Maternal mortality after cesarean section in The Netherlands

Cesarean section rates in a tertiary referral hospital in Beirut from 2018 to 2020: Our experience using the Robson Classification

OBJECTIVE

To evaluate the cesarean section rate using the Robson Classification for the first time in Lebanon, at Hôtel-Dieu de France University Hospital, a tertiary referral center in Beirut.

METHODS

Routine medical record data that included all live births from January 1, 2018 to September 30, 2020 was investigated. The overall cesarean section rate was recorded, and the size, cesarean section rate, and absolute and relative contributions were calculated within each group.

RESULTS

The overall cesarean section rate was 56.8%. The highest relative contribution to this rate came from Robson groups 5, 2 and 10, respectively. A decrease in cesarean section rate was noted in 2020 among women admitted for induction of labor (groups 2 and 4) following the implementation of new department policies and the restrictions caused by the coronavirus disease 2019 pandemic.

CONCLUSION

More than 50% of the deliveries in our department were by cesarean sections (CS). Strategies to reduce this rate should include stricter departmental policies for avoidance of unindicated primary CS and raising practitioners' and patients' awareness about trial of labor after cesarean section.

Why the Elective Caesarean Lottery is Ethically Impermissible

In the United Kingdom the law and medical guidance is supportive of women making choices in childbirth. NICE guidelines are explicit that a competent woman's informed request for MRCS (elective caesarean in the absence of any clinical indications) should be respected. However, in reality pregnant women are routinely denied MRCS. In this paper I consider whether there is sufficient justification for restricting MRCS. The physical and emotive significance of childbirth as an event in a woman's life cannot be understated. It is, therefore, concerning that women are having their wishes ignored, and we must ascertain whether the denial of agency is justifiable. To answer this question I first demonstrate that access to MRCS is a lottery in the UK. Second, I argue that there is nothing unique about pregnancy that displaces the ethical norm of respecting patents' sufficiently autonomous choices. Thus, the starting presumption is that all informed choices regarding MRCS should be respected. To ascertain whether any restriction of MRCS is justifiable the burden of proof must be placed on those who argue that MRCS is ethically impermissible. I argue that the most common justifications in the literature against MRCS are insufficient to displace the presumption in favour of autonomous choice in childbirth. I conclude that MRCS should be available to pregnant women, and we must strive to reduce the lottery in access to choice.

Laparotomy in women with severe acute maternal morbidity: secondary analysis of a nationwide cohort study

BACKGROUND

Although pregnancy-related laparotomy is a major intervention, literature is limited to small case-control or single center studies. We aimed to identify national incidence rates for postpartum laparotomy related to severe acute maternal morbidity (SAMM) in a high-income country and test the hypothesis that risk of postpartum laparotomy differs by mode of birth.

METHODS

In a population-based cohort study in all 98 hospitals with a maternity unit in the Netherlands, pregnant women with SAMM according to specified disease and management criteria were included from 01/08/2004 to 01/08/2006. We calculated the incidence of postpartum laparotomy after vaginal and cesarean births. Laparotomies were analyzed in relation to mode of birth using all births in the country as reference. Relative risks (RR) were calculated for laparotomy following emergency and planned cesarean section compared to vaginal birth, excluding laparotomies following births before 24 weeks' gestation and hysterectomies performed during cesarean section.

RESULTS

The incidence of postpartum laparotomy in women with SAMM in the Netherlands was 6.0 per 10,000 births. Incidence was 30.1 and 1.8 per 10,000 following cesarean and vaginal birth respectively. Compared to vaginal birth, RR of laparotomy after cesarean birth was 16.7 (95% confidence interval [95% CI] 12.2-22.6). RR was 21.8 (95% CI 15.8-30.2) for emergency and 10.5 (95% CI 7.1-15.6) for planned cesarean section.

CONCLUSIONS

Risk of laparotomy, although small, was considerably elevated in women who gave birth by cesarean section. This should be considered in counseling and clinical decision making.

Factors affecting the choice of type of delivery with breast feeding in Iranian mothers

OBJECTIVE

This study assessed the factors affecting the choice of type of delivery with breast feeding in Iranian mothers.

METHODS

This Cross section descriptive analytic study was performed using a random sampling technique, using data from 400 pregnant women who attended the maternity centers in Borazjan and Kazerun in Iran in 2014. A questionnaire covering demographic characteristics, mode of delivery and postpartum conditions was completed for each mother. Descriptive analysis and Chi square test were used along with SPSS 23 software to statistically analyze the data and p-value less than 0.05 was considered for statistical significance.

RESULTS

In this study, the rate of normal delivery and cesarean operation are considered equal. In the main factors influencing the choice of delivery, mothers' education level (p=0.028) and pregnancy status (p=0.041) showed a significant relationship. Although no significant association between child nutrition with the type of delivery was found, duration of breastfeeding with the type of delivery showed significant association (p=0.046).

CONCLUSION

Although cesarean delivery in many cases is life-saving for mother and fetus; in addition to medical indications, parents with higher education and pregnancy status are also important factors in increasing the rate of cesarean section compared to vaginal delivery. Babies of mothers with normal delivery had a longer time of breastfeeding. Further studies in Iran are necessary, regarding the reasons for high cesarean section and their outcomes.

Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data

BACKGROUND

Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.

METHODS

We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.

FINDINGS

From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.

INTERPRETATION

All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.

FUNDING

None.

Relative Risk of Postpartum Complications in the Ohio Medicaid Population: Vaginal Versus Cesarean Delivery

The objective of this study was to estimate the relative risk of postpartum complication by type of delivery among Ohio Medicaid beneficiaries. The study uses the linked Medicaid and Ohio birth certificate data for births occurring from July 1991 through April 1996 (N = 168,736). The results indicate that the incidence of major puerperal infection, thromboembolic events, anesthetic complications, and obstetrical surgical wound infection was higher among women undergoing a C-section as compared to those with vaginal delivery, even after limiting the analysis to elective cesarean deliveries and uncomplicated vaginal deliveries. On the other hand, women with C-sections were less likely to experience obstetrical trauma, and results on postpartum hemorrhage were inconclusive. Aside from obstetrical trauma, the relative risk of postpartum complications remains significantly higher among women undergoing C-section. These findings are of particular relevance in light of the substantial proportion of repeat C-sections performed on an elective basis.

