Timing and mode of delivery with advancing maternal age

Examining Cesarean Among Individuals of Advanced Maternal Age in Nurse-Midwifery Care

INTRODUCTION

Cesarean rates are rising, especially for individuals of advanced maternal age (AMA), defined as aged 35 or older. The Robson 10-Group Classification System (TGCS) facilitates assessment and comparison of cesarean rates among individuals in different settings. In midwifery-led care, in which pregnant people are typically healthier and seek a vaginal birth, it is unknown whether individuals of AMA have different antecedents leading to cesarean compared with younger counterparts. This study aimed to examine antecedents contributing to cesarean using Robson TGCS for individuals across age groups in midwifery care.

METHODS

This study was a secondary analysis of 2 cohort data sets from Oregon Health & Science University (OHSU) and University of Michigan Health Systems (UMHS) hospitals. The samples were individuals in midwifery-led care birthing at either OHSU from 2012 to 2019 or UMHS from 2007 to 2019.

RESULTS

A total of 11,951 individuals were studied. Overall cesarean rates were low; however, the rate for individuals of AMA was higher than the rate of their younger counterparts (18.30% vs 15.10%). The Robson groups were similar; however, the primary contributor among AMA individuals was group 5 (multiparous with previous cesarean), followed by group 2 [nulliparous with labor induced or prelabor cesarean], and group 1 [nulliparous with spontaneous labor]. In contrast, the primary contributors for younger individuals were groups 1, 2, and 5, respectively. In addition, prelabor cesarean and induced labor partly mediated the relationship between AMA and cesarean among nulliparous individuals, whereas prelabor cesarean was the key contributor to cesarean among multiparous people.

DISCUSSION

The cesarean rate in midwifery-led care was low. Using Robson TGCS provided additional insight into the antecedents to cesarean, rather than viewing cesarean as a single outcome. Future studies should continue to use Robson TGCS and investigate antecedents to cesarean, including factors influencing successful vaginal birth after cesarean in individuals of AMA.

Unplanned cesarean sections in advanced maternal age: A predictive model

INTRODUCTION

As maternal age during pregnancy is rising all over the world, there is a growing need for prognostic factors that determine maternal and perinatal outcomes in older women.

MATERIAL AND METHODS

This study is a retrospective cohort study of women aged 40 years or older at the time of delivery in four Santeon hospitals across the Netherlands between January 2016 and December 2019. Outcomes were compared between women of 40-44 years (advanced maternal age) and 45 years and older (very advanced maternal age). Primary outcome was unplanned cesarean section, secondary outcomes included postpartum hemorrhage and neonatal outcomes. Multivariate regression analysis was performed to analyze predictive factors for unplanned cesarean sections in women who attempted vaginal delivery. Subsequently, a predictive model and risk scores were constructed to predict unplanned cesarean section.

RESULTS

A cohort of 1660 women was analyzed; mean maternal age was 41.4 years, 4.8% of the women were 45 years and older. In both groups, more than half of the women had not delivered vaginally before. Unplanned cesarean sections were performed in 21.1% of the deliveries in advanced maternal age and in 29.1% in very advanced maternal age. Four predictive factors were significantly correlated with unplanned cesarean sections: higher body mass index (BMI), no previous vaginal delivery, spontaneous start of delivery and number of days needed for cervical priming. A predictive model was constructed from these factors with an area under the curve of 0.75 (95% confidence interval 0.72-0.78). A sensitivity analysis in nulliparous women proved that BMI, days of cervical priming, age, and gestational age were risk factors, whereas spontaneous start of delivery and induction were protective factors. There was one occurrence of neonatal death.

CONCLUSIONS

Women of advanced maternal age and those of very advanced maternal age have a higher chance of having an unplanned cesarean section compared to the general obstetric population in the Netherlands. Unplanned cesarean sections can be predicted through use of our predictive model. Risk increases with higher BMI, no previous vaginal delivery, and increasing number of days needed for cervical priming, whereas spontaneous start of labor lowers the risk. In nulliparous women, age and gestational age also increase risk, but induction lowers the risk of having an unplanned cesarean section.

Induction of labour care in the UK: A cross-sectional survey of maternity units

OBJECTIVES

To explore local induction of labour pathways in the UK National Health Service to provide insight into current practice.

DESIGN

National survey.

SETTING

Hospital maternity services in all four nations of the UK.

SAMPLE

Convenience sample of 71 UK maternity units.

METHODS

An online cross-sectional survey was disseminated and completed via a national network of obstetrics and gynaecology specialist trainees (October 2021-March 2022). Results were analysed descriptively, with associations explored using Fisher's Exact and ANOVA.

MAIN OUTCOME MEASURES

Induction rates, criteria, processes, delays, incidents, safety concerns.

RESULTS

54/71 units responded (76%, 35% of UK units). Induction rate range 19.2%-53.4%, median 36.3%. 72% (39/54) had agreed induction criteria: these varied widely and were not all in national guidance. Multidisciplinary booking decision-making was not reported by 38/54 (70%). Delays reported 'often/always' in hospital admission for induction (19%, 10/54) and Delivery Suite transfer once induction in progress (63%, 34/54). Staffing was frequently reported cause of delay (76%, 41/54 'often/always'). Delays triggered incident reports in 36/54 (67%) and resulted in harm in 3/54 (6%). Induction was an area of concern (44%, 24/54); 61% (33/54) reported induction-focused quality improvement work.

CONCLUSIONS

There is substantial variation in induction rates, processes and policies across UK maternity services. Delays appear to be common and are a cause of safety concerns. With induction rates likely to increase, improved guidance and pathways are critically needed to improve safety and experience of care.

Preimplantation Genetic Testing for Aneuploidy With Comprehensive Chromosome Screening in Patients Undergoing In Vitro Fertilization: A Systematic Review and Meta-analysis

OBJECTIVE

To review the effect of comprehensive chromosome screening-based preimplantation genetic testing for aneuploidy (PGT-A) in women undergoing in vitro fertilization (IVF) treatment, we conducted this meta-analysis to compare pregnancy outcomes of women who did and did not undergo such testing.

DATA SOURCES

We searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from their inception until February 28, 2022, for randomized controlled trials focusing on PGT-A treatment without any language restrictions.

METHODS OF STUDY SELECTION

Randomized controlled trials involving women undergoing IVF with or without PGT-A and comprehensive chromosome testing. Pooled relative risks (RRs) with 95% CIs were calculated for the primary outcome using a random-effects model with the Mantel-Haenszel method.

RESULTS

A total of nine trials with 3,334 participants were included. Overall, PGT-A was not associated with an increased live-birth rate (RR 1.13, 95% CI 0.96-1.34, I 2 =79%). However, PGT-A raised the live-birth rate in women of advanced maternal age (RR 1.34, 95% CI 1.02-1.77, I 2 =50%) but not in women of nonadvanced age (RR 0.94, 95% CI 0.89-0.99, I 2 =0%).

CONCLUSION

Preimplantation genetic testing for aneuploidy increases the live-birth rate in women of advanced maternal age.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022311540.