Maternal hypothermia during elective caesarean delivery: A prospective observational study

BACKGROUND

Patients undergoing caesarean delivery are at risk of developing unintended perioperative hypothermia, defined as a core temperature <36.0°C. Most previous studies of core temperature in caesarean delivery patients have not been conducted with accurate measurements for the complete perioperative period. Therefore, we conducted a prospective observational study to identify the incidence and duration of pre- and post-operative maternal hypothermia with a high accuracy continuous temperature monitoring system.

METHODS

Women ≥18 years old presenting for elective caesarean delivery under spinal anaesthesia were invited to participate in the study. The primary outcomes were the incidence and duration of perioperative maternal hypothermia (<36.0°C). Maternal core temperatures were measured with the non-invasive zero-heat-flux thermometer (Bair Hugger Temperature Monitoring System, 3M) throughout the perioperative course.

RESULTS

A total of 40 participants were recruited to the study. The incidence of perioperative hypothermia was 32.5%, with a duration of 77 ± 40 min (mean ± standard deviation). The hypothermic patients had similar core temperature as the normothermic patients at baseline preoperatively, but significantly lower temperature at operating room arrival and during the remaining study period. Forty percent of all patients reported thermal discomfort and felt cold on admission to post anaesthesia care unit, whereas 33% had shivering. Neither thermal discomfort nor shivering were associated with hypothermia.

CONCLUSION

In the present study almost a third of the women undergoing elective caesarean delivery developed perioperative hypothermia with a core temperature <36.0°C. The mean duration of maternal hypothermia was 77 min, lasting well into the postoperative period for many patients. These data should remind healthcare professionals of the importance of measuring core temperature in all phases of the perioperative setting and to consider optimal warming measures to avoid and treat hypothermia.

Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study

OBJECTIVES

To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD.

DESIGN

Population-based cohort study.

SETTING

The Swedish Medical Birth registry.

POPULATION

Women with their first and second singletons between 1982 and 2012.

METHODS

Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum).

MAIN OUTCOME MEASURES

Stillbirth (antepartum and intrapartum fetal death).

RESULTS

Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD.

CONCLUSIONS

This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

The Impact of Cesarean Section Delivery on Intestinal Microbiota: Mechanisms, Consequences, and Perspectives-A Systematic Review

The relationship between cesarean section (CS) delivery and intestinal microbiota is increasingly studied. CS-born infants display distinct gut microbial compositions due to the absence of maternal birth canal microorganisms. These alterations potentially link to long-term health implications like immune-related disorders and allergies. This correlation underscores the intricate connection between birth mode and the establishment of diverse intestinal microbiota. A systematic literature review was conducted on the PubMed, Scopus, and Web of Science databases by analyzing the articles and examining the intricate interactions between CS delivery and the infant's intestinal microbiota. The analysis, based on a wide-ranging selection of studies, elucidates the multifaceted dynamics involved in CS-associated shifts in the establishment of fetal microbiota. We also explore the potential ramifications of these microbial changes on neonatal health and development, providing a comprehensive overview for clinicians and researchers. By synthesizing current findings, this review contributes to a deeper understanding of the interplay between delivery mode and early microbial colonization, paving the way for informed clinical decisions and future investigations in the field of perinatal medicine.

Women with Endometriosis-Who Is at Risk for Complications Associated with Pregnancy and Childbirth? A Retrospective Case-Control Study

Women with endometriosis (EM), particularly the manifestations of adenomyosis (AM) and deep infiltrating endometriosis (DIE), suffer from pain and sterility. DIE also appears with several specific obstetric complications. To determine the risk profile, we designed a retrospective case-control study. Primary outcomes were defined as the risk of preterm birth and caesarean delivery (CD). Primiparous singleton pregnancies in women with DIE were compared with controls without EM. We matched for mode of conception and maternal age. A total of 41 women diagnosed with DIE and 164 controls were recruited. A total of 92.7% of the cases were also diagnosed with AM. Preterm birth occurred in 12.2% of cases and in 6.7% of controls. The difference was not statistically significant (OR: 1.932; 95% CI: 0.632-5.907). The rate of CD was similar in both groups. Remarkably, placental implantation disorders in the form of placenta praevia were eight times more frequent in women with DIE (9.8%) than in controls (1.2%, OR: 8.757; 95% CI: 1.545-49.614). Neonatal outcome was similar in both groups. Four out of fourteen cases reported abdominal wall endometriosis after CD. Women with DIE/AM and with placenta praevia are at risk of bleeding complications. After CD, they can develop abdominal wall EM. We therefore suggest evaluating the birth mode in each woman with DIE/AM.

Birth by emergency caesarean delivery: Perspectives of Wāhine Māori in Aotearoa New Zealand

In Aotearoa New Zealand, wāhine Māori (Māori women) are overrepresented in several negative post-natal outcomes, including negative outcomes related to caesarean deliveries. We aimed to understand the experiences of wāhine Māori who had experienced a caesarean delivery and to identify how healthcare systems can better meet the needs of wāhine Māori during pre- and post-natal care. Using kaupapa Māori principles, thematic analysis of one-on-one interviews identified eight themes covering a range of issues related to overall wellbeing. Bodily autonomy and choice were discussed by all participants, as was the need for mental wellbeing to be a larger focus of perinatal care. Participants also shared positive encounters with midwives and nurses, as well as a desire to incorporate religious and cultural practices within perinatal care. The caesarean delivery birthing stories of wāhine Māori highlighted the importance of Māori health models in understanding and providing culturally-affirming healthcare to wāhine Māori across Aotearoa.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

A Population-Based Cross-Sectional Study of Paediatric Coeliac Disease in Catalonia Showed a Downward Trend in Prevalence Compared to the Previous Decade

(1) Background: Previous studies showed an increased prevalence and incidence of coeliac disease (CD) over time. The objective is to ascertain whether the CD prevalence in Catalonia (a region of Southern Europe) among children aged 1-5 is as high as previously found in 2004-2009; (2) Methods: From 2013 to 2019, 3659 subjects aged 1-5 years were recruited following the previously used methodology. Factors with a potential impact on CD prevalence were investigated; (3) Results: In 2013-2019, 43/3659 subjects had positive serology, giving a standardised seroprevalence of 12.55/1000 (95% CI: 8.92; 17.40), compared to 23.62 (13.21; 39.40) in 2004-2007. The biopsy-proven crude prevalence was 7.92/1000 (95% CI: 5.50; 11.30), and the crude prevalence based on ESPGHAN criteria was 8.74/1000 (95% CI: 6.20-12.30). In contrast to 2004-2009, we did not find differences in the seroprevalence rates between 1 and 2 years vs. 3 and 4 years of age (age percentage of change -7.0 (-29.5; 22.8) vs. -45.3 (-67.5; -8.0)). Rotavirus vaccination was the most remarkable potential protective factor (48% vs. 9% in 2004-2009; p < 0.0001), but not the time of gluten introduction. (4) Conclusion: The present study did not confirm a worldwide CD prevalence increase and emphasizes the need to perform prevalence studies over time using the same methodology in the same geographical areas.

Fostering Excellence in Obstetrical Surgery

Introduction

This obstetric surgery review is directed toward the common obstetrical surgeries (caesarean delivery, VBAC/TOLAC, operative vaginal delivery, placenta accreta spectrum) with evidence for quality and safety to allow for obstetrical outcome excellence.

Materials and Methods

This focused scoping review has used a structured process for article identification and inclusion for each of the focused surgeries.

Results

The review results provide an obstetrical surgery (OS) overview for caesarean delivery, vaginal birth after caesarean delivery and/or trial of labor after caesarean delivery, operative vaginal delivery, placenta accreta spectrum; considerations for quality and safety variance due to non-clinical human factors; quality improvement (QI) tools; OS QI implementation cohorts; implementation considering certain barriers and solutions.

Conclusion

Administrative health care systems and obstetrical surgery care providers cannot afford, not to consider and implement, certain evidenced-based "bottom-up/top-down" processes for quality and safety, as the patients will demand the quality and the safety, but the lawyers should not have to enforce it.

The impact of body mass index on labour management and mode of delivery: A retrospective matched cohort study

AIM

This study aims to examine the association between body mass index (BMI) and mode of delivery, progression of labour, and intrapartum interventions.

