high-frequency ventilation (aOR: 2.891, 95% CI: 1.477-5.658), and pulmonary hypertension (aOR: 2.890, 95% CI: 1.436-5.819).

CONCLUSIONS

In our cohort of VLBW infants, NRFS was a significant risk factor for a low 5 min Apgar score, increased respiratory support requirement, and pulmonary hypertension. Accurate assessment of fetal well-being, timely delivery, and presence of a resuscitation team fully aware of perinatal conditions and anesthetic impact is important.

Umbilical cord prolapse: revisiting its definition and management

Umbilical cord prolapse is an unpredictable obstetrical emergency with an incidence ranging from 1 to 6 per 1000 pregnancies. It is associated with high perinatal mortality, ranging from 23% to 27% in low-income countries to 6% to 10% in high-income countries. In this review, we specifically addressed 3 issues. First, its definition is not consistent in the current literature, and "occult cord prolapse" is a misnomer because the cord is still above the cervix. We proposed that cord prolapse, cord presentation, and compound cord presentation should be classified according to the positional relationship among the cord, the fetal presenting part, and the cervix. All of them may occur with either ruptured or intact membranes. The fetal risk is highest in cord prolapse, followed by cord presentation, and lastly by compound cord presentation, which replaces the misnomer "occult cord prolapse." Second, the mainstay of treatment of cord prolapse is urgent delivery, which means cesarean delivery in most cases, unless vaginal delivery is imminent. The urgency depends on the fetal heart rate pattern, which can be bradycardia, recurrent decelerations, or normal. It is most urgent in cases with bradycardia, because a recent study showed that cord arterial pH declines significantly with the bradycardia-to-delivery interval at a rate of 0.009 per minute (95% confident interval, 0.0003-0.0180), and this may indicate an irreversible pathology such as vasospasm or persistent cord compression. However, cord arterial pH does not correlate with either deceleration-to-delivery interval or decision-to-delivery interval, indicating that intermittent cord compression causing decelerations is reversible and less risk. Third, while cesarean delivery is being arranged, different maneuvers should be adopted to relieve cord compression by elevating the fetal presenting part and to prevent further cord prolapse beyond the vagina. A recent study showed that the knee-chest position provides the greatest elevation effect, followed by filling of the maternal urinary bladder with 500 mL of fluid, and then the Trendelenburg position (15°) and other maneuvers. However, each maneuver has its own advantages and limitations; thus, they should be applied wisely and with great caution, depending on the actual clinical situation. Therefore, we have proposed an algorithm to guide this acute management.

Transperineal ultrasound assessment of fetal head elevation by maneuvers used for managing umbilical cord prolapse

OBJECTIVE

To assess objectively the degree of fetal head elevation achieved by different maneuvers commonly used for managing umbilical cord prolapse.

METHODS

This was a prospective observational study of pregnant women at term before elective Cesarean delivery. A baseline assessment of fetal head station was performed with the woman in the supine position, using transperineal ultrasound for measuring the parasagittal angle of progression (psAOP), head-symphysis distance (HSD) and head-perineum distance (HPD). The ultrasonographic measurements of fetal head station were repeated during different maneuvers, including elevation of the maternal buttocks using a wedge, knee-chest position, Trendelenburg position with a 15° tilt and filling the maternal urinary bladder with 100 mL, 300 mL and 500 mL of normal saline. The measurements obtained during the maneuvers were compared with the baseline measurements.

RESULTS

Twenty pregnant women scheduled for elective Cesarean section at term were included in the study. When compared with baseline (median psAOP, 103.6°), the knee-chest position gave the strongest elevation effect, with the greatest reduction in psAOP (psAOP, 80.7°; P < 0.001), followed by filling the bladder with 500 mL (psAOP, 89.9°; P < 0.001) and 300 mL (psAOP, 94.4°; P < 0.001) of normal saline. Filling the maternal bladder with 100 mL of normal saline (psAOP, 96.1°; P = 0.001), the Trendelenburg position (psAOP, 96.8°; P = 0.014) and elevating the maternal buttocks (psAOP, 98.3°; P = 0.033) gave modest elevation effects. Similar findings were reported for HSD and HPD. The fetal head elevation effects of the knee-chest position, Trendelenburg position and elevation of the maternal buttocks were independent of the initial fetal head station, but that of bladder filling was greater when the initial head station was low.

