Maternal and Neonatal Morbidity and Mortality in Cesarean Section

Childbirth simulation to assess cephalopelvic disproportion and chances for failed labor in a French population

Reducing failed labor and emergency cesarean section (CS) rates is an important goal. A childbirth simulation tool (PREDIBIRTH software and SIM37 platform) that evaluates a 5-min magnetic resonance imaging (MRI) assessment performed at 37 weeks of gestation was developed to enhance the consulting obstetrician's ability to predict the optimal delivery mode. We aimed to determine the potential value of this childbirth simulation tool in facilitating the selection of an optimal delivery mode for both mother and infant. A retrospective cohort study was performed on all patients referred by their obstetricians to our level 2 maternity radiology department between December 15, 2015 and November 15, 2016, to undergo MRI pelvimetry at approximately 37 weeks of gestation. The childbirth simulation software was employed to predict the optimal delivery mode based on the assessment of cephalopelvic disproportion. The prediction was compared with the actual outcome for each case. Including childbirth simulations in the decision-making process had the potential to reduce emergency CSs, inappropriately scheduled CSs, and instrumental vaginal deliveries by up to 30.1%, 20.7%, and 20.0%, respectively. Although the use of the simulation tool might not have affected the overall CS rate, consideration of predicted birthing outcomes has the potential to improve the allocation between scheduled CS and trial of labor. The routine use of childbirth simulation software as a clinical support tool when choosing the optimal delivery mode for singleton pregnancies with a cephalic presentation could reduce the number of emergency CSs, insufficiently justified CSs, and instrumental deliveries.

Determinants of cesarean-related complications: high number of repeat cesarean, operation type or placental pathologies?

Background: Cesarean delivery (CD) is one of the most common operations worldwide. Vaginal birth after cesarean (VBAC) could be a solution to decrease increased CD rates. On the other hand, risks of VBAC on maternal and neonatal outcomes drifts physicians and patients to a scheduled CD. Successive CDs, especially after the 3rd operation, increase complications for the fetus and the mother. Operation type (emergency or elective CD) could be a risk factor of increased morbidities, like placental implantation anomalies. Evaluation of these conditions related to complications and morbidities were investigated. Material and methods: Women who underwent the fourth and more repeat CD in Bursa Yuksek Ihtisas Training Research Hospital between March 2016 and December 2019 were retrospectively reviewed. Pre-operative characteristics, per-operative and post-operative complications were reviewed. Patients were separated into groups as operational type, repeat cesarean number, and major morbidities. A comparison between groups was evaluated. Results: A total of 46.048 women gave birth, of which 17,721 underwent CDs with a rate of 38%. The rate of primary CD was 18%. The number of the fourth or more CD performed was 854. The number of patients who underwent fourth and fifth or more CD and of these operational data could be accessed was 599 and 145, respectively. The overall complications were detected as severe adhesions (n: 220), preterm delivery (n: 91), stillbirth (n: 9), admission to NICU (n: 98), bladder injury (n: 10), uterine scar dehiscence (n: 6), uterine rupture (n: 6), uterine atony (n: 26), blood transfusion requirement (n: 68), preterm delivery (n: 91), placenta previa totalis (n: 24), morbidly adherent placenta (n: 14), hysterectomy (n: 12), partial uterine resection (n: 2), uterus-conserving interventions (n: 26). The number of patients with major morbidity was 105. Emergency cesarean performed in 339 of 744 patients. A comparison of the emergency cesarean group with elective repeat cesarean group revealed no significant difference in operative adverse outcomes. Comparing patients between 4th repeat CD with 5th and more CD revealed a significant difference in severe adhesion, morbidly adherent placenta and hysterectomy. Previa totalis were detected in 24 patients. All of them experienced major morbidity with 12 of them underwent hysterectomy. The rest of them performed Uterus-conserving treatments (B-Lynch Suture, Bacri Balloon, Hypogastric artery ligation ) and a total of 51 units of packed red blood cells and 32 units of Fresh Frozen Plasma were transfused to 9 (37%) of 24 patients. Conclusion: The major risk factor of the morbidity is placenta previa whose incidence has dramatically increased after 3rd cesarean. Emergency cesarean did not increase the complication rate in the present study. Fourth and more repeat CDs ought to be performed by experienced obstetricians in high-equipped tertiary hospitals.

Risk factors and clinical significance of abdomino-pelvic free fluid after cesarean section: a prospective study

Introduction: Post-partum hemorrhage is a major cause of maternal mortality. Ultrasonography is a safe, rapid, and noninvasive diagnostic tool which can be used to identify and measure the abdomino-pelvic free fluid in post-partum period.Objective: This study was conducted to evaluate the risk factors and clinical significance of abdomino-pelvic free fluid after cesarean section.Method: Demographic data, indication of cesarean section, duration of operation, volume of intraoperative blood loss, and instability in vital signs, blood transfusion, decreased Hb level, and decreased urine output were documented in 100 women with cesarean delivery 4 and 24 h after surgery. Abdomino-pelvic free fluid volume was estimated by ultrasound study.Result: Four hours after cesarean, minimal, moderate, and large amount of free fluid was seen in 38(38%), 45(45%), and 17(17%) patients respectively. The volume of free fluid was decreased generally as 73 (73%) of patients had minimal amount of free fluid 24 h after surgery. There was statistically significant relationship between volume of blood loss during cesarean and the volume of free fluid 4 h (and not 24 h) after surgery. There was no statistically significant relationship between duration of operation and the volume of free fluid 4 and 24 h after cesarean. There is statistically significant relationship between free fluid volume 4 h after surgery and hemodynamic instability.Conclusion: Ultrasonography detects even minimal amount of free fluid in post-cesarean patients but cannot predict their clinical course.