Restriction of oral intake during labor: whither are we bound?

In 1946, Dr Curtis Mendelson suggested that aspiration during general anesthesia for delivery was avoidable by restricting oral intake during labor. This suggestion proved influential, and restriction of oral intake in labor became the norm. These limitations may contribute to fear and feelings of intimidation among parturients. Modern obstetrics, especially in the setting of advances in obstetric anesthesia, does not mirror the clinical landscape of Mendelson; hence, one is left to question if his findings remain relevant or if they should inform current recommendations. The use of general anesthesia at time of cesarean delivery has seen a remarkable decline with increased use of effective neuraxial analgesia as the standard of care in modern obstetric anesthesia. While the American College of Obstetricians and Gynecologists now endorses clear liquids during labor, current recommendations continue to suggest that solid food intake should be avoided. Recent evidence from a systematic review involving 3130 women in active labor suggests that oral intake should not be restricted in women at low risk of complications, given there were no identified benefits or harms of a liberal diet. Aspiration and other adverse maternal outcomes may be unrelated to oral intake in labor and as such, qualitative measures such as patient satisfaction should be paramount. It is time to reassess the impact of oral intake restriction during labor given the minimal risk of aspiration during labor in the setting of modern obstetric anesthesia practices.

Changing trends in emergency peripartum hysterectomy in a tertiary obstetric center in Turkey during 2000-2013

OBJECTIVE

To evaluate emergency peripartum hysterectomy (EPH) cases over a 14-year period in a tertiary center in İstanbul, Turkey.

MATERIAL AND METHODS

In this retrospective descriptive study, the records of all cases of EPH performed at the Zeynep Kamil Women and Children's Training and Research Hospital between January 2000 and January 2014 were analyzed. Results for 2000-2006 and 2007-2013 were compared to identify changing trends. Demographic and clinical factors associated with EPH were assessed.

RESULTS

During the 14-year study period, a total of 161,836 births occurred, out of which 104,783 (64.8%) were vaginal deliveries and 57,053 (35.2%) were cesarean section (CS). EPH was performed in 81 patients with an overall incidence of 0.5 in 1000 deliveries. The EPH rate in 2007-2013 (0.07%) was significantly higher than in 2000-2006 (0.03%). The major difference in the EPH populations between the two periods was the higher number of previous CS in 2007-2013 compared with 2000-2006 (p=0.01). Indications for EPH did not differ between the two periods. There were 7 (8.6%) maternal deaths in 2000-2013, with significantly fewer maternal deaths in 2007-2013 than in 2000-2006 (19.2% vs. 3.6%).

CONCLUSION

Rate of EPH increased considerably from 2000 to 2013. This increase was mostly related to the increasing rate of CS. Indications for EPH did not change over the study period, and the number of maternal deaths markedly decreased.

Surgically avertable burden of obstetric conditions in low- and middle-income regions: a modelled analysis

OBJECTIVE

To quantify the burden of maternal and neonatal conditions in low- and middle-income countries (LMICs) that could be averted by full access to quality first-level obstetric surgical procedures.

DESIGN

Burden of disease and epidemiological modelling.

SETTING

LMICs from all global regions.

POPULATION

The entire population in 2010.

METHODS

We included five conditions in our analysis: maternal haemorrhage; obstructed labour; obstetric fistula; abortion(1) ; and neonatal encephalopathy. Demographic and epidemiological data were obtained from the Global Burden of Disease 2010 study. We split the disability-adjusted life years (DALYs) of these conditions into surgically 'avertable' and 'non-avertable' burdens. We applied the lowest age-specific fatality rates from all global regions to each LMIC region to estimate the avertable deaths, assuming that the differences of death rates between each region and the lowest rates reflect the gap in surgical care.

MAIN OUTCOME MEASURES

Deaths and DALYs avertable.

RESULTS

Of the estimated 56.6 million DALYs (i.e. 56.6 million years of healthy life lost) of the selected five conditions, 21.1 million DALYs (37%) are avertable by full coverage of quality obstetric surgery in LMICs. The avertable burden in absolute term is substantial given the size of burden of these conditions in LMICs. Neonatal encephalopathy constitutes the largest portion of avertable burden (16.2 million DALYs) among the five conditions, followed by abortion (2.1 million DALYs).

CONCLUSIONS

Improving access to quality surgical care at first-level hospitals could reduce a tremendous burden of maternal and neonatal conditions in LMICs.

Prophylactic manual rotation for fetal malposition to reduce operative delivery

BACKGROUND

Manual rotation is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Manual rotation has the potential to prevent operative delivery and caesarean section, and reduce obstetric and neonatal complications.

OBJECTIVES

To assess the effect of prophylactic manual rotation for women with malposition in labour on mode of delivery, and maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014), the Australian and New Zealand Clinical Trials Registry (ANZCTR), ClinicalTrials.gov, Current Controlled Trials and the WHO International Clinical Trials Registry Platform (ICTRP) (all searched 23 February 2014), previous reviews and, references of retrieved studies.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster-randomised clinical trials comparing prophylactic manual rotation in labour for fetal malposition versus expectant management, augmentation of labour or operative delivery. We defined prophylactic manual rotation as rotation performed without immediate assisted delivery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality, and extracted data.