CONCLUSIONS

To elevate the fetal presenting part, the knee-chest position provides the best effect, followed by filling the maternal urinary bladder with 500 mL then 300 mL of fluid, respectively. Filling the bladder with 100 mL of fluid, the Trendelenburg position and elevation of the maternal buttocks have modest effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluating the Decision-to-Delivery Interval in Emergency Cesarean Sections and its Impact on Neonatal Outcome

BACKGROUND/AIM

In Germany, performance of an emergency Cesarean section (ECS) is recommended within an interval of ≤20 min from decision to delivery (DDI). The aim of the study was to assess the duration of DDI in ECS as well as its impact on neonatal outcome.

PATIENTS AND METHODS

Data from 437 patients at a single, tertiary care hospital were retrospectively analysed regarding influence on the duration of DDI. Subsequently the impact of DDI on neonatal outcome and incidence of adverse neonatal outcome was analysed.

RESULTS

DDI of ECS performed outside core working hours was significantly prolonged (p<0.001). Shorter DDI showed a statistically worse arterial cord blood pH (p=0.001, r=0.162) and base excess (p=0.05; r=0.094). Duration of DDI had no significant impact on the incidence of adverse neonatal outcome (p=0.123).

CONCLUSION

Awareness of influence on DDI might contribute to expediting DDI, but duration of DDI showed no impact on the incidence of adverse neonatal outcome. Data were not adequate to suggest a recommendation for DDI time standards.

Cesarean section complications according to degree of emergency during labour

OBJECTIVE

Evaluate the complications rate of cesarean section delivery based on degree of labour emergency.

STUDY DESIGN

Monocentric (Lille, France), retrospective study of all term, singleton, and cesarean deliveries during labour. Three groups were categorized based on the degree of emergency according to a color code: green (no time limit between surgical decision and birth), orange (birth within 30 min), and red (birth within 20 min). Scheduled cesareans were excluded. Complications were defined as minor/major and intra-/post-operative.

RESULTS

A total of 881 patients were included. Among these, 303 (34.5 %) were in the green group, 353 (40.1 %) in the orange group, and 225 (25.4 %) in the red group. Major intra-operative complications, mainly postpartum hemorrhage, were more frequent in the red group compared with the green group (16.9 % vs. 9.9 %, p = 0.05; OR 1.9; 95 % CI [1.1-3.1]). Among the minor complications, there was no difference on moderate postpartum hemorrhage and four times uterine artery wounds in the red group (1.7 % vs. 7.1 %, respectively; p = 0.007; OR 4.6; 95 % CI [1.6-12.6]). The overall major post-operative complication rate, mainly infectious morbidity, was 6.1 % and this was more frequent in the red group compared with the green group (12.4 % vs. 1.7 %, respectively; p < 0.0001; OR 8.5; 95 % CI [3.2-22.3]).

CONCLUSION

Pre- and post-operative complications of cesarean section delivery during labour (i.e., emergency cesarean) increase with the degree of labour emergency. It would be ideal to identify women in labour who are at increased risk of emergency cesarean earlier, so that the situation does not escalate to a red code cesarean.

Prolonged Fetal Heart Rate Decelerations in Labor: Can We Reduce Unplanned Primary Cesarean Sections in This Group?

INTRODUCTION

Non-reassuring fetal tracing is the second leading cause of primary cesarean delivery in the United States. Prolonged fetal heart rate decelerations are non-reassuring fetal heart rate characteristics, which do not uniformly predict poor fetal outcome but can prompt obstetricians to proceed with cesarean delivery. The objective of this manuscript is to identify a strategy to reduce the primary cesarean section rate in patients with prolonged fetal heart rate decelerations in labor.

METHODS

This is a retrospective cohort study over a 5-year period at an academic medical center, including patients undergoing primary cesarean section following labor induction, augmentation, or spontaneous labor who were noted to have prolonged fetal heart rate deceleration(s) in the 1 h prior to the time of delivery. Two groups were compared: "crash" cesarean sections versus "emergent" cesarean sections. The primary outcome was if fetal heart tones were rechecked in the operating room prior to cesarean section incision. Secondary outcomes included maternal-fetal monitoring versus Doppler fetal heart tones in the operating room, return to baseline noted in the operating room, fetal outcomes, fetal monitoring characteristics, and anesthesia type between crash versus emergent groups.

