Does structured obstetric management play a role in the delivery mode and neonatal outcome of twin pregnancies?

PURPOSE

While the optimal delivery method of twin pregnancies is debated, the rate of cesarean deliveries is increasing. This retrospective study evaluates delivery methods and neonatal outcome of twin pregnancies during two time periods and aims to identify predictive factors for the delivery outcome.

METHODS

553 twin pregnancies were identified in the institutional database of the University Women's Hospital Freiburg, Germany. 230 and 323 deliveries occurred in period I (2009-2014) and period II (2015-2021), respectively. Cesarean births due to non-vertex position of the first fetus were excluded. In period II, the management of twin pregnancies was reviewed; adjusted and systematic training with standardized procedures was implemented.

RESULTS

Period II showed significantly lower rates of planned cesarean deliveries (44.0% vs. 63.5%, p < 0.0001) and higher rates of vaginal deliveries (68% vs. 52.4%, p = 0.02). Independent risk factors for primary cesarean delivery were period I, maternal age > 40 years, nulliparity, a history with a previous cesarean, gestational age < 37 completed weeks, monochorionicity and increasing birth weight difference (per 100 g or > 20%). Predictive factors for successful vaginal delivery were previous vaginal delivery gestational age between 34 and 36 weeks and vertex/vertex presentation of the fetuses. The neonatal outcomes of period I and II were not significantly different, but planned cesareans in general were associated with increased admission rates to the neonatal intensive care units. Inter-twin interval had no significant impact on neonatal outcome.

CONCLUSION

Structured regular training of obstetrical procedures may significantly reduce high cesarean rates and increase the benefit-risk ratio of vaginal deliveries.

Distinguishable Influence of the Delivery Mode, Feeding Pattern, and Infant Sex on Dynamic Alterations in the Intestinal Microbiota in the First Year of Life

The delivery mode, the feeding pattern and infant sex significantly influence the development of the infant gut flora. However, the extent to which these factors contribute to the establishment of the gut microbiota at different stages has rarely been studied. The factors that play a dominant role in determining microbial colonization of the infant gut at specific time points are unknown. The purpose of this study was to assess the different contributions of the delivery mode, the feeding pattern and infant sex to the composition of the infant gut microbiome. Here, 213 fecal samples from 55 infants at five ages (0, 1, 3, 6, and 12 months postpartum) were collected, and the composition of the gut microbiota via 16S rRNA sequencing was analyzed. The results showed that the average relative abundances of four genera, Bifidobacterium, Bacteroides, Parabacteroides, and Phascolarctobacterium, were increased in vaginally delivered infants versus cesarean section-delivered infants, while those of ten genera, such as Salmonella and Enterobacter, were reduced. The relative proportions of Anaerococcus and Peptostreptococcaceae were higher in exclusive breastfeeding than in combined feeding, while those of Coriobacteriaceae, Lachnospiraceae and Erysipelotrichaceae were lower. The average relative abundances of two genera, Alistipes and Anaeroglobus, were increased in male infants compared with female infants, whereas those of the phyla Firmicutes and Proteobacteria were reduced. During the first year of life, the average UniFrac distances revealed that the individual difference in the gut microbial composition in vaginally delivered infants was greater than that in cesarean section-delivered infants (P < 0.001) and that infants who received combined feeding had greater individual microbiota differences than exclusively breastfed infants (P < 0.01). The delivery mode, infant sex, and the feeding pattern were the dominant factors determining colonization of the infant gut microbiota at 0 months, from 1 to 6 months, and at 12 months postpartum, respectively. This study demonstrated for the first time that infant sex accounted for the dominant contribution to infant gut microbial development from 1 to 6 months postpartum. More broadly, this study effectively established the extent to which the delivery mode, the feeding pattern and infant sex contribute to the development of the gut microbiota at various time points during the first year of life.

Evaluation of Mode of Delivery and Various Postnatal Factors on Acquisition of Oral Streptococcus mutans in Infants: A Prospective Study

Aim of the study

The objective of the current study is to assess and establish a relationship between the mode of delivery and postnatal factors in the early colonization of Streptococcus mutans (S. mutans) in infants' oral cavities.

Materials and methods

The primary goal of the investigation is to assess and compare the oral microflora of newborns immediately after birth and at 3, 6, 9, and 12 months of age in babies born by normal vaginal delivery and lower segment cesarean section and divided into (group III) and (group V), respectively. Around 50 mother-baby pairs in total had their swab samples collected for the identification of S. mutans and were monitored for a year. The role of other postnatal factors in the acquisition of S. mutans in infants was also evaluated.

Results

Data analysis showed that different postnatal factors like feeding patterns, oral hygiene practices, and socioeconomic factors affected the infant's oral cavity's initial colonization by S. mutans.

Conclusion

Infants' first exposure to oral S. mutans depends on the delivery method and various postnatal factors.

How to cite this article

Sharma N, Bhargava N, Boruah B, et al. Evaluation of Mode of Delivery and Various Postnatal Factors on Acquisition of Oral Streptococcus mutans in Infants: A Prospective Study. Int J Clin Pediatr Dent 2023;16(5):663-666.

Impact of parity and delivery mode on pelvic floor function in young women: a 3D ultrasound evaluation

INTRODUCTION AND HYPOTHESIS

The objectives were to evaluate clinical and anatomical parameters assessed by three-dimensional pelvic floor ultrasound (3D ultrasound) in parous and nulliparous women of childbearing age and to assess underreported symptoms of sexual dysfunction (SD), urinary incontinence (UI) and flatus incontinence (FI).

METHODS

Women without complaints of pelvic floor dysfunction, aged 20-50 years, were eligible for this prospective cross-sectional study. They completed the King's Health Questionnaire, Female Sexual Function Index and St Mark's Incontinence Score adapted for this study. Next, a physical examination and 3D ultrasound were performed. The scores obtained in the questionnaires were compared with the 3D ultrasound data.

RESULTS

In total, 326 women were invited to participate. Of these, 203 women met the inclusion criteria, and their cases were classified as nulliparity (NU, 59), vaginal delivery (VD, 80), forceps delivery (FD, 18) and caesarean section (CS, 48). These groups were homogeneous regarding age (p=0.096), parity (p=0.051) and body mass index (p=0.06). The hiatal dimension (HD; p=0.003) and transverse diameter (TD) (p=0.001) were significantly different among the groups. Compared with the NU and CS groups, the VD and FD groups had an increased HD and TD. The frequencies of underreported symptoms identified by questionnaires were as follows: SD (46.3%), UI (35%) and FI (28%). After VD and FD, women were more likely to present UI (p<0.001), FI (p<0.001) and SD (p=0.002) than the women with NU and those who had undergone a CS. UI was related to a greater HD (p=0.002) and anteroposterior diameter (p=0.022), FI was associated with a thinner left pubovisceral muscle (p=0.013), and SD was related to a greater HD (p=0.026).

CONCLUSIONS

Three-dimensional ultrasound can identify mild morphological changes in young women with apparently normal physical examinations, mainly after VD and FD. In such individuals, these findings are associated with higher incidences of underreported sexual, urinary and anal symptoms.

Determinants of microbial colonization in the premature gut

Abnormal microbial colonization in the gut at an early stage of life affects growth, development, and health, resulting in short- and long-term adverse effects. Microbial colonization patterns of preterm infants differ from those of full-term infants in that preterm babies and their mothers have more complicated prenatal and postnatal medical conditions. Maternal complications, antibiotic exposure, delivery mode, feeding type, and the use of probiotics may significantly shape the gut microbiota of preterm infants at an early stage of life; however, these influences subside with age. Although some factors and processes are difficult to intervene in or avoid, understanding the potential factors and determinants will help in developing timely strategies for a healthy gut microbiota in preterm infants. This review discusses potential determinants of gut microbial colonization in preterm infants and their underlying mechanisms.

Adaptations to scale-up an early childhood education and care physical activity intervention for real-world availability - Play Active

BACKGROUND

Adaptations for scale-up are ubiquitous but are rarely described in detail. Adaptations may be a key reason for the "scale-up penalty" which is when there is a reduction in intervention effect size following scale-up. The Play Active intervention consists of a physical activity policy for early childhood education and care (ECEC) services, with accompanying implementation support strategies. It was first implemented with 81 ECEC services in Perth, Western Australia, in 2021 - with significant positive changes in physical activity practice uptake. The aim of this paper is to describe the extent, type, fidelity consistency, goals, size, scope, and proposed impact of proposed adaptations to the implementation support strategies for scaling-up Play Active.

METHODS

Proposed adaptations were defined as planned changes, made prior to making the intervention available. The authors created a list of adaptations from a comparison of the Play Active implementation support strategies, before and after adaptation for proposed statewide availability across Western Australia, Queensland and South Australia, Australia. We used the Framework for Reporting Adaptations and Modifications-Enhanced Implementation Strategies (FRAME-IS) to code adaptations to implementation support strategies. Three authors coded each adaptation and rated their size, scope and proposed impact.

RESULTS

Fifty-three adaptations to Play Active were identified. Most (68%) were proposed for the 'content' of implementation strategies, including aspects of their delivery. In practice, this involved changing the delivery mode of implementation support strategies from phone call and email support, to website-based delivery. More than half (56%) of adaptations involved 'adding elements' for scale-up. Most adaptations were 'fidelity consistent' (95%). The main goals for adaptations were related to 'increasing the acceptability, appropriateness, or feasibility' (45%), 'decreasing the costs' (19%) and 'increasing adoption of the evidence-based practice' (19%). Adaptations were small to medium in size, with most proposed to have a positive (87%) or neutral (8%) effect on the effectiveness of the intervention, rather than negative (4%).

