Indications for caesarean section in a consultant obstetric unit over three decades

Do specific maternal sensations experienced in late pregnancy correlate to a breech presenting baby? Evaluation of a simple maternal questionnaire

OBJECTIVES

To investigate the effectiveness of a structured questionnaire completed at 36 weeks gestation in predicting breech presentation.

DESIGN

Questionnaire-based study.

SETTING

Tertiary NHS Foundation Trust.

PARTICIPANTS

Women attending for a universally offered 36-week fetal growth scan.

INTERVENTION

Completion of a previously designed maternal questionnaire detailing sensation of fetal movements during the past week, immediately before a routine growth scan.

RESULTS

Between September 01, 2018 and September 30, 2019, 2341 questionnaires were handed out and 2053 were returned. Analysis was performed in 1938 (94.4%) completed questionnaires. Recorded presentation was breech in 109 (5.6%), transverse/oblique in 15 (0.8%), and cephalic in 1814 (93.6%). Women "thinking their baby was breech" had a high positive likelihood ratio, at 11.8 (95% CI 7.4-19.1), but poor sensitivity (27.3%). "Feeling kicks low down or near the bladder" was sensitive for non-cephalic presentation (76.3%) but with poor specificity (48.9%). The questions "kicks low" ("no") (P = 0.013, aOR 2.18 [1.18-4.04]) and 'thinks cephalic ("no")' (P = 0.001, aOR 0.12 (0.04-0.43) were independent risk factors for a non-cephalic presentation.

CONCLUSIONS

The questions posed in this questionnaire could aid the detection of breech presentation, but do not perform better than published data on palpation. Missing a breech presentation near term through palpation alone is well reported. Combining the concept of palpation to exclude breech presentation and these questions may help focus a clinician and improve both palpation skills and breech detection. As a minimum, a woman who believes her baby is breech should be taken seriously.

How to reach trustworthy decisions for caesarean sections on maternal request: a call for beneficial power

Caesarean delivery is a common and life-saving intervention. However, it involves an overall increased risk for short-term and long-term complications for both mother and child compared with vaginal delivery. From a medical point of view, healthcare professionals should, therefore, not recommend caesarean sections without any anticipated medical benefit. Consequently, caesarean sections requested by women for maternal reasons can cause conflict between professional recommendations and maternal autonomy. How can we assure ethically justified decisions in the case of caesarean sections on maternal request in healthcare systems that also respect patients' autonomy and aspire for shared decisions? In the maternal-professional relationship, which can be characterised in terms of reciprocal obligations and rights, women may not be entitled to demand a C-section. Nevertheless, women have a right to respect for their deliberative capacity in the decision-making process. How should we deal with a situation of non-agreement between a woman and healthcare professional when the woman requests a caesarean section in the absence of obvious medical indications? In this paper, we illustrate how the maternal-professional relationship is embedded in a nexus of power, trust and risk that reinforces a structural inferiority for women. To accommodate for beneficial use of power, these decision processes need to be trustworthy. We propose a framework, inspired by Lukes' three-dimensional notion of power, which serves to facilitate trust and allows for beneficial power in shared processes of decision-making about the delivery mode for women requesting planned C-sections.

Cesarean delivery: Trend in indications over three decades within a major city hospital network

INTRODUCTION

The cesarean delivery rate has been increasing globally in recent decades. The reasons for this are complex and subject to ongoing debate. Investigation of the indications for cesarean delivery and how these have changed over an extended period of time could provide insight into the reasons for changing obstetric practice. Our objective was to explore contributing factors to the increasing rate of cesarean delivery by examining the incidence of and indications for cesarean delivery over the past three decades at our institutions.

MATERIAL AND METHODS

We conducted a retrospective observational study of all cesarean deliveries, from 24 weeks' gestational age onwards, within an inner-city hospital network in Sydney, Australia, between August 1989 and December 2016. The primary outcome measures were the rates of and indications for emergency and planned cesarean delivery. We also examined our data within the Robson 10-Group Classification system.

RESULTS

There were 147 722 births over the study period, with 37 309 cesarean deliveries for an overall rate of 25.3%. The rate of cesarean delivery increased from 18.7% in 1989-1994 (8.7% emergency, 10% planned) to 30.4% in 2010-2016 (11.4% emergency, 19% planned). Emergency cesarean delivery for slow progress increased from 3.4% to 5.5% of all births (a relative increase of 62%) and other emergency cesareans mainly performed for suspected intrapartum fetal compromise increased from 5.2% to 5.6% (a relative increase of 8%). Previous uterine surgery (predominantly cesarean section) was the largest contributor to the increase in planned procedures from 3.8% to 9.0% of all births, and 29% of all cesarean deliveries. Primary cesarean delivery for planned antenatal fetal indications, previous pregnancy problems, multiple gestation and maternal choice all increased substantially in combined rate from 0.7% to 4.9%. Cesarean rates in Robson groups 6, 7 and 8 (term breech and multiple gestations) increased most over time.

