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PubMedDate not supplied

Rates of and factors associated with recurrence of preterm delivery.

CONTEXT: Information about risk of recurrent preterm delivery is useful to clinicians, researchers, and policy makers for counseling, generating etiologic leads, and measuring the related public health burden. OBJECTIVES: To identify the rate of recurrence of preterm delivery in second pregnancies, factors associated with recurrence, and the percentage of preterm deliveries in women with a history of preterm delivery. DESIGN AND SETTING: Population-based cohort study of data from birth and fetal death certificates from the state of Georgia between 1980 and 1995. SUBJECTS: A total of 122 722 white and 56174 black women with first and second singleton deliveries at 20 to 44 weeks' gestation. MAIN OUTCOME MEASURE: Length of gestation (categorized as 20-31, 32-36, or > or =37 weeks) at second delivery compared with length of gestation at first delivery, by age and race. RESULTS: Most women whose first delivery was preterm subsequently had term deliveries. Of 1023 white women whose first delivery occurred at 20 to 31 weeks, 8.2% (95% confidence interval [CI], 6.6%-10.1%) delivered their second birth at 20 to 31 weeks and 20.1% (95% CI, 17.7%-22.8%) at 32 to 36 weeks. Of 1084 comparable black women, 13.4% (95 % CI, 11.4%-15.6%) delivered at 20 to 31 weeks and 23.4% (95% CI, 20.9%-26.1%) delivered at 32 to 36 weeks. Among women whose first delivery occurred at 32 to 36 weeks, all corresponding rates were lower than those whose first birth was at 20 to 31 weeks; the rates of second birth at 20 to 31 weeks were substantially lower (for white women, 1.9% [95% CI, 1.7%-2.2%]; for black women, 3.8% [95% CI, 3.4%-4.2%]). Compared with women aged 20 to 49 years at their second delivery, women younger than 18 years had twice the risk of recurrence of delivery at 20 to 31 weeks. Of all second deliveries at 20 to 31 weeks, 29.4% for white women and 37.8% for black women were preceded by a preterm delivery. CONCLUSIONS: Our data suggest that recurrence of preterm delivery contributes a notable portion of all preterm deliveries, especially at the shortest gestations.

Adolescent↗
PubMed2004

[Mode of delivery on urinary incontinence].

OBJECTIVE: To evaluate the association of route of delivery in primiparae with prevalence of urinary incontinence. METHODS: One thousand primiparae who had birth deliveries from March 2001 to March 2002 in our hospital were telephone interviewed through a questionnaire about symptoms of urinary incontinence before and during pregnancy, and after delivery. Totally 548 women answered the questionnaire based on International Consultant on Incontinence completely. The incidence and degrees of different kinds of urinary incontinence in connection with different ways of delivery and the associated factors were evaluated using SPSS software. RESULTS: (1) Among 548 cases, urinary incontinence was diagnosed in 167 (30.5%). (2) According to logistic regression, cesarean section and neonatal weight were associated factors with incontinence. If the odds ratio (OR) were taken as 1.0 for the incontinence women who had a normal vaginal delivery, then OR for cesarean section would be 0.326. OR for neonatal weight would be 1.633. Neonatal weight was the only high risk factor related with incontinence in women with vaginal delivery (P = 0.013, OR = 2.081). (3) The incidence of urinary incontinence in spontaneous vaginal delivery, forceps and cesarean section was 38.6% (105/272), 43.8% (21/48) and 18.0% (41/228) respectively. There was no difference in the incidence of urinary incontinence between spontaneous vaginal delivery and forceps (P > 0.05). A lower incidence of urinary incontinence was found in cesarean section than in other ways of delivery (P < 0.05). (4) The incidences of stress urinary incontinence, mixed incontinence and urgent incontinence were 33.8%, 4.4% and 0.4% respectively in spontaneous vaginal delivery; 35.4%, 8.3% and 0% in forceps delivery; and 14.5%, 3.1% and 0.4% in cesarean section. The incidence of stress urinary incontinence was higher in vaginal delivery women than in cesarean section women (P < 0.05). Severe cases of stress urinary incontinence were more in spontaneous vaginal delivery than in cesarean section (P < 0.05). (5) 1.2% (2/167) women reported urinary incontinence before pregnancy; 7.8% (13/167) during pregnancy; 44% (75/167) within one year after delivery; 40.7% (68/167) persisting for more than one year after delivery; and 2.4% (4/167) in recent time. CONCLUSIONS: (1) Cesarean section may decrease the risk of urinary incontinence compared with vaginal delivery. (2) Most patients have the symptoms of incontinence within one year after delivery, with some lasting for more than one year. (3) Heavy fetal weight increases the risk of stress incontinence.