CONCLUSIONS

A large number of small, fidelity-consistent, adaptations were proposed for Play Active scale-up. Overall, the process of reporting adaptations was found to be feasible. To understand the impact of these adaptations, it will be important to re-evaluate implementation, effectiveness and process outcomes, at-scale.

Maternal exposure to fine particulate matter and brain-derived neurotrophic factor (BDNF) in the fetus: A prospective cohort study

Maternal exposure to ambient fine particulate matter (PM_2.5) during pregnancy has been associated with impaired neurobehavioral development in children. However, the specific mechanism remains unclear. Brain derived neurotrophic factor (BDNF) is an important growth factor in the nervous system. We evaluated the associations of maternal PM_2.5 exposures with fetal BDNF in the umbilical cord blood in a prospective cohort study. A total of 711 eligible mother-infant pairs from the Shanghai Birth Cohort were included in the current study. Daily maternal exposures to ambient PM_2.5 were assessed with a gap-filling approach at 1 * 1 km² resolution based on self-reported home addresses. The concentrations of BDNF in the cord blood were measured by ELISA. A linear regression model was applied to evaluate the association of maternal ambient PM_2.5 exposure with fetal BDNF level at birth. The median concentration of BDNF was 13,403 pg/ml. Vaginal deliveries and female infants had higher BDNF levels than cesarean deliveries and male infants. One natural log (ln) unit increase in maternal PM_2.5 exposure during the second trimester was significantly associated with - 0.20 (95% CI: -0.36, -0.05) ln-unit decrease in BDNF level in all births. These effects were stronger and more significant in vaginal deliveries and in male infants. Our study suggests that BDNF in the cord blood may serve as a potential biomarker in assessing the neurodevelopmental effects of maternal PM_2.5 exposure.

Breastfeeding might partially contribute to gut microbiota construction and stabilization of propionate metabolism in cesarean-section infants

PURPOSE

This study was aimed to determine how delivery mode and feeding pattern influence the infant's gut microbiota construction and the variation of fecal microbial metabolites from a birth cohort.

METHODS

Fecal samples collected from 61 full-term born Chinese infants at four time points: day 0, day 7, month 1, and month 3. Based on delivery mode (vaginal delivery [V] or cesarean section [C]) and feeding pattern (breastfeeding [B] or mixed feeding [M]), infants were divided into four groups, namely VB, CB, VM, and CM groups. The gut microbiota composition and bacterial diversity were assessed using 16S rRNA sequencing. Short-chain fatty acid (SCFA) concentrations were determined via gas chromatography-mass spectrometry (GC-MS).

RESULTS

The CM group had a significantly higher relative abundance of Firmicutes (day 0 and month 1), Enterococcaceae (month 3), and Enterococcus (month 3) than the VB group and a significantly higher abundance of Firmicutes (month 1) and Blautia (month 3) than the CB group. The VB and CB groups exhibited a stable SCFA variation and a significantly lower level of propionate compared with the VM and CM groups. All groups showed an intense transition of enterotypes within 1 month and became stable at 3 months. The correlation between SCFA and enterotypes showed a significant positive correlation between Bifidobacteriaceae and acetate in the CB group (day 7 and month 3) and a significant positive correlation between Clostridiaceae and butyrate in the CB and VB groups (day 7 and month 3), respectively.

CONCLUSION

These results indicated that C-section was associated with higher abundance of the phylum Firmicutes and family Enterococcaceae, and intense fluctuation of SCFA, at least propionate. And breastfeeding might partially contribute to gut microbiota construction and stabilization propionate metabolism in cesarean-section infants.

Influence of prenatal urinary incontinence and mode of delivery in postnatal urinary incontinence: A systematic review and meta-analysis

BACKGROUND

It is likely that the pathophysiology of urinary incontinence (UI) differs between women who are incontinent before the first delivery and those whose incontinence occurs after. In this systematic review, we aimed to assess the association between the mode of delivery and the risk of postpartum UI in primiparous women with and without prenatal UI.

METHODS

We searched MEDLINE, Cochrane, Web of Science, Embase and CINHAL databases. Prospective studies including primiparous women during their pregnancy with a comparison of the rate of postpartum UI in women who underwent cesarean delivery or vaginal delivery according to continence status before delivery were included. The Risk Ratio (RR) was calculated with a 95% confidence interval (95% CI) using the total number of events and patients extracted from the individual studies. A subgroup comparison analysed the potential influence of women's prenatal continence status. Heterogeneity was estimated using I² statistics.

RESULTS

The risk of postpartum UI was significantly higher after vaginal delivery than after cesarean section (RR 1.80, 95% CI 1.48- 2.18). According to the subgroup test, the postpartum UI risk following a vaginal delivery, compared to cesarean section, was significantly higher in the subgroup of continent women during pregnancy (RR 2.57, 95% CI 2.17-3.04) than in the subgroup of incontinent pregnant women (1.56, 95% CI 1.27-1.92).

CONCLUSIONS

The effect of a cesarean section in preventing postpartum UI appears controversial, particularly in women with prenatal UI.

Is urethral pressure associated with parity and delivery mode?

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence is the most prevalent type of urinary incontinence and childbirth is a risk factor. The aim of this study is to evaluate the association between delivery mode and urethral sphincter function as measured by the maximum urethral pressure (MUP).

METHODS

A retrospective study on women seen in a tertiary urogynaecological center for urodynamic testing between January 2017 to December 2019. Women were classified into the following groups: (1) nulliparous; (2) caesarean section only; (3) at least one spontaneous vaginal delivery but no instrumental deliveries; (4) at least one vacuum delivery but no forceps; (5) at least one forceps delivery.

RESULTS

The complete data sets of 1238 women were analysed; 1112 (90%) were vaginally parous. Mean age was 58 (18-95) years. Mean parity was 2.6 (0-9); 57 (4.6%) were nulliparous, 69 (5.6%) had only been delivered by caesarean section, 762 (61.6%) had at least one spontaneous vaginal delivery but no instrumental deliveries, 41 (3.3%) had at least one vacuum but no forceps delivery, and 309 (25%) had at least one forceps delivery. Mean MUP was 41.8 cmH₂O. There was a significant association between vaginal parity and MUP (P < 0.001). On ANOVA test, delivery mode was significantly associated with MUP. This became nonsignificant on regression analysis, with only age significantly associated with MUP (P < 0.001).

CONCLUSIONS

The effect of childbirth on urethral sphincter function seems to be largely due to the first vaginal birth. We failed to show an effect of instrumental delivery.

The neonatal intestinal resistome and factors that influence it - a systematic review

BACKGROUND

The intestinal microbiome provides a reservoir for antibiotic resistance genes (ARGs). The neonatal microbiome is more susceptible to disturbance from external factors than the established microbiome.

OBJECTIVES

In this review, we systematically summarise studies which investigated the intestinal resistome in neonates.

DATA SOURCES

MEDLINE and Embase databases were searched.

STUDY ELIGIBILITY CRITERIA

We included original studies which investigated ARGs in stool or rectal swabs in neonates using molecular diagnostics.

METHODS OF DATA SYNTHESIS

Two authors independently extracted data. Data was summarised in tables.

RESULTS

Our search identified 2,701 studies, of which 23 (22 cohorts) were included. The studies show that the neonatal intestine harbours a high abundance and variety of ARGs, even in the absence of direct antibiotic exposure. The most-commonly found ARGs confer resistance to aminoglycosides, beta-lactams, macrolides, tetracyclines or multi-drug resistance. There is evidence that ARGs can be transferred from mothers to neonates. Interestingly, however, compared to mothers, neonates are reported to have a higher abundance of ARGs. One likely reason for this is the bacterial phylogenetic composition with a high abundance of Gammaproteobacteria in neonatal stool. Factors that have been associated with a higher abundance of ARGs are intrapartum and neonatal antibiotic use. Breastfeeding and neonatal probiotic use have been associated with a lower abundance of ARGs. Antibiotics during pregnancy, delivery mode or sex are reported to have little effect. However, this might be because studies were underpowered and because it is difficult to account for effect modifiers.

DISCUSSION

The neonatal intestine seems to have a lower colonisation resistance, which could make it easier for antibiotic-resistant populations to establish themselves. Future studies will help in the development of evidence-based interventions to modulate the abundance of ARGs in neonates, for example, by the use of pre- and probiotics and bacteriophages.

Pregnancy and delivery after augmentation cystoplasty: A case report and review of literature

BACKGROUND

Augmentation cystoplasty, first described by Mikulicz in 1899 involves segments of bowel, stomach or mega-ureter to increase bladder capacity in those with inadequate bladder function or lack of detrusor compliance. The most widely used bowel segment is a detubularised patch of ileum. When ileum is not suitable for augmentation, sigmoid colon is the alternative. However, only eight pregnancies after sigmoidocystoplasty have been reported without detail and clinicians may be uncertain about the effects of sigmoidocystoplasty on reproductive health and pregnancy.