RESULTS

Of 1969 term singleton cesarean sections, 119 patients met our inclusion criteria (emergent group n = 80) (crash group n = 39), which accounted for 13.9% of all primary cesarean sections during the study period. The emergent group had a significantly higher rate of reassessment of fetal heart tones in the operating room n = 61 (76.2%) versus the crash group n = 15 (38.4%) (p ≤ 0.0001). There were no statistically significant differences regarding fetal outcomes between the two groups. The crash group had a higher rate of category 1 fetal heart rate tracing prior to the prolonged deceleration, a longer median prolonged deceleration, and a deeper median nadir of the prolonged deceleration; these differences were statistically significant. The prolonged-to-delivery interval was significantly shorter in the crash group (median = 15 min) than tin he emergent group (median = 33 min) (p ≤ 0.0001). The crash group also had a higher rate of general anesthesia (n = 11, 28.2%) than the emergent group (n = 6, 7.5%) (p = 0.002). The crash group was specifically investigated. Of the 15 patients with fetal heart tones rechecked in the crash group, 7 had returned to baseline in the operating room, but underwent cesarean section without fetal monitoring.

CONCLUSION

Our results indicate that the practice of placing patients on fetal monitor upon arrival to the operating room prior to performing crash cesarean delivery could reduce the rate of primary cesarean deliveries performed for prolonged decelerations in labor. When fetal heart tones have returned to baseline upon arrival in the operating room, the decision to proceed with cesarean delivery can be reconsidered. However, many clinical factors must be taken into consideration, and the decision to proceed is ultimately at the discretion of the obstetrics provider.

Gestational weight gain targets during the second and third trimesters of pregnancy for women with gestational diabetes mellitus in China

BACKGROUND/OBJECTIVES

Gestational weight gain (GWG) recommendations for pregnant women with gestational diabetes mellitus (GDM) in China are lacking. The present study aims to examine whether specific GWG targets for women with GDM can improve pregnancy outcomes in comparison with GWG according to the Institute of Medicine (IOM) targets.

SUBJECTS/METHODS

Pregnant women diagnosed with GDM were selected from a retrospective cohort study of 8299 singleton pregnant women aged 18-45 years in 2012 (n = 1820). GWG ranges were calculated using a receiver operating characteristic (ROC) curve analysis (ROC targets) and the interquartile range (IR) method (the range from the 25th to 75th percentiles of the GWG among GDM women without adverse pregnancy outcomes, IR targets).

RESULTS

The incidences of small for gestational age (SGA) births and pregnancy hypertension among women with GDM who gained weight within the ROC targets were lower than the incidences in women who gained weight within the IOM targets (SGA, 7.5% vs. 8.6%; pregnancy hypertension, 12.6% vs. 14.1%; both P < 0.05). GWG was associated with a risk of adverse pregnancy outcomes in the total sample (estimated values ranged from -2.95 to 2.08, all P < 0.05). No statistically significant associations between GWG and adverse pregnancy outcomes were observed in subgroups of pregnant women with appropriate GWGs according to the ROC, IR, and IOM targets. The ROC targets exhibited higher negative predictive values for adverse pregnancy outcomes than the IR and IOM targets.

CONCLUSION

The ROC targets improved pregnancy outcomes and thus represent potential special GWG guidelines for women with GDM in China.

Decision-to-Delivery Time and Perinatal Complications in Emergency Cesarean Section

BACKGROUND

A decision-to-delivery interval (DDI) of no more than 20 minutes has long been considered a requirement for cesarean sections, even though there have hardly been any studies on this topic. We retrospectively investigated data relevant to DDI for emergency cesarean sections performed for the most common indications, namely, suspected and documented fetal asphyxia.

METHODS

We analyzed data on emergency in-hospital cesarean sections in the period 2008-2015. Low 5- and 10-minute Apgar scores (a scheme with points awarded for breathing, heart rate, muscle tone, skin coloration, and the elicitability of reflexes) were the primary endpoints; acid-base status in arterial cord blood and in-hospital neonatal death were the secondary endpoints. The raw analysis was supplemented by an analysis adjusted for various factors including gestational age, maternal age, and obstetrical presentation.