Adult↗
PubMedDate not supplied

Assisted delivery in the teenage population: the effect of inter-hospital variation, deprivation, and age.

UNLABELLED: The objective was to determine the relationship between the risk of assisted delivery in women aged under 20 years and place of treatment, deprivation and age. DESIGN: Cross sectional survey utilising routinely collected hospitals admissions data. POPULATION: Teenagers (women aged under 20 years) whose delivery resulted in a hospital admission in the period April 1st 1994 to March 31st 1997 in the Trent Health Region of England. METHODS: The cases were identified using Office of Population Census and Surveys procedural codes, and International Classification of Diseases diagnostic codes associated with delivery. Variables collected included type of delivery, age at delivery and place of treatment. The data were analysed using the chi-square test for categorical data and the independent samples t-test for continuous data. Logistic regression analysis was used to calculate adjusted odds ratios for the variables of type of assisted delivery and place of treatment. MAIN OUTCOME MEASURES: Factors associated with increased risk of assisted delivery. RESULTS: There was variation in rates of instrumental delivery between hospitals, with two having a significantly increased risk of assisted delivery, suggesting that place of treatment may be a factor in the risk of teenage patients experiencing an assisted delivery. There was also a large amount of variation in terms of the risk of experiencing a forceps or vacuum extraction compared to caesarean section. Age (under 16 years and 16-19 years of age) had no effect on the risk of a teenage patient experiencing an assisted delivery (X2 = 2.59 df = 1 P = 0.11 OR 1.27 (95% CI 0.94 to 1.72)). Similarly, teenagers who experience an assisted delivery were not more likely to come from a more deprived area than teenagers who did not have an assisted delivery (P = 0.189). CONCLUSIONS: The risk of assisted delivery varied between hospitals, suggesting that this factor is important in terms of a young women's risk of an assisted delivery. The young women in this study who had experienced an assisted delivery were not significantly different to young women who had a normal delivery. They were not more likely to be aged under 16 years of age, and were not more likely to be from a more deprived area.

Adolescent↗
PubMed2002

Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries.

OBJECTIVE: To analyze the instrumental deliveries carried out at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia during the year 2000 and compare the outcome of ventouse and forceps deliveries. METHODS: A retrospective case note review of all instrumental deliveries, carried out at the Armed Forces Hospital, Riyadh, during the year 2000. RESULTS: Three hundred and four vaginal deliveries, of whom 258 were ventouse and 46 were forceps deliveries, were assisted. Seventy percent of forceps deliveries were carried out in primigravida as compared to 49% of ventouse deliveries. Fetal distress was the indication in 81.4% of ventouse deliveries as compared to 76% of forceps deliveries. Prolonged 2nd stage of labor was an indication in 11% of forceps and 2.3% of ventouse deliveries. Consultants and Senior Registrars were more likely to use forceps while registrars use ventouse as their preferred instrument for delivery. Attempted ventouse delivery was successful in 91.4% as compared to 95.7% in forceps. Extension of an episiotomy was more likely to occur with ventouse than forceps deliveries while 3rd degree perineal tear occurred more with forceps deliveries. Babies who had attempted ventouse deliveries have lower apgar score at one minute than attempted forceps. No babies required admission to neonatal intensive care unit. There was only one stillbirth in the ventouse delivery group due to intrapartum asphyxia and true knot in the umbilical cord. CONCLUSION: Forceps is more likely to be used in the primigravida and prolonged 2nd stage of labor and less likely to fail. Ventouse is more likely to be used by registrars. Extension of an episiotomy and low apgar score at one minute is more likely to occur with ventouse deliveries.