METHODS

This was a retrospective matched cohort study including Class III obese (BMI ≥40 kg/m2 ) and normal BMI (BMI <25 kg/m2 ) women planning a vaginal birth who had a live, singleton delivery from January 2015 to December 2018. Patients were matched (1:1) based on age, gestational age, parity, onset of labour and birth weight. The primary outcome was caesarean delivery (CD). Secondary outcomes were delivery outcomes, intrapartum management and interventions. Rates of each outcome were compared with matched analysis, and duration of labour with time-to-event analysis.

RESULTS

We studied two groups of 300 pregnant women. The CD rate was significantly higher for obese women than the normal BMI cohort (19.3% vs 13.3%; risk ratio (RR) 1.43, 95% CI 1.02-1.98, P = 0.035). Cervical dilation prior to CD for failure to progress was slower in obese than normal BMI (0.04 vs 0.16 cm/h). The obese cohort had a longer duration of labour in those who underwent induction (13.70 vs 11.48 h, P = 0.024). Intrapartum intervention rates were higher for obese women, with significant differences in rates of fetal scalp electrodes (72.7% vs 22.7%, RR 3.20, 95% CI 2.58-3.99, P < 0.001), intrauterine pressure catheters (18.3% vs 0%, P < 0.001), epidural analgesia (44.0% vs 37.0%, RR 1.20, 95% CI 1.01-1.44, P = 0.040) and fetal scalp lactate sampling (8.0% vs 3.0%, RR = 2.67, 95% CI 1.33-5.33, P = 0.004).

CONCLUSION

Class III obesity is associated with an increased risk of CD and intrapartum interventions.

Perioperative Complications in Patients with Preeclampsia Undergoing Caesarean Section Surgery

Caesarean section has risks of bleeding, infection and thromboembolism, and neuroendocrine-metabolic, and inflammatory-immune responses that may worsen outcomes in patients with preeclampsia. There is little research examining perioperative, as opposed to peripartum, outcomes in patients with preeclampsia. We conducted a single-centrecentre retrospective cohort study of perioperative patients with preeclampsia over an eight-month period to determine the rate of perioperative complication. Seventy-two patients were included. The maternal complication rate was 59.7 per 100 operations (95% CI 48.2 to 70.3%). Severe complications included pulmonary oedema 2 (2.8%), haemorrhage > 1000 mL 5 (6.9%), and blood transfusion 2 (2.8%). Twenty (27.8%) patients had a hospital length of stay ≥7 days. The rate of anaemia (haemoglobin < 110 g/L) on hospital discharge was 42 per 100 operations (95% CI 31.0 to 53.2%). Patient representation rate to hospital after discharge was 23.6% per 100 operations (95% CI 15.3 to 34.6%). There were no maternal deaths. The neonatal complication rate was 38.9 per 100 operations (95% CI 28.9 to 51.1%) with one foetal death. Patients with preeclampsia undergoing caesarean section are a very high-risk surgical group who experience significant perioperative complications. Urgent action is needed to confirm these findings and improve outcomes in these patients.

Developing a nomogram for estimating the risk of needing to perform a caesarean section after induction of labour in pregnancies using a COOK® Cervical Ripening Balloon

BACKGROUND

Using a COOK® Cervical Ripening Balloon (CCRB) for cervical maturity has become a common clinical practice for the induction of labour (IOL).

OBJECTIVE

To develop and validate a predictive instrument that could estimate the risk of a caesarean after IOL in term pregnancies with CCRB treatment.

METHODS

The medical records of 415 pregnant women requiring IOL from January 2018 to October 2022 were retrospectively reviewed and randomly selected for training (290) and validation (125) sets in a 7:3 ratio. A model for predicting the risk of a caesarean was virtualised by a nomogram using logistic regression analysis.

RESULTS

After completing the multivariate analysis, parity (odds ratio [OR] = 0.226; p= 0.017), modified Bishop score at induction (OR =0.688; p= 0.005) and the artificial rupture of membranes (OR = 0.436; p= 0.010) were identified as the predictors for implementing a caesarean delivery after IOL. The decision curve analysis showed that the model achieved a net benefit across all threshold probabilities.

CONCLUSION

We successfully constructed a nomogram for caesarean delivery after IOL in pregnancies with CCRB treatment using factors including parity, modified Bishop score at induction and the artificial rupture of membrane.

Developing and testing a protocol using a common data model for federated collection and analysis of national perinatal health indicators in Europe

Context: International comparisons of the health of mothers and babies provide essential benchmarks for guiding health practice and policy, but statistics are not routinely compiled in a comparable way. These data are especially critical during health emergencies, such as the coronavirus disease (COVID-19) pandemic. The Population Health Information Research Infrastructure (PHIRI) project aimed to promote the exchange of population data in Europe and included a Use Case on perinatal health. Objective: To develop and test a protocol for federated analysis of population birth data in Europe. Methods: The Euro-Peristat network with participants from 31 countries developed a Common Data Model (CDM) and R scripts to exchange and analyse aggregated data on perinatal indicators. Building on recommended Euro-Peristat indicators, complemented by a three-round consensus process, the network specified variables for a CDM and common outputs. The protocol was tested using routine birth data for 2015 to 2020; a survey was conducted assessing data provider experiences and opinions. Results: The CDM included 17 core data items for the testing phase and 18 for a future expanded phase. 28 countries and the four UK nations created individual person-level databases and ran R scripts to produce anonymous aggregate tables. Seven had all core items, 17 had 13-16, while eight had ≤12. Limitations were not having all items in the same database, required for this protocol. Infant death and mode of birth were most frequently missing. Countries took from under a day to several weeks to set up the CDM, after which the protocol was easy and quick to use. Conclusion: This open-source protocol enables rapid production and analysis of perinatal indicators and constitutes a roadmap for a sustainable European information system. It also provides minimum standards for improving national data systems and can be used in other countries to facilitate comparison of perinatal indicators.

Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria

OBJECTIVES

Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation.

METHODS

A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus.

RESULTS

The β-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01).

CONCLUSIONS

The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.

Management of preeclampsia with severe features in a patient with relapsing polychondritis affecting the tracheobronchial tree

Relapsing polychondritis is a rare disease that affects cartilaginous structures throughout the body. Progressive destruction of the laryngeal structures and the tracheobronchial tree occurs in 50% of patients, potentially leading to loss of patency and collapse of the airway. Respiratory involvement in relapsing polychondritis includes airway stenosis, tracheomalacia and recurrent lung infections due to chronic inflammation caused by the destruction of upper and lower airway cartilage. Pregnancy and preeclampsia can worsen pharyngolaryngeal oedema, while treatment with magnesium sulphate can affect neuromuscular function, exacerbating the degree of airway collapse in the most serious cases of relapsing polychondritis, possibly altering obstetric outcomes. Here, we present the management of a pregnant woman with relapsing polychondritis who presented with features of severe preeclampsia at 29 weeks and 6 days gestation. We believe that this is the first published case of the combination of the two disorders, complicated by acute respiratory failure after treatment with magnesium sulphate.

Efficacy of analgesia using ilioinguinal-iliohypogastric (IIIH) nerve block, transversus abdominis plane (TAP) block and diclofenac after caesarean delivery under spinal anaesthesia: A non-randomised clinical trial

Background and Aims

Our aim was to assess the efficacy of analgesia using ilioinguinal-iliohypogastric (IIIH) nerve block, transversus abdominis plane (TAP) block and diclofenac after caesarean delivery (CD) under spinal anaesthesia (SA).].

Methods

A total of 457 healthy parturients undergoing CD under SA were included in this prospective, observational study. Groups differed in the postoperative analgesic strategies received by the parturient at the end of surgery: group D (n = 148) received intramuscular diclofenac sodium, group I (n = 153) received bilateral IIIH block with bupivacaine plus clonidine and group T (n = 156) received bilateral TAP block with bupivacaine plus clonidine. Total duration of postoperative analgesia, numerical pain rating scale (NRS) scores, patient satisfaction score, rescue analgesics in the first 48 h postoperatively and adverse effects were observed. A value of P < 0.05 was taken as significant.

Results

Total duration of analgesia was longest (18.2 ± 1.3 h) in group T and shortest in group D (6.3 ± 0.8 h) compared to group I (13.1 ± 1.2 h) (P < 0.001). Total analgesic requirement in postoperative 48 h was lowest in group T (152.1 ± 34.9 mg), highest in group D (355.0 ± 25.6 mg) and intermediate in group I (221.0 ± 30.0 mg) (P < 0.001). Mean NRS scores were lower in group T compared to those in groups D and I. The patients in group T were extremely satisfied, in group I were satisfied and in group D were dissatisfied (P < 0.001).