RESULTS

Data from 39 291 neonates were included. The DDI was up to 10 minutes in 64.6% of cases, from 11 to 20 minutes in 34.3%, and over 20 minutes in 1.1%. Low Apgar scores were less common in children whose emergency cesarean sections were performed within 10 minutes or within 20 minutes. For example, the adjusted odds ratio for a 10-minute Apgar score below 4 was 0.49 (95% confidence interval [0.25; 0.96] when a DDI of more than 20 minutes was used as the reference criterion.

CONCLUSION

This is the largest population-based, risk-adjusted analysis to be carried out on this topic to date. It reveals, for the first time, an association between DDI of 20 minutes or less and the avoidance of outcomes that are dangerous to the child. As it is not possible to predict such obstetrical emergencies in advance, it seems reasonable to ensure the availability of caredelivery structures that make it possible for emergency cesarean sections to be performed within 20 minutes of the decision to do so.

[Compliance to the color codes protocol according to the indication of cesarean and to the decision-to-delivery interval]

OBJECTIVE

Evaluation of the compliance of the color codes protocol according to the indication of ceasarean section and on the decision-to-delivery interval according to the color code, the operator and the period.

METHODS

This is a retrospective monocentric study including women who had to undergo an emergency cesarean section after 37 weeks of amenorrhea in the Jeanne-de-Flandre hospital between 2015 and 2017. Three groups were created: cesarean section with green code, orange code and red code. We compared population characteristics and obstetrical data, then drew up a reassessed color code and analyzed the correspondence between the initial color code and the reassessed one. Finally, we considered the respect of decision-to-delivery interval according to color code, operator level and period.

RESULTS

Eight hundred and eighty-one patients were included, amongst which 303 (34%) fell into the green c-section, 353 (40%) into the orange c-section and 225 (26%) into the red c-section. In the three groups, there was a significant consistency between the initial color code and the reassessed one, with a kappa agreement test of 95% 0.95 (0.93-0.97). The average decision-to-delivery interval was 37±20min for the green c-section, 20±6min for the orange c-section and 12±3min for the red c-section with a significant respect of the decision-to-delivery interval according to color code P<0.001. The decision-to-delivery interval was similar considering the operator level and the period.

CONCLUSION

In our study, we observed the compliance with color code regarding the indication of ceasarean section and the respect of the decision-to-delivery interval whatever the time of occurrence and the operator.

Does an Immigrant Background Affect the Indication, Incidence or Outcome of Emergency Cesarean Section? Results of the Prospective Data Collection of 111 Births

OBJECTIVES

Does the incidence and/or indication(s) for emergency cesarean section differ if the pregnant woman has an immigrant background (IB)? Does a lack of language proficiency (communication problems) and a low acculturation level result in a longer decision-to-delivery interval (D-D interval)? Are neonates born to women with IB by emergency cesarean section in a poorer condition post delivery?

PATIENT COHORTS AND METHOD

Standardized interviews were carried out before or immediately after delivery in three Berlin obstetric hospitals. Questions were asked about the sociodemographic background and care aspects as well as about immigration and level of acculturation. Collected data were linked to information obtained from the expectant mother's antenatal records and to care data and perinatal data routinely recorded by the hospitals. Data was analyzed using regression models which adjusted for age, parity, and socio-economic status.

RESULTS

The total patient population consisted of 7100 women (rate of response: 89.6%); of these women, 111 required emergency cesarean section (50 women without IB, 61 immigrant women). Risk factors such as late first antenatal check-up, gestational diabetes, pregnancy-induced hypertension, fetal macrosomia, smoking, and weight gain were similar in both patient cohorts. The incidence of and indications for emergency cesarean section and the D-D interval were similar for both groups. Limited German language proficiency and low levels of acculturation among immigrant women did not prolong the D-D interval. There were no statistically relevant differences between immigrant and non-immigrant cohorts with regard to adverse neonatal conditions (5-minute Apgar score ≤ 7, umbilical cord arterial pH < 7.00) or with regard to immediate transfer of the neonate to a pediatric clinic following emergency cesarean section.