Adult↗
PubMed2006

Rates of cesarean delivery among Puerto Rican women--Puerto Rico and the U.S. mainland, 1992-2002.

Cesarean delivery has been associated with greater risks for maternal morbidity, longer hospital stays, and rehospitalization after childbirth than vaginal delivery. On the U.S. mainland (i.e., 50 states and District of Columbia), rates of total cesarean delivery and primary cesarean delivery (i.e., for women without a previous cesarean) per 100 live births decreased from 1992 to 1996 before increasing from 1996 to 2002. During 2002, among all U.S. mainland births (approximately 4 million), 26% were by cesarean delivery; among all mainland births to women without a previous cesarean delivery, 18% were by primary cesarean. Cesarean delivery rates for Puerto Rican women who delivered on the U.S. mainland were similar to those for all women on the mainland. By contrast, among all 52,747 births in Puerto Rico in 2002, 45% were by cesarean delivery; among births in Puerto Rico to women without a previous cesarean delivery, 33% were primary cesarean deliveries. In addition, during 1996-2002, annual rates of vaginal births after cesarean delivery (VBAC) (i.e., per 100 live births to women who had a previous cesarean delivery) were lower in Puerto Rico than on the U.S. mainland. To compare trends in cesarean delivery during 1992-2002 among Puerto Rican women who delivered in Puerto Rico and on the U.S. mainland, CDC and the Puerto Rico Department of Health analyzed birth certificate data from the National Vital Statistics System (NVSS). This report summarizes the results of that analysis, which determined that, during 1992-2002, total and primary cesarean rates were consistently higher in Puerto Rico than among Puerto Rican women on the mainland. From 1996 to 2002, total and primary cesarean rates increased for Puerto Rican women in both places of delivery, but rates increased more sharply for women in Puerto Rico than on the mainland. The results suggest that measures to reduce the number of cesarean deliveries in Puerto Rico should focus on lowering the rate of primary cesarean deliveries, especially among women at low risk for a cesarean delivery.

Adult↗
PubMed2005

Outcomes of term vaginal breech delivery.

In December 2001, the American College of Obstetricians and Gynecologists revised their recommendations for breech delivery. These recommendations acknowledge that although a planned vaginal delivery may no longer be appropriate, there are instances in which vaginal breech delivery is inevitable. Moreover, there continues to be patients who for any number of reasons will choose vaginal over cesarean delivery when faced with a fetus in the breech presentation. We sought to review maternal and fetal outcomes in such circumstances when vaginal breech delivery occurs, and compare these outcomes to elective cesarean deliveries for breech presentation. We performed a retrospective review of all singleton breech deliveries at our county hospital from January 2002 through June 2003. We reviewed maternal age, ethnicity, gestational age, gravity, parity, birthweight, mode of delivery, Apgar scores, umbilical arterial blood gases, and maternal and infant complications of both cesarean deliveries and vaginal breech deliveries. Univariate and logistic regression statistical analyses were performed with NCSS software. We had a total of 150 term breech deliveries with gestational ages between 37 and 42 weeks. Of these, 41 were vaginal breech and 109 were cesarean deliveries. Greater than 95% of patients are of Hispanic origin. There were no statistically significant differences in maternal age, ethnicity, gravity, or gestational age. Mean birthweight was significantly lower and parity was significantly higher in the vaginal delivery group. There was also a higher proportion of patients who underwent labor induction/augmentation in the vaginal group. We found no differences in the outcomes of 5-minute Apgar scores, umbilical arterial blood gas values, neonatal intensive care unit admissions, deaths or maternal/fetal complications reported between the two groups. Mean umbilical arterial blood gas values were greater than 7.18 in both groups. Vaginal breech delivery cannot always be avoided. Moreover, at our county hospital several patients continue to choose vaginal breech delivery. Our data would suggest that vaginal breech delivery remains a viable option in selected patients.

Apgar Score↗
PubMed2002

Delivery of macrosomic babies: management and outcomes of 330 cases.