Elective cesarean delivery at term and the long-term risk for respiratory morbidity of the offspring

Maternal morbidity is associated with cesarean deliveries. However, new evidence suggests that short- and long-term neonatal morbidity is also associated. This includes respiratory morbidity with conflicting results. To determine whether mode of delivery has an impact on the long-term risk for respiratory morbidity in the offspring, a population-based cohort analysis was conducted including all singleton term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via elective cesarean delivery (CD) and those delivered vaginally. Multiple gestations and fetuses with congenital malformations were excluded from the analysis as were all cases of urgent CDs. Pediatric hospitalizations involving respiratory morbidity of offspring up to the age of 18 years were evaluated. A Kaplan-Meier survival curve was used to compare cumulative respiratory morbidity incidence and a Cox regression model to control for confounders. During the study period, 132,054 term deliveries met the inclusion criteria; 8.9% were via elective CDs (n = 11,746) and 91.1% (n = 120,308) were vaginal deliveries. Hospitalizations of the offspring involving respiratory morbidity were significantly more common in offspring delivered by CDs (5.2 vs. 4.3% in vaginal deliveries, p < 0.001). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of respiratory morbidity in the elective CD group (log rank p < 0.001). In a Cox proportional hazards model, while controlling for maternal age, gestational age, and birthweight, CD exhibited a significant and independent association with long-term respiratory morbidity of the offspring (adjusted hazard ratio = 1.22 (CI, 1.12-1.33), p < 0.001).Conclusion: Elective cesarean delivery at term is a significant risk factor for long-term pediatric respiratory morbidity of the offspring. What is Known: • Cesarean delivery is a major surgery with known possible complications. • Cesarean delivery has possible immediate complications for the newborn including respiratory complications. What is New: • Our study shows more long term respiratory morbidity in the CD group including asthma and obstructive sleep apnea. • Different possible explanations have been proposed including exposure to maternal flora during vaginal delivery and the stress hormones secreted during contractions and delivery.

Morbidity in neonates according to the mode of delivery: a comparative study

OBJECTIVE

The objective of this study was to compare the effects of the modes of delivery on the health of newborns in a private maternity hospital in the city of São Paulo.

METHODS

Between January 1995 and December 1998, all patients consecutively admitted for deliveries were included in this cross-sectional retrospective study. A total of 8,457 medical records were analyzed, being excluded of the sample 460 multiple pregnancies and 517 pregnant women with obstetric and/or clinical disorders. The incidence of neonatal birth injury, respiratory distress and anoxia was analyzed, as well as birth weight, type of delivery and gestational age (according to Näegele and Capurro).

RESULTS

The final sample consisted of 7,480 neonates, and 69.6% were born by cesarean section, 24% vaginally and 6.4% through the vagina with the aid of forceps. A significant association was found between anoxia and the three types of delivery (p < 0.001). Respiratory distress was more frequent in cesarean delivery in newborns with gestational age superior to 37 weeks and in newborns weighing more than or equal to 2,500 g. Respiratory distress was significantly associated with cesarean delivery and/or forceps delivery, as compared with vaginal delivery, in the entire sample. Neonatal birth injury was associated with the use of forceps. In neonates born by cesarean section, anoxia was associated with lower gestational age estimated by the Capurro method and with lower weight.

CONCLUSIONS

The abdominal approach is associated with greater morbidity of fetuses due to respiratory distress. Vaginal delivery is safer in newborns with more than 37 weeks of gestation and in those weighing more than 2,500 g.

Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: a chart review

Background

Increasing appropriate use and documentation of caesarean section (CS) has the potential to decrease maternal and perinatal mortality in settings with low CS rates. We analyzed data collected as part of a comprehensive needs assessment of emergency obstetric and newborn care (EmONC) facilities in Afghanistan to gain a greater understanding of the clinical indications, timeliness, and outcomes of CS deliveries.

Methods

Records were reviewed at 78 government health facilities expected to function as EmONC providers that were located in secure areas of the country. Information was collected on the three most recent CS deliveries in the preceding 12 months at facilities with at least one CS delivery in the preceding three months. After excluding 16 facilities with no recent CS deliveries, the sample includes 173 CS deliveries at 62 facilities.

Results

No CS deliveries were performed in the previous three months at 21% of facilities surveyed; all of these were lower-level facilities. Most CS deliveries (88%) were classified as emergencies, and only 12% were referrals from another facility. General anesthesia was used in 62% of cases, and spinal or epidural anesthesia in 34%. Only 28% of cases were managed with a partograph. Surgery began less than one hour after the decision for a CS delivery in just 30% of emergency cases. Among the 173 cases, 27 maternal deaths, 28 stillbirths, and 3 early neonatal deaths were documented. In cases of maternal and fetal death, the most common indications for CS delivery were placenta praevia or abruption and malpresentation. In 62% of maternal deaths, the fetus was stillborn or died shortly after birth. In 48% of stillbirths, the fetus had a normal heart rate at the last check. Information on partograph use was missing in 38% of cases, information on parity missing in 23% of cases and indications for cesareans missing in 9%.

Conclusions

Timely referral within and to EmONC facilities would decrease the proportion of CS deliveries that develop to emergency status. While the substantial mortality associated with CS in Afghanistan may be partly due to women coming late for obstetric care, efforts to increase the availability and utilization of CS must also focus on improving the quality of care to reduce mortality. Key goals should be encouraging use of partographs and improving decision-making and documentation around CS deliveries.

