Changes in the cesarean section rate in Korea (1982-2012) and a review of the associated factors

Incidence of Pregnancy-Associated Venous Thromboembolism: Second Nationwide Study

BACKGROUND

 Pregnancy is a transient risk factor for venous thromboembolism (VTE). This second nationwide study aimed to inspect trend changes in the incidence rate of pregnancy-associated VTE (PA-VTE) during the study period (2014-2018) compared with that reported in a previous study (2006-2010).

METHODS

 Using the Korean Health Insurance Review and Assessment Service database, we retrospectively identified all PA-VTE events using both diagnostic and medication codes.

RESULTS

 Of the 124,228 VTE events, 510 (0.4%) cases of PA-VTE were identified in 499 women (median age: 34 years; range: 20-49 years). The incidence rate of PA-VTE/10,000 deliveries (PA-VTE/104D) in this second study (2.62) was 3.2 times higher than that in the first study (0.82). In the second study, the PA-VTE/104D ratio of women in their 40s (5.46) was three times higher than that of women in their 20s (1.80) (relative risk: 3.03; 95% confidence interval: 2.04-4.51; p < 0.01). The incidence rate for women in their 40s in the second study was 2.3 times higher than that in the first study. PA-VTE/104D cases occurred more frequently in multiparous than in primiparous women, in cesarean section cases compared with vaginal delivery, and in multiple rather than single pregnancies. Most PA-VTE cases occurred during the postpartum period (321/510, 62.9%), of which pulmonary embolism was the most frequently occurring type (231/321, 72%).

CONCLUSION

 Advanced maternal age, cesarean section, multiparity, and multifetal pregnancies increased the risk of PA-VTE. Obstetricians need to be cautious of VTE, particularly during the postpartum period, in high-risk pregnant patients.

Prevalence and predictors of elective and emergency caesarean delivery among reproductive-aged women in Bangladesh: evidence from demographic and health survey, 2017-18

Background

Over the years, an increasing trend of unnecessary caesarean section (c-section) deliveries has raised concerns in Bangladesh. So far, many studies have reported the risk factors of c-section delivery in Bangladesh. However, most of these studies did not estimate the predictors of the two c-section procedures (i.e., emergency and elective) separately based on the timing of the c-section decision. This study solely brings forward the role of socio-demographic and economic factors that may be associated differently with emergency and elective c-section deliveries.

Methods

Data for the study were drawn from the 2017–18 Bangladesh Demographic and Health Survey with 5,299 women aged 15–49 years who gave birth at a health facility during three years preceding the survey. Descriptive statistics along with bivariate analysis were used to fulfill the study objectives. Further, multivariable logistic regression analysis was conducted on binary outcome variables of elective/emergency c-section deliveries.

Results

Approximately one-third of women in the reproductive-age group opted for delivery through c-section. Out of them, 18.7% of women had elective c-sections, and 14.1% had emergency c-sections. Women who had mass media exposure were 32% more likely to deliver through elective c-sections than women who had no exposure [AOR: 1.32; CI: 1.02–1.72]. Women with higher education had a 56% lower likelihood of delivering through emergency c-section than women with no educational status [AOR: 0.44; CI: 0.24–0.83]. Children from the third or higher birth order were significantly more likely to be delivered through elective c-sections than those from the first birth order [AOR: 2.67; CI: 1.75–4.05]. In contrast, children with higher birth order had fewer chances of emergency c-section than children with first birth order [AOR: 0.29; CI: 0.18 -0.45]. Both elective and emergency c-section deliveries were significantly higher among private health facilities.

Conclusion

Although c-section delivery has emerged as a life-saving intervention, the overuse of such practice has created lucrative risks for the mother and unborn child. Proper sensitization of mothers and families can enhance the knowledge of the unsafe nature of unnecessary c-section deliveries. Authorizations in case of over-use of elective and emergency c-sections should be observed to minimize the unnecessary c-sections and related complications and to increase normal institutional deliveries in Bangladesh.

Association between interleukin-6 levels in amniotic fluid after rupture of membranes during labour at term pregnancy and successful vaginal delivery: a prospective cohort study

We compared the mean interleukin-6 (IL-6) level in the amniotic fluid after rupture of membranes during labour at term pregnancy according to the delivery methods through prospective cohort study. Cases with premature rupture of membranes, multifetal pregnancy, and major congenital anomalies were excluded. Amniotic fluid was obtained from vaginal canal immediately after spontaneous rupture of membranes. A total of 47 cases were analysed, and 72.3% (34/47) had successful vaginal delivery. The mean concentration of IL-6 in the amniotic fluid was significantly higher in the vaginal delivery group than in the caesarean section group (5,229 pg/mL vs. 1,702 pg/mL, p = .022). The concentration of IL-6 from the amniotic fluid tended to increase as the cervical dilatation increased. The association between high IL-6 level (>2,500 pg/mL) and successful vaginal delivery was not significant after adjusting the degree of cervical dilatation in multivariate logistic regression analysis. IMPACT STATEMENTWhat is already known on this subject? Multiparity, active and strong uterine contractions, dilated cervical os, and the position of foetal head are known clinical factors affecting the successful vaginal delivery. There are few studies on markers for successful vaginal delivery in patients with labour.What do the results of this study add? The mean value of IL-6 concentration from the amniotic fluid collected from vagina immediately after rupture of membranes was significantly higher in the patients who had resulted in successful vaginal delivery than those who had failed.What are the implications are of these findings for clinical practice and/or further research? Measurement of IL-6 concentration in the amniotic fluid from vaginal canal in patients with labour might help to predict the successful vaginal delivery and shorten the time before decision of caesarean section.

Risk of Pregnancy Complications and Low Birth Weight Offsprings in Korean Women With Rheumatic Diseases: A Nationwide Population-Based Study

BACKGROUND

To determine the risk of pregnancy complications and adverse offspring outcomes in Korean women with rheumatic diseases (RDs).

