Role of maternal characteristics and epidural analgesia on caesarean section rate in groups 1 and 3 according to Robson's classification: a cohort study in an Italian university hospital setting

Programmed intermittent epidural bolus regimen vs continuous epidural infusion: a retrospective study of motor block and obstetric outcomes using the Robson's Ten Group Classification System

BACKGROUND

Use of a programmed intermittent epidural bolus (PIEB) regimen during labour is associated with several benefits over a continuous epidural infusion (CEI), including reduced local anaesthetic consumption and reduced risk of motor block. We hypothesise that the benefits of a PIEB regimen may vary according to the Robson Ten Group Classification System (TGCS). The aim of this study was to determine if introduction of a PIEB regimen was associated with reduced incidence of motor block. We also wished to examine changes in obstetric outcomes following PIEB introduction across the Robson TGCS.

METHODS

This was a single-centre retrospective cohort study. Data were collected over two three-month periods before and after PIEB introduction. The primary outcome was the incidence of motor block. Maternal and obstetric outcomes across Robson Groups 1-4 were analysed.

RESULTS

Introduction of PIEB was associated with reduced incidence of motor block (28.4% (95% CI 25.7% to 31.3%) vs 22.4%, (95% CI 19.9% to 25.2%), difference 5.9% (95% CI 1.0% to 21.1%), P=0.003), with no association with changes in rates of caesarean section, operative vaginal delivery or other obstetric outcomes. Use of a PIEB regimen was associated with reduced incidence of motor block in Robson Group 4a (20.3% (16.0%, 28.0%) vs 12.0%, (7.6%, 16.4%), difference 9.9% (95% CI -17.4% to -2.4%) P=0.009). There were no significant changes in other outcomes assessed across Robson TGCS.

CONCLUSION

Introduction of PIEB for maintenance of labour analgesia was associated with reduced incidence of motor block in our institution compared with CEI. Presenting results according to Robson's TGCS in future studies may allow better elucidation of the impact of neuraxial analgesia on maternal and obstetric outcomes.

Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016

BACKGROUND

The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time.

METHODS AND FINDINGS

We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates.

CONCLUSIONS

In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.

Interaction between delivery mode and maternal age in predicting overweight and obesity in 1,123 Chinese preschool children

Background

Pediatric overweight/obesity has escalated to epidemic proportions worldwide. In this study, we aimed to assess the association of delivery mode and maternal age, both individually and interactively, with the risk of being overweight or obese among Chinese preschool children.

Methods

We cross-sectionally recruited 1,123 preschool children from five kindergartens in Beijing. Data were collected by a pre-validated self-developed questionnaire. Overweight and obesity are defined according to the World Health Organization (WHO), International Obesity Task Force (IOTF), and China criteria, respectively.

Results

Cesarean delivery was significantly associated with pediatric overweight/obesity under the WHO [adjusted odds ratio (aOR), 95% confidence interval (CI): 1.60, 1.12-2.29], IOTF (1.77, 1.23-2.53), and China (1.43, 1.06-1.94) criteria, respectively. Maternal age <28 years reached statistical significance under both WHO (1.69, 1.09-2.61) and IOTF (1.69, 1.09-2.61) criteria in predicting pediatric overweight/obesity. The interaction between cesarean delivery and maternal age <28 years was remarkably significant under the WHO (2.26, 1.10-4.67), IOTF (2.92, 1.43-5.96), and China (2.36, 1.24-4.50) criteria.

Conclusions

Our findings indicate that the interaction between cesarean delivery and maternal age <28 years can remarkably increase the risk of overweight/obesity among Chinese preschool children.

Old and novel insights into emergency peripartum hysterectomy: a time-trend analysis

PURPOSE

To assess changing trends, role of the triad patient-pregnancy-health professionals and health care cost in emergency peripartum hysterectomy (EPH).

METHODS

Demographics, indications, perinatal outcomes, perioperative complications in EPH cases performed in a 10-year period were extracted from the local birth registry. Experience of health professionals in the management of the post-partum haemorrhage was valued. Two subgroups (Period I, 2009-2013 vs. Period II, 2014-2018) were recognized. Overall and detailed EPH ratios/1000 deliveries were calculated. Cost analysis was achieved in agreement with the diagnosis-related group (DGR) system.

RESULTS

A total of 39 EPH were performed among 36,053 deliveries. EPH incidence increased from 0.8 to 1.32‰ across study periods (p < 0.001). The mean maternal age (36.9 ± 4.7 vs. 38.9 ± 5.9 years, p = 0.035) and the high socio-economic status (0 vs. 19.2%, p = 0.027) were statistically different. Multiparity (84.6 vs. 96.2%, p = 0.005), previous caesarean section (CS) (0.9 ± 0.9 vs. 1.2 ± 1.6, p = 0.049), and emergent CS (7.7 vs. 19.2%, p = 0.048) were found statistically different. In Period II, increased attempts in conservative approaches (7.7 vs. 36.8%, p = 0.007), reduction in blood loss (3184 ± 1753 vs. 2511 ± 1252 mL, p = 0.045), advanced age of gynecologists performing EPH (54.5 ± 9.2 vs. 60.3 ± 6.4 years, p = 0.024), and augmented health care costs (mean DRG of € 2.782 vs. 3.371,95, p < 0.001) were observed.

CONCLUSIONS

As a "near-miss" event, advances on identification of EPH factors are mandatory. Time-trend analyses might add information and address novel strategies.