CASE SUMMARY

We followed the patient from gestational week 32+3 until 6 wk after delivery. During pregnancy, our patient suffered urinary tract infection twice and had to undergo percutaneous nephrostomy drainage due to progressive hydronephrosis. Despite a dense adhesion between the uterus and neobladder, we were able to deliver a healthy baby by cesarian section in the presence of the attending urologist.

CONCLUSION

Augmentation cystoplasty-afflicted women can have a healthy reproductive life. Certain perioperative measures may be advisable to avoid serious surgical complications.

Delivery mode and severe maternal and neonatal morbidity among singleton term breech births: A population-based cohort study

OBJECTIVE

The aim of this study was to examine the association between delivery mode and severe maternal and neonatal morbidity in singleton term breech births.

STUDY DESIGN

This nationwide population-based cohort study includes 41 319 singleton term and post-term breech births (37 + 0-42 + 6 gestational weeks) in Sweden from 1998 to 2016. Data was retrieved from the Swedish Medical Birth Register. The primary outcomes were two separate composite outcomes, maternal and neonatal severe morbidity. Secondary outcomes were separate severe maternal and neonatal morbidity outcomes. Hospitalization and out-patient visits during childhood were also analyzed in ages 0-5 years. Logistic regression was used to estimate unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals (CI) of severe maternal and neonatal morbidity in women with vaginal breech birth or intrapartum cesarean section. Women with a prelabor breech cesarean section was used as the reference group.

RESULTS

No difference between vaginal delivery and prelabor cesarean section was seen regarding maternal morbidity. Intrapartum cesarean section was associated with elevated odds for maternal morbidity (aOR 1.27, 95% CI 1.10-1.47) compared with prelabor cesarean section. A similar result was observed for vaginal delivery and intrapartum cesarean section combined (aOR 1.29, 95% CI 1.11-1.50). Vaginal delivery was associated with higher odds for composite neonatal morbidity (aOR 1.85, CI 1.54-2.21) and most separate outcomes, as well as increased number of hospital nights and out-patient visits during first year of life, compared with prelabor cesarean section.

CONCLUSIONS

Prelabor cesarean section in breech births improved short-term neonatal health without increasing risks for severe maternal short-term complications.

Behavior Change Techniques and Delivery Modes in Interventions Targeting Adolescent Gambling: A Systematic Review

BACKGROUND

Adolescent gambling can lead to significant harms, yet participation rates continue to rise. Interventions targeting gambling reduction have been implemented in this population. However, it is not clear which behavior change techniques (BCTs) and modes of delivery (MOD) are most effective at reducing gambling.

OBJECTIVE

The objective of the study was to identify 'promising' BCTs and MODs by systematically reviewing interventions targeting adolescent gambling behavior. 'Promising' was defined as those present in at least 25% of all interventions and in at least two effective interventions.

METHODS

Three databases were searched (PsycINFO, Medline, and Scopus) from database inception to May 2021. Interventions were eligible if they were randomized controlled trials; targeting adolescents (aged 10-25 years); and assessing gambling behavior post-intervention. BCTs were identified using the Behavior Change Technique Taxonomy v1.

RESULTS

From the initial 3,315 studies, the removal of duplicates and ineligible articles resulted in sixteen studies included in the review. Eleven of these reported successfully reducing gambling behavior. Eighteen BCTs and six MODs were used across the interventions. The BCTs identified as promising were '4.2. Information about antecedents', '4.4. Behavioral experiments', '5.3. Information about social and environmental consequences', and '5.6. Information about emotional consequences'. Promising MODs were 'face-to-face', 'computer', and 'playable electronic storage'.

CONCLUSIONS

The study reviewed the content of interventions targeting adolescent gambling behavior. Four BCTs were identified as promising and should therefore be adopted in future interventions. To facilitate the delivery of these techniques, the study also identified three promising MODs. Interventions developed using these BCTs and MODs may successfully reduce adolescent gambling behavior.

Impact of postpartum pain and birth pain management on the pelvic floor function. A retrospective study including over 300 mothers

OBJECTIVES

It is known that pregnancy and childbirth bring biological, psychological and social changes in a woman's life. Studies regarding the pelvic floor function focus on the year after delivery, but unfortunately, long-term studies are rare. Furthermore, an association between postpartum pain and birth pain management on the pelvic floor function has rarely been examined. The aim of this study is the evaluation of the pelvic floor function years after delivery in order to detect possible risk factors.

STUDY DESIGN

This is a retrospective cohort study. All women who delivered in our hospital between 2015 and 2016 were contacted by mail between 2018 and 2019 and asked to participate. The letters included study information, declaration of consent, the "Pelvic floor questionnaire for pregnant women and women after childbirth" (PFQ), contact information and pre-paid envelopes. Questions about pain after childbirth and the management of birth related fear and pain were particularly of interest in the surveys. The interested participants were asked to return the completed declaration of consent and the questionnaire. Overall, 308 women were included in the analysis. Due to the large number of participants, different subgroups were defined in order to compare influencing factors adequately.

RESULTS

No significant association between the mode of delivery and the total score of the PFQ was found after 3-4 years in primiparous women (p = 0.688). Our study also showed that recorded pain after childbirth and insufficient pain and fear management after childbirth had a negative impact on the pelvic floor function (total scores: pain after childbirth p = 0.00; no pain management p = 0.04; no fear management p = 0.021).

CONCLUSION

No association was found between delivery mode and pelvic floor function in primiparous women three to four years after childbirth. On the other hand, a negative impact of birth related pain and fears on the pelvic floor function years after delivery was significant. Therefore, these revealing findings should certainly be considered in postpartum management.

The mediating effect of the prolonged second stage of labor on delivery mode and urinary incontinence among postpartum women: evidence from Shandong, China

INTRODUCTION AND HYPOTHESIS

This study was aimed at exploring the mediating role of the prolonged second stage of labor (PSSL) in the association between delivery mode and urinary incontinence (UI) among postpartum women in Shandong, China.

METHODS

A cross-sectional study involving postnatal women from the Women's Pelvic Floor Functional Health Center in Shandong, China, was conducted. An electronic questionnaire was used to collect the data between June 2020 and February 2021. UI was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Logistic regression and multiple linear regression were employed to explore the association among delivery mode, PSSL, and UI, and the mediating role of PSSL.

RESULTS

Among the total of 5,586 postpartum women included in this study, the prevalence of UI was 13.3%. Among the 742 patients with UI, the prevalence of stress urinary incontinence (78.3%) was greater than urge urinary incontinence (8.6%), mixed urinary incontinence (9.3%), and others (3.8%). After adjusting for controlling variables, delivery mode was found to be significantly associated with PSSL, whereby women with vaginal delivery were more likely to be in PSSL, and women with PSSL had a higher probability of suffering from UI. PSSL played a partial mediating effect in delivery mode and UI.

CONCLUSIONS

This study provided evidence that the effect of delivery mode on UI was partially mediated by PSSL among postpartum women in Shandong, China. Strategies to prevent PSSL should be actively adopted to reduce the risk of UI in women.

Association of cesarean birth with prevalence of functional constipation in toddlers at 3 years of age: results from the Japan Environment and Children's Study (JECS)

BACKGROUND

The association between delivery mode and subsequent development of diseases is a growing area of research. Cesarean delivery affects the diversity of the microbiota in the infant gut, which may be associated with gastrointestinal disorders, including functional constipation, in infants. In this study, we investigated the association between delivery mode and prevalence of functional constipation in 3-year-old Japanese toddlers.

METHODS

This study used data from the Japan Environment and Children's Study, an ongoing nationwide birth cohort study. We analyzed 71,878 toddler-mother pairs. The presence of functional constipation was determined according to the Rome III diagnostic criteria. Odds ratios and 95% confidence intervals were calculated using logistic regression analysis.

RESULTS

The prevalence of functional constipation in 3-year-old Japanese toddlers was estimated to be 12.3%. Logistic regression analysis revealed that the prevalence of functional constipation was higher in toddlers born by cesarean delivery (13.1%) compared with those born by vaginal delivery (12.1%), independent of 22 confounders (adjusted odds ratios = 1.064, 95% confidence interval = 1.004-1.128).

CONCLUSIONS

We determined the prevalence of functional constipation in 3-year-old Japanese toddlers and found that delivery mode was associated with the prevalence of functional constipation in Japanese toddlers.

Pelvic floor function and morphological abnormalities in primiparas with postpartum symptomatic stress urinary incontinence based on the type of delivery: a 1:1 matched case-control study

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess pelvic floor muscle (PFM) morphology and function in primiparas with postpartum symptomatic SUI after different types of delivery.

METHODS

Retrospective analyses were carried out with individuals with postpartum symptomatic stress urinary incontinence (SUI). Among the women screened in our center from January 2018 to December 2019, participants were divided into elective cesarean section (eCS) and spontaneous vaginal delivery (sVD) groups, while being matched 1:1 on age (±5 years), body mass index (BMI; ±0.5 kg/m²), neonatal birth weight (±300 g), gestational age (±1 week), degree of pelvic organ prolapse quantification (POP-Q), International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) degree, Incontinence Impact Questionnaire short form (IIQ-7) score, and postpartum days (±10 days); all participants had no sphincter defects or levator ani muscle avulsion. The bioelectrical activity of the PFM was collected using an endovaginal electrode with the Glazer protocol. For the assessment of PFM function, PFM morphometry was evaluated with 3D/4D transperineal ultrasound.