MAIN RESULTS

We included only one small pilot study (involving 30 women). The study, which we considered to be at low risk of bias, was conducted in a tertiary referral hospital in Australia, and involved women with cephalic, singleton pregnancies. The primary outcome was operative delivery (instrumental delivery or caesarean section).In the manual rotation group, 13/15 women went on to have an instrumental delivery or caesarean section, whereas in the control group, 12/15 women had an operative delivery. The estimated risk ratio was 1.08 (95% confidence interval 0.79 to 1.49). There were no maternal or fetal mortalities in either groupThere were no clear differences for any of the secondary maternal or neonatal outcomes reported (e.g. perineal trauma, analgesia use duration of labour).In terms of adverse events, there were no reported cases of umbilical cord prolapse or cervical laceration and a single case of a non-reassuring or pathological cardiotocograph during the procedure.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to determine the efficacy of prophylactic manual rotation early in the second stage of labour for prevention of operative delivery. One additional study is ongoing. Further appropriately designed trials are required to determine the efficacy of manual rotation.

Intravenous fluids for reducing the duration of labour in low risk nulliparous women

BACKGROUND

Several factors may influence the progression of normal labour. It has been postulated that the routine administration of intravenous fluids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle, and may ultimately reduce the duration of the labour. It has also been suggested that intravenous fluids may reduce caesarean sections (CS) for prolonged labour. However, the routine administration of intravenous fluids to labouring women has not been adequately elucidated although it is a widely-adopted policy, and there is no consensus on the type or volume of fluids that are required, or indeed, whether intravenous fluids are at all necessary. Women may be able to adequately hydrate themselves if they were allowed oral fluids during labour.Furthermore, excessive volumes of intravenous fluids may pose risks to both the mother and her newborn and different fluids are associated with different risks.

OBJECTIVES

To evaluate whether the routine administration of intravenous fluids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous fluids on maternal and neonatal health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013).

SELECTION CRITERIA

Randomised controlled trials of intravenous fluid administration to spontaneously labouring low-risk nulliparous women.

DATA COLLECTION AND ANALYSIS

The review authors independently assessed trials for inclusion, trial quality and extracted data.

MAIN RESULTS

We included nine randomised trials with 1781 women. Three trials had more than two treatment arms and were included in more than one comparison.Two trials compared women randomised to receive up to 250 mL/hour of Ringer's lactate solution as well as oral intake versus oral intake only. For women delivering vaginally, there was a reduction in the duration of labour in the Ringer's lactate group (mean difference (MD) -28.86 minutes, 95% confidence interval (CI) -47.41 to -10.30). There was no statistical reduction in the number of CS in the Ringer's lactate group (risk ratio (RR), 0.73 95% CI 0.49 to 1.08).Three trials compared women who received 125 mL/hour versus 250 mL/hour of intravenous fluids with free oral fluids in both groups. Women receiving a greater hourly volume of intravenous fluids (250 mL) had shorter labours than those receiving 125 mL (MD 23.87 minutes, 95% CI 3.72 to 44.02, 256 women). There was no statistically significant reduction in the number of CS in the 250 mL intravenous fluid group (average RR 1.00, 95% CI 0.54 to1.87, three studies, 334 women). In one study the number of assisted vaginal deliveries was lower in the group receiving 125 mL/hour (RR 0.47, 95% CI 0.27 to 0.81).Four trials compared rates of intravenous fluids in women where oral intake was restricted (125 mL/hour versus 250 mL/hour). There was a reduction in the duration of labour in women who received the higher infusion rate (MD 105.61 minutes, 95% CI 53.19 to 158.02); P < 0.0001, however, findings must be interpreted with caution as there was high heterogeneity amongst trials (I(2) = 53%). There was a significant reduction in CS in women receiving the higher rate of intravenous fluid infusion (RR 1.56, 95% CI 1.10 to 2.21; P = 0.01). There was no difference identified in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40). There was no clear difference between groups in the number of babies admitted to the NICU (RR 0.48, 95% CI 0.07 to 3.17).Two trials compared normal saline versus 5% dextrose. Only one reported the mean duration of labour, and there was no strong evidence of a difference between groups (MD -12.00, 95% CI -30.09 to 6.09). A trial reporting the median suggested that the duration was reduced in the dextrose group. There was no significant difference in CS or assisted deliveries (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. Only one trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). For neonatal complications, there was no difference in the admission to NICU) or in low Apgar scores, however 33.3% of babies developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93) (P = 0.03). One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group of babies. There was no difference in neonatal hypoglycaemic episodes between groups.

AUTHORS' CONCLUSIONS

Although the administration of intravenous fluids compared with oral intake alone demonstrated a reduction in the duration of labour, this finding emerged from only two trials. The findings of other trials suggest that if a policy of no oral intake is applied, then the duration of labour in nulliparous women may be shortened by the administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour. However, it may be possible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justifiable to persist with a policy of 'nil by mouth'. One trial raised concerns about the safety of dextrose and this needs further exploration.None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour. Furthermore, there was no objective assessment of dehydration. The evidence from this review does not provide robust evidence to recommend routine administration of intravenous fluids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral fluids were not restricted there was considerable variation in the amount of oral fluid consumed by women in different arms of the same trial, and between different trials. In addition, results from trials were not consistent and risk of bias varied. Some important research questions were addressed by single trials only, and important outcomes relating to maternal and infant morbidity were frequently not reported.

Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality

Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality.

Assessing health and economic outcomes of interventions to reduce pregnancy-related mortality in Nigeria

BACKGROUND

Women in Nigeria face some of the highest maternal mortality risks in the world. We explore the benefits and cost-effectiveness of individual and integrated packages of interventions to prevent pregnancy-related deaths.

METHODS

We adapt a previously validated maternal mortality model to Nigeria. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to Southwest and Northeast zones using survey-based data. Strategies consisted of improving coverage of effective interventions, and could include improved logistics.