Prevention of mother-to-child transmission of HIV-1: the role of cesarean delivery

The risk of mother-to-child transmission (MTCT) of HIV can be reduced through cesarean delivery prior to the onset of labor and prior to rupture of the membranes (elective cesarean delivery [ECD]). As a result of this evidence, the American College of Obstetricians and Gynecologists and the Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission developed guidelines recommending ECD for HIV-infected women with plasma viral loads of more than 1000 copies/mL. Since the release of the recommendations, an increase in ECD has been seen among HIV-infected women in the United States. This article discusses the evidence on efficacy of ECD, current recommendations in the United States, and risks and morbidity related to ECD. Although the benefit of ECD in preventing MTCT of HIV is substantial, some questions remain. Specifically, the benefit of ECD for women with very low viral loads or for women using combination antiretroviral regimens is unclear, as is the timeframe after onset of labor or rupture of membranes within which ECD will still confer preventive benefits.

Cesarean and VBAC rates among immigrant vs. native-born women: a retrospective observational study from Taiwan Cesarean delivery and VBAC among immigrant women in Taiwan

BACKGROUND

Cultural and ethnic roots impact women's fertility and delivery preferences This study investigated whether the likelihood of cesarean delivery, primary cesarean, and vaginal delivery after cesarean (VBAC) varies by maternal national origin.

METHODS

We conducted a nation-wide, population-based, observational study using secondary data from Taiwan. De-identified data were obtained on all 392,246 singleton live births (≥500 g; ≥20 weeks) born to native-born Taiwanese, Vietnamese and mainland Chinese-born mothers between January 1, 2006 and December 31, 2007 from Taiwan's nation-wide birth certificate data. Our analytic samples consisted of the following: for overall cesarean likelihood 392,246 births, primary cesarean 336,766 (excluding repeat cesarean and VBAC), and VBAC 55,480 births (excluding primary cesarean and vaginal births without previous cesarean). Our main outcome measures were the odds of cesarean delivery, primary cesarean delivery and VBAC for Vietnamese and Chinese immigrant mothers relative to Taiwanese mothers, using multiple regression analyses to adjust for maternal and neonatal characteristics, paternal age, institutional setting, and major obstetric complications.

RESULTS

Unadjusted overall cesarean, primary cesarean, and VBAC rates were 33.9%, 23.0% and 4.0% for Taiwanese, 27.6%, 20.1% and 5.0% for mainland Chinese, and 19.3%, 13.9 and 6.1% for Vietnamese respectively. Adjusted for confounders, Vietnamese mothers were less likely than native-born Taiwanese to have overall and primary cesarean delivery (OR = 0.59 and 0.58 respectively), followed by Chinese mothers (both ORs = 0.90 relative to native-born Taiwanese). Vietnamese mothers were most likely to have successful VBAC (OR = 1.58), followed by Chinese mothers (OR = 1.25).

CONCLUSION

Immigrant Vietnamese and Chinese mothers have lower odds of cesarean and higher VBAC odds than native-born Taiwanese, consistent with lower cesarean rates prevailing in their home countries (Vietnam 10.1%; mainland China 20%-50% rural and urban respectively).

External cephalic version at term

It is remarkable that, for all the sophistication of current obstetric practice, uncertainty should persist concerning the management of as fundamental a problem as breech presentation, particularly with respect to the place of external cephalic version (ECV). This review will focus on information available for guiding clinical decisions, and practical aspects of the procedure.

Elective caesarean section versus vaginal delivery for preventing mother to child transmission of hepatitis B virus--a systematic review

Background

Caesarean section before labor or before ruptured membranes ("elective caesarean section", or ECS) has been introduced as an intervention for preventing mother-to-child transmission (MTCT) of hepatitis B virus (HBV). Currently, no evidence that ECS versus vaginal delivery reduces the rate of MTCT of HBV has been generally provided. The aim of this review is to assess, from randomized control trails (RCTs), the efficacy and safety of ECS versus vaginal delivery in preventing mother-to-child HBV transmission.

Results

We searched Cochrane Pregnancy and Childbirth Group's Trials Register (January, 2008), the Cochrane Central Register of Controlled Trials (the Cochrane Library 2008, issue 1), PubMed (1950 to 2008), EMBASE (1974 to 2008), Chinese Biomedical Literature Database (CBM) (1975 to 2008), China National Knowledge Infrastructure (CNKI) (1979 to 2008), VIP database (1989 to 2008), as well as reference lists of relevant studies. Finally, four randomized trails involving 789 people were included. Based on meta-analysis, There was strong evidence that ECS versus vaginal delivery could effectively reduce the rate of MTCT of HBV (ECS: 10.5%; vaginal delivery: 28.0%). The difference between the two groups (ECS versus vaginal delivery) had statistical significance (RR 0.41, 95% CI 0.28 to 0.60, P < 0.000001). No data regarding maternal morbidity or infant morbidity according to mode of delivery were available.

Conclusion

ECS appears to be effective in preventing MTCT of HBV and no postpartum morbidity (PPM) was reported. However, the conclusions of this review must be considered with great caution due to high risk of bias in each included study (graded C).

Increased risk of stroke in patients who undergo cesarean section delivery: a nationwide population-based study

OBJECTIVE

This study used a population-based dataset to determine whether (compared with vaginal deliveries), cesarean section deliveries increase the risk of postpartum stroke during the 3-, 6-, or 12-month period after delivery.

STUDY DESIGN

This study used 1998-2003 records from the Taiwan National Health Insurance Research Database for 987,010 women with singleton deliveries from 1998-2002. Cox proportional hazard regressions were carried out to compute stroke-free survival rates between the 2 delivery modes.

RESULTS

The regression model indicated that, compared with patients who delivered vaginally, the hazard ratio for postpartum stroke among those who delivered by cesarean section was 1.67 times greater within 3 months of delivery (95% CI, 1.29-2.16), was 1.61 times greater within 6 months of delivery (95% CI, 1.31-1.98), and was 1.49 times greater within 12 months of delivery (95% CI, 1.27-1.76).

