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As interest in enteral feeding formulas and techniques grows, the hardware (tubes, bags, pumps) is becoming increasingly sophisticated. Newer materials have eliminated earlier problems with feeding tubes, and different lengths and lumen sizes have made access to the gastrointestinal tract more efficient. Patients can be fed via nasoenteric access or directly via gastrostomy or jejunostomy. Enteral nutrition can be administered safely if a protocol for feeding patients and monitoring them regularly is followed. If done carefully, transitional feedings can also be carried out effectively.
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OBJECTIVE: To describe postpartum maternal morbidity associated with mode of delivery in term, singleton pregnancies. METHODS: The Magee Obstetric Medical and Infant database was examined for the years 1995 to 2000. Patients were grouped into 6 types of delivery mode: spontaneous vaginal delivery, operative vaginal delivery, primary cesarean delivery without trial of labor, primary cesarean delivery with trial of labor, repeat cesarean delivery without trial of labor, and repeat cesarean delivery with trial of labor. Multivariable logistic regression provided odds ratios and 95% confidence intervals (CI) for morbidity by delivery mode adjusted for demographic characteristics and comorbidities. Spontaneous vaginal delivery was used as the referent group (odds ratio = 1). RESULTS: Of 32,834 subjects, 27,178 had vaginal delivery (operative = 4,908; spontaneous = 22,270) and 5,656 had cesarean delivery. Third- or fourth-degree lacerations occurred in 1,733 (7.8%) women who had spontaneous vaginal delivery compared with 1,098 (22.3%) who had operative vaginal delivery. Overall, 523 women (1.6%) had endometritis. Compared with spontaneous vaginal delivery, primary cesarean delivery with trial of labor conferred a 21.2-fold increased risk of endometritis (95% CI 15.4, 29.1). Even without trial of labor, women after primary cesarean delivery were 10.3 times more likely to develop endometritis (95% CI 5.9, 17.9) than after spontaneous vaginal delivery. The risk of transfusion was highest in women delivered by primary cesarean after labor, 4.2 times higher (95% CI 1.8, 10.1) than spontaneous vaginal delivery. The risk of pneumonia was 9.3 times higher (95% CI 3.4, 25.6) after repeat cesarean delivery with labor. Deep venous thromboses occurred in 15 (0.1%) after spontaneous vaginal delivery, 2 (0.04%) after operative vaginal delivery, and 12 (0.2%) after cesarean delivery. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery is associated with increased risks of endometritis, the need for transfusion, and pneumonia; however, these rates are lower than reported previously.
OBJECTIVE: The purpose of this study was to evaluate the effect of increasing birth weight on the success rates for a trial of labor in women with one previous cesarean delivery. STUDY DESIGN: To evaluate the effect of increasing birth weight for women who undergo a trial of labor, the medical records of women who had attempted a vaginal birth after cesarean delivery (VBAC) from 1995 through 1999 in 16 community and university hospitals were reviewed retrospectively by trained abstractors. Information was collected about demographics, medical history, obstetric history, neonatal birth weight, complications, treatment, and outcome of the index pregnancy. The analysis was limited to women with singleton gestations with a history of 1 previous cesarean delivery. Because women with previous vaginal deliveries have higher vaginal birth after cesarean delivery success rates, the women were divided into four risk groups on the basis of their birth history. Groups were defined as women with no previous vaginal deliveries (group 1), women with a history of a previous vaginal birth after cesarean delivery (group 2), women with a history of a vaginal delivery before their cesarean delivery (group 3), and a group of women with a vaginal delivery both before and after the previous cesarean delivery (group 4). RESULTS: There were 9960 women with a singleton gestation and a history of one previous cesarean delivery. The overall vaginal birth after cesarean delivery success rate for the cohort was 74%. The overall vaginal birth after cesarean delivery success rates for groups 1, 2, 3, and 4 were 65%, 94%, 83%, and 93%, respectively. An analysis of neonatal birth weights of <4000 g, 4000 to 4249 g, 4250 to 4500 g, and >4500 g in group 1 showed a reduction in vaginal birth after cesarean delivery success rates from 68%, 52%, 45%, and 38%, respectively. In the remaining groups, there was no success rate below 63% for any of the birth weight strata. For group 1, vaginal birth after cesarean delivery success rates were decreased when the indication for the previous cesarean delivery was cephalopelvic disproportion or failure to progress or when the treatment was either an induction or augmentation of labor. The uterine rupture rate was higher in women for group 1 with birth weights of > or =4000 g (relative risk, 2.3; P <.001). CONCLUSION: Women with macrosomic fetuses and a history of a previous vaginal delivery should be informed of the favorable vaginal birth after cesarean delivery success rates. Given the risks of vaginal birth after cesarean delivery, those women with no history of a vaginal delivery should be counseled that the success rates may be <50% when the neonatal birth weight exceeds 4000 g and that the success rates may be even lower if the indication for the previous cesarean delivery was cephalopelvic disproportion or failure to progress or if the treatment requires either induction or augmentation of labor. The uterine rupture rate was 3.6% in women for group 1 with a birth weight > or =4000 g.