RESULTS

Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality, was cost saving in the Southwest zone and cost-effective elsewhere, and prevented nearly 1 in 5 abortion-related deaths. However, with a singular focus on family planning and safe abortion, mortality reduction would plateau below MDG 5. Strategies that could prevent 4 out of 5 maternal deaths included an integrated and stepwise approach that includes increased skilled deliveries, facility births, access to antenatal/postpartum care, improved recognition of referral need, transport, and availability quality of EmOC in addition to family planning and safe abortion. The economic benefits of these strategies ranged from being cost-saving to having incremental cost-effectiveness ratios less than $500 per YLS, well below Nigeria's per capita GDP.

CONCLUSIONS

Early intensive efforts to improve family planning and control of fertility choices, accompanied by a stepwise effort to scale-up capacity for integrated maternal health services over several years, will save lives and provide equal or greater value than many public health interventions we consider among the most cost-effective (e.g., childhood immunization).

Rekindling of Nurse‐Midwifery in Brazil: Public Policy and Childbirth Trends

In the last decade, nurse-midwifery in Brazil has experienced many changes both professionally and politically. In the 1990s, Brazil's Ministry of Health generated policies to improve childbirth services. Included in these policy initiatives was legislation for the reimbursement of nurse-midwifery services and a substantial increase in financing of nurse-midwifery schools throughout the country. It was during this period that the Brazilian National Nurse-Midwifery Organization was formed to provide professional leadership and an alternative model of childbirth care. The future is hopeful, but the nurse-midwifery profession will need collective determination to succeed in changing practices and improving services to women and families.

Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis

BACKGROUND

Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Taking into account the costs, feasibility, and operational complexity of alternative interventions, we estimate the clinical and population-level benefits associated with strategies to improve the safety of pregnancy and childbirth in India.

METHODS AND FINDINGS

Country- and region-specific data were synthesized using a computer-based model that simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications in individual women; and considers delivery location, attendant, and facility level. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to urban and rural India using survey-based data (e.g., unmet need for birth spacing/limiting, facility births, skilled birth attendants). Model validation compared projected maternal indicators with empiric data. Strategies consisted of improving coverage of effective interventions that could be provided individually or packaged as integrated services, could reduce the incidence of a complication or its case fatality rate, and could include improved logistics such as reliable transport to an appropriate referral facility as well as recognition of referral need and quality of care. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. If over the next 5 y the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Still, reductions in maternal mortality reached a threshold ( approximately 23%-35%) without including strategies that ensured reliable access to intrapartum and emergency obstetrical care (EmOC). An integrated and stepwise approach was identified that would ultimately prevent four of five maternal deaths; this approach coupled stepwise improvements in family planning and safe abortion with consecutively implemented strategies that incrementally increased skilled attendants, improved antenatal/postpartum care, shifted births away from home, and improved recognition of referral need, transport, and availability/quality of EmOC. The strategies in this approach ranged from being cost-saving to having incremental cost-effectiveness ratios less than US$500 per year of life saved (YLS), well below India's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness.

CONCLUSIONS

Early intensive efforts to improve family planning and control of fertility choices and to provide safe abortion, accompanied by a paced systematic and stepwise effort to scale up capacity for integrated maternal health services over several years, is as cost-effective as childhood immunization or treatment of malaria, tuberculosis, or HIV. In just 5 y, more than 150,000 maternal deaths would be averted through increasing contraception rates to meet women's needs for spacing and limiting births; nearly US$1.5 billion would be saved by coupling safe abortion to aggressive family planning efforts; and with stepwise investments to improve access to pregnancy-related health services and to high-quality facility-based intrapartum care, more than 75% of maternal deaths could be prevented. If accomplished over the next decade, the lives of more than one million women would be saved.

Caesarean section--past and present

Prior to 1500, postmortem Caesarean section was advocated and occasionally carried out as an effort to save the child. Caesarean section on the living woman was first advocated during the 16th and 17th centuries but was opposed by the leading authorities of the day. During the 18th century and the first half of the 19th, understanding of the mechanism of labour improved. Caesarean section was advocated when a woman could not be delivered by any other means. However, many opposed Caesarean section because of the maternal mortality associated with this procedure. Important developments during the last half of the 19th century included anaesthesia, improved surgical techniques, and the introduction of asepsis and antiseptic procedures. A gradual reduction in maternal mortality followed, with a striking decrease throughout the 20th century. This has been associated with an increased reliance on Caesarean section, with rates that vary widely by country, health care facility, and delivering physician. The optimal role of Caesarean section for the benefit of both mother and child has yet to be determined.

Cost-effectiveness of breech version by acupuncture-type interventions on BL 67, including moxibustion, for women with a breech foetus at 33 weeks gestation: a modelling approach

OBJECTIVES

To assess, using a modelling approach, the effectiveness and costs of breech version with acupuncture-type interventions on BL67 (BVA-T), including moxibustion, compared to expectant management for women with a foetal breech presentation at 33 weeks gestation.

DESIGN

A decision tree was developed to predict the number of caesarean sections prevented by BVA-T compared to expectant management to rectify breech presentation. The model accounted for external cephalic versions (ECV), treatment compliance, and costs for 10,000 simulated breech presentations at 33 weeks gestational age. Event rates were taken from Dutch population data and the international literature, and the relative effectiveness of BVA-T was based on a specific meta-analysis. Sensitivity analyses were conducted to evaluate the robustness of the results.

MAIN OUTCOME MEASURES

We calculated percentages of breech presentations at term, caesarean sections, and costs from the third-party payer perspective. Odds ratios (OR) and cost differences of BVA-T versus expectant management were calculated. (Probabilistic) sensitivity analysis and expected value of perfect information analysis were performed.