This study reviews the deliveries of macrosomic babies and their outcomes. A total of 330 macrosomic (birth weight > or =4 kg) cases were studied retrospectively from July 1999 to December 1999 in the Maternity Hospital of Kuala Lumpur. The variables studied included induction of labour, mode of delivery and the incidence of maternal and perinatal complications. Three hundred and thirty macrosomic infants were delivered during the period of study. Vaginal delivery was achived in 56% of the study cases. The percentage of vaginal delivery was higher among those who had induction of labour (63%) compared to the group without induction of labour (50%). Vaginal delivery was planned in 267 mothers and of these 69% achieved vaginal delivery. Twelve per cent of the macrosomic infants were delivered by elective caesarean section. Shoulder dystocia occurred in 4.9% of vaginal deliveries. Eighty-eight neonates were admitted to the special care nursery unit and 57% of these infants were delivered by elective caesarean section. Perineal trauma occurred in 26% of vaginal deliveries. Post-partum haemorrhage occurred in 32% of caesarean deliveries compared to 4% in vaginal deliveries. Two cases of stillbirths were documented but no maternal death occurred during the period of study. Vaginal delivery is the most frequent mode of delivery for a fetus weighing in excess of 4 kg and vaginal delivery should be attempted in the absence of contraindications, because vaginal delivery has less maternal morbidity compared to caesarean delivery. However, shoulder dystocia remains a significant complication of vaginal delivery for macrosomic fetuses.

Adult↗
PubMed1982

In-hospital maternal mortality in the United States: time trends and relation to method of delivery.

To study time trends in maternal mortality in the United States and to attempt to compare the risk of cesarean with vaginal delivery, information from the Professional Activities Study of the Commission on Professional and Hospital Activities for 3 years-1970, 1974, and 1978-was reviewed. For all deliveries, mortality per 100,000 deliveries declined from 25.7 in 1970 to 14.3 in 1978. For vaginal deliveries, mortality per 100,000 deliveries declined from 20.4 to 9.8. For cesarean deliveries, mortality per 100,000 births decreased more than for vaginal deliveries, from 113.8 to 40.9. Mortality for deliveries with no mention of complications, lacerations, or uterine rupture declined significantly from 1970 to 1978. Mortality for deliveries complicated by dystocia or malpresentation declined significantly from 1970 to 1974, but failed to decline thereafter. Mortality for deliveries complicated by a previous cesarean or by antepartum hemorrhage did not decline significantly from 1970 to 1978. For all complications with a sufficient number of vaginal and cesarean deliveries, except deliveries complicated by malpresentation or antepartum hemorrhage, mortality was at least twice as high in cesarean as in vaginal deliveries. Based on a comparison of mortality after a previous cesarean with mortality for all vaginal deliveries with no complication, the authors conclude that cesarean delivery is probably neither less than 2 nor more than 4 times more hazardous than vaginal delivery.

Adolescent↗
PubMed2002

The risk of lower urinary tract symptoms five years after the first delivery.

AIM OF THE STUDY: To estimate the prevalence and 5-year incidence of lower urinary tract symptoms (LUTS) after the first delivery and to evaluate the impact of pregnancy per se and delivery per se on long-lasting symptoms. MATERIALS AND METHODS: A longitudinal cohort study of 305 primiparae questioned a few days, 3 months, and 5 years after their delivery. The questionnaire used was tested and validated, and the questions were formulated according to the definitions of the International Continence Society (ICS). Maternal, obstetric, and neonatal data concerning every delivery and objective data concerning surgeries during the observation period were obtained from the records. From the sample of 278 women (91%) who responded 5 years after their first delivery, three subpopulations were defined: 1) women without initial LUTS before or during the first pregnancy or during the puerperal period, 2) women with onset of LUTS during the first pregnancy, and 3) women with onset of LUTS during the first puerperium. The risk of LUTS 5 years after the first delivery was examined using bivariate analyses. The obstetric variables in the bivariate tests with a significant association with long-lasting urinary incontinence were entered into a multivariate logistic regression. RESULTS: The prevalence of stress and urge incontinence 5 years after first delivery was 30% and 15%, respectively, whereas the 5-year incidence was 19% and 11%, respectively. The prevalence of urgency, diurnal frequency, and nocturia 5 years after the first delivery was 18%, 24%, and 2%, respectively, whereas the 5-year incidence was 15%, 20%, and 0.5%, respectively. The prevalence of all LUTS except nocturia increased significantly during the 5 years of observation. The risk of long-lasting stress and urge incontinence was related to the onset and duration of the symptom after the first pregnancy and delivery in a dose-response-like manner. Vacuum extraction at the first delivery was used significantly more often in the group of women with onset of stress incontinence during the first puerperium, whereas an episiotomy at the first delivery was performed significantly more often in the group of women with onset of stress incontinence in the 5 years of observation. The prevalence of urgency and diurnal frequency 5 years after the first delivery was not increased in women with symptom onset during the first pregnancy or puerperium compared with those without such symptoms. The frequency of nocturia 5 years after the first delivery was too low for statistical analysis. CONCLUSION: The first pregnancy and delivery may result in stress and urge incontinence 5 years later. Women with stress and urge incontinence 3 months after the first delivery have a very high risk of long-lasting symptoms. An episiotomy or a vacuum extraction at the first delivery seems to increase the risk. Subsequent childbearing or surgery seems without significant contribution. Long-lasting urgency, diurnal frequency, or nocturia cannot be predicted from onset during the first pregnancy or puerperium.