CONCLUSION

Our data indicates that cesarean section delivery is an independent risk factor for stroke.

Cesarean delivery for HIV-infected women: recommendations and controversies

Two studies that were published in 1999 demonstrated that cesarean delivery before labor and before the rupture of membranes (elective cesarean delivery) reduces the risk of mother-to-child transmission of the human immunodeficiency virus (HIV). On the basis of these results, the American College of Obstetricians and Gynecologists and the US Public Health Service recommend that HIV-infected pregnant women with plasma viral loads of >1000 copies per milliliter be counseled regarding the benefits of elective cesarean delivery. Since the release of these guidelines, the cesarean delivery rate among HIV-infected women in the United States has increased dramatically. Major postpartum morbidity is uncommon, and cesarean delivery among HIV-infected women is relatively safe and cost-effective. However, a number of important questions remain unanswered, including whether cesarean delivery has a role among HIV-infected women with low plasma viral loads or who receive combination antiretroviral regimens.

Obstetric management in gestational diabetes

Reviewing the areas of controversy related to the obstetric management of women with GDM, we are unfortunately unable to provide significant refinement of the recommendations agreed upon after the Fourth International Workshop-Conference due to the lack of properly controlled and powered clinical studies in this area since 1997. In the area of the need for antenatal fetal surveillance in women with milder degrees of GDM, we may be able to draw indirect conclusions from ongoing cohort studies that will include large numbers of women. In the area of optimal timing and mode of delivery to avoid fetal injury, large well-controlled prospective studies do not currently exist and are urgently needed. In addition, refinement of fetal and pelvic imaging techniques to more accurately identify the maternal-fetal pairs most likely to benefit from avoiding vaginal delivery, and the more widespread availability of these technologies, may also prove to be of benefit in the obstetric management of women with GDM.

Cesarean births in Taiwan

OBJECTIVE

To evaluate the use of cesarean delivery in Taiwan by comparing local clinical indications with those in international cohorts.

METHODS

In-patient claims from the National Health Insurance (NHI) in Taiwan were analyzed. Indications for cesarean delivery were evaluated with primary diagnosis codes and procedure codes from the NHI dataset. To produce a stable numerator for cesarean section, 3 years (1998-2000) of claims for cesarean delivery were abstracted and annualized.

RESULTS

Rates ranged between 27.3% and 28.7% for primary cesarean delivery and were below 5% for vaginal birth after a cesarean section (VBAC). Compared with rates in other countries, rates for overall and primary cesarean section as well as for VBAC were significantly higher in medical centers in Taiwan (P<0.001). However, the clinics contributed the most to the difference in both overall and primary cesarean rates. The most common indication for cesarean section was prior cesarean section (43.3%-45.5%), followed by malpresentation (19.6%-23.4%). The proportion of fetuses with malpresentation delivered by cesarean section in Taiwan was 7.9%, almost twice the upper limit expected for all pregnancies as indicated in international studies.

CONCLUSION

It is important to use appropriately documented data and to compare them with international data when monitoring local obstetric practices. The disproportionately high cesarean delivery rates in Taiwan may hold major lessons for the many countries contemplating or having universal health insurance coverage with a similar mix of providers.

Comparative analysis of neonatal morbidity for vaginal and caesarean section deliveries using hospital charge

AIM

To assess the neonatal morbidity of alternative modes of delivery using economic data.

METHODS

Two groups of neonatal morbidity data were extracted according to mode of delivery from inpatient claims on National Health Insurance in Taiwan: uncomplicated vaginal and caesarean section deliveries. Outcome variables included number of infants treated as inpatients, duration of hospital stay, and hospital charge during both the first month and the first year of age.

RESULTS

Uncomplicated caesarean section delivery of term infants carried a significant increase either in the first month of life or during the first year after birth in both duration of hospital stay and hospital discharge when compared with uncomplicated vaginal delivery. Neonatal jaundice accounted for the greatest morbidity among term newborns, irrespective of delivery mode, followed by infectious, gastrointestinal and respiratory morbidity. Logistic regression analysis demonstrated that uncomplicated vaginal delivery was associated with skin diseases. Uncomplicated caesarean section delivery was associated with infectious disease and disease of the respiratory, digestive and circulatory systems.

CONCLUSION

The findings of this study may provide further information for clinicians and would be an important consideration when advising pregnant women on the preferred route of delivery.

Mode of delivery and postpartum morbidity in Latin American and Caribbean countries among women who are infected with human immunodeficiency virus-1: the NICHD International Site Development Initiative (NISDI) Perinatal Study

OBJECTIVE

The purpose of this study was to test whether cesarean delivery before labor and before ruptured membranes is associated with a higher risk of postpartum morbidity than vaginal delivery among women who are infected with human immunodeficiency virus-1 in Latin America and the Caribbean.

STUDY DESIGN

Data from a prospective cohort study (National Institute of Child Health and Human Development International Site Development Initiative Perinatal Study) were analyzed. The study population consisted of women who were followed for > or = 6 to 12 weeks after delivery, who had singleton infants, and with a known mode of delivery.

RESULTS

Of 819 enrollees, 697 women met inclusion criteria (299 vaginal deliveries, 260 cesarean deliveries before labor and before ruptured membranes, 138 cesarean deliveries after labor and/or after ruptured membranes); 36 women (5%) had postpartum morbidity (18 major, 18 minor). Mode of delivery was associated with postpartum morbidity (P = .02). Unadjusted odds ratios (95% CIs) for postpartum morbidity according to mode of delivery were cesarean delivery before labor and before ruptured membranes (odds ratio, 1.16 [95% CI, 0.5, 2.7]), cesarean delivery after labor and/or after ruptured membranes (odds ratio, 2.96 [95% CI, 1.3, 6.7]), and vaginal delivery (reference). These results did not differ appreciably with covariate adjustment.