RESULTS

The simulated outcomes demonstrated 32% breech presentations after BVA-T versus 53% with expectant management (OR 0.61, 95% CI 0.43, 0.83). The percentage caesarean section was 37% after BVA-T versus 50% with expectant management (OR 0.73, 95% CI 0.59, 0.88). The mean cost-savings per woman was euro 451 (95% CI euro 109, euro 775; p=0.005) using moxibustion. Sensitivity analysis showed that if 16% or more of women offered moxibustion complied, it was more effective and less costly than expectant management. To prevent one caesarean section, 7 women had to use BVA-T. The expected value of perfect information from further research was euro0.32 per woman.

CONCLUSIONS

The results suggest that offering BVA-T to women with a breech foetus at 33 weeks gestation reduces the number of breech presentations at term, thus reducing the number of caesarean sections, and is cost-effective compared to expectant management, including external cephalic version.

Maternal health outcomes two years after term breech delivery

OBJECTIVE

To evaluate maternal health outcomes two years after term breech delivery.

DESIGN

This was a non-randomized single-center prospective cohort study. Mothers were asked to fill out questionnaires at two years postpartum to judge their health in the previous three to six months. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed.

RESULTS

One hundred and eighty-three women completed a follow-up questionnaire at two years postpartum. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed. No differences in maternal experiences concerning breastfeeding, taking care of her child and the relationship with her partner were found between the two groups. Also, no differences were found in all investigated maternal health items, or in sexual activity and fertility.

CONCLUSION

Maternal health outcomes two years after term breech delivery were similar after planned cesarean section and planned vaginal delivery.

Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery

OBJECTIVE

We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006.

STUDY DESIGN

This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined.

RESULTS

Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20.

CONCLUSION

Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

Mothers' views of their childbirth experience two years after term breech delivery

INTRODUCTION

This study was performed to evaluate mothers' views of their childbirth experience two years after term breech delivery.

METHODS

Two years after delivery mothers were asked to fill out a questionnaire concerning their breech birth experience and their view about the care provided to them while giving birth. Outcomes of the planned cesarean section (CS) group were compared with outcomes of the planned vaginal delivery (VD) group, whether or not a vaginal birth was realized or an emergency cesarean section was performed. Any differences were further analyzed by use of logistic regression, controlling for potential confounders.

RESULTS

Significantly more women in the planned CS group were reassured about their baby's health (67.4% vs. 37.9%, p=0.0006) at the time of delivery, whereas more women in the planned VD group recalled having been worried about their baby's health at the time of delivery (45.0% vs. 25.6%, p=0.02). Also, more women in the planned VD group experienced more pain during labor and delivery than expected (46.9% vs. 18.5%, p=0.008). In the planned VD group fewer women indicated they had an active say in decision-making (59.1% vs. 85.3%, p=0.001).

CONCLUSIONS

Evaluation of the mothers' views of their childbirth experience two years after term breech delivery showed that more women in the planned VD group recalled having been worried about their child's health at the time of delivery, experienced more pain than expected, and reported less involvement in decision-making.

Techniques for caesarean section

BACKGROUND

Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique.

OBJECTIVES

To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers.

SELECTION CRITERIA

Randomised controlled trials of intention to perform caesarean section using different techniques.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data.

MAIN RESULTS

'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes).

AUTHORS' CONCLUSIONS

'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.

Maternal mortality in the United States

Despite a significant improvement in the US maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that - essentially - no progress has been made in most US States since 1982. Additionally, the US Centers for Disease Control and Prevention has stated that most cases are probably preventable. Two disheartening issues within this topic include a gross underestimation of the magnitude of maternal mortality - particularly before 1987, but which likely persists to a lesser degree today - and the continued significant racial disparity in maternal mortality. Explanations for the plateau in maternal mortality include the recent trend of delayed childbearing, with the potential accompanying complications associated with older reproductive age (particularly over 35 years) and multiparity. The impressive increase in multifetal pregnancies related to delayed childbearing and assisted reproductive technology also plays a role. Finally, peripartum cardiomyopathy has become an increasingly recognized source of maternal mortality. Pregnancy-related mortality is largely accounted for by thromboembolic disease, hemorrhage, hypertension and its associated complications, and infection. However, since the inclusion of maternal deaths occurring after 42 days post-delivery as pregnancy related, traumatic injuries - including homicides and suicides - are an alarming source of maternal mortality. An especially important contemporary issue to consider within this topic is cesarean delivery "on maternal request", opponents of which cite concerns not only for immediate morbidity and mortality increased over that associated with a vaginal birth, but also for potential morbidity and mortality associated with future pregnancies. One particularly appealing opportunity to reduce maternal mortality is to recognize, examine, and learn from so-called "near-miss" cases.

Conservative management in breech deliveries leads to similar results compared with cephalic deliveries

OBJECTIVE

To compare the difference in neonatal mortality and morbidity between breech and cephalic presentations at term.

METHODS

This was a retrospective matched cohort study in two centers between July 1998 and April 2000, including all breech deliveries between 37(+0) and 41(+6) weeks, except cases with multiple gestations and antepartum intrauterine deaths. All breech presentations were matched with two cephalic presentations. Onset of labor and route of delivery were recorded, and neonatal data were categorized into variables belonging to serious morbidity or moderate morbidity.

RESULTS

One thousand one hundred and nineteen deliveries were included. Three hundred and seventy-three babies were in breech position and 746 in cephalic position. The gestational age and birth weight of the babies in the breech group were lower than in the cephalic group (p < 0.001). Congenital abnormalities occurred more often in the breech group (p < 0.005). An elective cesarean section was performed in 23.3% of breech presentations versus 3.5% of cephalic presentations (p < 0.001). Emergency cesarean sections were done in 29.2% of breech presentations versus 8.8% of cephalic presentations (p < 0.001). Children born in breech presentation had lower Apgar scores after 1 minute (p < 0.0001), but 5-minute Apgar scores were the same in both groups (p = 0.22). Children born in breech presentation received significantly more resuscitation than children born in cephalic presentation (p < 0.001). In both groups no perinatal mortality occurred. No differences were observed in percentages of children with serious or moderate neonatal morbidity between the breech and cephalic lies.

