Mode of delivery in antepartum stillbirths

Mode of delivery and outcomes among inborn extremely preterm singletons: A cohort study

INTRODUCTION

Cesarean delivery is the most common mode of delivery among extremely preterm infants but there are insufficient data regarding the best mode of delivery among extremely preterm singletons. The objective of this study was to compare the rate of death or severe neurodevelopmental impairment among extremely preterm singletons by actual mode of delivery.

MATERIAL AND METHODS

Observational study using prospectively collected data from 25 US medical centers. We included postnatally-treated singletons with birth weight 401-1000 g, gestational age 22 + 0/7-26 + 6/7 weeks, without a major birth defect, born 2006-2016. Death or severe neurodevelopmental impairment (Bayley Scales of Infant Development-3rd edition cognitive composite score<70, cerebral palsy (Gross Motor Function Classification Scale >3), bilateral blindness, or bilateral hearing loss) at 18-26 month follow-up were compared by mode of delivery (cesarean, vaginal including vertex or breech) using propensity score analysis to adjust for baseline characteristics.

RESULTS

There was no difference in death or severe neurodevelopmental impairment between cesarean and vaginal (vertex or breech) births (42.4% cesarean vs. 47.2% vaginal; adjusted odds ratio (aOR), 95% confidence intervals (CI); 1.03, 0.91-1.17). Both cesarean delivery (26.8% cesarean vs. 51.5% breech vaginal; aOR: 0.71; 95% CI: 0.55-0.92) and vertex vaginal delivery (28.5% vertex vaginal vs. 51.5% breech vaginal; aOR: 0.59; 95% CI: 0.45-0.76) were associated with lower mortality compared with breech vaginal delivery.

CONCLUSIONS

Among postnatally-treated extremely preterm singletons, there was no difference in death or severe neurodevelopmental impairment between cesarean or vaginal delivery. Both vertex vaginal and cesarean delivery were associated with lower mortality compared with breech vaginal delivery.

Postpartum readmission risk: a comparison between stillbirths and live births

BACKGROUND

Stillbirth occurs more commonly among pregnant people with comorbid conditions and obstetrical complications. Stillbirth also independently increases maternal morbidity and imparts a psychosocial hazard when compared with live birth. These distinct needs and burden may increase the risk for postpartum readmission after stillbirth.

OBJECTIVE

This study aimed to examine the risk for maternal postpartum readmission after stillbirth in comparison with live birth and to identify indications for readmission and the associated risk factors.

STUDY DESIGN

This was a retrospective cohort of patients with singleton stillbirths or live births, delivered at ≥20 weeks' gestation, who were identified from the 2019 Nationwide Readmissions Database. The primary outcome was all-cause readmission within 6 weeks of discharge from the childbirth hospitalization. The association between stillbirth (vs live birth) and risk for readmission was assessed using multivariable regression models with adjustment for maternal age, sociodemographic characteristics, maternal and obstetrical conditions, and delivery characteristics. Within the stillbirth group, risk factors for readmission were further examined using multivariable regression. The secondary outcomes included principal indication for readmission (categorized based on principal diagnosis code of the readmission hospitalization) and timing of readmission (number of weeks after childbirth hospitalization). Differences in these secondary outcomes were compared between the stillbirth and live birth groups using chi-square tests. All analyses accounted for the complex sample design to generate nationally representative estimates.