Adolescent↗
PubMed2006

Prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy: analysis of U.S. perinatal mortality data, 1995-1997.

OBJECTIVE: An association between cesarean delivery and an increased risk of stillbirth in a subsequent pregnancy has been reported in the United Kingdom. This study investigated the association between prior cesarean delivery and unexplained intrauterine fetal demise at term in the United States. STUDY DESIGN: We conducted a cross-sectional study using the U.S. perinatal mortality data (1995 to 1997). Women aged 15 to 44 years with singleton term (37 weeks or longer) pregnancies were included in the analysis. Study groups were defined as pregnant women with a prior cesarean delivery (prior cesarean delivery) and women with no prior cesarean delivery (no cesarean delivery). Adjustments were made for maternal age, race, underlying medical conditions, and fetal congenital abnormalities. The Cochran-Mantel-Haenszel method was used for relative risk estimation at the 95% confidence interval calculation. RESULTS: A total of 11,061,599 deliveries of singleton pregnancies were recorded in the United States from January 1, 1995, to December 31, 1997. The cesarean delivery rate was 19.6%. The crude term intrauterine fetal demise rate was 1.5 per 1000 births for no cesarean delivery and 1.3 per 1000 births for prior cesarean delivery. After correction for parity greater than 1, congenital anomalies, and underlying maternal medical conditions, term intrauterine fetal demise rates were 0.6 and 0.4 per 1000 births for no cesarean delivery and prior cesarean delivery, respectively. Restriction of the analysis to women with only 1 prior delivery resulted in term intrauterine fetal demise rates of 0.8 and 0.7 per 1000 births for no cesarean delivery and prior cesarean delivery, respectively (relative risk 0.90; 95% confidence interval 0.76-1.06). CONCLUSION: A prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy.

Adult↗
PubMed1998

Perinatal HIV-1 transmission: interaction between zidovudine prophylaxis and mode of delivery in the French Perinatal Cohort.