CONCLUSIONS

Although the numbers are small, this study shows that the conservative (vaginal) approach in selected fetuses in breech position can be safely pursued with neonatal results similar to fetuses in cephalic presentation.

The costs, benefits, and cost-effectiveness of interventions to reduce maternal morbidity and mortality in Mexico

BACKGROUND

In Mexico, the lifetime risk of dying from maternal causes is 1 in 370 compared to 1 in 2,500 in the U.S. Although national efforts have been made to improve maternal services in the last decade, it is unclear if Millennium Development Goal 5--to reduce maternal mortality by three-quarters by 2015--will be met.

METHODOLOGY/PRINCIPAL FINDINGS

We developed an empirically calibrated model that simulates the natural history of pregnancy and pregnancy-related complications in a cohort of 15-year-old women followed over their lifetime. After synthesizing national and sub-national trends in maternal mortality, the model was calibrated to current intervention-specific coverage levels and validated by comparing model-projected life expectancy, total fertility rate, crude birth rate and maternal mortality ratio with Mexico-specific data. Using both published and primary data, we assessed the comparative health and economic outcomes of alternative strategies to reduce maternal morbidity and mortality. A dual approach that increased coverage of family planning by 15%, and assured access to safe abortion for all women desiring elective termination of pregnancy, reduced mortality by 43% and was cost saving compared to current practice. The most effective strategy added a third component, enhanced access to comprehensive emergency obstetric care for at least 90% of women requiring referral. At a national level, this strategy reduced mortality by 75%, cost less than current practice, and had an incremental cost-effectiveness ratio of $300 per DALY relative to the next best strategy. Analyses conducted at the state level yielded similar results.

CONCLUSIONS/SIGNIFICANCE

Increasing the provision of family planning and assuring access to safe abortion are feasible, complementary and cost-effective strategies that would provide the greatest benefit within a short-time frame. Incremental improvements in access to high-quality intrapartum and emergency obstetric care will further reduce maternal deaths and disability.

Factors Associated with Maternal Morbidity in the Term Breech Trial

OBJECTIVE

In the Term Breech Trial, the risk of maternal morbidity in women who delivered after planning for a caesarean section (CS) was not significantly different from those who delivered after planning for a vaginal birth. We undertook secondary analyses to determine factors associated with maternal morbidity among 2078 women.

METHODS

By using multiple logistic regression analyses, we determined the effect of prelabour CS, CS during early labour, CS during active labour, vaginal birth, and other factors on maternal morbidity. For 1536 women delivered after labour, we determined the effect of variables associated with labour on maternal morbidity.

RESULTS

The risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS during active labour (OR 3.33; 95% confidence intervals [CI] 1.75-6.33, P < 0.001). For those delivered after labour, a short active phase of the second stage of labour (< 30 minutes) was associated with the lowest risk of maternal morbidity (OR 0.25; 95% CI 0.11-0.57, P < 0.001).

CONCLUSION

For women with a singleton fetus in breech resentation at term, maternal morbidity is lowest following vaginal birth and highest following CS during active labour.

Postpartum maternal mortality and cesarean delivery

OBJECTIVE

A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery.

METHODS

A population-based case-control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996-2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders.

RESULTS

After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries.

CONCLUSION

Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.

Maternal mortality with cesarean delivery: a literature review

OBJECTIVE

We sought to determine the present-day risk of maternal death with cesarean delivery.

METHODS

We reviewed the recent literature (years in analysis: 1975-2001) identified in a literature search and included data from the Royal College of Obstetricians and Gynaecologists.

FINDINGS

There were no publications with an ideal trial design and adequate power to establish the relationship between maternal mortality and method of delivery. Three studies, including the one randomized control trial included in analysis, and the Royal College of Obstetricians and Gynaecologists data suggest no significant difference in maternal mortality with cesarean delivery as compared with vaginal delivery.

CONCLUSIONS

The strongest publications suggest there may not be an increased risk of maternal death with cesarean delivery as compared with vaginal delivery; however, there are inadequate data to accurately demonstrate the present-day risk of maternal death with cesarean delivery.

Vaginal delivery for fetuses at risk of alloimmune thrombocytopenia?

OBJECTIVES

To evaluate the safety of vaginal delivery in pregnancies with fetal and neonatal alloimmune thrombocytopenia (FNAIT).

DESIGN

Prospective data collection.

SETTING

Leiden University Medical Centre, the national centre for management of severe red cell and platelet alloimmunisation.

POPULATION

Thirty-two pregnancies with FNAIT, with a sibling with thrombocytopenia but without an intracranial haemorrhage (ICH).

METHODS

The mode of delivery, platelet count in cord blood and neonatal outcome were analysed. All women received weekly intravenous immunoglobulin from 32 to 38 weeks of gestation. Head ultrasound scan was performed in all neonates.

MAIN OUTCOME MEASURES

Signs of ICH or other bleeding in the neonates.

RESULTS

Twenty-three women delivered vaginally. Nine caesarean sections were performed, all for obstetric reasons. Median platelet count at birth was 142 x 10(9)/l (range, 4-252 x 10(9)/l), with severe thrombocytopenia (<50 x10(9)/l) in four neonates, of which three were born vaginally. None of the neonates showed signs of ICH or other bleeding.

CONCLUSIONS

In pregnancies with FNAIT and a thrombocytopenic sibling without ICH, vaginal delivery was not associated with neonatal intracranial bleeding. These initial results support our noninvasive management of these pregnancies with FNAIT.

Impact of a cultural belief about ghost month on delivery mode in Taiwan

BACKGROUND

Many Chinese believe the lunar month of July, "ghost month" is inauspicious for major surgical procedures. This study hypothesised that caesaren delivery (CS) rates will be significantly lower during lunar July, and higher than normal during June, representing preemptive caesaren delivery to avoid delivering in July.