CONCLUSIONS

The increased rate of cesarean delivery is mainly attributable to a greater number of procedures performed for slow progress in labor, breech presentation or repeat cesarean section.

Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study

BACKGROUND

Aim of this study is to assess women's utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive.

METHODS

A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May-September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models.

RESULTS

Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women's socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services.

CONCLUSION

Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women's expectations on essential services during pregnancy is needed as well as strengthening community participation.

A cross-sectional study exploring the incidence of and indications for second-stage cesarean delivery over three decades

OBJECTIVE

To observe the incidence of, indications for, and complications associated with second-stage cesarean delivery in 10-year intervals over 30 years.

METHODS

The present analysis of prospectively collected data compared cesarean deliveries during 1976, 1986, 1996, and 2006 at John Radcliffe Hospital in Oxford, UK (n=3222). Pregnancy, delivery, and neonatal details were reviewed.

RESULTS

The proportion of deliveries by cesarean in the second stage of labor increased from 0.5% (22/4464) in 1976 to 2.1% (124/5998) in 2006 (P<0.001). The proportion of cesarean deliveries during the second stage because of failed instrumental delivery also increased over the study period from 59.1% (13/22) in 1976 to 71.0% (88/124) in 2006. Compared with cesareans at other stages, uterine trauma (P<0.001), blood loss greater than 1000 mL (P=0.002), and blood transfusion (P=0.001) were more frequent in second-stage cesarean delivery. Neonates delivered by second-stage cesarean had lower Apgar scores (P<0.001 for 1-min and 5-min scores) and cord arterial pH values (P<0.001) than did those delivered by cesarean earlier in labor. A trend towards an increase in neonatal trauma with second-stage cesarean compared with cesarean delivery before labor or during the first stage did not reach statistical significance.

CONCLUSION

The proportion of deliveries by cesarean in the second stage of labor increased; these deliveries were associated with greater maternal and neonatal morbidity, but were not influenced by the indication for cesarean.

Blood loss and blood transfusion at caesarean section: a prospective observational study covering 30 years

OBJECTIVE

Attitudes to acute blood loss and transfusion have changed during the last 40 years. This study observed the trends in blood loss and transfusion rates at caesarean section during that period to identify any trends between 1976 and 2006.

STUDY DESIGN

Prospective analysis of clinical notes of women delivered by caesarean sections in a major district hospital obstetric unit in the UK, delivering around 6000 annually during four 12-month periods every 10 years from 1976 to 2006. Details including demographic, pregnancy, delivery, blood loss, transfusion, and puerperal observations were recorded.

RESULTS

3222 of 22,998 women were delivered by caesarean section during the four study years, increasing from 7.2% in 1976 to 23.4% in 2006 (P<0.001). The median recorded blood loss was 500ml, which did not change significantly over the study years. The rate of excess blood loss however increased in low-risk cases in 2006 compared with 1996 (P<0.001); this increase followed the recommended restricted intra-operative oxytocin dose. Transfusion rates declined significantly from 22% in 1976 to 4-5% in 1996 and 2006 (P<0.001).

CONCLUSIONS

Median blood loss remained steady for each of the study years but with an increase in excess blood loss cases in the last study year compared with the two previous study years. The explanation for this is presently uncertain, but was possibly influenced by the 2001 recommendation for a reduced dose of oxytocin at delivery. Transfusion rates declined, probably precipitated by anxieties over infections associated blood products. There was no indication of increased morbidity with the reduced transfusion rates accessed by the surrogate of post-delivery discharge times.

Role of public and private funding in the rising caesarean section rate: a cohort study

OBJECTIVE

The caesarean section rates have been rising in the developed world for over two decades. This study assessed the involvement of the public and private health sectors in this increase.

DESIGN

Population-based, retrospective cohort study.

SETTING

Public and private hospitals in Western Australia.

PARTICIPANTS

Included in this study were 155 646 births to nulliparous women during 1996-2008.

MAIN OUTCOME MEASURES

Caesarean section rates were calculated separately for four patient type groups defined according to mothers' funding source at the time of birth (public/private) and type of delivery hospital (public/private). The average annual per cent change (AAPC) for the caesarean section rates was calculated using joinpoint regression.

RESULTS

Overall, there were 45 903 caesarean sections performed (29%) during the study period, 24 803 in-labour and 21 100 prelabour. Until 2005, the rate of caesarean deliveries increased most rapidly on average annually for private patients delivering in private hospitals (AAPC=6.5%) compared with public patients in public hospitals (AAPC=4.3%, p<0.0001). This increase could mostly be attributed to an increase in prelabour caesarean deliveries for this group of women and could not be explained by an increase in breech deliveries, placenta praevia or multiple pregnancies.