Conclusion

Bilateral TAP block with bupivacaine and clonidine after CD under SA increases the duration of postoperative analgesia.

Frequency of Caesarean Section Classified by Robson's Ten Group Classification System: A Scoping Review

The prevalence of caesarean section (CS) is rising rapidly. However, it should be carried out only under valid obstetric indications due to the various complications associated with it. Therefore, to record CS incidences, Robson's Ten Group Classification System (TGCS) was implemented. This review focuses on the prevalence of CS rates found in various studies and identifies the clinically important groups that were most involved in CS deliveries. Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review (PRISMA-ScR) guidelines were followed in this review. "Caesarean delivery" OR "Robson's Ten Group" OR "Classification System" were keywords used to search literature. Twenty-one studies were included in this review based on eligibility criteria. We concluded that group 5 was the major contributing factor for the increase in CS rates followed by group 10, group 4, group 2, and group 1. Previous CS was the most common factor responsible for increasing CS rates. We emphasize that Robson's TGCS is an essential parameter for recording CS rates and is simple to use for CS rate comparison.

Women's Involvement in Decision-Making and Associated Factors Among Women Who Underwent a Caesarean Section in Sidama Region, South Ethiopia: Cross-Sectional Study

Background

A caesarean delivery without maternal involvement in decision-making reduces the quality of health care and breaks women's autonomy. However, the involvement of women in decision-making to have a caesarean delivery is minimal. Still, now paternalism is widely practised. The study aims to assess women's involvement in decision-making and associated factors among women who underwent a caesarean delivery.

Methods

Institutional-based cross-sectional study was conducted in Sidama region Public hospitals from June 22/2022-August 5/2022, among women who underwent a caesarean delivery. The total sample size was 457. The collected data was exported from the ODK toolbox server to excel and then to SPSS version 26 for further data cleaning and analysis. The variables with a p-value ≤ 0.25 in the bivariable analysis were included in a multivariable ordinal logistic regression model to control possible confounders. The resulting odds ratio and 95% confidence interval were computed, and a p-value of less than 0.05 is considered statistically significant.

Results

Women's agreed decision-making involvement to have a caesarean delivery is 165(37.9%). Women who had an scheduled caesarean delivery [AOR: 7.6; 95% CI: 3.3, 17.8], had adequate information about caesarean delivery [AOR: 5.7; 95% CI:3.3, 10.0], had adequate time for decision-making [AOR: 4.6; 95% CI:2.09, 6.4], language of consent [AOR: 1.9; 95% CI: 1.2, 3.1], and women-healthcare providers relationship [AOR: 5.2; 95% CI: 3.2, 8.6]are higher odds of being involved in decision-making, but women's being primary school [AOR: 0.53; 95% CI: 0.3,0.97] are lower odds of involvement in decision-making to have a caesarean delivery.

Conclusion and recommendation

In this study, women's agreed decision-making involvement to have a caesarean delivery is low compared with other studies. Women-healthcare providers' relationship and an unscheduled caesarean delivery are highly affect their involvement in decision-making. Therefore, hospitals should translate and prepare the consent form in an understandable way for women and families, and healthcare providers should develop good relationship and encourage her involvement.

Does a physiology-based interpretation of cardiotocography allow to dispense with second-line methods? A cross-sectional online survey

CONTEXT

Second line methods are used to help obstetricians to identify abnormalities that reflect fetal acidosis. Since the use of a new technique of cardiotocography (CTG) interpretation based on the pathophysiology of the fetal period, the use of second-line tests has been questioned.

OBJECTIVE

To evaluate the impact of specific training in CTG physiology-based interpretation on professional attitudes towards the use of second-line methods.

METHODS

This cross-sectional study included 57 French obstetricians divided into two groups: the trained group (obstetricians who had already participated in a training course in physiology-based interpretation of CTG) and the control group. Ten medical records of patients who had abnormal CTG tracings and underwent fetal blood sampling pH measurement during labour were presented to the participants. They were given three choices: use a second-line method, continue labour without using second-line method, or perform a caesarean section. The main outcome measures was the median number of decisions to use second-line method.

RESULTS

Forty participants were included in the trained group and 17 in the control group. The median number of recourses to second-line method was significantly inferior for the trained group (4/10 second-line methods) than for the control group (6/10, p=0.040). Regarding the 4 records for which a caesarean section was the real outcome, the median number of decisions of continuing labour was significantly superior in the trained group than in the control group (p=0.032).

CONCLUSIONS

Participation in a training course in physiology-based interpretation of CTG could be associated with a less frequent use of second-line method at the cost of more frequently continuing labour with the risk compromising fetal and maternal well-being. Additional studies are required to determine whether this change in attitude is safe for the fetal well-being.

Pregnancy- and birth-related risk factors for the development of childhood celiac disease

AIM

To evaluate whether pregnancy and birth-related factors are associated with celiac disease (CD) in a large, United States (US)-based mother-child cohort.

METHODS

We analysed data gathering from the Massachusetts General Hospital Maternal Child Cohort (MMCC) of children born between 1998 and 2016. Data included the mode of delivery, maternal pregnancy and their offspring characteristics. We searched for CD cases by using diagnosis billing codes. Cox proportional hazard regression models were created to identify variables associated with CD.

RESULTS

We identified 44 539 mother-child pairs who had at least one encounter by 5 years old and identified 173 children (0.4%) with CD diagnosis; median age at the diagnosis was 6 years. Overall, the adjusted hazard ratio (aHR) of caesarean delivery for CD was 1.39 (95% CI: 0.99, 1.96, p = 0.06) when compared to children born vaginally. After stratifying for the presence of labour, children born by Caesarean delivery without labour had a higher risk of CD (aHR 1.56; 95%CI: 1.01, 2.41; p = 0.046) while infants born by Caesarean delivery with labour did not (aHR 1.26; 95% CI: 0.83, 1.93; p = 0.28).

CONCLUSION

Being born by Caesarean delivery without labour may be associated with an increased risk for CD in the US children.

A novel injection technique for ilioinguinal nerve block for post-operative pain relief in caesarean delivery - a randomized, double-blind, placebo-controlled trial

AIM

To determine whether the novel method is successful in blocking both ilioinguinal nerves to lessen postoperative pain following caesarean surgery.

MATERIALS AND METHODS

Between January 2022 and January 2023, 300 patients were enrolled in this study at the Obstetrics and Gynaecology Departments of the Faculty of Medicine at Al-Azhar University. About 150 of these patients received bupivacaine infiltration on both sides close to the anterior superior iliac spine, and 150 received a normal saline injection at the same locations.

RESULTS

The study compared the two groups and discovered significant differences in the timing of analgesic requests, interval before the patient's first ambulation, length of hospital stay, postoperative pain score, and incidence of postoperative nausea and vomiting, with group A performing better.

CONCLUSION

After a caesarean section, the local anaesthetic "bupivacaine" injection used to block the ilioinguinal nerves bilaterally is an efficient way to lessen postoperative discomfort and analgesic use.

Sufentanil vs. Dexmedetomidine as Neuraxial Adjuvants in Cesarean Section: A Mono-Centric Retrospective Comparative Study

Spinal anesthesia is the best choice for caesarean delivery. This technique is characterized by a complete and predictable nerve block with a fast onset and few complications. Several intrathecal adjuvants are used in order to improve the quality and duration of anesthesia and reduce its side effects. Sixty-two patients who underwent caesarean delivery under spinal anesthesia were included in this medical records review. In this retrospective study, after adopting exclusion criteria, we assessed 24 patients who received Hyperbaric Bupivacaine 0.5% 10 mg and dexmedetomidine 10 μg (G1), and 28 patients who received an institutional standard treatment with Hyperbaric Bupivacaine 0.5% 10 mg and sufentanil 5 μg (G2). We evaluated the difference in terms of motor and sensory block, postoperative pain, and adverse effects during the first 24 h following delivery and neonatal outcome. Our study found that the sufentanil group had a significantly lower requirement for analgesia than the dexmedetomidine group. Postoperative pain, assessed with the VAS scale, was stronger in G1 than in G2 (4 ± 2 vs. 2 ± 1, p-value < 0.01). Differences between the two groups regarding the intraoperative degree of motor and sensory block, motor recovery time, and neonatal Apgar scores were not noticed. Pruritus and shivering were observed only in G2. Itching and shivering did not occur in the dexmedetomidine group. Postoperative analgesia was superior in the sufentanil group, but the incidence of side effects was higher. Adjuvant dexmedetomidine prevented postoperative shivering.