RESULTS

A total of 78 matched pairs were recruited based on delivery mode. Regarding functional differences, both fast-twitch and slow-twitch fiber strengths in the eCS group were significantly higher than those in the sVD group, but PFMs were more hyperactive in the eCS group. Regarding morphometric differences, the retrovesical angle (RVA) and bladder neck position were not significantly different in the resting state between the two groups, nor was the RVA during the Valsalva maneuver (eCS group: 130.68 ± 17.08°, sVD group: 136.33 ± 23.93°), p > 0.05. There were differences in bladder neck descent (BND; eCS group: 16.51 ± 7.55 mm, sVD group: 23.92 ± 8.47 mm) and urethral rotation angle (URA; eCS group: 37.53 ± 26.05°, sVD group: 59.94 ± 25.87°), all p < 0.05. BND showed a negative correlation with PFM strength, p < 0.05. URAs and RVAs showed no correlation with PFM strength, p > 0.05.

CONCLUSION

Pelvic floor muscle function disorder, hyperactivity, and instability also occurred after eCS, which resulted in postpartum symptomatic SUI. The effects of sVD compared with eCS on abnormalities in the lower urinary tract were related to bladder neck and urethral hyperactivity, without an RVA increase.

Influence of different delivery modes and HBV DNA titers on mother-to-child transmission of hepatitis B

BACKGROUND

The influence of different delivery modes on the mother-to-child transmission (MTCT) rate of pregnant women with high hepatitis B viremia was investigated.

METHODS

A retrospective analysis was performed on data for 855 hepatitis- B -virus (HBV) carrier mothers who received regular prenatal care and delivered at the First Affiliated Hospital of Jinan University from January 2011 to October 2015. The neonates were classified into three groups according to the delivery mode: eutocia (438 cases), Non-parturient cesarean delivery (371 cases), and parturient cesarean delivery (46 cases). The neonatal HBV surface antigen (HBsAg) positive rates of the three delivery groups were comparatively analyzed to determine the influence of the delivery mode on HBV MTCT. Of the 855 HBV-carrier mothers, 480 mothers and respective newborns were tested for HBV-DNA and classified into four groups: HBV DNA≥10⁷ copies/mL (96 cases), 10⁵≤HBV DNA<10⁷ copies/mL (37 cases), 10³≤HBV DNA<10⁵ copies/mL (85 cases), and HBV DNA<10³ copies/mL (262 cases). The effect of the HBV DNA titers of these pregnant women on HBV MTCT was analyzed.

RESULTS

Statistically significant (P<0.05) differences were found among the HBsAg positive rates of neonates of HBV-carrier pregnant women delivered by the three methods from HBV-carrier pregnant women with HBV DNA≥107 copies/mL. No statistically significant (P>0.05) differences among the HBsAg positive rates were found for neonates delivered by the three methods from HBV-carrier pregnant women with HBV DNA<10⁷ copies/mL.

CONCLUSIONS

The delivery mode may influence the risk of HBV maternal-to-infant vertical transmission for HBV-carrier pregnant women with HBV DNA≥10⁷ copies/mL. That is, elective cesarean section may reduce the HBV maternal-to-infant vertical transmission.

Association of birth mode of delivery with infant faecal microbiota, potential pathobionts, and short chain fatty acids: a longitudinal study over the first year of life

OBJECTIVE

Caesarean section (CS) interrupts mother-to-newborn microbial transfer at birth. Beyond the neonatal period, the impact of CS on offspring gut microbiota and their short-chain fatty acids (SCFAs) remains unclear. Here, we examine birth delivery mode (CS versus vaginal delivery) with the infant gut microbiota and faecal SCFAs measured 3 and 12 months after birth.

DESIGN

Longitudinal study.

SETTING

North Carolina.

POPULATION

In 2013-15, we enrolled pregnant women and followed up their offspring for 12 months. We asked a subset of participants, enrolled over a 3-month period, to provide faecal samples at the 3- and 12-month follow-up visits.

METHODS AND MAIN OUTCOMES

We sequenced the 16S rRNA V4 region with Illumina MiSeq and quantified SCFA concentrations using gas chromatography. We examined delivery mode with differential abundance of microbiota amplicon sequence variants (ASVs) using beta-binomial regression and faecal SCFAs using linear regression. We adjusted models for confounders.

RESULTS

Of the 70 infants in our sample, 25 (36%) were delivered by CS. Compared with vaginal delivery, CS was associated with differential abundance of 14 infant bacterial ASVs at 3 months and 13 ASVs at 12 months (all FDR P < 0.05). Of note, CS infants had a higher abundance of the potential pathobionts Clostridium neonatale (P = 0.04) and Clostridium perfringens (P = 0.04) and a lower abundance of potentially beneficial Bifidobacterium and Bacteroides spp. (both P < 0.05) at 3 months. Other ASVs were differentially abundant at 12 months. Infants delivered by CS also had higher faecal butyrate concentration at 3 months (P < 0.005) but not at 12 months.

CONCLUSIONS

Caesarean section was associated with increased butyrate excretion, decreased Bifidobacterium and Bacteroides spp., and more colonisation of the infant gut by pathobionts at 3 months of age. CS was also associated with altered gut microbiota composition, but not faecal SCFAs, at 12 months.

TWEETABLE ABSTRACT

Caesarean section delivery was associated with increased butyrate excretion, decreased Bifidobacterium, and increased colonisation of the infant gut by pathobionts at 3 months of age.

Cesarean section is associated with increased risk of postpartum depressive symptoms in Japan: the Kyushu Okinawa Maternal and Child Health Study

BACKGROUND

The association between cesarean section and the risk of postpartum depressive symptoms remains controversial. The present prebirth cohort study examined this issue in Japan.

METHODS

Study subjects were 1310 women. Information under study was obtained using a self-administered questionnaire. Postpartum depressive symptoms were defined as a total Edinburgh Postnatal Depression Scale score of nine or higher between three and four months postpartum. Multivariate logistic regression analysis was used to adjust for age, body mass index, gestational weeks at baseline, gestational weeks at delivery, number of children at baseline, previous miscarriage or stillbirth, previous abortion, history of depression, family history of depression, region of residence, employment status, educational level, household income, family structure, breastfeeding status, smoking during pregnancy, infant's birthweight, and infant's sex.

RESULTS

Postpartum depressive symptoms were identified in 8.2%. After adjustment for the confounding factors, compared with vaginal delivery, cesarean section was independently associated with an increased risk of postpartum depressive symptoms: the adjusted odds ratio (OR) was 1.95 (95% confidence interval [CI]: 1.16-3.23). This positive association was more apparent among those who had no other children at baseline than among those who already had one or more children: the adjusted ORs were 2.94 (95% CI: 1.35-6.26) and 1.45 (95% CI: 0.68-2.92), respectively; however, this interaction was not significant.

LIMITATIONS

Information on whether each cesarean section was emergency or elective and other obstetric complications was not available.

CONCLUSIONS

Cesarean section may be associated with an increased risk of postpartum depressive symptoms, especially among women without children at baseline.

Cesarean delivery and infant cortisol regulation

BACKGROUND

Cesarean delivery reduces the risk of infant and maternal morbidity and mortality when medically indicated, however, the cesarean delivery rate is estimated to be two to three times higher than medically necessary. The World Health Organization and American College of Obstetricians and Gynecologists have expressed concern over the high rates of cesarean delivery, citing evidence that cesarean delivery has negative short- and long-term consequences for the health of the infant, mother, and for future pregnancies. Infants delivered by cesarean are at an increased risk of metabolic disease and immune dysfunction throughout the lifespan. Preliminary research suggests that the hypothalamic pituitary adrenal (HPA) axis is a plausible pathway linking cesarean delivery to poor health later in life. The present study examines the relation between mode of delivery and HPA axis function in six-month-old infants. We also examine whether the cesarean delivery was elective or indicated altered to the relation between mode of delivery and infant cortisol profiles.

METHODS

The sample included 136 mother/infant pairs. Thirty-nine women delivered by cesarean and 97 delivered vaginally. Maternal and infant medical records were reviewed for prenatal medical history and birth outcomes. Infant saliva was collected for cortisol analysis at a 6-month well-baby checkup. Samples were collected upon arrival to the appointment (baseline) and 20 min after exposure to a painful stressor, the inoculation procedure (response). A mixed model ANCOVA was conducted to determine whether salivary cortisol concentrations differed between the two delivery groups. To examine whether complications related to having an indicated cesarean delivery contributed to any association between mode of delivery and cortisol production, cortisol concentrations were compared between the subgroup of infants whose cesarean deliveries were elective (e.g. maternal request or previous cesarean delivery) to infants delivered vaginally.

RESULTS

Infants delivered by cesarean had lower cortisol concentrations at baseline and after the inoculation procedure compared to those delivered vaginally. Further, the relation between mode of delivery and cortisol levels persisted even when the analyses were restricted to compare only the elective cesarean deliveries (e.g. maternal request or previous cesarean delivery) to those delivered vaginally.

DISCUSSION

This study provides evidence for an association between cesarean delivery and infant HPA axis function in infancy. Findings are consistent with the hypothesis that the HPA axis is a plausible pathway that links cesarean delivery with long-term health outcomes.

Breastfeeding restored the gut microbiota in caesarean section infants and lowered the infection risk in early life

BACKGROUND

The initialization of the neonatal gut microbiota (GM) is affected by diverse factors and is associated with infant development and health outcomes.