OBJECTIVE: To examine the cumulative costs of hospital care in the first and subsequent pregnancies associated with different methods in the initial delivery of nulliparous women. METHODS: An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared cumulative delivery costs in the first and subsequent pregnancies. Women were identified by initial method of delivery for nulliparous women with singleton cephalic presentation at term undergoing spontaneous or induced labor for planned vaginal delivery, and for nulliparous women undergoing cesarean delivery without labor. Costs that were assessed included nursing hours in antepartum, labor and delivery, postpartum and neonatal intensive care units, physician costs, labor induction agents, consumables, and costs for postpartum hysterectomy, tubal ligation, and dilatation and curettage. RESULTS: A total of 27,613 pregnancies satisfied inclusion and exclusion criteria. When cumulative costs by type of labor at first delivery were considered, induction of labor (7,220 dollars) was more costly than spontaneous onset of labor (6,919 dollars, P = .006). The cumulative costs of assisted vaginal delivery at first delivery (7,288 dollars) and cesarean delivery in labor at first delivery (9,524 dollars) were similar in magnitude and were higher than spontaneous vaginal delivery at first delivery (P < .001). Cesarean delivery in labor in the first delivery was the most costly type of delivery (9,524 dollars), and the differences in cost increased with increasing number of deliveries (P < .05). CONCLUSION: Cesarean delivery in labor in the first delivery is associated with increased cumulative costs compared with other methods of delivery, regardless of the number or type of subsequent deliveries.
OBJECTIVE: Our objective was to determine whether case mix model adjustment would help to explain differences in cesarean delivery rates between community and university hospitals. We also wished to define a patient population in which the cesarean delivery rate would be more reflective of individual practice patterns than of obstetric or medical risk. STUDY DESIGN: Established risk factors for cesarean delivery were identified by retrospective chart review at two community hospitals (designated A and B) and a university hospital. Each delivery was assigned exclusively to 1 of 6 risk categories: (1) multiple gestation, (2) fetal malpresentation, (3) delivery at <36 weeks' gestation, (4) not suitable for trial of labor, and (5) term delivery (> or =36 weeks' gestation) with medical complications, and (6) term delivery (> or =36 weeks' gestation) without medical complications. Parity and history of cesarean delivery further subdivided these categories into a total of 18 unique subgroups. Case mix was defined as the distribution of patients into each subgroup. Patients assigned to the categories of multiple gestation, fetal malpresentation, delivery at <36 weeks' gestation, and not eligible for trial of labor were considered to compose the group at high risk for cesarean delivery. The remaining patients composed the group at low risk for cesarean delivery. Observed cesarean delivery rates were calculated for each cell of the case mix grid within individual hospitals. Total, primary, and repeat cesarean delivery rates were determined for each hospital. The cesarean delivery rates for the low-risk populations were calculated. Data were evaluated both by chi(2) test and by direct standardization analysis with the university hospital case mix used as the standard population. RESULTS: A total of 5705 delivery reports were reviewed (university hospital, n = 4538; hospital A, n = 531; hospital B, n = 636). The cesarean delivery rates were significantly different between hospitals (university hospital, 16. 9%; hospital A, 13.6%; hospital B, 12.0%; P =.002). The distributions of patients in the high-risk group were also significantly different between hospitals (university hospital, 16. 8%; hospital A, 5.8%; hospital B, 8.8%; P = .001). The percentage of medically complicated cases in the low risk for cesarean group was significantly higher at the university hospital (university hospital, 16.9%; hospital A, 8.8%; hospital B, 9.8%; P =.001). However, no statistical differences were detected between hospitals in either the observed cesarean delivery rates or the standardized rates for the low-risk groups. CONCLUSION: The case mix model provides a more accurate method of comparing cesarean delivery rates between community and university hospitals. The low-risk group of patients discriminated in this model represents a population in which the cesarean delivery rate may be more reflective of individual practice patterns than of maternal or fetal risks.