RESULTS

Postpartum readmission occurred in 2.7% of 16,636 patients with stillbirths, whereas it occurred in 1.6% of 2,870,677 patients with live births (unadjusted risk ratio, 1.65; 95% confidence interval, 1.47-1.86). The higher risk for readmission after stillbirth (vs live birth) persisted after adjusting for maternal, obstetrical, and delivery characteristics (adjusted risk ratio, 1.27; 95% confidence interval, 1.11-1.46). The distribution of principal indication for readmission differed after stillbirth and after live birth and included hypertension (30.2% vs 39.5%; unadjusted risk ratio, 0.76; 95% confidence interval, 0.63-0.93), mental health or substance use disorders (6.8% vs 3.6%; unadjusted risk ratio, 1.90; 95% confidence interval, 1.15-3.16), and venous thromboembolism (5.8% vs 2.0%; unadjusted risk ratio, 2.87; 95% confidence interval, 1.60-5.17). Among patients with stillbirths, 56.0% of readmissions occurred within 1 week, 71.8% within 2 weeks, and 88.1% within 4 weeks; the timing of readmission did not differ significantly between the stillbirth and live birth cohorts. Pregestational diabetes (adjusted risk ratio, 1.87; 95% confidence interval, 1.20-2.93), gestational diabetes (adjusted risk ratio, 1.67; 95% confidence interval, 1.03-2.71), hypertensive disorders of pregnancy (adjusted risk ratio, 1.80; 95% confidence interval, 1.31-2.47), obesity (adjusted risk ratio, 1.46; 95% confidence interval, 1.01-2.12), and primary cesarean delivery (adjusted risk ratio, 1.74; 95% confidence interval, 1.17-2.58) were associated with a higher risk for readmission after stillbirth, whereas higher household income was associated with a lower risk for readmission (eg, adjusted risk ratio for income ≥$82,000 vs $1-$47,999, 0.48; 95% confidence interval, 0.30-0.77).

CONCLUSION

When compared with live births, the risk for postpartum readmission was higher after stillbirths, even after adjustment for differences in the patient demographic and clinical characteristics. Readmission for mental health or substance use disorders and venous thromboembolism is more common after stillbirths than after live births.

Mode of Delivery in Antepartum Singleton Stillbirths and Associated Risk Factors

OBJECTIVE

This study was aimed to investigate delivery management of patients with antepartum stillbirth.

STUDY DESIGN

Using data from fetal death certificates and linked maternal hospital discharge records, we identified a population-based sample of patients with singleton antepartum stillbirth at 20 to 42 weeks of gestation in California in 2007 to 2011. Primary outcomes were intended mode of delivery and actual mode of delivery. We used multivariable regressions to examine the association between patient demographic, clinical, and hospital characteristics and their mode of delivery. Separate analysis was performed for patients who had prior cesarean delivery versus those who did not.

RESULTS

Of 7,813 patients with singleton antepartum stillbirth, 1,356 had prior cesarean, while 6,457 had no prior cesarean. Labor was attempted in 51.8% of patients with prior cesarean and 93.7% of patients without prior cesarean, with 76.2 and 95.8% of these patients, respectively, delivered vaginally. Overall, 18.9% of patients underwent a cesarean delivery (60.5% among those with prior cesarean and 10.2% among those without prior cesarean). Multivariable regression analysis identified several factors associated with the risk of cesarean delivery that were not medically indicated. For instance, among patients without prior cesarean, malpresentation (of which the vast majority was breech presentation) was associated with an increased likelihood of planned cesarean (adjusted odds ratio [OR] = 3.26, 95% confidence interval [CI]: 2.53-4.22) and cesarean delivery after attempting labor (adjusted OR = 3.09, 95% CI: 2.25-4.25). For both patients with and without prior cesarean, delivery at an urban teaching hospital was associated with a lower likelihood of planned cesarean and a lower likelihood of cesarean delivery after attempting labor (adjusted ORs ranged from 0.28 to 0.56, p < 0.001 for all).

CONCLUSION

Over one in six patients with antepartum stillbirth underwent cesarean delivery. Among patients who attempted labor, rate of vaginal delivery was generally high, suggesting a potential opportunity to increase vaginal delivery in this population.

KEY POINTS

· In singleton antepartum stillbirths, 18.9% underwent cesarean delivery.. · Rate of vaginal delivery was high when labor was attempted.. · Both clinical and non-clinical factors were associated with risk of cesarean delivery..