METHODS

In this study, we collected 207 faecal samples from 41 infants at 6 time points (1, 3, and 7 days and 1, 3, and 6 months after birth). The infants were assigned to four groups according to delivery mode (caesarean section (CS) or vaginal delivery (VD)) and feeding pattern (breastfeeding or formula milk).

RESULTS

The meconium bacterial diversity was slightly higher in CS than in VD. Three GM patterns were identified, including Escherichia/Shigella-Streptococcus-dominated, Bifidobacterium-Escherichia/Shigella-dominated and Bifidobacterium-dominated patterns, and they gradually changed over time. In CS infants, Bifidobacterium was less abundant, and the delay in GM establishment could be partially restored by breastfeeding. The frequency of respiratory tract infection and diarrhoea consequently decreased.

CONCLUSION

This study fills some gaps in the understanding of the restoration of the GM in CS towards that in VD.

Delivery mode and future infectious morbidity of the offspring: a sibling analysis

PURPOSE

Cesarean delivery (CD) has been recently suggested to be associated with offspring's long-term health implications. We aimed to investigate the association between delivery mode and long-term infectious morbidity of the offspring while employing sibling matched analysis to maximize confounder control.

METHODS

A retrospective population-based cohort study was performed, which included all sibling deliveries occurring between 1991 and 2014 at a regional tertiary medical center. Offsprings were followed up until the age of 18 years. The study included 13,516 individuals (6758 sibling pairs): the first born was via vaginal delivery and the second via CD. Each siblings pair was considered a matched set, with the aim to perform a within-family analysis. A Kaplan-Meier survival curve was used to compare the cumulative infectious morbidity incidence and a multivariable Cox survival hazards regression model to control for confounders.

RESULTS

Crude rates of total infectious hospitalizations were found to be significantly higher in the CD group (OR 1.25; 95% CI 1.12-1.40). Specifically, bronchiolitis (OR 2.02, 95% CI 1.56-2.63), otitis (OR 1.52, 95% CI 1.21-1.9), and gastroenteritis (OR 1.41, 95% CI 1.05-1.9) were all found to be significantly more common in the CD group. The survival curve demonstrated significantly higher cumulative infection-related hospitalization rates in the CD group (log-rank p < 0.001). The Cox model, adjusted for several confounders, confirmed the significant association between CD and offspring's infection-related morbidity (adjusted HR 1.25; 95% CI 1.02-1.53).

CONCLUSION

CD appears to be independently associated with later offspring infection-related morbidity, even while rigorously adjusting for confounders.

Prevalence of levator ani avulsion in a multicenter study (PAMELA study)

PURPOSE

The objective is to determine the prevalence of levator ani muscle (LAM) avulsion using four-dimensional ultrasound in primiparous women after vaginal delivery and according to delivery mode.

METHODS

This prospective, multicenter study included 322 women evaluated at 6-12 months postpartum by four-dimensional transperineal ultrasound to identify levator ani muscle avulsion. The researcher who performed the ultrasound was blinded to all clinical data. Meaningful data about the birth were also recorded: mode of delivery, mother's age and body mass index, duration of second stage, episiotomy, perineal tearing, anesthesia, assistant, head circumference and fetal weight.

RESULTS

303 volumes were valid for evaluation. The overall prevalence of levator ani muscle avulsion was 18.8% (95% CI 14.4-23.2%). In our multivariate analysis, only mode of delivery reached statistical significance as a risk factor for levator ani muscle avulsion (p < 0.001). The prevalence according to the different modes of delivery was 7.8% in spontaneous delivery, 28.8% in vacuum-assisted and 51.1% in forceps-assisted delivery. Compared with spontaneous delivery, the OR for LAM avulsion was 12.31 with forceps (CI 95% 5.65-26.80) and 4.78 with vacuum-assisted delivery (CI 95% 2.15-10.63).

CONCLUSIONS

Levator ani avulsion during vaginal delivery in primiparous women occurs in nearly one in every five deliveries. Delivery mode is a significant and modifiable intrapartum risk factor for this lesion. The incidence is lower in spontaneous delivery and significantly increases when an instrument is used to assist delivery, especially forceps.

Human milk microbiota associated with early colonization of the neonatal gut in Mexican newborns

Background

Human milk microbiota plays a role in the bacterial colonization of the neonatal gut, which has important consequences in the health and development of the newborn. However, there are few studies about the vertical transfer of bacteria from mother to infant in Latin American populations.

Methods

We performed a cross-sectional study characterizing the bacterial diversity of 67 human milk-neonatal stool pairs by high-throughput sequencing of V3-16S rDNA libraries, to assess the effect of the human milk microbiota on the bacterial composition of the neonate's gut at early days.

Results

Human milk showed higher microbial diversity as compared to the neonatal stool. Members of the Staphylococcaceae and Sphingomonadaceae families were more prevalent in human milk, whereas the Pseudomonadaceae family, Clostridium and Bifidobacterium genera were in the neonatal stool. The delivery mode showed association with the neonatal gut microbiota diversity, but not with the human milk microbiota diversity; for instance, neonates born by C-section showed greater richness and diversity in stool microbiota than those born vaginally. We found 25 bacterial taxa shared by both ecosystems and 67.7% of bacteria found in neonate stool were predicted to originate from human milk. This study contributes to the knowledge of human milk and neonatal stool microbiota in healthy Mexican population and supports the idea of vertical mother-neonate transmission through exclusive breastfeeding.

Maternal and neonatal outcome after vaginal breech delivery of nulliparous versus multiparous women of singletons at term-A prospective evaluation of the Frankfurt breech at term cohort (FRABAT)

INTRODUCTION

The best way to deliver a term breech infant is still a much discussed topic among obstetricians. The question whether nulliparity should be considered an exclusion criterion for an intended vaginal breech delivery is not fully answered.

OBJECTIVE

We compared maternal and neonatal outcome of intended vaginal breech deliveries of nulliparous versus multiparous women at term.

STUDY DESIGN

We conducted a prospective case-control study between January 2004 and December 2016. 1046 women expecting singletons at term with favorable pelvic measurements were enrolled in the study.

RESULTS

Neonatal morbidity and mortality was not significantly different in deliveries of nulliparous (n = 647) versus multiparous (n = 399) women. Nulliparous women had a significantly higher rate of a cesarean section during labor than multiparous women. Maternal birth-injury rates and the use of epidural anesthesia were significantly higher comparing vaginal births of nulliparous (n = 384) versus multiparous (n = 331) women.

CONCLUSION

Nulliparity seems not be an exclusion criterion for intended vaginal breech birth at term. It is still important to inform the women of an increased risk of a cesarean section during labor. A clinical management built on this evidence might reduce negative implications for future pregnancies.

Vaginal breech delivery of pregnancy before and after the estimated due date-A prospective cohort study

INTRODUCTION

3-4% of pregnant women present with a fetal breech position at term. National societies regard vaginal breech delivery as a safe option, but only for a specific and thoroughly counseled group of patients. To avoid adverse outcome, many practitioners recommend elective cesarean section once their patients go past the estimated due date. Since encompassing evidence is missing, the evaluation on this common clinical practice is needed.

OBJECTIVE

This study compares the short-term maternal and fetal outcome in intended vaginally breech deliveries before the estimated due date (until 40 0/7 weeks of gestation) to the outcome of deliveries carried out past the estimated due date (later than 40 0/7 weeks of gestation).

METHODS

This prospective cohort study includes 827 women who presented for an intended vaginal breech delivery of a singleton at our perinatal center between January 2010 and December 2016.

RESULTS

447 patients (54%) delivered before or at their estimated due date, 380 (46%) of pregnancies continued after the estimated due date. Comparing both groups, no significant difference in maternal and neonatal short-term mortality and morbidity was found. The rate of caesarian sections was increased in the group of patients, who delivered later than 40 1/7 weeks of gestation. Here, the likelihood for delivery maneuvers was also increased.

CONCLUSION

This study provides evidence, that an elective cesarean section for breech presentations at term is not obligatory when the estimated due date has passed in singleton pregnancy.

Impact of some social and clinical factors on the development of postpartum depression in Chinese women

Background

Postpartum depression (PPD) is prevalent and may present major adverse impacts on mother and child health. According to previous studies, mostly from the western society, PPD may have complicated etiologies, such as genetic, social and psychological factors. The aim of this study was to explore the associations of some social and clinical factors, particularly those unique in Chinese, with significant PPD symptoms.

Methods

A sample of 556 pregnant women in their 36th to 40th gestational week were randomly recruited in a cross-sectional study using a self-reported questionnaire, which collected maternal sociodemographic and clinical information. During their 2nd to 4th postpartum months, 522 participants responded to our screening of significant PPD symptoms, based on a score of Edinburgh Postnatal Depression Scale ≥9.

Results

A total of 90 (17.3%) participants were identified with significant PPD symptoms, and the following factors were observed more frequently in women with significant PPD symptoms (PPD⁺) than with fewer symptoms (PPD⁻): intensive involvement of parents-in-law in a participant’s life (living together with her, taking care of her, or discriminating against a female baby), lack of support from husband, cesarean delivery, and breast milk insufficiency (supplemented with formula). After multiple logistic regression analysis, parents-in-law’s preference to baby boy while devaluing baby girl, dissatisfaction with husband’s support, cesarean delivery, and mixed feeding were strongly associated with significant PPD symptoms.