CONCLUSION

The factor "immigrant background" did not affect the indication or obstetric outcome following emergency cesarean section.

Pregnancy in a woman with a Fontan circulation: A review

More women with congenital heart disease survive to childbearing ages, due to improvements in surgical practice and postoperative care. This review discusses pregnancy in women with a single ventricle, describing maternal obstetric and cardiovascular complications and the increased risks of prematurity and adverse neonatal outcomes. Recommendations are made based on current understanding, guidelines and published literature, with recognition that there is much knowledge yet to be gained.

Assessment of an urgency classification for assisted vaginal delivery

We performed a prospective observational audit to evaluate the application of the Lucas caesarean section urgency classification to assisted vaginal delivery in the operating theatre. We collected data from 400 women having category 1-3 delivery in the operating theatre. Twenty percent of the caesarean sections and 4% of the vaginal deliveries were category 1. The median (IQR) decision-delivery interval was 25 (19.5-37) min for category 1 caesarean section and 19.5 (15-29) min for category 1 vaginal delivery, and 43.5 (36-57) min and 45 (32-57) for category 2 caesarean section and vaginal delivery, respectively. Sixty-three percent of category 1 caesarean section and 75% of category 1 vaginal delivery were performed in ≤30 min. Antenatal or intrapartum risk factors were present before the decision for delivery in 82% of caesarean sections and 80% of vaginal deliveries. The application of the Lucas urgency classification to assisted vaginal delivery merits further evaluation.

The effect of the use of a new type of partogram on the cesarean section rates

OBJECTIVE

To assess the contribution of a new type of partogram, used in labor monitoring, in caesarean section rates.

MATERIAL AND METHODS

The study included term singleton uncomplicated pregnancies divided into two groups. Two types of partogram were used in labor monitoring. In the first group, the classical WHO partogram (A) was used. In the second group, a new type of partogram, in which cervical dilatation and the position of descending head (B) (one line) were estimated and reported, was used. The labor duration and caesarean section rates were calculated and compared in the two groups.

RESULTS

A statistically significant decrease in labor duration (from the initiation of the active phase of labor to the delivery time) (dt1+dt2+dt3) (p<0.001, A: median: 318.4±10.4 min, B: 246.56±8.28 min) and in caesarean section rates was noted (p<0.001, A: 89 vs B: 49).

CONCLUSION

The new type of partogram seems to have potential benefits such as reducing the incidence of prolonged labor and decreasing the caesarean section rates.

Is there a safe limit of delay for emergency caesarean section in Ghana? Results of analysis of early perinatal outcome

OBJECTIVE

To determine the limits of delaying caesarean section in a busy obstetric unit in a developing country setting that is not associated with neonatal survival.

METHODS

Retrospective cohort study of emergency cesarean sections. Indications were sub-divided into imminent threat and no imminent threat to fetal wellbeing. The primary outcomes was a composite measure of adverse perinatal outcome including stillbirth, 5-minute Apgar score < 7 and neonatal intensive care unit admission. Effect of decision-to-delivery interval on perinatal outcomes was evaluated using Kaplan-Meier survival analysis.

RESULTS

495 women met inclusion criteria (142 'imminent threat' group, 353 'no imminent threat' group). The median decision-to-delivery interval was significantly shorter in the 'imminent threat' group (2.25 [95% CI 1.38 - 5.83] versus 3.42 [95% CI 1.83 - 5.85] hours, p <0.001). Only 1.7% and 12.7% sections were performed within 30 minutes and 1 hour, respectively. Risk of the composite outcome was significantly higher in the 'imminent threat group (46.5% versus 31.2%, RR=1.49 [95% CI 1.18 - 1.89], p=0.001). A 95% probability of 'live intact' survival occurred at 1 hr and 2 hrs respectively, for the imminent threat and the no imminent threat groups.

CONCLUSION

Increasing decision-to-delivery interval is associated with higher risk of adverse perinatal outcomes, but a 95% live intact survival can be achieved if the delivery occurs within 2 hours.

Enhancing midwives' scope of practice: an innovative educational program for delivery suite operating rooms

BACKGROUND

This retrospective study examined the enhancement of practice, knowledge, and skill of delivery suite midwives undertaking the circulating and instrument roles during emergent caesarean sections following a tailored educational program implemented to the benchmark standard.