CONCLUSION

The rate of postpartum morbidity was low. Mode of delivery was associated with postpartum morbidity, possibly reflecting the larger proportion of minor postpartum morbidity events among those with cesarean delivery after labor and/or after ruptured membranes.

Mode of delivery and postpartum HIV-1 disease progression: the Women and Infants Transmission Study

OBJECTIVE

To assess the relationship between mode of delivery and subsequent maternal HIV-1 disease progression.

DESIGN AND METHODS

Changes in CD4+ lymphocyte percentage (CD4%) and plasma HIV-1 RNA concentration (HIV RNA), and time to progression to AIDS or death among HIV-1-infected women were compared according to mode of delivery [cesarean section before labor and ruptured membranes (SCS), cesarean section after labor and/or after ruptured membranes (NSCS), and vaginal delivery]. Generalized estimating equations were used to compare changes in adjusted mean CD4% and HIV RNA counts by mode of delivery. Cox proportional hazard models were used to assess differences in time to AIDS or death.

RESULTS

In adjusted analyses, there were no clinically important differences in HIV-1 disease progression according to mode of delivery (SCS, n = 183; NSCS, n = 221; vaginal, n = 1087), as assessed by changes in CD4% and HIV RNA during the 18 months following delivery, and by progression to AIDS or death during a mean postpartum follow-up of 2.66 years.

CONCLUSIONS

The present results suggest that, among HIV-1-infected women in North America, mode of delivery is not associated with subsequent HIV-1 disease progression.

Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1

BACKGROUND

Cesarean section before labor and before ruptured membranes ("elective cesarean section", or ECS) has been introduced as an intervention for the prevention of mother-to-child transmission (MTCT) of HIV-1. The role of mode of delivery in the management of HIV-1-infected women should be assessed in light of risks as well as benefits, since HIV-1-infected pregnant women must be provided with available information with which to make informed decisions regarding cesarean section and other options to prevent transmission of infection to their children.

OBJECTIVES

Our objectives were to assess the efficacy (for prevention of MTCT of HIV-1) and the safety of ECS among HIV-1-infected women.

SEARCH STRATEGY

Electronic searches were undertaken using MEDLINE and other databases. Hand searches of reference lists of pertinent reviews and studies, as well as abstracts from relevant conferences, were also conducted. Experts in the field were contacted to locate any other studies. The search strategy was iterative.

SELECTION CRITERIA

Randomized clinical trials assessing the efficacy and safety of ECS for prevention of MTCT of HIV-1 were included in the analysis, as were observational studies with relevant data.

DATA COLLECTION AND ANALYSIS

Data regarding HIV-1 infection status of infants born to HIV-1-infected women according to mode of delivery were extracted from the reports of the studies. Similarly, data regarding postpartum morbidity (PPM) (including minor (e.g., febrile morbidity, urinary tract infection) and major (e.g., endometritis, thromboembolism) morbidity) of the HIV-1-infected women, and infant morbidity, according to mode of delivery were extracted.

MAIN RESULTS

One randomized clinical trial of the efficacy of ECS for prevention of MTCT of HIV-1 was identified. No data regarding infant morbidity according to the HIV-1-infected mother's mode of delivery were available. Data regarding PPM according to mode of delivery were available from this clinical trial as well as from five observational studies. Among HIV-1-infected women not taking antiretrovirals (ARVs) during pregnancy or taking only zidovudine, ECS was found to be efficacious for prevention of MTCT of HIV-1. PPM is generally higher among HIV-1-infected women who undergo cesarean as compared to vaginal delivery, with the risk with ECS being intermediate between that of vaginal delivery and NECS (including emergency procedures). Other factors associated with the risk of PPM among HIV-1-infected women include HIV-1 disease stage (more advanced disease, as manifested by lower CD4 counts and higher viral loads, being associated with a greater risk of PPM) and co-morbid conditions (e.g., diabetes).

AUTHORS' CONCLUSIONS

ECS is an efficacious intervention for the prevention of MTCT among HIV-1-infected women not taking ARVs or taking only zidovudine. The risk of PPM with ECS is higher than that associated with vaginal delivery, yet lower than with NECS. Among HIV-1-infected women, more advanced maternal HIV-1 disease stage and concomitant medical conditions (e.g., diabetes) are independent risk factors for PPM. The risk of MTCT of HIV-1 according to mode of delivery among HIV-1-infected women with low viral loads (low either because the woman's HIV-1 disease is not advanced, or because her HIV-1 disease is well-controlled with ARVs) is unclear. Therefore, an important issue to be addressed in one or more large studies (individual studies or an individual patient data meta-analysis combining data from more than one study) is assessment of the effectiveness of ECS for prevention of MTCT of HIV-1 among HIV-1-infected women with undetectable viral loads (with or without receipt of highly active ARV therapy (HAART)).