METHODS

Women aged 20-44 years with pregnancies ending in delivery were identified from the National Health Insurance Service-National Health Information Database (2009-2016). Women with RD including systemic lupus erythematosus (SLE), seropositive rheumatoid arthritis (SPRA), and ankylosing spondylitis (AS) (n = 4,284) were age-matched with controls (n = 26,023). Outcome variables included threatened abortion (TA), preterm birth (PB), preeclampsia/eclampsia (PE/E), intrauterine growth retardation (IGR), urinary tract infection, low birth weight (LBW) offsprings, and offspring death within 1 year of birth.

RESULTS

Women with RDs had increased risks for cesarean section delivery (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.4-1.6), TA (OR, 1.4; 95% CI, 1.2-1.5), PB (OR, 2.4; 95% CI, 1.9-3.2), PE/E (OR, 4.4; 95% CI, 3.3-5.9), and IGR (OR, 2.4; 95% CI, 2.0-3.1) than the controls. The risk of pregnancy complications was increased in SLE and SPRA pregnancies but not in AS pregnancies. Offsprings of women with RDs had an increased risk of LBW (OR, 4.0; 95% CI, 3.2-4.9). The offspring mortality rate within 1 year of birth was higher in women with RDs (6.2/10,000 persons) than in the controls (4.9/10,000 persons).

CONCLUSION

Women with RDs are at a risk of developing pregnancy complications, and the risk of LBW offsprings and offspring death within 1 year of birth is increased in these women. Therefore, this population requires special attention during their childbearing years.

How Can We Adopt the Glucose Tolerance Test to Facilitate Predicting Pregnancy Outcome in Gestational Diabetes Mellitus?

BACKGROUND

We investigated how 100-g oral glucose tolerance test (OGTT) results can be used to predict adverse pregnancy outcomes in gestational diabetes mellitus (GDM) patients.

METHODS

We analyzed 1,059 pregnant women who completed the 100-g OGTT between 24 and 28 weeks of gestation. We compared the risk of adverse pregnancy outcomes according to OGTT patterns by latent profile analysis (LPA), numbers to meet the OGTT criteria, and area under the curve (AUC) of the OGTT graph. Adverse pregnancy outcomes were defined as a composite of preterm birth, macrosomia, large for gestational age, low APGAR score at 1 minute, and pregnancy-induced hypertension.

RESULTS

Overall, 257 participants were diagnosed with GDM, with a median age of 34 years. An LPA led to three different clusters of OGTT patterns; however, there were no significant associations between the clusters and adverse pregnancy outcomes after adjusting for confounders. Notwithstanding, the risk of adverse pregnancy outcome increased with an increase in number to meet the OGTT criteria (P for trend=0.011); odds ratios in a full adjustment model were 1.27 (95% confidence interval [CI], 0.72 to 2.23), 2.16 (95% CI, 1.21 to 3.85), and 2.32 (95% CI, 0.66 to 8.15) in those meeting the 2, 3, and 4 criteria, respectively. The AUCs of the OGTT curves also distinguished the patients at risk of adverse pregnancy outcomes; the larger the AUC, the higher the risk (P for trend=0.007).

CONCLUSION

The total number of abnormal values and calculated AUCs for the 100-g OGTT may facilitate tailored management of patients with GDM by predicting adverse pregnancy outcomes.

Pregnancy outcomes in Korean women with ankylosing spondylitis

BACKGROUND/AIMS

Because ankylosing spondylitis (AS) mainly affects sacroiliac joints, special attention should be given to normal labour and pregnancy outcomes. Here, we investigate pregnancy outcomes in Korean women with AS.

METHODS

Based on data from the Korean Health Insurance Review and Assessment Service claims database since July 2007, maternal complications were compared between women with AS and 1:10 matched general population by maternal age and year of delivery. Additionally, the 27 deliveries from 21 patients with AS who were seen at a tertiary hospital were retrospectively evaluated using 1:4 matched control group by maternal and gestational age.

RESULTS

In the population-based cohort, there were 1,293 deliveries in 996 patients with AS. Higher maternal age and more comorbidities were reported than in the general population. However, compared to age and delivery-year matched population, only the rate of Caesarean section (CS) was higher in women with AS (odds ratio, 1.52; 95% confidence interval, 1.36 to 1.70). Incidence of other maternal complications was comparable between women with AS and control subjects. In the hospital-based cohort, the CS rate was higher in women with AS (44.4% vs. 20.4%, p = 0.002). Causes of CS was not different in both groups, including previous uterine surgery. There were no significant differences in foetal outcomes, including growth restriction, foetal malformations and Apgar score.

CONCLUSION

CS deliveries were performed more often in women with AS. However, other maternal complications and offspring complications were similar between women with AS and healthy control subjects.

Using Social Marketing to Reduce Intention of Cesarean Section in Iranian Women

Introduction

In Iran, the rate of cesarean section is three times more than the acceptable rate considered by the World Health Organization. This study aimed at reducing the selection of cesarean section by primigravida through an intervention based on social marketing in Boyer-Ahmad County, Iran, 2015.

Methods

In this field trial, 39 of primigravida women were identified and selected as a target group. Formative research (a quantitative survey and a qualitative study) was done to achieve the social marketing mix. The tailored intervention was developed based on the findings of formative research. The intervention was implemented for one month for pregnant women who had cesarean section intention. Their intention for the cesarean section was studied again one month after the implementation of the intervention. The effectiveness of the intervention was evaluated by the proportion test.

Results

The average age of the women was 25.82. All of the women 38.5 percent had a diploma degree and lower than and 61.5 percent had a university degree. Before the intervention, 39 women intended to do Cesarean. The intention of 30 pregnant women was changed significantly one month after the intervention.