METHOD

All midwives who attended the educational program were invited to participate (N = 48); a total of 20 responses were received. Descriptive data analysis of the bivariate nominal data was performed.

RESULTS

Clinically significant outcomes were noted across all theme areas: knowledge of the Australian College of Operating Room Nurses standards, competence and knowledge of the main roles during a caesarean section, knowledge of policies and procedures, and patient safety. An improved working relationship between the perioperative and delivery ward staff also was identified.

CONCLUSION

An educational program for midwives on the instrument and circulating roles for caesarean sections provides the knowledge and skill development required for clinically safe practice.

Decision - delivery interval and perinatal outcome of emergency caesarean sections at a tertiary institution

Background and objective: A decision-to-delivery interval (DDI) of 30 minutes for emergency Caesarean sections (CS) has been widely recommended, but there is little evidence to support it. Recent studies however, have questioned not only the practicability of this target but also its anticipated beneficial effect on neonatal outcome and medico-legal implications. Our objective in this study was to find out the time between decision-delivery interval and perinatal outcome of emergency caesarean section at a tertiary care institution in Nigeria

Methods: This was a retrospective study of cases of emergency Caesarean section performed over a 12-month period. Relevant data were collected from the labour ward and theatre records and case files of the University of Benin Teaching Hospital, Benin City, Nigeria between January 1 and December 31, 2012.

Results: A total of 352 emergency Caesarean sections done during the period were reviewed. Only 20 (5.7%) of these were performed within the recommended 30 minutes DDI. The mean DDI was 106.3 + 79.5 minutes and there was no significant correlation between DDI and perinatal outcome. The major causes of delay were anaesthetic delay and busy theatre suits.

Conclusion: This study demonstrated a lack of correlation between DDI and perinatal outcome, which may indicate decision delivery interval of 30 minutes or less may not be applicable to all emergency CS, especially in developing countries with infrastructural challenges. However when faced with acute or catastrophic foetal or maternal conditions, expedited delivery is indicated.

Prospective risk of abruptio placentae

AIM

The aim of this study was to better characterize the nature of abruptio placentae (AP) with regard to the timing of onset.

MATERIAL AND METHODS

Prevalence and prospective risk of AP according to gestational week (GW) were determined among 293,899 women who gave birth to singleton infants at and after GW 30. The prospective risk of AP at gestational week N was defined as the number of all women who experienced an AP at ≥GW N divided by the number of all women who gave birth at ≥GW N.

RESULTS

AP developed in 2649 (0.90%) women. The prevalence of AP (6.7% among women who gave birth at GW 30-33) sharply decreased with advancing GW at delivery to 0.9% for GW 37 and 0.1% for ≥GW 42. The highest prospective risk of AP, 9 per 1000 women at GW 30, decreased linearly with advancing gestation to 1 per 1000 women at ≥GW 42. AP accounted for 4.7% (1591/33,725) of all preterm births at GW <37, while prevalence of AP was 0.41% (1058/260,174) among term births. Preterm AP accounted for 60.1% (1591/2649) of all AP.

CONCLUSION

Our figures indicate that AP is more common in preterm births than in term birth and may be helpful for better understanding the epidemiology of this condition.

Labor induction by transcervical balloon catheter and cerebral palsy associated with umbilical cord prolapse

AIM

The aim of this study was to determine whether the use of transcervical balloon catheter (TCBC) for induction of labor (IOL) is a risk factor for cerebral palsy (CP) associated with umbilical cord prolapse (UCP-CP) in singleton pregnancies with cephalic presentation.

MATERIAL AND METHODS

Among all 102 infants with CP who were preliminarily determined as caused by antenatal and/or intrapartum hypoxemia by the Japan Council for Quality Health Care until April 2012, all 56 infants who met all of the following criteria were studied: cephalic singleton pregnancy, reassuring fetal status on electronic cardiotocogram at time of admission to obstetric facilities for labor pains, ruptured fetal membranes, and/or IOL, and hypoxic-ischemic encephalopathy at birth. Clinical backgrounds were compared between six infants with UCP-CP and the remaining 50 infants with CP not associated with UCP (non-UCP-CP).