CONCLUSIONS

Our results indicate that an increase in the prelabour caesarean delivery rate for private patients in private hospitals has been driving the increase in the caesarean section rate for nulliparous women since 1996. Future research with more detailed information on indication for the prelabour caesarean section is needed to understand the reasons for these findings.

A thirty-year analysis of cesarean section rate in gestational diabetes and normal pregnant population in Tehran, Iran: a concerning trend

BACKGROUND

The aims of this study were to analyze the trend of cesarean section (CS), determining possible risk factors and also comparing the rate of CS in mothers with gestational diabetes (GDM) and normal pregnant population.

MATERIALS AND METHODS

A hospital-based midwives data collection including 37,997 pregnancies in Tehran was used for this study. The study population included all women giving birth between 1 January 1980 and 31 December 2009.

RESULTS

The global rate for CS was 37.8 and 85.9% in normal pregnant population and GDM subjects, respectively. An increase in the rate of CS was observed in normal population from 16.97% during 1980-1989 to 71.08% during 2000-2009. There was a similar upward trend for GDM subjects from 79.17 to 93.55%. The most frequent indications for CS in GDM subjects were unsuccessful induction (31%) and repeat CS (22.76%).

CONCLUSION

The rate of CS is surprisingly very high in normal pregnant population as well as subjects with GDM. This should be an alarming issue for healthcare policy-makers and a trigger for monitoring situation in the country.

Does discussion of possible scar rupture influence preferred mode of delivery after a caesarean section?

Using retrospective and prospective analyses of antenatal records, it was found that by 2003, discussions about the options for delivery after one lower segment caesarean section (LSCS) were almost always documented in antenatal notes, compared with only rare entries in 1993; specific mention of the risks of scar rupture were made in just under 50% in 2003. There was a considerable reduction in the proportion of women whose preference was to labour in 2003 compared with 1993 and also in the number who ultimately delivered vaginally. There was, however, no evidence that those women with whom possible scar rupture had been discussed were discouraged from attempting vaginal delivery. These data suggest that, contrary to expectations, increasing patients' involvement in their management in this situation does not result in fewer caesarean sections.

Herniated gravid uterus through an incisional hernia treated with the component separation technique

Herniation of a gravid uterus through an incisional hernia of the anterior abdominal wall is a rare but serious condition due to the potentially severe maternal and foetal risks. Because of the rarity of the condition, no consensus exists regarding the optimal treatment. The component separation technique (CST) has proven to be effective for the treatment of those giant abdominal hernias in which prosthetic material utilisation is not indicated. We report the case of a woman who presented at 38 weeks of gestation with non-reducible herniation of the pregnant uterus through an anterior abdominal wall incisional hernia treated with CST immediately after caesarean section. Review of the existing literature is performed to further underline the efficacy of CST and the need for the practising surgeons to be familiar with this technique and the scenarios when it may become extremely valuable.

How much influence do women in Sweden have on caesarean section? A follow-up study of women's preferences in early pregnancy

OBJECTIVE

to investigate factors associated with having a caesarean section, with special emphasis on women's preferences in early pregnancy.

DESIGN

a cohort study using data from questionnaires in early pregnancy and 2 months after childbirth, and data from the Swedish Medical Birth Register.

SETTING

women were recruited from 97% of all antenatal clinics in Sweden at their booking visit during 3 weeks between 1999 and 2000, and followed up 2 months after birth.

PARTICIPANTS

a total of 2878 Swedish-speaking women were included in the study (87% of those who consented to participate and 63% of all women eligible for the study).

FINDINGS

Of 236 women who wished to have their babies delivered by caesarean section when asked in early pregnancy, 30.5% subsequently had an elective caesarean section and 14.8% an emergency caesarean section. The logistic regression analyses showed that, a preference for caesarean section in early pregnancy (odds ratio [OR] 9.63, 95% confidence interval [CI] 5.94-15.59), a medical diagnosis (OR 9.03, 95% CI 5.68-14.34), age (OR 1.08, 95% CI 1.03-1.13), parity (OR 0.58, 95% CI 0.37-0.91), a previous elective caesarean section (OR 15.11, 95% CI 6.83-33.41) and a previous emergency caesarean section (OR 18.29, 95% CI 10.00-33.44) was associated with having an elective caesarean section. Having an emergency caesarean section was associated with a preference for a caesarean section (OR 2.59, 95% 1.61 to 4.18), a medical diagnosis (OR 4.12, 95% CI 2.91-5.88), age (OR 1.08, 95% CI 1.05-1.12), primiparity (OR 3.34, 95% CI 1.78-6.27), a previous emergency caesarean section (OR 10.69, 95% CI 6.03-18.94), and a previous elective caesarean section (OR 7.21, 95% CI 2.90-17.92).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

a woman's own preference about caesarean section was associated with the subsequent mode of delivery. Asking women about their preference regarding mode of delivery in early pregnancy may increase the opportunity to provide adequate support and possibly also to reduce the caesarean section rate.