Stillbirth: prevention and supportive bereavement care

Around half of the two million stillbirths occurring worldwide each year are preventable. This review compiles the most up-to-date evidence to inform stillbirth prevention. Many general maternal health interventions also reduce the risk of stillbirth, for example, antenatal care attendance. This review focuses on specific aspects of care: glucose metabolism, targeted aspirin prophylaxis, clotting and immune disorders, sleep positions, fetal movement monitoring, and preconception and interconception health. In the past few years, covid-19 infection during pregnancy has emerged as a risk factor for stillbirth, particularly among women who were not vaccinated. Alongside prevention, efforts to address stillbirth must include provision of high quality, supportive, and compassionate bereavement care to improve parents' wellbeing. A growing body of evidence suggests beneficial effects for parents who received supportive care and were offered choices such as mode of birth and the option to see and hold their baby. Staff need support to be able to care for parents effectively, yet, studies consistently highlight the scarcity of specific bereavement care training for healthcare providers. Action is urgently needed and is possible. Action must be taken with the evidence available now, in healthcare settings with high or low resources, to reduce stillbirths and improve training and care.

Prevalence and Mode of Birth in Late Fetal Mortality in Spain, 2016-2019

(1) Background: The rate of cesarean sections in late fetal mortality remains high. We aimed to determine the prevalence of late fetal mortality in Spain and risk factors for cesarean birth in women with stillbirth ≥ 28 weeks gestation between 2016-2019. (2) Methods: A retrospective observational study with national data between 2016-2019. A total of 3504 births with fetal dead were included. Sociodemographic, obstetrical and neonatal variables were analyzed using univariate and multivariate logistic regression (MLR), with cesarean birth with a stillborn ≥ 28 weeks gestation as the dependent variable. (3) Results: The late fetal mortality rate was 2.8 × 1000; 22.7% of births were by cesarean section. Factors associated with cesarean were having a multiple birth (aOR 6.78); stillbirth weight (aOR 2.41); birth taking place in towns with over 50,000 inhabitants (aOR 1.34); and mother's age ≥ 35 (aOR 1.23). (4) Conclusions: The late fetal mortality rate increased during the period. The performance of cesarean sections was associated with the mother's age, obstetric factors and place of birth. Our findings encourage reflection on how to best put into practice national clinical and socio-educational prevention strategies, as well as the approved protocols on how childbirth should be correctly conducted.

Classifying caesarean section to understand rising rates among Palestinian refugees: results from 290,047 electronic medical records across five settings

BACKGROUND

Rising caesarean-section rates worldwide are driven by non-medically indicated caesarean-sections. A systematic review concluded that the ten-group classification system (Robson) is the most appropriate for assessing drivers of caesarean deliveries. Evidence on the drivers of caesarean-section rates from conflict-affected settings is scarce. This study examines caesareans-section rates among Palestinian refugees by seven-group classification, compares to WHO guidelines, and to rates in the host settings, and estimates the costs of high rates.

METHODS

Electronic medical records of 290,047 Palestinian refugee women using UNRWA's (United Nations Relief and Works Agency for Palestine Refugees in the Near East) antenatal service from 2017-2020 in five settings (Jordan, Lebanon, Syria, West Bank, Gaza) were used. We modified Robson criteria to compare rates within each group with WHO guidelines. The host setting data were extracted from publicly available reports. Data on costs came from UNRWA's accounts.

FINDINGS

Palestinian refugees in Gaza had the lowest caesarean-section rates (22%), followed by those residing in Jordan (28%), West Bank (30%), Lebanon (50%) and Syria (64%). The seven groups caesarean section classification showed women with previous caesarean-sections contributed the most to overall rates. Caesarean-section rates were substantially higher than the WHO guidelines, and excess caesarean-sections (2017-2020) were modelled to cost up to 6.8 million USD. We documented a steady increase in caesarean-section rates in all five settings for refugee and host communities; refugee rates paralleled or were below those in their host country.

INTERPRETATION

Caesarean-section rates exceed recommended guidance within most groups. The high rates in the nulliparous groups will drive future increases as they become multiparous women with a previous caesarean-section and in turn, face high caesarean rates. Our analysis helps suggest targeted and tailored strategies to reduce caesarean-section rates in priority groups (among low-risk women) organized by those aimed at national governments, and UNRWA, and those aimed at health-care providers.