Conclusion

The study showed the effectiveness of an intervention based on consumer-oriented social marketing theory and could be used to reduce Cesarean intention. More studies about related factors of vaginal delivery selection especially from behavioral intention up to behavior are suggested.

Defensive medicine and cesarean sections in Brazil

Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.

Gestational diabetes in Korea: Temporal trends in prevalence, treatment, and short-term consequences from a national health insurance claims database between 2012 and 2016

AIMS

This population-based cross-sectional study aimed to investigate recent trends in the prevalence and treatment of gestational diabetes mellitus (GDM) in Korea. We also investigated trends in annual prevalence rate of pregnancy-induced hypertension (PIH) and cesarean section (C-section) in GDM patients.

METHODS

We used data from the Health Insurance Review and Assessment-National Patient Sample (HIRA-NPS) database, 2012-2016. Non-GDM (n = 53,698) and GDM (n = 7956) patient data were analyzed for each year.

RESULTS

The annual increase in the prevalence of GDM was 11.1% over 2012-2016, with a significant continuously increasing trend (p < 0.0001). Age-stratified analysis showed that the annual prevalence of GDM significantly increased in patients below 40 years of age, but was not statistically significant as an increasing trend in patients above 40 years of age. Annual PIH prevalence rate among GDM women showed decreasing trend but was not statistically significant. An annual increase in C-section rate above 5% in GDM patients was statistically significant in both unadjusted and adjusted for age and PIH models.

CONCLUSIONS

The prevalence of GDM in Korean women and C-section rates in women with GDM showed a significantly increasing trend, 2012-2016. There is a need for further efforts to monitor this trend and to identify associated risk factors for GDM in Korean women.

Summary of clinically diagnosed amniotic fluid embolism cases in Korea and disagreement with 4 criteria proposed for research purpose

OBJECTIVE

This study aimed 1) to investigate the clinical characteristics of amniotic fluid embolism (AFE) cases clinically diagnosed by maternal fetal medicine (MFM) specialists in Korea, 2) to check the disagreement with 4 recently proposed criteria by the Society for Maternal-Fetal Medicine (SMFM) for research purpose, and 3) to compare maternal outcomes between cases satisfying all 4 criteria and cases with at least 1 missing criterion.

METHODS

This study included 12 patients clinically diagnosed with AFE from 7 referral hospitals in Korea. We collected information, including maternal age, symptoms of AFE, the amount of transfusion, and maternal mortality.

RESULTS

The median maternal age was 33 years (range, 28-40 years). Regarding symptoms, cardiovascular arrest, hypotension, respiratory compromise, clinical coagulopathy, and neurologic signs were observed in 41.7%, 83.3%, 83.3%, 100%, and 66.7% of the cases, respectively. Among the 12 cases, 5 women died and 2 suffered severe neurologic disability, showing an intact survival rate of 41.7%. Disagreement with all 4 criteria proposed by the SMFM was found in 66.7% of the cases, due to the lack of criteria for disseminated intravascular coagulation or strict onset time (<30 minutes after delivery). There was no difference in maternal mortality and the amount of transfusion between cases satisfying all 4 criteria and cases with at least 1 missing criterion.

CONCLUSION

Two-thirds of clinically confirmed AFE cases did not satisfy all 4 criteria proposed by the SMFM, despite similar rates of maternal mortality with cases satisfying all 4 criteria. Our study suggests that there may be some discrepancy between the clinical diagnosis of AFE and the recent diagnostic criteria proposed by the SMFM for research purpose.

Effect of maternal age on emergency cesarean section

Objectives: This study aims to investigate the independent influence of maternal age on the risk of emergency cesarean section (CS) due to nonreassuring fetal heart rate or arrest disorder.Methods: This was a cross-sectional study on women with nulliparous pregnancies, who are attempting vaginal delivery at term and have a cephalic presentation without the indication of elective CS at the onset of labor. The primary outcome was the rate of emergency CS. Independent risk factors were elucidated using multivariate logistic regression analysis.Results: Of 3513 women, 541 (15.4%) delivered by emergency CS during a trial of vaginal delivery, with theses being due to nonreassuring fetal heart rate (N = 150) or arrest disorder (N = 391). In univariate analysis, both individual CS rate due to nonreassuring fetal heart rate or arrest disorder and total emergent CS rate increased with maternal age. The risk of emergency CS was also significantly higher when labor induction was performed (odds ratio (OR) 2.489, 95% confidence interval (CI) 2.043-3.033), while fetal weight was heavier (neonatal weight ≥3.5 kg; OR 2.396, 95% CI 1.956-2.934), and maternal BMI was higher (before pregnancy ≥25 kg/m²; OR 2.751, 95% CI 1.980-3.823, at delivery ≥28 kg/m²; OR 2.375 95% CI 1.915-2.946). Multivariate stepwise regression analysis showed a statistically significant increase in the risk of total emergency CS in mothers over 35 years of age, compared to that in women less than 30 years old (35-39 years group; adjusted OR 1.805 95% CI 1.347-2.418, ≥40 years group; adjusted OR 4.659 95% CI 2.709-8.013). CS due to nonreassuring fetal heart rate increased in mothers over 40 years of age (adjusted OR 5.354, 95% CI 2.386-12.017) and CS due to arrest disorder was also increased in mothers over 30 years of age (30-34 years group; adjusted OR 1.343, 95% CI 1.010-1.785, 35-39 years group; adjusted OR 1.906, 95% CI 1.357-2.679, ≥40 years group; adjusted OR 4.663, 95% CI 2.480-8.768). Similar to the result of univariate analysis, labor induction increased the risk of emergency CS (adjusted OR 2.241, 95% CI 1.828-2.747).Conclusions: Advanced maternal age is an independent risk factor of emergency CS due to nonreassuring fetal heart rate or arrest disorder during the trial of vaginal delivery. The risk of emergency CS was also increased when labor induction was performed. Therefore, the risk of emergency CS needs to be considered, especially when the labor induction is planned, in women aged 40 or more.