OBJECTIVE: This study provides revised population-based measurements for the occurrence rates of cancer associated with obstetric delivery and examines perinatal and cancer-related outcomes within the group of women with 4,846,505 obstetric deliveries in California, inclusive of the years 1991 through 1999. STUDY DESIGN: This observational study used a population-based retrospective review of cases identified as a result of computer linkage of maternal/neonatal hospital discharge and birth/death records with case files in the California Cancer Registry (CCR). The effect of timing of cancer diagnosis on clinical outcomes was studied by dividing the cases into three groups as follows: "prenatal" for cancer diagnosis within 9 months before delivery, "at delivery" for cancer diagnosis during delivery hospitalization, and "post partum" for cancer diagnosis within 12 months after delivery. Computerized records for 4,846,505 obstetric patients and 4,906,920 newborn infants comprising the linked vital statistics birth/patient discharge database (VS/PDD) were used to identity-match cases within the CCR case files. Cases of malignant disease were categorized into 22 anatomic or histologic subgroups. Perinatal clinical outcomes including preterm delivery, prolonged neonatal hospital stay, stillbirth, neonatal death, frequency of first trimester prenatal care, and cesarean delivery were analyzed by use of International Classification of Diseases, 9th Revision, Clinical Modification codes from the VS/PDD. Clinical cancer outcomes including cancer stage and vital status on follow-up were drawn from CCR records. Statistical comparisons for trends were performed with the Cochran-Armitage test, outcomes comparisons with the Fisher exact test, and survival comparisons were performed with the Cox proportional hazard model. RESULTS: Among 4,846,505 obstetric deliveries, 4,539 cases of invasive malignancy were identified for an observed occurrence rate of 0.94 per 1000 births. Sixty-four percent of the cases occurred post partum; cancers of the breast, thyroid, cervix, along with malignant melanoma, and Hodgkin's disease accounted for 64% of the cases. The timing of cancer diagnosis affected clinical outcomes: for all cancer cases as a group, the most favorable perinatal and cancer outcomes occurred in women whose cancer diagnosis was made 6 to 9 months before delivery (6% of cases). The most unfavorable perinatal and cancer outcomes were associated with cancer diagnosis made 0 to 3 months before delivery (14% of cases). For women whose cancer was diagnosed post partum, perinatal outcomes were minimally affected by the presumed existence of occult cancer at the time of obstetric delivery. CONCLUSION: The use of computer-linkage to the CCR files enhanced identification of cases of maternal malignancy associated with obstetric delivery. Cancer diagnosis was associated with approximately 1 in 1000 deliveries. Most cases were diagnosed after delivery and were comprised predominantly of cancers of the breast, thyroid, cervix, malignant melanoma, and Hodgkin's disease. A small group of women (approximately 1 per 5000 deliveries) are seen within a few months before delivery or at delivery with malignant disease, many of whom have rapidly progressing disease and may require high-risk perinatal and oncology services.
OBJECTIVE: To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery. DATA SOURCES: We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria. METHODS OF STUDY SELECTION: We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery. TABULATION, INTEGRATION, AND RESULTS: We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency. CONCLUSION: The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.