Conclusion

The potential risk factors for significant PPD symptoms, i.e., “son preference” custom, cesarean delivery and mixed feeding, deserve confirmation in continued, especially clinical diagnosis-based longitudinal studies.

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

Background

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

Methods

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

Results

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

Conclusions

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

The effectiveness of prenatal yoga on delivery outcomes: A meta-analysis

BACKGROUND

The efficacy of yoga on delivery outcomes remaining controversy.

OBJECTIVES

To evaluate the effects of prenatal yoga on delivery outcomes.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, CINAHL and Elsevier databases were searched from inception to January 22, 2020, and randomized, quasi-randomized and non-randomized controlled trials evaluating the effect of yoga on the delivery outcomes in pregnant women were included. The methodological quality was assessed by the Cochrane Collaboration's tool. Meta-analysis was performed using Revman 5.3.

RESULTS

This meta-analysis identified that yoga improved vaginal delivery, decreased premature delivery and birth weight of newborns, shorten the labor duration.

CONCLUSION

Prenatal yoga is an effective complementary medicine to improve delivery outcomes and not to increase the risk of fetus, which is worth recommending to pregnant women. But studies involved in this meta-analysis were not all of high quality. The Registration Number in PROSPERO is CRD42019132490.

Predictors of emergency cesarean section in women with preexisting diabetes

OBJECTIVE

Preexisting diabetes in pregnancy is associated with a high risk of emergency cesarean section (CS), which is associated with increased risk of maternal and neonatal complications. Thus, the aim of this study was to identify possible predictors of emergency CS in women with preexisting diabetes.

STUDY DESIGN

This is a secondary analysis of a prospective observational study of 204 women with preexisting diabetes (118 with type 1 diabetes and 86 with type 2) with singleton pregnancies recruited at Rigshospitalet, Copenhagen, Denmark from August 2015 to February 2018. Mode of delivery (trial of labor or planned CS) was individually planned in late pregnancy based on clinical variables reflecting maternal and fetal health including glycemic control and ultrasonically estimated fetal weight. Univariate and multivariable analyses were performed to identify possible predictors of in labor emergency CS.

RESULTS

Trial of labor was planned in 79 % (n = 162) of the women of whom 65 % (n = 105) were delivered vaginally and 35 % (n = 57) by an emergency CS, while the remaining 21 % (n = 42) were offered a planned CS. Nulliparity (adjusted odds ratio (aOR) 5.6 95 % CI 1.7-18.8), presence of a hypertensive disorder (aOR 2.8, 95 % CI 1.2-6.7) and previous CS (aOR 6.7, 95 % CI 1.5-28.9) were independently associated with an emergency CS. Maternal height was inversely associated with emergency CS (aOR 0.6 95 %, CI 0.5-0.9 per 5 cm decrease). Neither maternal HbA1c nor ultrasonically estimated fetal size in late pregnancy were associated with emergency CS. Women scheduled for a planned CS were characterized by poorer glycemic control and higher estimated fetal size than those offered a trial of labor.

CONCLUSION

Nulliparity, presence of a hypertensive disorder, previous CS and shorter maternal height were predictors of emergency CS in women with a planned trial of labor, whereas this not was the case for late pregnancy maternal Hba1c or fetal size estimated by ultrasound.

Social determinants of delivery mode in Jiangsu, China

Background

Less evidence exists regarding the association of social determinants and delivery mode in Jiangsu, and if the trend is influenced by the type of residence. This study aims to identify the significant social determinants of delivery mode, and also to compare the main differences in delivery mode between urban and rural areas.

Methods

We used data from the cross-sectional National Health Service Surveys conducted in Jiangsu Province in 2013. For the purposes of this study, information from women (15–64 years old) who had experienced childbirth the last 5 years were examined, and a total of 1365 participants were selected as research subjects.

Results

Participants using vaginal delivery mode and cesarean delivery mode were found in 616 (45.1%) and 751(54.9%) participants, respectively. The proportion of women using cesarean delivery was 53.5% in rural area and 58.2% in urban area. Meanwhile, our results showed that women in middle Jiangsu were more likely to use cesarean delivery, and cesarean delivery is more prevalent among richer women. We also find that the more use of prenatal care visit, the more use of cesarean delivery.

Conclusions

This study validated the relationship between social determinants and the mode of delivery in Jiangsu province. Social determinants are contextual factors, which may vary by region and additional work is needed to fully understand these relationships globally. Further studies are needed to elucidate mechanisms and pathways across various populations, and these social determinants should be incorporated into future multi-level interventions designed to decrease the cesarean delivery rate.

Delivery mode is associated with maternal mental health following childbirth

Childbirth is a life-transforming event often followed by a time of heightened psychological vulnerability in the mother. There is a growing recognition of the importance of obstetrics aspects in maternal well-being with the way of labor potentially influencing psychological adjustment following parturition or failure thereof. Empirical scrutiny on the association between mode of delivery and postpartum well-being remains limited. We studied 685 women who were on average 3 months following childbirth and collected information concerning mode of delivery and pre- and postpartum mental health. Analysis of variance revealed that women who had cesarean section or vaginal instrumental delivery had higher somatization, obsessive compulsive, depression, and anxiety symptom levels than those who had natural or vaginal delivery as well as overall general distress, controlling for premorbid mental health, maternal age, education, primiparity, and medical complication in newborn. Women who underwent unplanned cesarean also had higher levels of childbirth-related PTSD symptoms excluding those with vaginal instrumental. The risk for endorsing psychiatric symptoms reflecting clinically relevant cases increased by twofold following unplanned cesarean and was threefold for probable childbirth-related PTSD. Maternal well-being following childbirth is associated with the experienced mode of delivery. Increasing awareness in routine care of the implications of operative delivery and obstetric interventions in delivery on a woman's mental health is needed. Screening at-risk women could improve the quality of care and prevent enduring symptoms. Research is warranted on the psychological and biological factors implicated in the mode of delivery and their role in postpartum adjustment.

Is the delivery mode a critical factor for the microbial communities in the meconium?

Background

Mothers are the primary source of bacteria for newborns, but it is unclear whether mother-to-newborn transmission occurs prior to, during or after birth. Similarly, the effect of the delivery mode on neonatal microorganisms has been the focus of controversy.

Methods

Healthy maternal and neonatal pairs that underwent vaginal birth and caesarean section were enrolled in this study. Meconium, placenta, membrane and amniotic fluid samples for newborns and vaginal, rectal and oral samples for mothers were collected. All samples were amplified and sequenced by a 16S rRNA gene primer set targeting bacteria and archaea.

Findings

A total of 550 samples from 36 mother-neonate pairs with vaginal births and 42 mother-neonate pairs with caesarean sections were included in this study. The negative controls showed that the data analysis in this study was not affected by contamination. There was a high diversity of microbial communities in the pregnancy environment of the foetus. Meconium samples could be divided into three distinct types that were not influenced by the delivery method.

Interpretation

The distribution patterns of bacterial communities in the meconium, placenta, and foetal membranes were highly similar and had nothing to do with the mode of delivery. For approximately half of the placental microorganisms, the same sequence could be found in the vaginal, rectal, and oral samples of the mother.

Effects on developmental outcomes after cesarean birth versus vaginal birth in Chinese children aged 1-59 months: a cross-sectional community-based survey

Objective

It is controversial whether the mode of delivery is associated with developmental outcome, and little was known about growth and development of cesarean children in poor rural areas in China. We aim to measure the development of both cesarean and vaginal-delivered children by Ages and Stages Questionnaires (ASQ) and explore the association between mode of delivery and developmental outcome in poor rural areas in China.

Methods

Data were collected from a cross-sectional community-based survey, which recruited 1,755 vaginal delivered and cesarean children ages 1 to 59 months in eight counties of China. Caregivers of those children completed the Chinese version of ASQ-3 (ASQ-C) while physical examination andquestionnaires on socio-demographic and neonatal characteristics were conducted. Multivariate logistic regressions were used to measure the association between developmental delay and mode of delivery as well as each socio-demographic factor, respectively, after adjusting other socio-demographic characteristics.

Results

The prevalence of suspected overall developmental delay was 23.4% in the cesarean group, compared with 21.3% in the vaginal delivered group, yet without statistical difference (p < 0.05). Developmental delay was also not significantly different between cesarean and vaginal delivered group in five ASQ domains of communication (7.7% vs. 7.8%, p = 0.949), fine motor (7.0% vs. 6.1%, p = 0.538), gross motor (8.5% vs. 6.4%, p = 0.154), problem solving (7.2% vs. 6.7%, p = 0.722) and personal social (8.0% vs. 7.9%, p = 0.960).

Conclusions

Our findings suggest that cesarean delivery does not increase or decrease the risk of suspected developmental in children delay as compared with vaginal delivery.

Can delivery mode influence future ovarian reserve? Anti-Mullerian hormone levels and antral follicle count following cesarean section: a prospective cohort study

Background

The incidence of Cesarean has increased in recent years. The purpose of this study is to evaluate the effect of cesarean section on ovarian reserve.

This is a prospective cohort study from January 2016 to November 2017. Inclusion criteria included singleton primigravid pregnant women whose gestational age was above 37 weeks. Exclusion criteria included history of infertility, pelvic surgery, underlying chronic diseases, any adverse pregnancy outcome and postpartum complication in current pregnancy and hormonal medication within six months of delivery. Anti-Mullerian hormone was measured at the admission time for delivery. The type of delivery was determined based on obstetrics indications. Six months after delivery, antral follicle count was performed and anti-Mullerian hormone was measured again.