METHODS

Population based data from Taiwan on all singleton deliveries during 1997-2003 (1 750 862 cases) were subjected to multivariate autoregressive integrated moving average (ARIMA) modelling, adjusting for major obstetric complications (previous CS, breech presentation, dystocia, and fetal distress).

RESULTS

ARIMA intervention models showed significantly lower CS rates in lunar July, and among younger age groups (p<0.001), but not among 35 plus aged mothers. Incidence of previous CS, is significantly higher among June deliveries, while the incidence of the remaining major complications is similar in July, June, and other months. Patients with clinically less salient obstetric complications show significantly lower CS rates in July.

CONCLUSIONS

Adjusted CS rates during the ghost month are significantly lower than other months. Lunar June shows an increase in deliveries of previous CS mothers (almost all by CS), suggesting elective CS to preempt CS in July. A major policy implication is that health education must be launched to dissipate the cultural belief about the ghost month. Evidence also implies some proportion of clinically un-indicated CS in other months, showing the need for professional and policy initiatives to reduce unnecessary CS. Policy makers and researchers in other countries should be alert to cultural beliefs associated with delivery to enable informed delivery choices by mothers.

A double blind, randomized trial on augmentation of labour with a combination of intravenous propranolol and oxytocin versus oxytocin only

OBJECTIVE

To compare the combination of intravenous propranolol and oxytocin with oxytocin only in augmentation of labour.

STUDY DESIGN

A prospective randomized double-blind study in an obstetric department of a large university hospital in Finland. A total of 107 parturients with arrested first stage of labour owing to inadequate uterine contractility were randomized to receive intravenously once or twice a 2 mg dose of propranolol or placebo combined with oxytocin infusion. The main outcome measure was the effect of intravenous propranolol on the frequency of Caesarean section among parturients with arrested labour. The secondary outcome measures were the duration of labour, the required dosage of oxytocin, CTG readings, neonatal outcome and maternal and cord plasma levels of beta-adrenoceptor-binding component of propranolol. Categorial variables between the groups were compared using Chi square and Fisher's exact tests. Continuous variables were compared using the Mann-Whitney U-test and Student's t-test.

RESULTS

No reduction in Caesarean section rate was found in the propranolol group. Seventy-three percent of the parturients in the propranolol group and 85% in the placebo group had spontaneous vaginal delivery, RR=0.86 (95% CI 0.70-1.05). The percentage proportion of the augmented part of labour was significantly shorter in the propranolol group than in the placebo group. No differences in the required oxytocin dosage or CTG pathology were found between the groups. Propranolol was found to be safe for the neonates. The concentrations of its beta-adrenoceptor-binding component after a 2mg intravenous dose were quite similar in parturients and neonates at the time of delivery. The active drug component crossed placental barriers with an average neonate umbilical artery/parturient venous plasma ratio of 0.7. After a 4 mg dose the active drug concentrations in parturients were rather similar to those measured after 2 mg dose, whereas in neonates there were signs of drug accumulation. No picture could be obtained from the kinetics of the beta-adrenoceptor-binding component of propranolol from the data.

CONCLUSIONS

Propranolol (2 or 4 mg i.v.) combined with oxytocin, as treatment for arrested labour did not affect the Caesarean section rate compared with placebo plus oxytocin. The percentage proportion of the augmented part of labour was significantly shorter after propranolol. Propranolol was safe for the neonates and can be used as an additional medication among parturients with arrested labour.

Rising rates, changing relationships: caesarean section and its correlates in South Korea, 1988-2000

OBJECTIVE

To examine the trends in the relationship between caesarean section rates in South Korea and its correlates.

DESIGN

Five rounds (1988, 1991, 1994, 1997 and 2000) of population-based National Fertility and Family Health Survey of South Korea.

SETTING

South Korea. Sample Mothers (N= 9184) aged 15-44 years.

METHODS

Caesarean rates were calculated according to correlates and then directly adjusted to five-year age and parity groups. Distribution of all samples (9184 mothers) was standard, producing age- and parity-adjusted caesarean rates. Linear trends of correlates with caesarean rates were examined for ordinal variables such as education, income, urbanisation level (area of residence) and level of prenatal visits.

MAIN OUTCOME MEASURE

Age- and parity-adjusted caesarean section rates.

RESULTS

As caesarean rates rose by year, the relationship of caesarean section with education, occupation and area of residence has been reversed. Associations between caesarean rates, income level, place of delivery and level of prenatal visit were found in 1988 but disappeared by 2000. In 2000, relatively low caesarean rates were found in variables that will be more prevalent in the future, such as higher maternal education, higher maternal occupation and residence in big cities.

CONCLUSION

Caesarean rates may have reached a plateau in South Korea. No maternal or health service factors were detected to further increase the proportion of caesarean deliveries.

Emergency peripartum hysterectomy: A prospective study in The Netherlands

OBJECTIVE

To determine the incidence, indication, association with caesarean section (CS) and outcome of emergency peripartum hysterectomy (EPH) in The Netherlands.

STUDY DESIGN

All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of EPH between 1 April 2002 and 1 April 2003. For every case, a form with questions about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed.

RESULTS

Eighty-nine (89%) hospitals participated and registered in total 48 EPH. The estimated incidence of EPH is 0.33/1000 births. The main indication for EPH was placenta accreta (50%), followed by uterine atony (27%). There were two maternal deaths (4%). Severe maternal morbidity included: urinary tract injury 15%, relaparotomy 25%, transfusion >10 units red blood cells 67%, intensive care admission 77%. Both previous CS and CS in the index pregnancy were associated with a significant increased risk of EPH. The number of previous CS was related to an increased risk of placenta accreta, from 0.19% for one previous CS to 9.1% for four or more previous CS.