Trends in mode of delivery during 1984-2003: can they be explained by pregnancy and delivery complications?

OBJECTIVES

To describe trends in mode of delivery, to identify significant factors which affected mode of delivery, and to describe how these factors and their impact have changed over time.

DESIGN

Total population birth cohort.

SETTING

Western Australia 1984-2003.

PARTICIPANTS

The analysis was restricted to all singleton infants delivered at 37-42 weeks of gestation with a cephalic presentation (n = 432,327).

METHODS

Logistic regression analyses were undertaken to estimate significant independent risk factors separately for elective and emergency caesarean sections compared with vaginal delivery (spontaneous and instrumental), adjusting for potential confounding variables.

MAIN OUTCOME MEASURES

Trends in mode of delivery, demographic factors, and pregnancy and delivery complications. Estimated likelihood of elective caesarean section compared with vaginal delivery and emergency caesarean section compared with vaginal delivery.

RESULTS

Between 1984-88 and 1999-2003, the likelihood of women having an elective caesarean section increased by a factor of 2.35 times (95% CI 2.28-2.42) and the likelihood of an emergency caesarean section increased 1.89 times (95% CI 1.83-1.96). These caesarean section rate increases remained even after adjustment for their strong associations with many sociodemographic factors, obstetric risk factors, and obstetric complications. Rates of caesarean section were higher in older mothers, especially those older than 40 years of age (elective caesarean section, OR 5.42 [95% CI 4.88-6.01]; emergency caesarean section, OR 2.67 [95% CI 2.39-2.97]), and in nulliparous women (elective caesarean section, OR 1.54 [95% CI 1.47-1.61]; emergency caesarean section, OR 3.61 [95% CI 3.47-3.76]).

CONCLUSIONS

Our data show significant changes in mode of delivery in Western Australia from 1984-2003, with an increasing trend in both elective and emergency caesarean section rates that do not appear to be explained by increased risk or indication.

Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis

OBJECTIVE

To estimate the national occurrence of pregnancies in women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) and to compare pregnancy outcomes in these patients with those in women with pregestational diabetes mellitus (DM) and with the general obstetric population.

METHODS

We studied the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project to estimate the number of obstetric hospitalizations, deliveries, and cesarean deliveries in women with SLE, RA, pregestational DM, and the general obstetric population. Pregnancy outcomes included length of hospital stay, hypertensive disorders including preeclampsia, premature rupture of membranes, and intrauterine growth restriction.

RESULTS

Of an estimated 4.04 million deliveries, 3,264 occurred in women with SLE, 1,425 in women with RA, and 13,574 in women with pregestational DM. Women with SLE, RA, and pregestational DM had significantly increased rates of hypertensive disorders compared with the general obstetric population (23.2%, 11.1%, 27.4%, and 7.8%, respectively), longer hospital stays, and significantly higher risk of cesarean delivery. Although women with SLE, RA, and pregestational DM were significantly older than women in the general obstetric population, disparities in the risk of adverse outcomes of pregnancy remained statistically significant after adjustment for maternal age.

CONCLUSION

To our knowledge, this is the first study to examine national data on pregnancy outcomes in women with common rheumatic diseases. As with underlying pregestational DM, women with SLE and RA appear to have a higher age-adjusted risk of adverse outcomes of pregnancy and longer hospital stays than do pregnant women in the general population, and careful antenatal monitoring should be performed.

Mode d’accouchement des femmes avec une présentation du siège à terme dans l’étude PREMODA (PREsentation et MODe d’accouchement)

OBJECTIVES

The purpose of this work was to report labor and birth management practices for term breech presentation in France and Belgium in 2001-2002 and to describe indications for cesarean sections (before labor, emergency situations) in breech presentations.

MATERIAL AND METHODS

The PREMODA cohort is a survey population which included 19408 deliveries, 8108 of which were term breech presentations.

RESULTS

Infants were delivered by cesarean section before labor (59.1%), emergency cesarean section during labor (18.4%) or vaginally (22.5%). The decision for cesarean section before labor was empirical (breech presentation) in 44.3% of the cases. Half of the cesarean sections performed during labor (n=704, 49.3%) were planned C-sections. Overall, 67.8% of the breech presentations were delivered during planned cesarean sections (before or during labor). When vaginal delivery was attempted, the rate of vaginal birth was 70%.

CONCLUSION

These early results reveal a high rate of cesarean section as well as differences in inter-regional practices. Considering all cesarean sections performed before labor, the most frequent indication was an empirical decision because of the breech presentation. An increased rate of planned cesarean section does not reduce the rate of vaginal delivery when attempted.