Nationwide population-based incidence and etiologies of pediatric and adult Horner syndrome

PURPOSE

To determine age- and sex-specific incidence and possible etiologies of pediatric and adult Horner syndrome in South Korea.

METHODS

A nationwide, population-based, cohort study using data from the Korean National Health Claims database from 2007 to 2018. All patients with Horner syndrome from the entire Korean population (n = 51,629,512) were included. To find possible causes of Horner syndrome, we searched concurrent codes for systemic diseases, trauma, or surgical procedures.

RESULTS

A total of 139 pediatric patients (59.7% male) and 1331 adults (51.0% male) were newly diagnosed as having Horner syndrome. The cumulative incidence was 2.12 (95% CI 2.08-2.17) per 100,000 pediatric population and 2.95 (2.94-2.96) per 100,000 adults. The peak incidence occurred at 0-4 years of age in the pediatric population, and at 50-54 years in the adult population. A total of 835 (56.8%) patients had underlying conditions or related surgical procedures associated with Horner syndrome. The underlying causes were recognized in 695 (83.2%) patients before the diagnosis of Horner syndrome, in 75 (9.0%) patients at the same time as the Horner syndrome diagnosis, and in 65 (7.8%) patients after the diagnosis of Horner syndrome. There were four cases of Horner syndrome that preceded neuroblastoma diagnosis. The most common tumor related with Horner syndrome was that of the thyroid in the adult population.

CONCLUSIONS

This study determined the estimated incidence and possible causes of pediatric and adult Horner syndrome. As Horner syndrome with unknown etiologies may harbor serious malignancy, extensive evaluations are required, especially in children.

Secular trends in cesarean sections and risk factors in South Korea (2006-2015)

OBJECTIVE

This study aimed to investigate trends in the rate of cesarean sections (CSs) in South Korea from 2006 to 2015 and identify the risk factors associated with these changes.

METHODS

Using the National Health Insurance Corporation dataset, all women who gave birth between 2006 and 2015 were included in the study. We investigated 1) the mode of delivery, 2) the complication rates during pregnancy (i.e., preeclampsia and placenta previa), and 3) pre-pregnancy factors (body mass index, hypertension [HTN], diabetes mellitus [DM], and other pre-existing medical conditions), and their trends during the study period.

RESULTS

Over 10 years, the rate of CS increased from 36.3% in 2006 to 40.6% in 2015 (P<0.01). The rate of CS increased in primiparous women, women with multiple pregnancy, and women with preeclampsia. Maternal age and the incidence of placenta previa also increased. In contrast, the rate of vacuum deliveries and vaginal birth after CS decreased during the study period. The rate of women with pre-pregnancy obesity and DM increased, but the rate of women with pre-pregnancy HTN decreased.

CONCLUSION

The rate of CS in South Korea increased from 2006 to 2015. This trend may reflect changes in the rate of different risk factors. Identifying the causes of the increasing CS trend observed in this study will allow clinicians to monitor these factors and possibly reduce the rate of CS.

The Effect of Socioeconomic Status on All-Cause Maternal Mortality: A Nationwide Population-Based Cohort Study

Improving maternal health is one of the 13 targets of Sustainable Development Goal 3; consequently, preventing maternal death, which usually occurs in women’s prime productive years, is an important issue that needs to be addressed immediately. This study examines the association between socioeconomic status and all-cause maternal mortality in South Korea and provides evidence of preventable risk factors for maternal death. For this population-based retrospective cohort study, data on 3,334,663 nulliparous women were extracted from the Korean National Health Insurance Service database between 2003 and 2018. The outcome variables were all-cause maternal mortality within six weeks and a year after childbirth. A log-binomial regression model determined the association between maternal mortality and income-level adjusted covariates. Women with lower income levels had higher risk of maternal death within six weeks (risk ratio (RR) = 2.42, 95% confidence interval (CI) = 1.65–3.53) and within one year (RR = 1.83, 95% CI = 1.47–2.28), especially those who were aged 35–39 years, lived in rural areas, delivered via cesarean section, and had maternal comorbidities. The study identifies a significant relationship between South Korean primiparas’ socioeconomic status and maternal death within six weeks or one year after childbirth, suggesting interventions to alleviate the risk of maternal death.

Reasons for the High Cesarean Delivery Rate among Women with Ankylosing Spondylitis: Using the Korean National Health Insurance Database

OBJECTIVE

Women with ankylosing spondylitis (AS) have reported a higher rate of cesarean births than healthy controls. This study aimed to identify factors associated with cesarean births in women with AS.

METHODS

Based on the Korean Health Insurance Review and Assessment Service claims database, the subjects comprised female patients aged 20-49 years old with AS. In total, 1293 deliveries after AS diagnosis were included. A logistic regression analysis was performed to identify factors associated with cesarean births.

RESULTS

Among the 1293 deliveries in women with AS, 657 were cesarean and 636 were vaginal deliveries. Compared to vaginal delivery, the women who had cesarean deliveries were older, had a longer disease duration, and had a higher portion of primipara and dispensation of drugs. These factors were associated with a higher risk of cesarean delivery: maternal age (OR 1.08, 95% CI 1.04-1.12), disease duration (OR 1.09, 95% CI 1.03-1.14), and preeclampsia (OR 3.94, 95% CI 1.17-13.32). Further, compared to no drug dispensation, these drugs showed higher risks of cesarean delivery: nonsteroidal antiinflammatory drugs (NSAID; OR 1.64, 95% CI 1.31-2.37), tumor necrosis factor inhibitor (TNFi), disease-modifying antirheumatic drugs (DMARD), or corticosteroids (OR 2.01, 95% CI 1.57-2.58). In the subgroup analysis in primiparas, maternal age, or dispensation of NSAID alone, or TNFi, DMARD, or corticosteroids was associated with a higher risk of cesarean delivery.