CONCLUSION

Emergency peripartum hysterectomy is associated with a high incidence of maternal morbidity and a case fatality rate of 4%. It is significantly related to CS in index or previous pregnancy. Placenta accreta is the most common indication to perform a peripartum hysterectomy.

An investigation of Caesarean sections in three Greek hospitals: the impact of financial incentives and convenience

BACKGROUND

Caesarean section (CS) rates have been increasing dramatically in the past decades around the world. The objective of our study was to investigate the factors increasing the likelihood of undergoing CS in two public hospitals and one private hospital in Athens, Greece. Specifically, the purpose was primarily to assess the impact of non-medical factors such as private health insurance, potential for making informal payments, physician convenience and socio-economic status on the rate of CS deliveries.

METHODS

All available demographic, socio-economic and medical information from the medical records of all deliveries in the three hospitals in January 2002 were analysed. The relative importance of the variables in predicting delivery with CS rather than normal vaginal delivery was calculated in multiple logistic regression models to generate odds ratios (OR).

RESULTS

The CS rate in the public hospitals was 41.6% (52.5% for Greeks and 26% for immigrants), while the CS rate in the private hospital was 53% (65.2% for women with private insurance and 23.9% for women who paid directly). In the public hospitals, after controlling for demographic and medical factors, Greek ethnic background, delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, and on Monday, Wednesday and Friday were found to increase the likelihood of CS delivery. In the private hospital, having private health insurance is the strongest predictor of CS delivery, followed by delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, delivery on a Saturday and being a housewife.

CONCLUSION

The results of this study lend support to the hypothesis that physicians are motivated to perform CS for financial and convenience incentives. The recent commercialization of gynaecology services in Greece is discussed, along with its implications on physicians' decisions to perform CS.

Carbohydrate solution intake during labour just before the start of the second stage: a double-blind study on metabolic effects and clinical outcome

OBJECTIVE

To study the effects of oral carbohydrate ingestion on clinical outcome and on maternal and fetal metabolism.

DESIGN

Prospective, double-blind, randomised study.

SETTING

Leyenburg Hospital, The Hague, The Netherlands.

POPULATION

Two hundred and two nulliparous women.

METHODS

In labour, at 8 to 10 cm of cervical dilatation, the women were asked to drink a solution containing either 25 g carbohydrates or placebo. In a subgroup of 28 women, metabolic parameters were measured.

MAIN OUTCOME MEASURES

Number of instrumental deliveries, fetal and maternal glucose, free fatty acids, lactate, pH, Pco2, base excess/deficit and beta-hydroxybutyrate.

RESULTS

Drinking a carbohydrate-enriched solution just before starting the second stage of labour did not reduce instrumental delivery rate (RR 1.1, 95% CI 0.9-1.3). Caesarean section rate was lower in the carbohydrate group, but the difference did not reach statistical significance (1% vs 7%, RR 0.2, 95% CI 0.02-1.2). In the carbohydrate group, maternal free fatty acids decreased and the lactate increased. In the umbilical cord there was a positive venous-arterial lactate difference in the carbohydrate group and a negative one in the placebo group, but the differences in pH and base deficit were comparable.

CONCLUSION

Intake of carbohydrates just before the second stage does not reduce instrumental delivery rate. The venous-arterial difference in the umbilical cord suggested lactate transport to the fetal circulation but did not result in fetal acidaemia.

Association between maternal age and the likelihood of a cesarean section: a population-based multivariate logistic regression analysis

BACKGROUND

A majority of studies examining the relationship between advancing maternal age and the likelihood of cesarean section (CS) use data from regional samples or from a limited number of medical institutions. This study uses population-based data from Taiwan to explore the relationship between maternal age and the likelihood of a CS.

METHODS

The National Health Insurance Research Database (NHIRD) on registries of medical facilities and board-certified physicians and monthly claim summaries for inpatients were used. In total, 502 524 singleton deliveries were included in the study. Multivariate logistic regressions were performed with the presence of CS as the dependent variable and maternal age (<20, 20-29, 30-34 and >34 years) as the independent variable. The study controlled for maternal indications, institution characteristics, maternal requests and attending physician characteristics.

RESULTS

CS rates for the age groups <20, 20-29, 30-34 and >34 years were 17.7, 27.4, 37.4 and 47.5%, respectively. The regression analyses consistently showed that the likelihood of a CS significantly increased with advancing maternal age within each category of complication after adjusting for medical institution characteristics and characteristics of the attending physician.

CONCLUSIONS

This study found that, after adjusting for maternal indications, and healthcare institution and physician characteristics, there was a significant relationship between advancing maternal age and an increased likelihood of a CS. This finding, together with the high CS rate of 32.1% in Taiwan, one of the highest reported in the world today, highlights an imperative need to devise interventions to reduce the frequency of CSs.

Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery

OBJECTIVE

This study was undertaken to assess the safety of trial of labor after previous cesarean delivery.

STUDY DESIGN

Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section.

RESULTS

Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume (<500) than in high volume (> or =500 births per year) obstetric units.

CONCLUSION

Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.

Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial

OBJECTIVE

This study was undertaken to compare maternal outcomes at 2 years postpartum after planned cesarean section and planned vaginal birth for the singleton fetus in breech presentation at term.

STUDY DESIGN

In selected centers in the Term Breech Trial, mothers completed a structured questionnaire at 2 or more years postpartum to determine their health in the previous 3 to 6 months.

RESULTS

A total of 917 of 1159 (79.1%) mothers from 85 centers completed a follow-up questionnaire at 2 years postpartum. There were no differences between groups in breast feeding, relationship with child or partner, pain, subsequent pregnancy, incontinence, depression, urinary, menstrual or sexual problems, fatigue, or distressing memories of the birth experience. Planned cesarean section was associated with a higher risk of constipation (P = .02).

CONCLUSION

Maternal outcomes at 2 years postpartum are similar after planned cesarean section and planned vaginal birth for the singleton breech fetus at term.