Protocol for the evaluation of a decision aid for women with a breech-presenting baby [ISRCTN14570598]

BACKGROUND: There is now good evidence about the management options for pregnant women with a breech presentation (buttocks or feet rather than head-first) at term; external cephalic version (ECV) - the turning of a breech baby to a head-down position and/or planned caesarean section (CS). Each of these options has benefits and risks and the relative importance of these vary for each woman, subject to her personal values and preferences, a situation where a decision aid may be helpful.Decision aids are designed to assist patients and their doctors in making informed decisions using information that is unbiased and based on high quality research evidence. Decision aids are non-directive in the sense that they do not aim to steer the user towards any one option, but rather to support decision making which is informed and consistent with personal values.The ECV decision aid was developed using the Ottawa Decision Support Framework, including a systematic review of the evidence about the benefits and risks of the options for breech pregnancy. It comprises an audiotape with a supplementary booklet and worksheet, a format that can be taken home and discussed with a partner. This project aims to evaluate the ECV decision aid for women with a breech presenting baby in late pregnancy. STUDY DESIGN: We aim to evaluate the effectiveness of the decision aid compared with usual care in a randomised controlled trial in maternity hospitals that offer ECV. The study group will receive the decision aid in addition to usual care and the control group will receive standard information on management options for breech presentation from their usual pregnancy care provider. Approximately 184 women with a single breech-presenting baby at greater than 34 weeks gestation and who are clinically eligible for ECV will be recruited for the trial.The primary outcomes of the study are knowledge, decisional conflict, anxiety and satisfaction with decision-making that will be assessed using self-administered questionnaires. The decision aid is not intended to influence either the uptake of either ECV or planned CS, however we will monitor health service utilisation rates and maternal and perinatal outcomes.

Patent Ductus Arteriosus as a Natural Cause of Pulmonary Hemorrhage in Infants

Patent ductus arteriosus (PDA) is a recognized risk factor for massive pulmonary hemorrhage (MPH) in the newborn and is generally seen in association with other MPH risk factors such as prematurity. We report 6 cases of sudden and unexpected death of infants older than 4 days with MPH and PDA at autopsy. The cases were reviewed for other factors that could contribute to MPH to ascertain whether PDA is directly linked to MPH. Histology samples were examined for distribution of hemorrhage in the lungs and iron stained for hemosiderin evaluation. All of the cases had clinical histories and scene examinations which raised the differential diagnosis of mechanical asphyxia in the form of so-called overlayings. The diagnostic dilemma of attributing the MPH to the PDA as the sole cause, dual cause, or incidental finding is discussed. These cases illustrate the medicolegal dilemma faced by the pathologist, as well as the need for further research into the potential association of PDA with MPH.

Complications of cesarean deliveries: rates and risk factors

OBJECTIVE

The purpose of this study was to determine complication rates after cesarean delivery and to identify independent risk factors for complications.

STUDY DESIGN

In a prospective population-based cohort study in Norway, rates of predefined types of complications from 2751 cesarean deliveries were determined. The complications that were studied were intraoperative complications, blood loss, wound infection, cystitis, endometritis, hematoma, and reoperation. Independent risk factors were identified by stratification and multiple logistic regression analysis.

RESULTS

Altogether, 21.4% of the women had > or =1 complications. The degree of cervical dilation, general anesthesia, low gestational age, and fetal macrosomia were independent risk factors. For operations that were performed at 9 to 10 cm cervical dilation, the complication rate was 32.6% versus 16.8% at 0 cm (odds ratio, 2.39; 95% CI, 1.77-3.22; P<.001).

CONCLUSION

Cesarean delivery was associated with a high complication rate. Increasing cervical dilation and, in particular, cervical dilation of 9 or 10 cm at the time of operation, general anesthesia, low gestational age, and fetal macrosomia were identified as independent risk factors.

Increasing trend of Cesarean deliveries in HIV-infected women in the United States from 1994 to 2000

BACKGROUND

Meta-analysis and randomized clinical trial results reported in June 1998 indicated a significant reduction in perinatal HIV transmission rates among mothers undergoing a cesarean section (C-section).

OBJECTIVE

The objective of this study was to examine recent trends in and factors associated with C-section deliveries among HIV-infected women in the United States.

DESIGN

A multisite pediatric medical record review of a cohort of HIV-exposed and HIV-infected infants in the Pediatric Spectrum of HIV Disease (PSD) Cohort study (n = 6467) and the national Pediatric HIV/AIDS Reporting System (HARS) (n = 8,306) was conducted.

SETTING/PATIENTS

All infants born between 1994 and 2000 to HIV-positive mothers referred to the PSD study or to a Pediatric HARS hospital or clinic site were enrolled.

RESULTS

The proportion of deliveries by C-section was steady at about 20% from 1994 through June 1998. From July 1998 through December 2000, this proportion increased to 44% in the PSD study and to nearly 50% in the Pediatric HARS. On analysis by multiple logistic regression, delivery of infants by C-section was associated with the release of study results (OR = 2.83), delivery in four PSD sites in reference to Texas (OR: 2.02-1.43), having private medical care reimbursement (OR = 1.62), and having maternal prenatal care (OR = 1.43).

CONCLUSIONS

The PSD and Pediatric HARS data demonstrate a sharp increase in C-section rates mainly among HIV-infected women in the United States after the release of the meta-analysis and randomized clinical trial results in 1998. This finding highlights the rapid impact of study results on obstetric practice. It underscores the critical role of prenatal care in offering perinatal interventions such as scheduled C-section when indicated to reduce the likelihood of HIV transmission.

Choosing route of delivery for the macrosomic infant of a diabetic mother: Cesarean section versus vaginal delivery

The macrosomic fetus of a diabetic woman faces increased risk for injury at the time of vaginal birth. Cesarean section offers the promise of avoiding trauma to the fetus, but can result in increased morbidity in the mother as compared to vaginal delivery. In this article, the advantages and disadvantages of the two routes of delivery for the overgrown fetus of a diabetic mother are discussed. Specifically, data regarding risk of permanent neurological damage to the infant from vaginal delivery, and maternal morbidity from elective, pre-labor Cesarean delivery are critically examined. In addition, methods for diagnosing macrosomia by ultrasound are discussed, along with the benefits and pitfalls of ultrasonic fetal weight estimation in the setting of diabetes. Finally, management approaches for selecting route of delivery for the macrosomic fetus are described and analyzed.