CONCLUSION

Women with AS showed a higher cesarean delivery rate, influenced by both maternal age and disease-related factors.

Risk factors for fungal infection in extremely low birthweight infants registered in the Korean neonatal network from 2013 to 2015: Male sex and hypotension

BACKGROUND

In Korea, improvement in the survival rates of extremely low birthweight (<1,000 g) infants has led to neonatal infection, especially fungal infection (FI), in the neonatal intensive care unit. The purpose of this study was to determine the risk factors for FI by analyzing the incidence of FI in extremely low birthweight infants in Korea.

METHODS

Data from 5,320 very low birthweight (<1,500 g) infants registered from 2013 to 2015 in the Korean Neonatal Network were analyzed. The infants were divided into two groups based on the presence or absence of FI.

RESULTS

Among infants, 1,524 with gestational ages of <27 weeks and birthweights of <1,000 g were included. The incidence of FI was 7.3% (111/1,524) and mortality of the infants with FI was 40% (44/111). The mean gestational age of infants with FI was 24.8 ± 1.0 weeks, which was significantly lower than those without FI. After logistic regression, being male, and having hypotension within 7 days of birth were independent risk factors for FI. Moreover, hypotension was strongly associated with mortality in FI. Adverse outcomes such as severe bronchopulmonary dysplasia, bacteremia, and abnormal hearing test occurred more frequently in infants with FI than non-FI.

CONCLUSIONS

As male sex and hypotension within 7 days of birth increased the risk of developing FI in infants with gestational ages of <27 weeks and birthweights of <1,000 g, preventive strategies to reduce the incidence of FI are required for infants with risk factors for the development of FI.

A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China

BACKGROUND

Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China.

METHODS

We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics.

RESULTS

A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate (adjusted OR = 0.92; 95% CI 0.73, 1.15). Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes (adjusted change of risk score = - 0.06; 95%CI - 0.43, 0.31).

CONCLUSIONS

A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use.

TRIAL REGISTRATION

This trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.

Pregnancy, childbirth, and puerperium outcomes in female firefighters in Korea

Background

Female firefighters are exposed to hazardous environmental (chemical and physical) and working (shift work, psychological, and ergonomic factors) conditions that have reported or are suspected of adverse effects on reproductive health. However, no previous studies have reported on pregnancy, childbirth, and puerperium outcomes (PCPOs) in female firefighters.

Methods

The present study compared hospital admissions for PCPOs, based on 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, among Korean female firefighters with those of the general Korean population. Standardized admission ratios (SARs) and their 95% confidence intervals (CIs) were calculated.

Results

The study population included 1,766 female firefighters. Total follow-up duration was 9,659 person-years. Compared to the general female population, the female firefighters' SARs were higher in all admissions for PCPOs (SAR, 1.92; 95% CI: 1.79–2.05); pregnancy and abortive outcomes (SAR, 1.56; 95% CI: 1.12–2.12); other maternal disorders predominantly related to pregnancy (SAR, 2.65; 95% CI: 1.99–3.46); maternal care related to the fetus, amniotic cavity, and possible delivery problems (SAR, 2.13; 95% CI: 1.74–2.57); labor and delivery complications (SAR, 1.55; 95% CI: 1.15–2.06); delivery (SAR, 1.94; 95% CI: 1.80–2.08); and complications predominantly related to puerperium (SAR, 4.68; 95% CI: 2.02–9.23).

Conclusion

The results of this study showed high SARs in all and specific subcategories of PCPOs in female firefighters.

Factors for cecal intubation time during colonoscopy in women: Impact of surgical history

BACKGROUND/AIM

Cecal intubation during colonoscopy is prone to be prolonged in women, which may be related to frequent exposure to pelvic/abdominal surgery. We evaluated the association between Cecal Intubation Time (CIT) and prior episodes of pelvic/abdominal surgery in women.

PATIENTS AND METHODS

A cross-sectional study was conducted on screening participants who underwent colonoscopy. Multivariate regression with parameter estimates (β) was performed to determine the factors affecting CIT, including age, body mass index (BMI), bowel preparation, sedation, diverticulosis, experience of colonoscopists, and a surgical history. Also, subgroup analyses according to type of surgery were performed.

RESULTS

A total of 835 women were enrolled. The mean CIT was 5.82 ± 3.40 min. 323 females (38.7%) had episodes of surgery. The CIT was prolonged in cases performed by non-experienced trainees (β = 3.61, P< 0.001) and with a history of gynecological surgery (β = 0.97, P = 0.001). In the subgroup of non-experienced trainees, lower BMI, poor preparation, and a history of cesarean section significantly prolonged the CIT. Also, the risk for difficult colonoscopy (CIT ≥ 15 min) was increased with a history of cesarean section (odds ratio = 4.43, P= 0.024).

CONCLUSION

A prior episode of gynecological surgery prolonged CIT. Also, cesarean section history was associated with difficult colonoscopy in the examination by non-experienced trainees.

Effects of Pregnancy and Delivery Methods on Change in Ankylosing Spondylitis Treatment Using the Korean Health Insurance Review and Assessment Service Claims Database

BACKGROUND

Women with ankylosing spondylitis (AS) show a higher rate of cesarean section (CS) compared with healthy women. In this study, we determined the effects of pregnancy and delivery methods on AS worsening by analyzing prescription patterns.

METHODS

The subjects were women with AS aged 20-49 years listed in the Korean Health Insurance Review and Assessment Service claims database. Change in treatment was defined as change in prescriptions 1-2 years before delivery or 1 year after delivery. We compared change in prescriptions between AS women with delivery or without delivery (1:1 matched). Moreover, we evaluated change in prescriptions according to delivery method among AS women with delivery.