The glitz and glamour randomized trial: the effect of fingernail polish on post-caesarean surgical site infection

Current surgical scrub guidelines suggest that fingernail polish should not be worn by healthcare providers despite collective evidence not demonstrating a relationship between fingernail polish and surgical-site infection (SSI). The purpose of this study was to determine the effect of surgical staff wearing nail polish on the incidence of SSI after caesarean delivery. In this calendar block-randomised clinical trial, surgical staff were assigned to wear nail polish or to have unpainted nails for alternating two-week periods. The primary outcome was surgical site infection within 6 weeks of caesarean delivery. There were 372 patients in the nail polish arm and 465 in the polish-free arm. The rate of SSIs was not significantly different between the nail polish arm and the polish-free arm (1.3% vs 2.8% p = .155). We found the rate of SSI following caesarean delivery is not significantly affected by surgical staff wearing fingernail polish.Impact StatementWhat is already known on this subject? Current surgical scrub guidelines state that fingernail polish should not be worn by healthcare providers even though the collective evidence has not been able to show the relationship between fingernail polish and surgical site infection. Previous studies have only used bacterial colony count after handwashing as a primary endpoint. The evidence they provide for developing scrub guidelines have been contradictory and inconclusive.What do the results of this study add? To better inform surgical scrub guidelines, evidence is needed that evaluates the effect of fingernail polish on clinically significant endpoints. Our study, Glitz & Glamour, examined 885 non-emergent Caesarian sections using a calendar-block schedule to determine if wearing nail polish had an impact on rates of surgical site infection.What are the implications of these findings for clinical practice and/or further research? Results suggested that fingernail polish had no difference on frequency of surgical site infections, and neither condition of the polish (chipped vs. freshly applied) nor the type of polish (gel vs. regular) had any impact either.

Vaginal misoprostol versus combined intracervical foley's catheter and oxytocin infusion for second trimester pregnancy termination in women with previous caesarean sections: a randomised control trial

Second trimester pregnancy termination has been reported to be associated with 3-5 times higher maternal morbidity and mortality risks more than first trimester termination. Medical methods had been thoroughly assessed and it is considered the anchor of the safe abortion care. Howevere, there is no global agreement regarding the ideal method for induction of the second trimester abortion in a scarred uterus. The aim of this study was to achieve vaginal expulsion in an expeditious manner with less maternal complications. A total of 158 women having, a history of previous caesarean section undergoing second trimester pregnancy termination, were randomly allocated into group (1) vaginal misoprostol group (n = 79) or group (2) combined intracervical foley's catheter plus intravenous oxytocin infusion group (n = 79). The primary endpoint was complete fetal expulsion. Meanwhile, secondary outcomes were the rates of maternal complications, in terms of the need for surgical evacuation of retained product of conception (ERPOC), severe haemorrhage, uterine rupture, blood transfusion, cervical laceration, diarrhoea, vomiting and fever. The registration number of this trial https://clinicaltrials.gov/ct2/show/NCT04501809. This study showed that the combined use of intracervical foley's catheter and oxytocin is an effective, and safe alternative to vaginal misoprostol for termination of the second trimester pregnancy in women having a previous caesarean delivery.Impact statementWhy was this study conducted? The purpose of this study is to achieve an expeditious delivery for second trimester pregnancy termination in a scarred uterus by combined mechanical and pharmacological methods without significant morbidity. Physicians should balance the benefit of achieving vaginal exlpusion in an expeditious manner versus the risk of uterine rupture or any other maternal complications.What does this add to what is known? This study showed that a combined mechanical and pharmacolohical approach for second trimester termination of pregnancy has comparable efficacy and safety to vaginal misoprostol which is more affordable to the low resources countries where termination of pregnancy in a scarred uterus still has an increased maternal morbidity.What is the implication of this study on clinical practice? The combined use of intracervical foley's catheter with intravenous oxytocin infusion is a safer option than vaginal misoprostol with less serious maternal complications.

Blessing of the moon: cultural beliefs, birth timing and child health in Nepal

In many South Asian contexts, specific dates are auspicious and inauspicious for health-related behaviours and outcomes. This study analysed the effect of lunar date-related auspicious beliefs in Nepal on childbirths and neonatal health outcomes. Using the daily birth records from a tertiary maternity hospital, we empirically examined whether births occurred disproportionally around full moon days. We found an average of 10.7 extra births on and before full moon days, with an average of 7.5 extra Caesarean deliveries on full moon days. We demonstrated that births occurring on or before the full moon day have poor neonatal health outcomes. However, a subsample analysis suggested better health outcomes for low-risk mothers and worse health outcomes for high-risk mothers. These findings suggest that low-risk mothers may move their deliveries to auspicious dates with fewer complications than high-risk mothers. The results emphasise the need for additional research to distinguish health service demand from supply influences on birth timing in Nepal.

oxytocin at elective caesarean delivery: a double-blind, randomised, controlled, non-inferiority trial of low- and high-dose regimens

Carbetocin or oxytocin are given routinely as first-line uterotonic drugs following delivery of the neonate during caesarean delivery to prevent postpartum haemorrhage. Low doses may be as effective as high doses with a potential reduction in adverse effects. In this double-blind, randomised, controlled, non-inferiority trial, we assigned low-risk patients undergoing elective caesarean delivery under spinal anaesthesia to one of four groups: carbetocin 20 μg; carbetocin 100 μg; oxytocin 0.5 IU bolus + infusion; and oxytocin 5 IU bolus + infusion. The study drug was given intravenously after delivery of the neonate. Uterine tone was assessed by the obstetrician 2, 5 and 10 minutes after study drug administration according to an 11-point verbal numerical rating scale (0 = atonic, 10 = excellent tone). The primary outcome measure was uterine tone 2 min after study drug administration. The pre-specified non-inferiority margin was 1.2 points on the 11-point scale. Secondary outcomes included uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects. Data were available for 277 patients. Carbetocin 20 μg resulting in uterine tone of (median (IQR [range])) 8 (7-8 [1-10]) was non-inferior to carbetocin 100 μg with tone 8 (7-9 [3-10]), median (95%CI) difference 0 (-0.44-0.44). Similarly, oxytocin 0.5 IU with tone 7 (6-8 [3-10]) was non-inferior to oxytocin 5 IU with tone 8 (6-8 [2-10]), median (95%CI) difference 1 (0.11-1.89). Carbetocin 20 μg was also non-inferior to oxytocin 5 IU, and oxytocin 0.5 IU was non-inferior to carbetocin 100 μg. Uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects were similar in all groups.

Changes in preterm birth and caesarean deliveries in the United States during the SARS-CoV-2 pandemic

BACKGROUND

Preliminary studies suggest that the SARS-CoV-2 pandemic and associated social, economic and clinical disruptions have affected pregnancy decision-making and outcomes. Whilst a few US-based studies have examined regional changes in birth outcomes during the pandemic's first months, much remains unknown of how the pandemic impacted perinatal health indicators at the national-level throughout 2020, including during the 'second wave' of infections that occurred later in the year.

OBJECTIVES

To describe changes in monthly rates of perinatal health indicators during the 2020 pandemic for the entire US.

METHODS

For the years 2015 to 2020, we obtained national monthly rates (per 100 births) for four perinatal indicators: preterm (<37 weeks' gestation), early preterm (<34 weeks' gestation), late preterm (34-36 weeks' gestation) and caesarean delivery. We used an interrupted time-series approach to compare the outcomes observed after the pandemic began (March 2020) to those expected had the pandemic not occurred for March through December of 2020.

RESULTS

Observed rates of preterm birth fell below expectation across several months of the 2020 pandemic. These declines were largest in magnitude in early and late 2020, with a 5%-6% relative difference between observed and expected occurring in March and November. For example, in March 2020, the observed preterm birth rate of 9.8 per 100 live births fell below the 95% prediction interval (PI) of the rate predicted from history, which was 10.5 preterm births per 100 live births (95% PI 10.2, 10.7). We detected no changes from expectation in the rate of caesarean deliveries.

CONCLUSIONS

Our findings provide nationwide evidence of unexpected reductions in preterm delivery during the 2020 SARS-CoV-2 pandemic in the US. Observed declines below expectation were differed by both timing of delivery and birth month, suggesting that several mechanisms, which require further study, may explain these patterns.