Cesarean section delivery to prevent vertical transmission of human immunodeficiency virus type 1. Associated risks and other considerations

Delivery by elective cesarean section (ECS), cesarean section prior to labor and rupture of membranes, is associated with a lower rate of vertical transmission of HIV compared with other modes of delivery. The efficacy of ECS among women receiving combination antiretroviral therapy or among women with low viral loads is unknown. In assessing the possible utility of ECS as an intervention to decrease vertical transmission in the United States and other countries, the potential risks associated with operative delivery as well as other considerations should also be addressed. Although cesarean section delivery is associated with an increased rate of postpartum morbidity compared with vaginal delivery in the general population, operative delivery performed emergently carries a higher risk of complications than scheduled or elective procedures. Analyses of the risk of postpartum morbidity according to mode of delivery among HIV-infected women have been performed in the Women and Infants Transmission Study (WITS), the largest database in North America with relevant data, as well as other, smaller databases. These analyses suggest a similar pattern to that observed in the general population. In addition to quantifying the incidence of postpartum morbidity events, it is also important to distinguish between minor and major morbidity. Neonatal morbidity related to ECS is generally due to iatrogenic preterm birth, that is, situations where the gestational age is not accurately assessed prior to delivery. Occupationally acquired HIV infection related to obstetric procedures is a possibility, although risk related to mode of delivery is unknown. The results of economic analyses of ECS compared to vaginal delivery in the US indicate that ECS is a cost-effective intervention in preventing vertical transmission of HIV among women who refrain from breastfeeding. However, more precise estimates of the risk of vertical transmission among women receiving combination antiretroviral therapy and of the potential risks of maternal and pediatric adverse events related to receipt of such therapy are needed. In summary, the benefit of ECS must be weighed against potential risks, and issues such as cost-effectiveness also should be taken into consideration.

Ogilvie's syndrome after cesarean delivery

Ogilvie's syndrome is a rare postsurgical complication that can be associated with cesarean delivery. It is characterized by massive dilation of the colon, much like that which occurs with an obstruction but in the absence of a mechanical obstruction. Early detection and intervention are necessary to avoid serious morbidity and/or mortality. Conservative treatment is effective in many cases, but surgical intervention may be required. Nursing assessment of the gastrointestinal system in the postsurgical patient is reviewed using a case report of a patient who developed Ogilvie's syndrome after a cesarean delivery.

Perfil de nascimentos no Município do Rio de Janeiro: uma análise espacial

Neste artigo analisou-se o perfil de nascimentos por bairros do Município do Rio de Janeiro, utilizando-se os dados do Sistema de Informações sobre Nascidos Vivos de 1994. Foram empregados mapas de padrão e o teste estatístico I de Moran para detecção de cluster espacial. As proporções de nascidos vivos com Apgar entre oito e dez, de cesáreas, de mães com escolaridade acima de segundo grau e de mães adolescentes apresentaram padrão espacial visualmente identificável e autocorrelação espacial significativa. O baixo peso apresentou padrão espacial aleatório, demonstrando que, nesta escala de análise, este indicador não discrimina grupos de risco, apesar do seu inquestionável valor preditivo para morbi-mortalidade infantil em nível individual. O Apgar, apesar do elevado número de não-resposta em alguns bairros, apresenta padrão mais consistente com a distribuição dos bairros, devendo, por isso, ser mais utilizado. Esta metodologia permitiu aprofundar o conhecimento sobre o perfil de nascimentos no Município, apresentando potencial no direcionamento de ações voltadas para áreas específicas.

A prospective study of the impact of psychosocial and lifestyle variables on pregnancy complications

This prospective study examines the influence of maternal stress, social support and lifestyle variables reported over the course of pregnancy on subsequent gestational and intrapartum complications. Demographic and biomedical factors were also studied. One hundred and two women were followed on a monthly basis beginning in the third month of pregnancy. Measures of daily stress (hassles), state-anxiety (STAI-state) and pregnancy-specific stress were taken monthly. Pregnancy progress and lifestyle behaviors such as smoking, caffeine and alcohol intake were assessed by trimester. One month following delivery, a telephone interview was conducted to inquire about the labor/delivery and infant status. Sixty-three per cent of the women experienced a pregnancy complication. Three groups consisting of women who experienced gestational complications, intrapartum complications only, and no complications were formed. Women who subsequently experienced gestational complications reported over the course of their pregnancy higher levels of state-anxiety, daily hassles and pregnancy-specific stress beginning in the third month of pregnancy. Women who experienced complications during the intrapartum period only reported higher daily hassles during pregnancy and consumed more caffeinated beverages compared to the other groups. Primiparous women were more likely to experience gestational and/or intrapartum complications than multiparous women. These findings support a role for psychosocial variables in pregnancy complications. The results indicate that certain psychosocial and lifestyle variables may be differentially associated with complications occurring at various phases of pregnancy.

Pregnancy outcome after successful external cephalic version for breech presentation at term

OBJECTIVE

Our purpose was to review the outcome of pregnancies after external cephalic version at term, in particular the incidence and indications of intrapartum cesarean section after successful external cephalic version.

STUDY DESIGN

A prospective study was performed of 241 term pregnancies that had a total of 243 external cephalic versions. Each case with successful external cephalic version was matched to two control cases with cephalic presentation to compare pregnancy outcome.

RESULTS

External cephalic version was successful in 169 attempts (69.5%), of which 7 (4.1%) reverted to breech presentation. There was one case of abruptio placentae and eight cases (3.3%) of transient fetal bradycardia after the procedure. Among those who had a successful external cephalic version, the incidence of intrapartum cesarean section was 16.9%, which was 2.25 times higher than that of the control group (p < 0.005). This large number of abdominal deliveries was due to a significantly higher incidence of fetal distress and dystocic labor. The incidence of augmentation of labor was also significantly higher in the study group (37.7% vs 27.6%, p < 0.05).