RESULTS

A total of 6,821 women with AS were included. Women in the delivery group (n = 996) were younger and showed less drug use and lower comorbidity rates than those in the no delivery group. Change in prescriptions did not differ between the delivery and no delivery groups (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.56-1.05). Furthermore, the overall change in prescriptions did not significantly differ between vaginal delivery (VD) and CS (OR, 0.72; 95% CI, 0.45-1.14).

CONCLUSION

The rate of change in prescriptions was comparable between AS patients with and without delivery. There was no association between the method of delivery and change in prescription. Therefore, pregnancy and VD may not be the factors associated with AS worsening.

Socio-cultural and clinician determinants in the maternal decision-making process in the choice for trial of labor vs. elective repeated cesarean section: a questionnaire comparison between Italian settings

Objective To identify socio-cultural and clinician determinants in the decision-making process in the choice for trial of labor after cesarean (TOLAC) or elective repeat cesarean section (ERCS) in delivering women. Methods A tailored questionnaire focused on epidemiological, socio-cultural and obstetric data was administered to 133 patients; of these, 95 were admitted for assistance at birth at Fondazione Policlinico Universitario "A. Gemelli" (FPG) IRCCS, Rome, and 38 at S. Chiara Hospital (SCH), Trento, Italy. Descriptive analysis and logistic regression modeling were performed. Results Vaginal birth after cesarean (VBAC) rates were higher at SCH than at FPG (68.4% vs. 23.2%; P < 0.05). Maternal age in the TOLAC/VBAC group was significantly higher at SCH than at FPG (37.1 vs. 34.9 years, P < 0.05). High levels of education and no-working condition corresponded to a lower rate of VBAC. Proposal on delivery mode after a previous CS was missed in the majority of cases. Participation in prenatal course was significantly less among women in the ERCS groups. Using logistic regression, the following determinants were found to be statistically significant in the decision-making process: maternal age [odds ratio (OR) = 0.968 (95% confidence interval [CI] 0.941-0.999); P = 0.019], education level [OR = 0.618 (95% CI 0.419-0.995); P = 0.043], information received after the previous CS [OR = 0.401 (95% CI 0.195-1.252); P = 0.029], participation in antenatal courses [OR = 0.534 (95% CI 0.407-1.223); P = 0.045] and self-determination in attempting TOLAC [OR = 0.756 (95% CI 0.522-1.077); P = 0.037]. Conclusion In the attempt to promote person-centered care, increases in TOLAC/VBAC rates could be achieved by focusing on individual maternal needs. An ad hoc strategy for making birth safer should begin from accurate information at the time of the previous CS.

Neighborhood Income and Cesarean Section Rates at a Tertiary Care Center in Canada

Background: With rising rates of cesarean sections (CSs) in Canada and worldwide, nonclinical factors for CS warrant consideration. Objective: To determine the association between a primigravid woman's neighborhood income and rates of CSs. Materials and Methods: A retrospective cohort study was conducted at an Ontario tertiary care center from January 2003 to December 2013. Rates of CSs were determined using data collected from the Discharge Abstract Database. Women with singleton live births were included. The main exposure variable was the neighborhood income quintile. A multivariable model was used to adjust for covariates and provide an estimate of the independent effect of neighborhood income on the CS rate. Results: The study cohort comprised 32,714 women. Compared with the lowest quintile, women in the highest quintile had increased rates of CSs (relative risk, RR 1.06, 95% confidence interval, CI [1.02-1.11]). Following adjustment for important confounders, there was no longer an association between the neighborhood income and CS rate (adjusted RR 1.00, 95% CI [0.99-1.01]). Women in the highest quintile were more likely to have greater maternal age (p < 0.01). Conclusions: Although differences in CS rates are seen by the neighborhood income quintile, they appear to be mediated through a combination of maternal age and other clinical factors. Neighborhood income does not appear to be an independent predictor of CS.

Impact of public release of performance data on the behaviour of healthcare consumers and providers

BACKGROUND

It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers.

OBJECTIVES

To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies.

SELECTION CRITERIA

We searched for randomised or non-randomised trials, interrupted time series, and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta-analysis.

MAIN RESULTS

We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster-randomised trials, one cluster-non-randomised trial, six interrupted time series studies, and one controlled before-after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality.There was low-certainty evidence that public release of performance data may make little or no difference to long-term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low-certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low-certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects.

AUTHORS' CONCLUSIONS

The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.

Prospective observations study protocol to investigate cost-effectiveness of various prenatal test strategies after the introduction of noninvasive prenatal testing

Background

Among the non-invasive screening methods for the identification of fetal aneuploidy, NIPT (non-invasive prenatal testing) shows the highest sensitivity and specificity in high-risk pregnancies. Due to the low false positive rate of NIPT, it is assumed that the implementation of NIPT as a primary screening method may reduce the number of invasive fetal tests and result in a similar or lowered cost in the overall detection of Down syndrome. However, most previous studies are based on theoretical economic analysis. This study aims to determine the cost effectiveness of various prenatal test strategies, including NIPT, in real clinical settings in both low risk and high risk pregnancies.

Methods/design

In this prospective observational study, women (< 24 weeks) with singleton or twin pregnancies will be enrolled in 12 different healthcare institutions. The participants will be grouped based on the risks of fetal chromosomal abnormalities and will be counseled on the various screening or diagnostic methods, including NIPT, according to the aneuploidy risk. The final decision on screening or diagnostic methods will be made by patients after counseling. Questionnaires regarding factors affecting the decision on prenatal test will be answered by the participants and physicians. The economic analysis on final total costs will be compared according to the various prenatal test strategies.

Discussion

The results of present study are expected to have a significant impact on national policies in determining Korean prenatal screening test strategies and to help in developing novel and effective prenatal screening tests in the future.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1930-y) contains supplementary material, which is available to authorized users.