BACKGROUND: Neonatologists are criticized for overtreating extremely premature infants who die despite invasive and costly care. Withholding resuscitation at delivery has been recommended as a way to minimize overtreatment. It is not known how decisions to forgo initiating aggressive care are made, or whether this strategy effectively decreases overtreatment. OBJECTIVE: To identify whether physicians' or parents' preferences primarily determine the amount of treatment provided at delivery, to examine factors associated with the provision of resuscitation, and to assess whether resuscitation at delivery significantly postpones death in nonsurvivors. METHODS: We evaluated delivery room resuscitation decisions and mortality for all infants born at 23 to 26 weeks gestation at the University of North Carolina Hospitals from November 1994 to October 1995. On the day of delivery, the attending neonatologist completed a questionnaire regarding discussion with the parents before delivery, the prognosis for survival estimated before delivery, the degree of certainty about the prognosis, parents' preference for the amount of treatment at delivery, and the degree of influence exerted by parents and physicians on the amount of delivery room treatment provided. Medical records were reviewed for demographics and hospital course. RESULTS: Thirty-one of 41 infants were resuscitated (intubation and/or cardiopulmonary resuscitation) at delivery. Resuscitation correlated with increasing gestational age, higher birth weight, estimated prognosis for survival greater than or equal to 10%, and uncertainty about prognostic accuracy. Physicians saw themselves as primarily responsible for delivery room resuscitation decisions when the parents' wishes about initiating care were unknown, and as equal partners with parents when they agreed on the level of care. When disagreement existed, doctors always thought parents preferred more aggressive resuscitation, and identified parents as responsible for the increased amount of treatment at delivery. Twenty-four infants died before hospital discharge. The median age at death was 2 days when physicians primarily determined the amount of treatment at delivery, 1 day when parents primarily determined the amount of treatment, and < 1 day when responsibility was shared equally. The median age at death was < 1 day when physicians and parents agreed about the preferred amount of treatment at delivery and 1.5 days when they disagreed. The median age at death was < 1 day when parents' preferences were known before delivery and 4 days when parents' preferences were unknown. CONCLUSIONS: Physicians resuscitated extremely premature infants at delivery when they were very uncertain about an infant's prognosis or when the parents' desires about treatment were unknown. When parents' preferences were known, parents usually determined the amount of treatment provided at delivery. Resuscitation at delivery usually postponed death by only a few days, decreasing prognostic uncertainty and honoring what physicians perceived were parents' wishes for care, without substantially contributing to overtreatment.
BACKGROUND: Previous preterm delivery and maternal smoking are associated with increased risks of preterm delivery. It is not known whether gestational age at the time of a preterm delivery is correlated with gestational age in successive preterm deliveries and whether changes in smoking habits influence the subsequent risk of preterm delivery. METHODS: We studied the associations among smoking habits, previous very preterm or moderately preterm delivery (before 32 weeks and at 32 to 36 weeks, respectively), and the risk of a subsequent very preterm or moderately preterm delivery in a population-based cohort of 243,858 women in Sweden between 1983 and 1993. The results were adjusted for covariates known to be associated with preterm delivery. RESULTS: The odds ratios for very or moderately preterm delivery in a subsequent pregnancy among women with a previous very preterm delivery, as compared with women who had a previous term delivery, were 12.4 (95 percent confidence interval, 9.1 to 17.0) and 7.1 (95 percent confidence interval, 6.0 to 8.4), respectively. Among women with a previous moderately preterm delivery, the corresponding odds ratios were 2.3 (95 percent confidence interval, 1.9 to 3.0) and 5.9 (95 percent confidence interval, 5.5 to 6.3), respectively. The odds ratios for a very preterm second delivery among the women who smoked 1 to 9 cigarettes per day and those who smoked 10 or more cigarettes per day, as compared with nonsmokers, were 1.4 (95 percent confidence interval, 1.1 to 1.7) and 1.6 (95 percent confidence interval, 1.3 to 2.0), respectively. The corresponding odds ratios for moderate preterm delivery were 1.3 (95% confidence interval, 1.2 to 1.4) and 1.5 (95 percent confidence interval, 1.4 to 1.6). The women who quit smoking between pregnancies were not at increased risk for very or moderately preterm delivery, whereas the women who started to smoke in the second pregnancy had the same risk as those who continued to smoke. CONCLUSIONS: The risk of a very preterm delivery in successive pregnancies is increased primarily among women with a previous very preterm delivery. Changes in smoking habits influence the risk of preterm delivery as well.
OBJECTIVE: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery. STUDY DESIGN: The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had > or =1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors. RESULTS: Of 3783 women with 1 prior scar, 1021 (27.0%) also had > or =1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant. CONCLUSION: Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.