CONCLUSION

Pregnancies after a successful external cephalic version at term are not the same as those with cephalic presentation. They are at higher risk of both dystocic labor and fetal distress and therefore require close intrapartum monitoring.

[On the hypothesis of cesarean birth rate stabilization in southeastern, Brazil]

Births in S. Paulo State (Brazil) between 1987 and 1993 were studied to test the association between cesarean section rates and the social and economic development. The study used both Health Regions and hospitals as units of analysis. The cross-sectional study of secondary data adopted as variables: cesarean section rates in 1987, 1992 and 1993 by hospital and region; kind of provider; link of hospital with medical school; post-neonatal infant mortality rate; number of banks per inhabitant; and consumption potential of the regional central town per inhabitant. The C-section rates in the period studied were around 48% for the State; between 21.3 and 85.5% for the regions; between zero and 100% for the hospitals; as for kind of provider, the higher rates were found in private hospitals (56% in 1993). Medical school hospitals held stable rates throughout the period, around 39%. The multiple linear regression showed that banks per inhabitant and consumption potential by inhabitants explained 48% of the variation of the regional C-section rates. The stabilization of the State C-section rates is questioned, since the data shows a shift in the mode of hospital rates to higher values. A re-structure of the care delivered to births is imperative in S. Paulo State, since cesarean sections, besides being medical procedures, have become a consumer good, a symptom of the perverse logic that pervades the current organization of the health system.

Cesarean delivery rates in women cared for by certified nurse-midwives in the United States: a review

The frequency of cesarean deliveries for women attended by certified nurse-midwives in the United States (1.8-10.4%) is lower than the rate for the general population of woman who gave birth in the United States in 1990 (23%). This paper describes the research that reported cesarean birth rates for certified nurse-midwives. Major methodology limitations of the research suggest that significant information gaps exist regarding nurse-midwifery care and its effect on cesarean delivery. Issues surrounding this common clinical procedure are complex, with its high cost and controversy over determinant factors. It is important to develop convincing evidence about the influence of nurse-midwives' care on reducing the frequency of cesarean delivery in the United States.

Changes in cesarean delivery in the United States, 1988 and 1993

The rate of cesarean delivery in the United States (22.8% in 1993) has remained stable since the mid-1980s after dramatic increases during the 1970s and early 1980s. The primary cesarean rate (16.3 cesareans in 1993 per 100 women with no history of previous cesarean delivery) was also stable from 1988 to 1993. During this same period, the rate of vaginal birth after previous cesarean (VBAC) doubled, from 12.6 to 25.4 percent. In both 1988 and 1993, rates of cesarean delivery were higher in the South than in other regions, for mothers 35 years or older than for younger women, for proprietary than for nonprofit or state and local government hospitals, and for women with private insurance than for women with Medicaid or self-pay as the expected source of payment. Even if VBAC rates continue to increase at the same rate as in the past, the Year 2000 goal of an overall cesarean rate of 15 percent cannot be met without reducing the primary cesarean rate by 50 percent.

How safe is caesarean section

Over an almost 5 year period, 8,017 caesarean sections were done, and there were 51 maternal deaths following caesarean section (of which 5 were done outside). Caesarean section deaths accounted for 1 in 8 overall maternal deaths in the hospital, and institutional mortality for caesarean section was 5.7/1,000 operations. The causes of death included haemorragic shock in 19 (37.3%), general anaesthesia (11.6%), hypertensive disorders 5 (9.8%), general anaesthesia in hypertensive pregnancies 4 (7.8%), septicaemia 7 (13.7%), hepatic failure 3 (5.9%), pulmonary edema 2 (3.9%) and unknown including pulmonary embolism 6 (11.6%). Five deaths followed elective operations. Caesarean section done in cases of antepartum haemorrhage, hypertensive disorders, post caesarean pregnancies with adherent placentae and obstructed labour caused the majority of caesarean mortalities.

Short-term morbidity associated with cesarean delivery

This study describes the short-term morbidity associated with cesarean delivery and women's knowledge of the reasons it was performed. It was conducted in a university teaching hospital that delivers approximately 4000 women per year. During 1986, 619 women (16%) were delivered by cesarean, 588 of whom were sent a questionnaire three months after delivery. The response rate was 76 percent. General questions were asked about the women's recovery and health state after the birth, and whether they had experienced more specific types of morbidity, including infection, backache, and depression, and the reasons for the cesarean delivery. Women's answers were then compared with the obstetric case record. In their comprehension of why the cesarean was necessary, 87 percent of women were right or partially right, 35 percent believed they had still not fully recovered, and 28 percent felt less healthy than before the pregnancy. Women experienced a wide variety of postnatal morbidity, most commonly backache (55%), constipation (49%), and depression (38%). The study showed that considerable maternal morbidity is associated with cesarean delivery, and it can persist long after the woman is discharged from hospital. Much more information is necessary about the health of women after delivery, and research is urgently required to determine the comparative rates of morbidity associated with different delivery methods.

Pulmonary hypertension and pregnancy--a lethal combination

Pulmonary hypertension may be either primary of unknown aetiology or secondary to existing cardio-respiratory disease. As a single entity the prognosis is poor but superimposition of the physiological changes of pregnancy and labour produces a lethal condition. This paper sets out two clinical cases of primary pulmonary hypertension as background for discussion to highlight the issues involved. Whatever this discussion does, let it be clearly spelled out that prevention is better than any proposed cure.