Cesarean Section Rate in Singleton Primiparae and Related Factors in Beijing, China

BACKGROUND

The cesarean section rate (CSR) has been a main concern worldwide. The present study aimed to investigate the CSR in Beijing, China, and to analyze the related factors of CS delivery.

METHODS

An observational study was conducted in 15 medical centers in Beijing using a systemic cluster sampling method. In total, 15,194 pregnancies were enrolled in the study between June 20, 2013 and November 30, 2013. Independent t-tests and Pearson's Chi-square test were used to examine differences between two groups, and related factors of the CSR were examined by multivariable logistic regression.

RESULTS

The CSR was 41.9% (4471/10,671) in singleton primiparae. Women who were more than 35 years old had a 7.4-fold increased risk of CS delivery compared with women <25 years old (odd ratio [OR] = 7.388, 95% confidence interval [CI] = 5.561-9.816, P < 0.001). Prepregnancy obese women had a 2-fold increased risk of CS delivery compared with prepregnancy normal weight women (OR = 2.058, 95% CI = 1.640-2.584, P < 0.001). The excessive weight gain group had a 1.4-fold increased risk of CS delivery compared with the adequate weight gain group (OR = 1.422, 95% CI = 1.289-1.568, P < 0.001). Gestational diabetes mellitus (GDM) women and DM women had an increased risk of CS delivery (1.2- and 1.7-fold, respectively) compared with normal blood glucose women. Women who were born in rural areas had a lower risk of CS delivery than did those who were born in urban areas (OR = 0.696, 95% CI = 0.625-0.775, P < 0.001). The risk of CS delivery gradually increased with a decreasing education level. Neonates weighing 3000-3499 g had the lowest CSR (36.2%). Neonates weighing <2500 g had a 2-fold increased risk of CS delivery compared with neonates weighing 3000-3499 g (OR = 2.020, 95% CI = 1.537-2.656, P < 0.001). Neonates weighing ≥4500 g had an 8.3-fold increased risk of CS delivery compared with neonates weighing 3000-3499 g (OR = 8.313, 95% CI = 4.436-15.579, P < 0.001).

CONCLUSIONS

Maternal age, prepregnancy body mass index, gestational weight gain, blood glucose levels, residence, education level, and singleton fetal birth weight are all factors that might significantly affect the CSR.

Pregnancy outcomes in patients with vitiligo: A nationwide population-based cohort study from Korea

BACKGROUND

Vitiligo is a chronic autoimmune skin disorder affecting 1% of populations worldwide. Few large-scale studies have explored adverse pregnancy outcomes in patients with vitiligo.

OBJECTIVE

To investigate adverse pregnancy outcomes in patients with vitiligo.

METHODS

We performed a retrospective cohort study on 4738 pregnancies of women with vitiligo and 47,380 pregnancies of age-matched controls without vitiligo using the Korean National Health Insurance Claims database from 2007 to 2016. Multivariate logistic regression models were used to evaluate the associations between vitiligo and pregnancy outcomes, including live births, spontaneous abortion, cesarean delivery, preterm delivery, gestational diabetes mellitus, stillbirth, pre-eclampsia/eclampsia, and intrauterine growth retardation.

RESULTS

Patients with vitiligo exhibited a significantly lower live birth rate (odds ratio, 0.870; 95% confidence interval, 0.816-0.927) and a higher incidence of spontaneous abortion (odds ratio, 1.250; 95% confidence interval, 1.148-1.362) than the control group.

LIMITATION

The Korean National Health Insurance Claims database lacks detailed clinical information on individual patients.

CONCLUSION

Vitiligo was significantly associated with an increased risk of spontaneous abortion. Further studies are needed to determine whether systemic autoimmunity explains our finding.

Risk of Emergency Operations, Adverse Maternal and Neonatal Outcomes according to the Planned Gestational Age for Cesarean Delivery

BACKGROUND

The objective of this study was to assess the risk of emergency cesarean deliveries (CDs) and adverse neonatal/maternal outcomes according to the planned gestational age at delivery (GAD) for elective CD.

METHODS

The study population consisted of term singleton pregnant women who were booked for elective CD and were subsequently delivered at term by CD, after excluding cases with a trial of labor. The relationship between the planned GAD, risk of emergency CD prior to planned date, and adverse neonatal/maternal outcomes were determined.

RESULTS

The frequency of emergency CD, adverse neonatal and maternal outcomes were 9.5%, 4.5%, and 5.9%, respectively. The risk of emergency CD prior to the planned delivery date increased significantly according to the planned GAD (5.8% at 37 weeks, 8.2% at 38 weeks, 13.6% at 39 weeks, and 26.7% at 40 weeks or more of planned GAD, P = 0.005). Emergency CD was associated with an increased risk of adverse maternal outcomes, whereas the risk of adverse neonatal outcomes did not differ. In the total study population including both cases with elective and emergency CD, the risk of adverse maternal outcomes did not increase according to the planned GAD, and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD.

CONCLUSION

The risk of emergency CD increased as the planned GAD increased, but the risk of adverse maternal outcomes did not increase and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD in the total study population including elective/emergency CD.

Determinants and materno-fetal outcomes related to cesarean section delivery in private and public hospitals in low- and middle-income countries: a systematic review and meta-analysis protocol

BACKGROUND

Despite the well-established morbidity, mortality, long-term effects, and unnecessary extra-cost burden associated with cesarean section delivery (CSD) worldwide, its rate has grown exponentially. This has become a great topical challenge for the international healthcare community and individual countries. Estimated at three times the acceptable rate as defined by the World Health Organization in 1985, the continued upward trend has been fuelled by higher income countries. Some low- and middle-income countries (LMICs) have now taken the lead, and the factors contributing to this situation are poorly understood. The expansion of the private healthcare sector may be playing a significant role. Distinguishing between the public and private hospitals' role is critical in this investigation as it has not yet been approached. This review aims to systematically synthesize knowledge on the determinants of the CSD rate rise in private and public hospitals in LMICs and to investigate materno-fetal and materno-infant outcomes of CSD in perinatal period, between private and public hospitals.

