Prise en charge du dépassement de terme

The risk of prelabor and intrapartum cesarean delivery among overweight and obese women: possible preventive actions

OBJECTIVE

The purpose of this study was to investigate prelabor and intrapartum cesarean delivery in overweight and obese women by parity, previous cesarean delivery, and labor induction to assess what preventive actions might be possible.

STUDY DESIGN

We modeled relative risks (RRs) and risk differences of prelabor and intrapartum cesarean delivery by prepregnancy body mass index (obese, ≥30 kg/m(2); overweight, 25-29.9 kg/m(2); normal weight, 18.5-24.9 kg/m(2)) in a nationally representative sample of 12,297 French women. Models were stratified by parity and previous cesarean status. Covariates included maternal sociodemographic characteristics, medical conditions, pregnancy complications, and induction of labor.

RESULTS

Risks of prelabor cesarean delivery were elevated only for obese multiparous women. This reflected not only a higher prevalence of previous cesarean delivery (26.4% vs 17.9% for normal-weight women) but also higher risks of prelabor cesarean delivery for multiparous women with no previous cesarean delivery after adjustment for medico-obstetric factors (RR, 1.82; 95% confidence interval [CI], 1.25-2.64). Obese primiparous women and multiparous women with no previous cesarean delivery had similarly increased adjusted RRs for intrapartum cesarean delivery (RR, 1.64; 95% CI, 1.36-1.98; and RR, 1.66; 95% CI, 1.15-2.39, respectively), but the risk difference was higher for primiparous women, with an absolute increase of 0.10 (95% CI, 0.05-0.14) compared with 0.02 (95% CI, 0.00-0.04) for multiparous women. Increased intrapartum cesarean delivery risks for primiparous women were related to more frequent labor induction (42.6% vs 23.8% for normal-weight women).

CONCLUSION

It may be possible to reduce primary and thus repeat cesarean delivery rates among obese women by preventive actions targeting labor induction in primiparous women and prelabor cesarean deliveries in multiparous women. Further research is needed on the impact of limiting inductions on cesarean delivery risks for obese primiparous women.

How important is placental examination in cases of perinatal deaths?

Research on stillbirths and placental pathology has traditionally been given low priority, causing a lack of understanding of the mechanisms leading to death. The purpose of this study was to gain knowledge on how many perinatal deaths relate to morphologic changes in the placenta, and what role the placenta plays in the pathogenesis of intrauterine, intrapartum, and neonatal deaths. The autopsy reports from 104 consecutive perinatal deaths in a 5-year period (2004-2008) were reviewed. Intrauterine, intrapartum, and neonatal deaths ranging from gestational age of 22 weeks up to 7 days postpartum were included. The following three questions were considered: Could placental examination (with autopsy) explain fetal/infant death; could the cause of death be explained by placental examination alone; and could the cause of death be explained with autopsy alone? The distribution of pathologic findings in the placenta was registered. The placenta had changes that could explain fetal/infant death in 69.2% of the cases. The cause of death could be explained by placental examination alone, without autopsy, in 48.1% of the cases. Only 16.3% of the deaths could be explained by autopsy alone. The most frequently observed diagnoses were infection (22.1%), degenerative changes (13.5%), and abruptio placentae (12.5%). To conclude, our study shows that placental examination in addition to autopsy is necessary in investigating the causes of perinatal deaths. Further research, including maternal and environmental factors, is needed to clarify the underlying causes of placental malfunction.