Hypertension in pregnancy and adverse outcomes among low-risk nulliparous women expectantly managed at or after 39 weeks: a secondary analysis of a randomised controlled trial

OBJECTIVE

To evaluate whether hypertensive disorders of pregnancy (HDP) among low-risk nulliparous women expectantly managed at or after 39 weeks of gestation are associated with adverse outcomes.

DESIGN

Secondary analysis of a randomised trial.

SETTING

Multicentre, USA.

POPULATION

Individuals in the expectantly managed group who delivered on or after 39 weeks.

METHODS

Multivariable analysis to estimate adjusted relative risks (aRR) for binomial outcomes, adjusted odds ratios (aOR) for multinomial outcomes and 95% CI.

MAIN OUTCOME MEASURES

Composite adverse maternal outcome including placental abruption, pulmonary oedema, postpartum haemorrhage, postpartum infection, venous thromboembolism or intensive care unit admission. Secondary outcomes included a composite of perinatal death or severe neonatal complications, mode of delivery, small and large for gestational age and neonatal intermediate or intensive unit length of stay.

RESULTS

Of the 3044 women randomised to expectant management in the original trial, 2718 (89.3%) were eligible for this analysis, of whom 373 (13.7%) developed HDP. Compared with participants who remained normotensive, those who developed HDP were more likely to experience the maternal composite (12% versus 6%, aRR 1.84, 95% CI 1.33-2.54) and caesarean delivery (29% versus 23%, aOR 1.32, 95% CI 1.01-1.71). Differences between the two groups were not significantly different for the adverse perinatal composite (7% versus 5%, aRR 1.38, 95% CI 0.92-2.07) or for other secondary outcomes.

CONCLUSION

Almost 14% of low-risk nulliparous individuals expectantly managed at 39 weeks developed HDP, and were more likely to experience adverse maternal outcomes compared with those who did not develop HDP.

TWEETABLE ABSTRACT

Almost 14% of low-risk nulliparous individuals expectantly managed at 39 weeks developed hypertensive disorders of pregnancy, and were more likely to experience adverse maternal outcomes compared with those who did not develop hypertensive disorders.

Maternal Obesity as a Risk Factor for Caesarean Delivery in Sub-Saharan Africa: A Systematic Review

Background: Maternal obesity is associated with several adverse reproductive outcomes. It is a growing public health burden in sub-Saharan Africa, a region with low resources and capacity to care for the large, affected population. Objectives: To assess the evidence of maternal obesity as a risk factor for caesarean delivery in women in sub-Saharan Africa. Methods: A systematic review of relevant original articles using PubMed, MEDLINE, and CINAHL was performed. Google Scholar and the reference lists of relevant systematic reviews and meta-analyses were also searched for other eligible studies. Observational studies assessing maternal body mass index (BMI) ≥ 30 kg/m2 before or during gestation and caesarean delivery as birth outcome were included. Results: All 17 studies were published between 2009 and 2021 and included 227,675 (236−153,102) participants. The prevalence of maternal obesity ranged from 3.9 to 44%. All except two studies (88%) indicated an association of obesity and risk of caesarean delivery in pregnant women in sub-Saharan Africa. Overweight/obese women had up to 4-fold increased risk of caesarean delivery compared to normal weight women. Three studies also reported a direct relationship between morbid obesity and prevalence of caesarean delivery in the sub-region. The risk of caesarean delivery appears to increase with increasing BMI e.g., >5 times in women with BMI ≥ 40 kg/m2 than in normal weight women. Conclusions: In sub-Saharan Africa, increased BMI in pregnancy is a risk factor for subsequent caesarean delivery. The risk of caesarean delivery appears to increase with increasing BMI. A robust meta-analysis and other patho-mechanistic studies can be conducted to confirm causal association. Culturally appropriate weight management and nutritional interventions should be implemented to reduce the incidence of obesity-induced caesarean delivery in sub-Saharan Africa.

Length of Hospital Stay After Cesarean Delivery and Its Determinants Among Women in Eastern Sudan

Background

There is an increasing caesarean delivery (CD) rate globally. Length of hospital stay (LoS) is longer in CD compared with vaginal delivery. There are few published data on LoS following CD in Africa, including Sudan. We aimed to investigate LoS after CD in eastern Sudan and its associated risk factors.

Methods

A cross-sectional study was conducted at Gadarif hospital in eastern Sudan from May to December 2020. Sociodemographic, clinical and obstetrical data were gathered through questionnaires. Poisson regressions were used to model the LoS and provide relative risk (RR) and a 95.0% confidence interval (CI).

Results

We enrolled 544 women with CD. The median (interquartile range, IQR) of their age and parity was 28.0 (24.0 ‒32.0) years and 3(2‒3), respectively. The LoS range was 1.0-9.0 days (mean = 2.7 days) and its median (IRQ) was 3.0 (2.0‒3.0) days. The median (IQR) of the LoS was significantly higher in women who had emergency CD vs elective CD, [3 (3.0‒3.0) vs 3 (2.0‒3.0) days, P < 0.001] and in women with maternal complications vs women who had no maternal complications [3 (2.0‒3.0) vs 3 (2.0‒3.0) days, P < 0.001]. Poisson regression showed that women with emergency CD stayed for 13.0% longer than women with elective CD (RR=1.13, 95% CI=1.01‒1.29). Women with maternal complications stayed 24.0% longer than women who had no maternal complications (RR=1.24, 95% CI=1.07‒1.43). Women who had neonatal complications stayed for 21.0% longer than women who had no neonatal complications (RR=1.21, 95% CI=1.05‒1.40). Age, parity, residence, education, occupation and postoperative haemoglobin were not associated with LoS.

Conclusion

The mean LoS in this study was 2.7 days, and women with emergency CD and maternal and neonatal complications had longer LoS.

Pentazocine with rectal diclofenac versus pentazocine alone for pain relief following caesarean delivery in Enugu, Nigeria: A randomized controlled trial

Objective

To measure postoperative pain relief following the use of rectal diclofenac combined with intramuscular pentazocine compared with intramuscular pentazocine alone in patients undergoing a caesarean delivery.

Methods

This single-blind randomized controlled trial enrolled pregnant women that had a caesarean section at the Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria. Study participants were randomized to receive either 100 mg of rectal diclofenac given every 12 h plus 30 mg of intramuscular pentazocine given every 6 h (group A) or 60 mg of intramuscular pentazocine given every 6 h (group B). The primary outcome was the level of pain as measured using a visual analogue scale. The secondary outcomes were the level of satisfaction with pain relief and need for rescue analgesia.

Results

A total of 200 participants were randomized equally into the two groups. Participants in group A had significantly better pain control and satisfaction over the 48 h after surgery compared with group B. Significantly more of group B required rescue analgesia for breakthrough pain compared with group A.

Conclusion

Rectal diclofenac combined with intramuscular pentazocine was significantly better at controlling pain compared with pentazocine alone in the first 48 h following caesarean section.

Trial registration number: PACTR202107706925314 at www.pactr.org on 28 July 2021.

Association between first and second stage of labour duration and mode of delivery: A population-based cohort study

BACKGROUND

Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied.

OBJECTIVES

To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery.

METHODS

A population-based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm-Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second-stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first-stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios.

RESULTS

Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non-linear trend is seen, demonstrated by a plateau in the second-stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80).

CONCLUSIONS

Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second-stage duration, with applications in obstetric and perinatal epidemiology.

Immediate birth for women between 34 and 37 weeks of gestation with prolonged preterm prelabour rupture of membranes and detection of vaginal or urine group B streptococcus: an economic evaluation

Objective

What are the costs, benefits and harms of immediate birth compared with expectant management in women with prolonged preterm prelabour rupture of membranes (PPROM) at 34⁺⁰–36⁺⁶ weeks of gestation and detection of vaginal or urine group B streptococcus (GBS)?

Design

Mathematical decision model comprising three independent decision trees.

Setting

UK National Health Service (NHS) and personal social services perspective.

Population

Women testing positive for GBS with PPROM at 34⁺⁰–36⁺⁶ weeks of gestation.

Methods

The model estimates lifetime costs and quality‐adjusted life years (QALYs) using evidence from randomised trials, UK NHS data sources and further observational studies. Simulated events include neonatal infections, morbidity associated with preterm birth and consequences of caesarean birth. Deterministic and probabilistic sensitivity analyses (PSAs) were performed.