METHODS/DESIGN

We will include studies published in English, French, Spanish, and Portuguese since 2000, using any experimental design, including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, and interrupted time series. Outcomes of interest are the determinants of CSD and materno-fetal and materno-infant outcomes. We will only include studies carried out in private and public hospitals in LMICs. The literature searches will be conducted in the following databases: MEDLINE, Embase, CINAHL, Cochrane database, LILACS, and HINARI. We will also include unpublished studies in the gray literature (theses and technical reports). Using the two-person approach, two independent review authors will screen eligible articles, extract data, and assess risk of bias. Disagreements will be resolved through discussion with a third author. Results will be presented as structured summaries of the included studies. If possible, a meta-analysis will be conducted and, subsequently, an analysis for heterogeneity will be implemented.

DISCUSSION

The proposed systematic review of the CSD rate rise will provide up-to-date evidence in regard to differences in proportions, determinants, and materno-fetal and materno-infant outcomes in perinatal period, between private and public hospitals in LMICs. We believe that this knowledge synthesis will help to shed light on the evidence and support evidence-informed decision-making with a view to addressing the issue in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016036871.

Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section

BACKGROUND

Bupivacaine is an amide local anaesthetic used in hyperbaric and isobaric forms. These are administered intrathecally into the spine to provide regional anaesthesia for caesarean section. Several trials have compared hyperbaric and isobaric bupivacaine but none have conclusively shown the benefit of either. This review was first published in 2013 and updated in 2016.

OBJECTIVES

Our objectives were to:1. Determine the effectiveness of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section;2. Determine the safety of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section.

SEARCH METHODS

We originally searched the following databases to January 2011: CENTRAL, MEDLINE and Embase.For this update, we reran our search in the above databases from January 2011 to March 2016; two studies are awaiting a response from authors for assessment and will be dealt with when we next update the review.We imposed no language restriction.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) involving parturients undergoing spinal anaesthesia for elective caesarean section that compared the use of hyperbaric with isobaric bupivacaine.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. The data that were extracted included the number of events and the sample sizes in both the intervention and control groups. For continuous outcomes, we extracted mean and standard deviation.We reported odds ratios (ORs) and risk ratios (RRs) for binary outcomes, and mean differences (MDs) for continuous outcomes.

MAIN RESULTS

We included three new RCTs in this update, which now comprises 10 studies with a total of 614 participants. We judged most trials as having uncertain risk of bias regarding randomization. Other than this, the overall risk of bias was low. Most included trials had small sample sizes. All of the trials assessed the primary outcome of conversion to general anaesthesia. Ten trials comparing anaesthesia performed with hyperbaric and isobaric bupivacaine failed to show any difference in need for conversion to general anaesthesia (RR 0.33, 95% CI 0.09 to 1.17, 614 participants, very low quality of evidence). Nine trials also failed to show a difference in the need for supplemental analgesics (RR 0.61, 95% CI 0.26 to 1.41, 554 participants, very low quality of evidence). Four trials comparing requirement for ephedrine did not show any difference (RR 0.89, 95% CI 0.57 to 1.38, 256 participants, very low quality of evidence). Seven trials did not provide convincing evidence of difference in nausea and vomiting (RR 0.99, 95% CI 0.57 to 1.72, 433 participants, low quality of evidence). Three trials failed to show a difference in headache (OR 1.82, 95% CI 0.47 to 6.99, 234 participants, low quality of evidence). Two trials showed that the time until sensory block to the thoracic 4th (T4) spinal level was shorter with hyperbaric bupivacaine (MD -1.06 minutes, 95% CI -1.80 to -0.31, 128 participants, moderate quality of evidence). Six trials showed no difference in the amount of ephedrine used (RR 0.23, 95% CI -1.65 to 2.12, 386 participants, moderate quality of evidence). Three trials failed to show any difference in high block (RR 0.88, 95% CI 0.16 to 4.90, 205 participants).

AUTHORS' CONCLUSIONS

Data are limited for some of the outcomes. Reporting of the included trials is less than optimal. For these reasons the overall quality of evidence is low or very low for most of the outcomes, based on the GRADE method of assessment. This review found that intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the 4th thoracic vertebra (T4) level than isobaric bupivacaine. Hower, despite incorporating more data in the analysis, we found little evidence that the need for conversion to general anaesthesia and supplemental analgesia differed between the hyperbaric or isobaric bupivacaine groups. This is mainly due to the rarity of these outcomes, variability in the dose, use of adjuvant drugs and differences in the technique used for regional anaesthesia. There were no differences in the adverse effects studied. Any possible advantage of hyperbaric bupivacaine needs to be confirmed in larger randomized trials. In future research, criteria for conversion to general anaesthesia need to be defined objectively and applied uniformly.

External cephalic version experiences in Korea

Objective

The aim of this study was to evaluate obstetric outcomes of external cephalic version (ECV) performed at or near term.

Methods

Single pregnant woman with breech presentation at or near term (n=145), who experienced ECV by one obstetrician from November 2009 to July 2014 in our institution were included in the study. Maternal baseline characteristic and fetal ultrasonographic variables were checked before the procedure. After ECV, the delivery outcomes of the women were gathered. Variables affecting the success or failure of ECV were evaluated.

Results

Success rate of ECV was 71.0% (n=103). Four variables (parity, amniotic fluid index, fetal spine position and rotational direction) were observed to be in correlation with success or failure of ECV. In contactable 83 individuals experienced successful ECV, cesarean delivery rates were 18.1%, 28.9%, and 5.3% in total, nulliparas, and multiparas, respectively.

Conclusion

Based on the results, ECV is proposed to be safe for both mother and her fetus. In addition, it is a valuable procedure that increases probability of vaginal delivery for women with breech presentation.