Result(s)

First blood sample was taken from 730 women. After excluding 550 women, the second blood sample was taken from 180 participants. The mean of first anti-Mullerian hormone in women with cesarean and vaginal delivery were 1.01 ng/mL (95% CI 0.82 to 1.18) and 1.18 ng/mL (95% CI 0.96 to 1.40) respectively (P = 0.211). The mean of second anti-Mullerian hormone in women with cesarean and vaginal delivery were 4.77 ng/mL (95% CI:3.91 to 5.63) and 4.92 ng/mL (95% CI: 4.01 to 5.82) respectively (P = 0.818). No statistically significant difference existed in total AFC between cesarean and vaginal delivery groups (MD: 0.41, 95% CI: − 1.05 to 1.89, P = 0.576).

Conclusion

Antral follicle count and anti-Mullerian hormone, six month after delivery, are not affected by delivery mode even after adjusting for women’s age, baseline Anti-Mullerian hormone, body mass index, gestational age at delivery, breastfeeding, postpartum menstruation, neonatal sex and weight. Based on our best knowledge, this is the first report that investigates the effects of delivery mode on ovarian reserve. Decreased fertility following cesarean has been shown in some previous studies but most of them had assessed this association based on the incidence of subsequent pregnancy. Since subsequent pregnancy can be influenced by several confounding factors, we investigated the effect of cesarean on fertility using its impact on anti-Mullerian hormone levels and antral follicle count. We hope that this study will be a beginning of more detailed studies in this field. We believe that this link is yet to be studied.

Effects of delivery mode and age on motor unit properties of the external anal sphincter in women

INTRODUCTION AND HYPOTHESIS

This study aimed to assess the individual and interactive effects of delivery mode and age on the function of the external anal sphincter (EAS) by analyzing the motor unit properties with intramuscular electromyography (EMG). Results are expected to improve the understanding of delivery-related occult obstetric EAS injuries and its development over the aging process and further support early clinical detection and intervention.

METHODS

A total of 49 postpartum women were recruited into four test groups according to their age and delivery mode: young vaginal delivery (Y-VD), elderly vaginal delivery (E-VD), young cesarean section (Y-CS), and elderly cesarean section (E-CS) groups. Anorectal ultrasonography, manometry, and intramuscular EMG were employed for comprehensive evaluation of EAS function.

RESULTS

No significant difference in anorectal ultrasonography and most manometry measurements was associated with delivery age or mode. Intramuscular EMG, however, revealed a statistically significant difference in the characteristics of motor unit potentials (MUPs), including duration, turns, phases, and multiphase wave ratio between four subject groups. No significant interaction effect between age and delivery mode was found.

CONCLUSIONS

Delivery mode and age have a significant effect on the neuromuscular function of the EAS, suggesting a potential protectiveness of cesarean section against impairment to the EAS. Our results do not provide significant evidence regarding the interaction effect of delivery mode and age; further investigations are needed to confirm this conclusion.

Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births

Background

Research on outcomes of out-of-hospital breech birth is scarce. This study evaluates the outcomes of singleton term breech and cephalic births in a home or birth center setting.

Methods

This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity.

Results

50 breech and 102 cephalic presentations were still in the obstetrician’s care at the onset of labor; of those, 10 breech and 11 cephalic mothers required transport during labor. 76% of breech and 92.2% of cephalic births were planned to occur at home, with the remainder at a freestanding birth center. When compared to the cephalic group, the breech group had a higher rate of antepartum and in-labor transfer of care and cesarean section. Among completed out-of-hospital births, the breech group had a significantly higher rate of 1-min Apgar scores < 7 but no significant difference at 5 min. Rates of vaginal birth for both groups were high, with 84% of breech and 97.1% of cephalic mothers giving birth vaginally in this series. Compared to primiparas, multiparas in both groups had less perineal trauma and higher rates of out-of-hospital birth, vaginal birth, and spontaneous vaginal birth. No breech infant or mother required postpartum hospital transport, while one cephalic infant and one cephalic mother required postpartum transport. Of the babies born out-of-hospital, there was one short-term and one longer-term birth injury among the breech group and one short-term brachial plexus injury in the cephalic group.

Conclusions

A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital breech birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.

Factors Associated With Infant Pain Severity Undergoing Immunization Injections

PURPOSE

Factors influencing infants' behavioral and vocal (cry) response to painful stimuli are explored to improve pain management plans for infants undergoing immunizations.

DESIGN AND METHODS

An observational study design was used. Pain responses of 60 to 75 days-old infants (44% male vs 56% female) undergoing two-month immunization injections were videotaped and coded using the Modified Behavioral Pain Scale (MBPS), and duration of total crying time during injection was recorded. The influences of five factors (gender, caregiver attendance, previous experience of nociception (circumcision), mode of delivery), and weight (birth and current) were examined at baseline, during and post-immunization.

RESULTS

Higher birth weight was the most significant factor that reduced pain responses during (p = 0.001) and post-immunization (p = 0.03). A higher birth weight reduced full lung crying (p = 0.04), which reflects crying during injection as compared to total crying time. Vaginal delivery had a significant effect on behavioral pain responses of infants only post-immunization (p = 0.006). Parent's presence in the immunization room significantly reduced total crying time (p = 0.03). Uncircumcised male infants had a significant reduction in behavioral pain responses during immunization (p = 0.01) compared to circumcised infants.

CONCLUSIONS

The literature well supports the acknowledgement of early pain experience and its psychological consequences. Knowing and controlling for each of mentioned factors early in life during every painful procedure could improve coping mechanisms of infants for any painful procedures later in life.

PRACTICE IMPLICATIONS

Control of certain factors during early life experiences can modify pain of immunization.

Intervention for Dysbiosis in Children Born by C-Section

The symbiotic relationship between microbes and human is fundamental for a physiological development and health. The microbiome of the newborn undergoes to dramatic changes during the process of birth and in the first thousand days of life. Mother Nature provided us with the best possible start to achieve eubiosis: vaginal delivery to receive our mother's microbiome and breast milk that favours the establishment of beneficial bacteria. Infants deprived of one or both of these evolutionary gifts undergo to important modification of the microbial communities leading to a state of dysbiosis enhancing the chance of the emergence of a variety of immune, inflammatory and metabolic disorders. Are we able to imitate nature? Is there any intervention for dysbiosis in children born by cesarean section? In this review we will try to answer to this intriguing question on the basis of the most recent scientific evidences.

C-section and the Neonatal Gut Microbiome Acquisition: Consequences for Future Health

BACKGROUND

The human gut microbiota is assembled during infancy with an increase in diversity and stability. The correct colonization and the establishment of this microbiome are linked to the early and future health status of the individual. It is known that caesarean delivery alters this optimal microbial foundation. C-section (CS) is a common obstetrician surgery; however, it is not without risk for the mother/infant dyad. The World Health Organization recommends not exceeding 10-15% of the total deliveries; nevertheless, this rate has been increasing rapidly worldwide in the last decades.

SUMMARY

This review discloses the clinical parameters for correct CS recommendation. Moreover, the major microbial changes in the infant gut microbiome acquisition as a consequence of delivery mode and medical practices surrounding it, as well as, the early and long-lasting effects for both mother and babies are discussed. In addition, some strategies for the gut microbiota restoration are analysed. The aim of this review is to show the need for the development of strategies for minimizing or limiting the impact of caesarean on the microbiome development, favouring future health.

Maternal diet during pregnancy is related with the infant stool microbiome in a delivery mode-dependent manner

BACKGROUND

The gut microbiome has an important role in infant health and immune development and may be affected by early-life exposures. Maternal diet may influence the infant gut microbiome through vertical transfer of maternal microbes to infants during vaginal delivery and breastfeeding. We aimed to examine the association of maternal diet during pregnancy with the infant gut microbiome 6 weeks post-delivery in mother-infant dyads enrolled in the New Hampshire Birth Cohort Study. Infant stool samples were collected from 145 infants, and maternal prenatal diet was assessed using a food frequency questionnaire. We used targeted sequencing of the 16S rRNA V4-V5 hypervariable region to characterize infant gut microbiota. To account for differences in baseline and trajectories of infant gut microbial profiles, we stratified analyses by delivery mode.

RESULTS

We identified three infant gut microbiome clusters, characterized by increased abundance of Bifidobacterium, Streptococcus and Clostridium, and Bacteroides, respectively, overall and in the vaginally delivered infant stratum. In the analyses stratified to infants born vaginally and adjusted for other potential confounders, maternal fruit intake was associated with infant gut microbial community structure (PERMANOVA, p < 0.05). In multinomial logistic regression analyses, increased fruit intake was associated with an increased odds of belonging to the high Streptococcus/Clostridium group among infants born vaginally (OR (95% CI) = 2.73 (1.36, 5.46)). In infants delivered by Cesarean section, we identified three clusters that differed slightly from vaginally delivered infants, which were characterized by a high abundance of Bifidobacterium, high Clostridium and low Streptococcus and Ruminococcus genera, and high abundance of the family Enterobacteriaceae. Maternal dairy intake was associated with an increased odds of infants belonging to the high Clostridium cluster in infants born by Cesarean section (OR (95% CI) = 2.36 (1.05, 5.30)). Linear models suggested additional associations between maternal diet and infant intestinal microbes in both delivery mode strata.