Main outcome measures

QALYs, costs and incremental cost‐effectiveness ratio (ICER).

Results

In this population, immediate birth dominates expectant management: it is more effective (average lifetime QALYs, 24.705 versus 24.371) and it is cheaper (average lifetime costs, £14,372 versus £19,311). In one‐way sensitivity analysis, results are robust to all but the odds ratio estimating the relative effect on incidence of infections. Threshold analysis shows that the odds of infection only need to be >1.5% with expectant management for the benefit of avoiding infections to outweigh the disadvantages of immediate birth. In PSA, immediate birth is the preferred option in >80% of simulations.

Conclusions

Neonatal GBS infections are expensive to treat and may result in substantial adverse health consequences. Therefore, immediate birth, which is associated with a reduced risk of neonatal infection compared with expectant management, is expected to generate better health outcomes and decreased lifetime costs.

Tweetable abstract

For women with preterm prelabour rupture of membranes and group B streptococcus in vaginal or urine samples, immediate birth is associated with improved health in their babies and reduced costs, compared with expectant management.

For women with preterm prelabour rupture of membranes and group B streptococcus in vaginal or urine samples, immediate birth is associated with improved health in their babies and reduced costs, compared with expectant management.

Caesarean delivery and pubertal timing in boys and girls: A Danish population-based cohort study

BACKGROUND

There is considerable public and scientific interest in the declining age of pubertal timing. Prenatal and postnatal stress has been proposed to relate with earlier pubertal timing, but it remains unknown whether intrapartum stress may affect pubertal timing as well.

OBJECTIVE

This study aims to examine the potential effect of caesarean delivery on pubertal timing in boys and girls.

METHODS

This study was based upon the nationwide Puberty Cohort nested within the Danish National Birth Cohort (DNBC) from 2000 to 2003. A total of 15,731 mother-child pairs with complete information on delivery mode and puberty were included in the main analysis. The delivery mode was categorised into non-instrumental vaginal delivery (reference), instrumental vaginal delivery, elective caesarean delivery before labour, emergency caesarean delivery during labour and un-specified caesarean delivery. Children's pubertal development were self-reported in web-based questionnaires from 11 years of age and every 6 months throughout puberty (2012-2019), including Tanner stages 2-5, menarche, voice break, first ejaculation, axillary hair growth and the onset of acne. Regression models for censored, normally distributed time-to-event data were used to estimate mean monthly differences in age at attaining the different pubertal milestones and the average of all these estimates for each sex (a combined indicator of pubertal timing).

RESULTS

A total of 2810 participants were born by caesarean delivery (17.9%). Neither elective nor emergency caesarean delivery was associated with earlier age at achieving the pubertal milestones in boys or in girls. For the combined indicator, the mean age differences for elective caesarean delivery and emergency caesarean delivery were 0.1 (95% CI -1.1, 1.4) months and -0.7 (95% CI -2.0, 0.5) months in boys and 0.7 (95% CI -0.7, 2.0) and 0.2 (95% CI -1.3, 1.7) in girls.

CONCLUSIONS

This study does not suggest a clinically important effect of caesarean delivery on children's pubertal timing.

Caesarean delivery and risk of childhood asthma development: meta-analysis

Introduction

Several studies indicate that delivery by caesarean section may be one of the risk factors for the development of childhood asthma.

Aim

A meta-analysis was carried out to establish the relationship between delivery by caesarean section and asthma in children.

Material and methods

After a review of bibliographic databases, 41 articles were obtained and 12 of which were accepted for further analysis. The odds ratios (OR) included in the analysis were specified on the basis of data from the presented studies or were calculated using reported prevalence. The analysis took into account unadjusted OR. The heterogeneity of results was assessed using the χ² test, determining p < 0.05 as the level of significance. The analysis was performed using Statistica 13.3 and kit 4.0.67.

Results

Caesarean delivery was associated with an increased risk of development of childhood asthma (OR = 1.41); however, significant heterogeneity of results was demonstrated. A significantly higher risk of asthma was found in children born by caesarean section in the case where the disease was confirmed in a questionnaire-based study (OR = 1.26, 95% CI: 1.05-1.5), and the results of that study were homogeneous.

Conclusions

In the case of the diagnosis of asthma declared by parents in the questionnaire-based study, a significantly higher risk of disease occurrence was observed in children born by caesarean section. Due to the significant heterogeneity of the results of the studies, it cannot be clearly stated that caesarean delivery is a risk factor for the development of bronchial asthma.

A study protocol for the cardiac effects of a single dose of either oxytocin 2.5 IU or carbetocin 100 µg after caesarean delivery: a prospective randomized controlled multi-centre trial in Norway

Background: Both oxytocin and carbetocin are used to prevent uterine atony and post-partum haemorrhage after caesarean delivery in many countries, including Norway. Oxytocin causes dose-dependent ST-depression, troponin release, prolongation of QT-time and arrythmia, but little is known about myocardial effects of carbetocin. We have previously demonstrated comparable vasodilatory effects of oxytocin and carbetocin and are now undertaking a Phase 4 trial to investigate whether carbetocin causes similar changes to myocardial markers compared with oxytocin. Methods: Our randomized controlled trial will be conducted at three obstetrics units at Oslo University Hospital and Akershus University Hospital, Norway. Planned enrolment will be of 240 healthy, singleton pregnant women aged 18 to 50 years undergoing planned caesarean delivery. Based on pilot study data, each participant will receive a one-minute intravenous injection of either oxytocin 2.5 IU or carbetocin 100 µg during caesarean delivery. The prespecified primary outcome is the change from baseline in high-sensitive troponin I plasma concentrations at 6-10 hours after study drug administration. Secondary outcomes include uterine tone grade at 2.5 and five minutes after study drug administration, adverse events for up to 48 hours after study drug administration, estimated blood loss within eight hours of delivery, need for rescue treatment and direct/indirect costs. Enrolment and primary analysis are expected to be completed by the end of 2021. Discussion: Women undergoing caesarean delivery should be assessed for cardiovascular risk particularly as women with an obstetric history of pregnancy induced hypertension, gestational diabetes mellitus, preterm birth, placental abruption, and stillbirth are at increased risk of future cardiovascular disease. Any additional ischaemic myocardial risk from uterotonic agents will need to be balanced with the benefit of reducing the risk of postpartum haemorrhage. Any potential cardiotoxicity difference between oxytocin and carbetocin will help inform treatment decisions for pregnant women. Registration: Clinicaltrials.gov NCT03899961 (02/04/2019).

The Association between the Type of Delivery and Factors Associated with Exclusive Breastfeeding Practice among Polish Women-A Cross-Sectional Study

The type of delivery influences breastfeeding, both in terms of initiation and duration. The aim of the study was to determine the association between the type of delivery and factors associated with exclusive breastfeeding (EBF) practice among Polish women. Data on sociodemographic variables, pre-pregnancy weight, height, course of pregnancy, type of delivery and duration of breastfeeding were collected using a Computer-Assisted Web Interview. Of the 1024 breastfeeding women who participated in the study, 59.9% gave birth vaginally and 40.1% gave birth by caesarean section. The chance of starting EBF [OR: 0.478; 95% Cl: 0.274, 0.832] and continuing it for four months [OR: 0.836; 95% Cl: 0.569, 0.949] was lower in the case of caesarean delivery. Starting EBF was negatively affected by pre-pregnancy overweight status and obesity in the case of caesarean delivery. EBF practice for four months was negatively affected by age [18–24 years and 25–34 years], elementary education and average income [2001–4000 PLN] in the case of caesarean delivery. A negative impact on the chance of EBF for six months was also observed for younger age [18–24 years], elementary and secondary education and average income [2001–4000 PLN] in the case of caesarean delivery. There was no association between starting EBF and age, net income, place of living, pregnancy complications or the child′s birth weight category in the case of both subgroups, as well as between education and previous pregnancies in the case of vaginal delivery. These results suggest that women who deliver by caesarean section need additional breastfeeding support.

Determinants of the decision-to-delivery interval and the effect on perinatal outcome after emergency caesarean delivery: a cross-sectional study

Background

Preventing prolongation of the decision-to-delivery interval (DDI) for emergency caesarean delivery (CD) remains central to improving perinatal health. This study evaluated the effects of the DDI on perinatal outcome following emergency CD.