RESULTS

Frequencies of IOL (83% [5/6] vs 32% [16/50], P = 0.0236), use of TCBC (67% [4/6] vs 10% [5/50], P = 0.0044), and amniotomy (67% [4/6] vs 24% [12/50], P = 0.0494) were significantly higher in the UCP-CP than the non-UCP-CP group. Only TCBC was a risk factor significantly associated with UCP-CP after logistic regression analysis, yielding an odds ratio of 18.0 (95% confidence interval, 2.6-124; P = 0.003). Saline volumes of 80-150 mL were used for TCBC inflation in the four UCP-CP patients.

CONCLUSION

Use of TCBC with a saline volume ≥ 80 mL was a significant risk factor for UCP-CP; however, the absolute risk of UCP-CP was estimated to be very low, approximately one in 7875 TCBC users.

Clinical features of abruptio placentae as a prominent cause of cerebral palsy

BACKGROUND

Although abruptio placentae causes hypoxia in the infant and thus leading to cerebral palsy (CP), its incidence and clinical features at a nationwide level have not been demonstrated.

AIMS

To determine the proportion of abruptio placentae among antenatal and intrapartum causative factors leading to cerebral palsy (CP) and clinical features of such abruptio placentae.

STUDY DESIGN

A review was conducted in 107 infants with CP in whom CP was determined to be due to antenatal and or intrapartum hypoxic conditions by the Japan Council for Quality Health Care until April 2012.

RESULTS

Abruptio placenta was responsible for 28 (26%) of the 107 CP infants, and was the single leading causative factor of CP. Of these 28 women, 22 (79%) exhibited non-reassuring fetal status on admission to obstetric facilities at 36.2 ± 2.6 weeks of gestation and had neonates with umbilical cord arterial blood pH (base excess) of 6.728 ± 0.164 (-25 ± 5.4 mmol/L). In these 22 women, strong abdominal pain and/or profuse vaginal bleeding occurred 159 ± 99 min prior to admission to an obstetric facility, and the interval until delivery after admission was 47 ± 31 min. Hypertension or isolated proteinuria preceded clinical events in one (4.5%) and five (23%) of these 22 women, respectively.

CONCLUSIONS

Abruptio placentae was responsible for CP in one quarter of all cases determined to be due to antenatal and/or intrapartum hypoxic conditions in Japan. New strategies to shorten the interval until admission to an obstetric facility after onset of symptoms are urgently needed.

The immediately available physician standard

The promulgation of the immediately available physician standard has contributed to the rapid decline in vaginal birth after cesareans (VBACs). While having an immediately available obstetrician during a VBAC trial will reduce risk, it is not clear that similar advantage wouldn't also accrue to women without uterine scars. However, many hospitals can't staff up to that standard. In this article we suggest 1) set a goal of providing an immediately available team for all women in labor, 2) tailor informed consent to women's unique risks- unique because of their own risk profile (e.g., previous scar, hypertension, etc) or unique because of characteristics of the birthing site (e.g. a team is or is not available), 3) in smaller hospitals, if an immediately available team cannot be routinely provided, consideration should be given to bringing in a team for the occasional patient requesting a trial, and to allowing labor for lower risk trials.

Is there a doctor in the house? Standards of physician availability for laboring women

Unexpected emergencies requiring urgent intervention can arise in the course of labor even among uncomplicated pregnancies in low-risk women. The possibility of such emergencies requires that responsible practitioners be available for management. The recent National Institutes of Health-sponsored consensus conference on vaginal birth after cesarean delivery highlighted this issue in discussing alternate standards of "ready" and "immediate" availability. The merits, feasibility, and ethics of alternate systems for coverage of all laboring women have not been widely or previously discussed and are considered in this opinion. Although there are potential advantages to having a responsible practitioner immediately available, logistic and economic considerations will make immediate availability unfeasible in all centers and systems, particularly on smaller services where distance or other factors may limit the option of consolidation (ie, the merging of different hospitals' obstetric services). We discuss training, systems, and planning to optimize response to emergencies in all systems, whether practitioners are readily or immediately available. Finally, we suggest that the ethical principle of respect for autonomy argues that particularly where alternate systems exist, practitioners and patients discuss the details, merits, and limitations of individual centers' clinical systems and plans for responding to emergencies.

Mode of delivery: toward responsible inclusion of patient preferences

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.