CONCLUSIONS

Our data indicate that maternal diet influences the infant gut microbiome and that these effects differ by delivery mode.

Heart rate variability in healthy term newborns is related to delivery mode: a prospective observational study

Background

Early postnatal period is characterized by dramatic adaptation changes of cardiovascular and respiratory systems in newborns. There is still insufficient data regarding maturation of autonomic regulatory mechanisms in neonates early after delivery. Aim of this study was to analyze cardiac autonomic regulation in newborns within the first few postnatal days in relation to different modes of delivery using time and spectral heart rate variability analysis.

Methods

Eutrophic healthy term newborns (n = 46) were divided into three groups according to the delivery mode: vaginal delivery (VD group; n = 16), vaginal delivery with epidural analgesia (EDA group; n = 16), and caesarean section under general anesthesia (CS group; n = 14). Heart rate variability (HRV), blood pressure (BP), and blood oxygen saturation (SpO₂) were measured within the first two hours after birth and on the third to fourth postnatal day. HRV parameters were evaluated in the time domain (RR intervals, mean square of successive differences – MSSD) and frequency domain (total spectral power – TP, absolute and relative low and high frequency powers).

Results

The HRV spectral analysis showed significantly higher relative power of the high-frequency band (HF%) in the VD group compared to the CS group early after delivery (p = 0.002). HRV parameters and BP significantly increased on the third to fourth postnatal day in all groups (p < 0.05). No significant differences in basic characteristics, BP and SpO₂ were identified between groups during both measurements.

Conclusions

HRV analysis revealed higher cardiovagal modulation in spontaneously born newborns without analgesia compared to neonates born by caesarean section. It could represent a potential pathomechanism that leads to discrete abnormal neurocardiac regulation associated with higher risk for worsened postnatal adaptation of cardiovascular system in surgically delivered neonates.

Placenta response of inflammation and oxidative stress in low-risk term childbirth: the implication of delivery mode

Background

Caesarean delivery rate is increasing gradually in China and there is no doubt that delivery mode is closely associated with the maternal health and infant development.This study examined the independent effect of delivery mode on placenta inflammation response and oxidative stress response.

Methods

A total of 3474 pregnant women recruited in Ma’anshan Birth Cohort Study were the initial study population. Data on maternal socio-demographic characteristics and pre-pregnancy BMI were collected at their 1st antenatal checkups. Pregnancy-specific anxiety was assessed during the three trimesters of pregnancy. Common pregnant complications were monitored in the whole pregnancy period. Delivery modes, as well as newborn characteristics were abstracted from medical records. Delivery modes included vaginal deliveries (VD), caesarean delivery with medical indications (CDMI), caesarean delivery on maternal request (CDMR) and urgent cesarean delivery (UCD). Placentas were collected during childbirth. The mRNA expression of IL-1β, TNF-a, IL-6, IFN-γ, IL-4, IL-10, IL-8, and HO-1 were assessed in the final sample of 1978 low-risk women with singleton term-births.

Results

The overall rate of caesarean delivery (CD) was 50.5% (1650/3265) in singleton term childbirths in this study. Among women who reported definite CD reasons, 56.8%of them chose the surgery without any medical indications.It shows a non-linear relationship between cytokines related with placenta inflammatory response, oxidative stress response and different delivery modes. At high percentiles of IL-1β, IFN-γ and IL-8, women with CDMR had higher expression levels compared to women with VD. Women with CDMI had higher levels at median percentiles of IL-1β, IFN-γ and IL-8. Women with CDMR had higher expression compared with VD at high percentiles of IL-6 and HO-1, and women with CDMI had higher levels of these two cytokines at their low percentiles. It is worth noting that at high percentiles, compared with normal delivery, the expression of IL-1β, IFN-γ, IL-8 and HO-1 have significantly altered in women with CDMR.

Conclusion

A high overall CD rate was found in this study, and caesarean delivery on maternal request was the major contributor to the high prevalence. Maternal placental oxidative stress and inflammatory response were closely associated with delivery mode. The effect is much amplified at high levels of expression in women who chose CD on maternal request.Such difference needs to be noticed and may have important implications for obstetricians, midwives and other perinatal health care workers.

Young microbes for adult obesity

Gut microbes are active participants of host metabolism. At birth, child physiology is committed towards healthiness or sickness depending, in part, on maternal condition (i.e. lean vs obesity) and delivery. Finally, changes from breastfeeding to solid food also account to define gut microbiota ecology in adulthood. Nowadays, alterations of gut microbiota, named dysbiosis, are acquired risk factors for multiple diseases, especially type 2 diabetes and obesity. Despite important evidence linking nutrition to dysbiosis to energetic dysmetabolism, molecular mechanisms for causality are still missing. That the status of gut microbiota of mother and child is crucial for future diseases is witnessed by adulthood overweight and obesity observed in children with dysbiosis. In this short review we highlight the importance of early life events related to the microbiota and their impact on future adult disease risk. Therefore, our effort to treat or prevent metabolic diseases should be addressed towards early or previous life steps, when microbial decisions are going to affect our metabolic fate.

The relationship between delivery mode and children's growth from birth to 6 months

BACKGROUND

Children's growth is one of the important components of health affected by various environmental factors like delivery type. This study aimed at determining the relationship between delivery mode and children's growth from birth to 6 months.

METHODS

In this prospective cohort study, the growth indices were studied among 526 children (272 Natural Vaginal Deliveries (NVDs) and 254 Caesarean sections (C/S) who were only breastfed. The primary samples consisted of pregnant women referred to Yasuj and Gachsaran Hospitals and health centers in 2014-2015. Data were collected using questionnaires and health records.

RESULTS

The results showed that there was no significant difference (p > .05) between the groups at birth, 2, 4 and 6 months in the mean (SD) of "weight, height and head circumference".

CONCLUSIONS

Attention to growth trend in NVD group was better, this is better for mothers that were encouraged to choose physiological and vaginal delivery.

Delivery mode and intraventricular hemorrhage risk in very-low-birth-weight infants: Observational data of the German Neonatal Network

BACKGROUND

Very-low-birth-weight infants (VLBWI) are frequently delivered by cesarean section (CS). However, it is unclear at what gestational age the benefits of spontaneous delivery outweigh the perinatal risks, i.e. intraventricular hemorrhage (IVH) or death.

OBJECTIVES

To assess the short-term outcome of VLBWI on IVH according to mode of delivery in a population-based cohort of the German Neonatal Network (GNN).

STUDY DESIGN

A total cohort of 2203 singleton VLBWI with a birth weight <1500g and gestational age between 22 0/7 and 36 6/7 weeks born and discharged between 1st of January 2009 and 31st of December 2015 was available for analysis. VLBWI were stratified into three categories according to mode of delivery: (1) planned cesarean section (n=1381), (2) vaginal delivery (n=632) and (3) emergency cesarean section (n=190). Outcome was assessed in univariate and logistic regression analyses.

RESULTS

Prevalence of IVH was significantly higher in the vaginal delivery (VD) (26.6%) and emergency CS group (31.1%) as compared to planned CS (17.2%), respectively. In a logistic regression analysis including known risk factors for IVH, vaginal delivery (OR 1.725 [1.325-2.202], p≤0.001) and emergency cesarean section (OR 1.916 [1.338-2.746], p≤0.001) were independently associated with IVH risk. In the subgroup of infants >30 weeks of gestation prevalence for IVH was not significantly different in VD and planned CS (5.3% vs. 4.4%).

CONCLUSIONS

Our observational data demonstrate that elective cesarean section is associated with a reduced risk of IVH in preterm infants <30 weeks gestational age when presenting with preterm labor.

Effect of delivery mode on neonatal outcome among preterm infants: an observational study

Background

The optimal mode of delivery as a predictor for outcomes in preterm infants is under debate. The purpose of this study was to evaluate the effect of the delivery mode on neonatal outcome among preterm infants in different birthweight categories.

Methods

A retrospective analysis of singleton preterm deliveries from 23 + 0 to 33 + 6 gestational weeks was performed. Infants were categorized based on birthweight as large for gestational age (LGA), appropriate for gestational age (AGA) and small for gestational age (SGA). The Apgar score at 5 min served as the main outcome parameter. A sensitivity analysis was performed to adjust for maternal age, parity and fetal malformations as potential confounders.

Results

Out of 1320 singleton preterm infants, 970 (73.5%) were delivered by cesarean section and 350 (26.5%) were delivered vaginally. The AGA infants between 23 + 0 and 27 + 6 weeks showed better outcomes after cesarean section (p < 0.01 from 23 + 0–24 + 6; p = 0.03 from 25 + 0–27 + 6), whereas AGA infants between 31 + 0 and 33 + 6 gestational weeks showed better outcomes after vaginal delivery (p = 0.02). Cesarean section was beneficial in extremely and very preterm SGA infants (p = 0.01 from 25 + 0–27 + 6; p = 0.02 from 28 + 0–30 + 6). The sensitivity analysis showed no confounding effect of other variables.

Conclusion

There is a benefit from cesarean section in AGA preterm infants until 28 weeks of gestation and in SGA preterm infants until 31 weeks of gestation. Vaginal delivery should be chosen for moderately preterm AGA infants.