Methods

A prospective cross-sectional study involving 205 consenting women who had emergency CD at a tertiary hospital in Nigeria was conducted. The time-motion documentation of events from decision to delivery was documented; the outcome measures were perinatal morbidity (neonatal resuscitation, 5-minute Apgar score, neonatal intensive admission) and mortality. Data analysis was performed with IBM SPSS Statistics version 20.0, and P<0.05 was considered significant.

Results

The overall mean DDI was 233.99±132.61 minutes (range 44–725 minutes); the mean DDI was shortest for cord prolapse (86.25±86.25 minutes) and was shorter for booked participants compared with unbooked participants (207.19±13.88 minutes vs 249.25±12.05 minutes; P=0.030) and for general anaesthesia compared with spinal anaesthesia (219.48±128.60 minutes vs 236.19±133.42 minutes; P=0.543). All neonatal parameters were significantly worse for unbooked women compared with booked women, including perinatal mortality (10.8% vs 1.3%; P=0.012). Neonatal morbidity increased with DDI for clinical indications, UK National Institute of Health and Care Excellence (NICE) and Robson classification for CDs; perinatal mortality was 73.2 per 1000 live births, all were category 1 CDs and all except one occurred with DDI greater than 90 minutes. Severe preeclampsia/eclampsia, obstructed labour and placenta praevia tolerated DDI greater than 90 minutes compared with abruptio placentae and umbilical cord prolapse. However, logistic regression showed no statistical correlation between the DDI and neonatal outcomes.

Conclusion

Perinatal morbidity and mortality increased with DDI relative to the clinical urgency but perinatal deaths were increased with DDI greater than 90 minutes. For no category of emergency CD should the DDI exceed 90 minutes, while patient and institutional factors should be addressed to reduce the DDI.

Oxytocin: at birth and beyond. A systematic review of the long-term effects of peripartum oxytocin

Oxytocin is one of the most commonly used medications during labour and delivery. Recent insights from basic neuroscience research suggest that the uterotonic effects of oxytocin may arguably be trivial when compared with its profound effects on higher-order human behaviour. The purpose of this review is to highlight the potential consequences of manipulating oxytocinergic signalling during the peripartum period and its long-term impact on the maternal-infant dyad. We identified four domains where modulation of oxytocinergic signalling might be consequential: postpartum depression; breastfeeding; neurodevelopment; and chronic pain, and performed a literature search to address the impact of peripartum oxytocin administration. We have shown modest, but inconsistent, evidence linking peripartum oxytocin administration with postpartum depression. Breastfeeding success appeared to be negatively correlated with peripartum oxytocin exposure, perhaps secondary to impaired primitive neonatal reflexes and maternal-infant bonding. The association between perinatal oxytocin exposure and subsequent development of neurodevelopmental disorders such as autism in the offspring was weak, but these studies were limited by the lack of information on the cumulative dose. Finally, we identified substantial evidence for analgesic and anti-hypersensitivity effects of oxytocin which might partly explain the low incidence of chronic pain after caesarean birth. Although most data presented here are observational, our review points to a compelling need for robust clinical studies to better dissect the impact of peripartum oxytocin administration, and as stewards of its use, increase the precision with which we administer oxytocin to prevent overuse of the drug.

Strategies to reduce the caesarean section rate in a private hospital and their impact

There is a concern around the world of an increasing caesarean section rate. It was estimated that between 2010 and 2015, caesarean section rates increased by almost 50%. There are several implications for this, considering that caesarean sections are associated with higher costs and worse clinical outcomes. In this context, several interventions have been considered to increase vaginal delivery rates, including the Adequate Childbirth Project (PPA) in Brazil. This study aimed to verify the impact of the strategies adopted internally in the Hospital Israelita Albert Einstein (HIAE) located in São Paulo, Brazil, regarding the reduction of caesarean sections and their perinatal results. Actions to support our study were implemented in two phases based on the PPA schedule. These actions involved three axes: a multidisciplinary team, pregnant women and facility improvements. All pregnant women admitted for childbirth at the HIAE between 2014 and 2019 were included in this study. The overall rate of vaginal delivery in this study population and among primiparous women and the percentage of admissions to the neonatal intensive care unit (NICU) were analysed in three periods: before the implementation of PPA actions (period A), after the first phase of the project (period B) and after its second phase (period C). The results showed an increase in the average vaginal delivery rate from 23.57% in period A to 27.88% in period B, and to 30.06% in period C (AxB, p<0.001; BxC, p=0.004). There was a decrease in the average of NICU admissions over the periods (period A 19.22%, period B 18.71% and period C 13.22%); a significant reduction was observed when periods B and C (p<0.001) were compared.

Early essential newborn care is associated with improved newborn outcomes following caesarean section births in a tertiary hospital in Da Nang, Vietnam: a pre/post-intervention study

Background

To improve maternal and neonatal outcomes, Vietnam implemented early essential newborn care (EENC) using clinical coaching and quality improvement self-assessments in hospitals to introduce policy, practice and environmental changes. Da Nang Hospital for Women and Children began EENC with caesarean section births to inform development of national guidelines. This study compared newborn outcomes after caesarean sections pre/post-EENC introduction.

Methods

Maternity records of all live in-born hospital caesarean births and separate case records of the subpopulation admitted to the neonatal intensive care unit (NICU) were reviewed pre-EENC (November 2013–October 2014) and post-EENC (November 2014–October 2015) implementation. NICU admissions and adverse outcomes on NICU admission were compared using descriptive statistics.

Findings

A total of 16 927 newborns were delivered by caesarean section: 7928 (46.8%) pre-EENC and 8999 post-EENC (53.2%). Total NICU admissions decreased from 16.7% to 11.8% (relative risk 0.71; 95% CI 0.66 to 0.76) after introduction of EENC. Compared with the pre-EENC period, babies with hypothermia on admission to the NICU declined from 5.0% to 3.7% (relative risk 0.73; 95% CI 0.63 to 0.84) and cases of sepsis from 3.2% to 0.8% (relative risk 0.26; 95% CI 0.20 to 0.33) post-EENC implementation. While more than half of all newborns in the NICU were fed something other than breastmilk pre-EENC introduction, 85.8% were exclusively breast fed post-EENC (relative risk 1.86; 95% CI 1.75 to 1.98). Preterm newborns <2000 g receiving kangaroo mother care (KMC) increased from 50% to 67% (relative risk 1.33; 95% CI 1.12 to 1.59).

Conclusion

The EENC quality improvement approach with caesarean section births was associated with reduced NICU admissions, admissions with hypothermia and sepsis, and increased rates of exclusive breast feeding and KMC in the NICU.

Caesarean delivery is associated with an absolute increase in the prevalence of overweight in the offspring: The SENDO project

AIM

The association between caesarean delivery and the risk of overweight/obesity in the offspring has been previously reported using conventional measures of association (relative risks or odds ratios). We aimed at refining the existing evidence by calculating the marginal effect of the exposure and estimating the unmeasured residual confounding.

METHODS

In the 'SEguimiento del Niño para un Desarrollo Óptimo' Project, a dynamic multipurpose paediatric cohort study, we collected information from parents through self-administered online questionnaires. We estimated the offspring's risk of overweight/obesity at age 4-6 years, associated with the type of delivery through marginal effect of the exposure. Unmeasured residual confounding was assessed using the E-value.

RESULTS

Among 407 participants (mean-age: 5.0 years (standard deviation: 0.9)), 86 (21.1%) were born by caesarean delivery. Children born by caesarean delivery had higher odds of overweight/obesity than those born vaginally. Subgroup analyses showed similar results. The multivariable adjusted marginal effect showed that caesarean delivery was associated with an 8.0% (95% confidence interval: 0.2-15.7) absolute increase in the prevalence of overweight/obesity. The estimated residual confounding showed an E-value of 4.03, higher than the OR obtained for all the confounding factors we accounted for.

CONCLUSIONS

Caesarean delivery was associated with an 8% absolute increase in the risk of overweight/obesity that is very unlikely explained by residual confounding.

Association between mode of delivery and breastfeeding practices in Egypt: secondary analysis of Egypt Demographic and Health Survey

Background

The rise in caesarean deliveries constitutes a major public health concern in low- and middle-income countries (LMICs). Evidence on the influence of caesarean delivery on breastfeeding practices in LMICs is currently lacking.

Aims

To examine the association between mode of delivery and breastfeeding initiation and prelacteal feeding practices in a nationally representative sample of Egyptian women.

Methods

A cross-sectional study was carried out on 3773 women from the 2014 Egypt Demographic and Health Survey. The outcomes of interest were the timing of breastfeeding initiation and prelacteal feeding practices. Descriptive statistics and multivariable logistic regression models were performed.

Results

Overall, 25.1% of mothers initiated breastfeeding within 1 hour of birth and 63.5% practised prelacteal feeding within 3 days of birth. Mothers who had caesarean delivery had higher odds of delayed breastfeeding initiation [adjusted odds ratio (AOR) 2.25; 95% confidence interval (CI): 1.84-2.74] and were more likely to engage in prelacteal feeding (AOR: 1.44; 95% CI, 1.19-1.74). Moreover, the relationship between caesarean delivery and delayed breastfeeding initiation varied by parity with stronger association among multiparous (AOR: 2.57; 95% CI, 2.04-3.24) compared with primiparous mothers (AOR: 1.52; 95% CI, 1.03-2.25).

Conclusion

Caesarean delivery significantly increased the likelihood of delayed breastfeeding initiation and increased prelacteal feeding practices. Breastfeeding support and guidance should target women considering caesarean delivery.

Postpartum voiding dysfunction following vaginal versus caesarean delivery

In this prospective study, we evaluated postpartum voiding dysfunction stratified by mode of delivery - vaginal delivery versus elective caesarean delivery (CD). We recruited nulliparous women carrying singleton gestation at term admitted to delivery room or elective CD. Pre-labour voiding function was assessed by recording the post-voiding residual volume (PVRV) using a bladder scan. PVRV evaluation was repeated at least 12 hours following delivery and before discharge. PVRVs were considered abnormal if ≥150 mL. PVRVs were compared between vaginal and CD. Overall, 54 women were included. Of them, 34 (63%) delivered vaginally and 20 (37%) had an elective CD. Postpartum mean PVRVs were significantly higher compared to pre-labour PVRVs (215 vs. 133 mL, p<.001). Abnormal postpartum PVRV was significantly higher in vaginal delivery compared to CD (73.5% vs. 45%, p<.05). In conclusion, delivery adversely affects voiding function. Vaginal delivery is associated with more severe voiding dysfunction compared to elective CD.Impact StatementWhat is already known on this subject? Delivery is associated with voiding dysfunction. While most studies on postpartum voiding dysfunction were related to vaginal delivery, little is known on the effect of mode of delivery (vaginal versus caesarean delivery (CD)) on voiding dysfunction.What the results of this study add? In this study, we found that postpartum post-voiding residual volume is significantly higher than the pre-labour PVRV in women delivered vaginally. In addition, postpartum PVRV was significantly higher in women delivered vaginally compared to elective CD.What the implications are of these findings for clinical practice and/or further research? This study implicates that women with vaginal delivery are more prone to voiding dysfunction compared to elective CD. However, larger observational studies are warranted to confirm these results and evaluate whether this difference still exists beyond the post-partum period.

Prophylactic Dose of Oxytocin for Uterine Atony during Caesarean Delivery: A Systematic Review

Objective—to overview, compare and generalize results of randomized clinical trials analyzing different oxytocin doses to prevent postpartum hemorrhage, initiate and maintain uterine contraction after Caesarean delivery. Methods—‘PubMed’, ‘EMBASE’, ‘CENTRAL’, and ‘CINAHL’ electronic databases were searched for clinical trials analyzing the effectiveness of different dose of oxytocin given intravenously during surgery for uterine contraction and to reduce postpartum hemorrhage. A systematic review of relevant literature sources was performed. Results—our search revealed 813 literature sources. A total of 15 randomized clinical trials, comparing different doses of oxytocin bolus and infusion used after caesarean delivery have met the selection criteria. Conclusion—oxytocin bolus 0.5–3 UI is considered an effective prophylactic dose. Recommended effective prophylactic oxytocin infusion dose is 7.72 IU/h, but it is unanswered whether we really need a prophylactic infusion of oxytocin if we choose effective bolus dose size and rate. Adverse hemodynamic effects were observed when a 5 UI oxytocin bolus was used. However, topics such as bolus dose size, infusion dose size and requirement as well as bolus injection rate, still remain unanswered. The doses that are recommended in the guidelines of peripartum hemorrhage prophylaxis are not confirmed by randomized controlled double-blind trials and more research should cover this topic.

Selective reduction in the expression of type-1 metabotropic glutamate receptors in the hippocampus of adult rats born by caesarean section

Perinatal hypoxia causes long-term neurobiological consequences, including alterations in mechanisms of activity-dependent synaptic plasticity and cognitive dysfunction. Changes in neurotransmitter receptors have been associated with these alterations, but little is known on how early hypoxia influences the expression and function of metabotropic glutamate (mGlu) receptors in adult life. This is an important issue because mGlu receptors are implicated in mechanisms of synaptic plasticity. Here, we examined the expression of mGlu1, mGlu5, and mGlu2/3 receptor subtypes in the hippocampus, nucleus accumbens, prefrontal cortex, and dorsal striatum in 6-month old Wistar rats (a) born by vaginal delivery; (b) born by caesarean section; and (c) born by caesarean section followed by 20 min of asphyxia. Unexpectedly, we found a large reduction of mGlu1α protein levels in the hippocampus of rats born by caesarean section regardless of the presence of asphyxia. No changes in mGlu1α receptor protein levels were found in the other brain regions. Levels of mGlu5 and mGlu2/3 receptors and levels of GluA2/3 and GluN1 subunits of AMPA and NMDA receptors did not differ among the three groups of rats in any brain region. These results are consistent with previous findings showing that changes in mGlu1 receptors occur within the epigenetic programming caused by early-life events.

Antenatal Corticosteroids: Extending the Practice for Late-Preterm and Scheduled Early-Term Deliveries?

Respiratory distress in late-preterm and early term infants generally may warrant admission to a special care nursery or an intensive care unit. In particular, respiratory distress syndrome and transient tachypnea of the newborn are the two most common respiratory morbidities. Antenatal corticosteroids (ACS) facilitate surfactant production and lung fluid resorption. The use of ACS has been proven to be beneficial for preterm infants delivered at less than 34 weeks' gestation. Literature suggests that the benefits of giving antenatal corticosteroids may extend to late-preterm and early term infants as well. This review discusses the short-term benefits of ACS administration in reducing respiratory morbidities, in addition to potential long term adverse effects. An update on the current practices of ACS use in pregnancies greater than 34 weeks' gestation and considerations of possibly extending versus restricting this practice to certain settings will also be provided.

The Anesthetic Management of a Parturient With Osteogenesis Imperfecta Type I Undergoing Cesarean Delivery

Osteogenesis imperfecta (OI) is a rare disorder of bone fragility caused by mutations in the COL1A1/2 genes, which encode type I procollagen. It commonly manifests with bone fractures, joint dislocations, and easy bruising. OI patients presenting for surgery may pose multiple challenges to the anesthesiologist such as management of a potentially difficult airway and heightened positional fracture risks. We present a case detailing the spinal anesthetic management of a 28-year-old woman with type I OI requiring cesarean delivery for a 32-week intrauterine pregnancy with fetal cardiac anomalies.

Recovery of uterine and ovarian function in patients with complete placenta previa after caesarean delivery: A retrospective study

This retrospective study was designed to explore the recovery of uterine and ovarian function in patients with complete placenta previa (PP) after caesarean delivery (CD). 136 complete placenta previa patients (group completed placenta previa) and 140 patients without complete PP (group non-PP, control group) were included in this study from Jan 2016 to Dec 2018. Subgroup analysis of patients with complete PP was made to determine the impact of different hemostatic methods used during CD on the recovery of uterine function. There were no statistically significant differences between the 2 groups in postpartum menstrual cycle changes, ovarian hormone, and uterine vascular supply as measured by pulsatility index and systolic/diastolic ratio (P > .05). However, the group with complete PP had a reduced endometrial thickness (0.47 ± 0.11 vs 0.50 ± 0.12, P < .001), a lower uterine resistance index at 42nd days (0.84 ± 0.03 vs 0.90 ± 0.03, P < .001), and a delayed resumption menstruation (7.07 ± 2.61 vs 5.31 ± 2.16, P < .001) when compared with control group. Subgroup analysis showed that RI index of all subgroups in completed PP group was lower, endometrial thickness was thinner and the time to menstrual recovery was longer than that of non-PP group. In conclusion, the endometrial thickness and blood supply at 42nd days, not ovarian function, maybe affected after CD in patients with complete PP.