CONTEXT: It is unclear whether elective cesarean delivery may have a protective effect against the transmission of human immunodeficiency virus 1 (HIV-1). OBJECTIVE: To investigate whether mode of delivery has an impact on perinatal HIV-1 transmission in the presence of zidovudine prophylaxis. DESIGN: A prospective cohort study. SETTING: The 85 perinatal centers in the French Perinatal Cohort, from 1985 to 1996. PATIENTS: A total of 2834 singleton children born to mothers with HIV-1 infection. MAIN OUTCOME MEASURE: Human immunodeficiency virus 1 infection of the infant. RESULTS: No zidovudine was used in 1917 pregnancies and zidovudine prophylaxis was used in 902 pregnancies. Cesarean deliveries were performed in 10.9% on an emergent basis and in 8.3% electively, prior to labor or membrane rupture. In 1917 mothers who did not receive zidovudine, of 1877 with information on mode of delivery, 17.2% transmitted HIV-1 to their child. Risk factors statistically significantly associated with transmission were maternal p24 antigenemia, cervicovaginal infections during pregnancy, amniotic fluid color, and rupture of membranes 4 hours or more before delivery. Mode of delivery was not related to transmission. In 902 mothers receiving zidovudine, transmission was 6.4% in 872 with information on mode of delivery, and elective cesarean delivery (n = 133) was associated with a lower transmission rate than emergent cesarean or vaginal delivery (0.8%, 11.4%, and 6.6%, respectively; P=.002). In a multivariate analysis of all mother-child pairs, including obstetrical risk factors, maternal p24 antigenemia, and zidovudine prophylaxis, interaction between mode of delivery and zidovudine prophylaxis was significant (P=.007). In the multivariate analysis of pregnancies with zidovudine prophylaxis, factors related to transmission rate were maternal p24 antigenemia, amniotic fluid color, and mode of delivery. Adjusted odds ratios (95% confidence intervals) were 1.6 (0.7-3.6) for emergent cesarean delivery and 0.2 (0.0-0.9) for elective cesarean delivery (P = .04) in comparison with vaginal delivery. CONCLUSIONS: We observed an interaction between zidovudine prophylaxis and elective cesarean delivery in decreasing transmission of HIV-1 from mother to child. This observation may have clinical implications for prevention.

Anti-HIV Agents↗
PubMed1999

Observations on labor epidural analgesia and operative delivery rates.

OBJECTIVE: Our purpose was to compare operative vaginal and abdominal delivery rates in a large population before and after on-demand labor epidural analgesia became available. STUDY DESIGN: We retrospectively compared patients who gave birth during a 20-month period immediately before the introduction of an on-demand labor epidural analgesia service with those who gave birth during a 20-month period after the epidural usage rate had reached a plateau at approximately 60%. Operative vaginal and cesarean delivery rates were stratified according to parity and history of prior cesarean delivery. RESULTS: A total of 4859 women gave birth during the study period when on-demand epidural analgesia was available, and 4778 women gave birth in the study period before the availability of on-demand epidural analgesia. Comparisons between the women with and those without on-demand availability of epidural analgesia demonstrated no statistically significant differences in the rate of spontaneous vaginal delivery (69.5% vs 68.3%), the overall cesarean delivery rate (19.0% vs 19.4%), the primary cesarean delivery rate (13.2% vs 13.4%), or the operative vaginal delivery rate (11.1% vs 11.9%) between the 2 periods. There were no statistically significant differences in mean gestational age at the time of delivery between the 2 groups, whereas there were statistically significant increases in the proportion of nulliparous women and in mean birth weight during the on-demand epidural period. Analysis after substratification of the study groups according to parity also revealed no statistically significant differences in the primary cesarean delivery rate or the proportion of women undergoing vaginal delivery. The sample size was adequate to exclude a 2% increase in the primary cesarean delivery rate between the 2 periods with 80% power. Subgroup analysis of the population of women who gave birth while epidural analgesia was available on request demonstrated that nulliparous parturient women who requested epidural analgesia were almost twice as likely to require operative vaginal or cesarean delivery as women who did not request epidural analgesia, a finding suggesting that women who request labor epidural analgesia have an inherent propensity toward operative delivery. CONCLUSION: The introduction of an on-demand labor epidural analgesia service does not increase the rate of cesarean delivery or operative vaginal delivery.

Adult↗
PubMed2003

Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery.

OBJECTIVE: To estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates. METHODS: We studied all deliveries in Nova Scotia, Canada, between 1988 and 2000 after excluding women who had a previous cesarean delivery (n = 127,564). Logistic regression was used to study the effect of changes in maternal characteristics and obstetric practice on primary cesarean delivery rates. The effect of changes in midpelvic forceps delivery was examined through ecologic Poisson regression. RESULTS: Primary cesarean delivery rates increased from 13.4% of deliveries in 1988 to 17.5% in 2000. This was due to increases in cesarean deliveries for dystocia (14% increase), breech (24% increase), suspected fetal distress (21% increase), hypertension (47% increase), and miscellaneous indications (73% increase). Adjustment for maternal characteristics reduced the temporal increase in primary cesarean delivery rates between 1988-1991 and 1998-2000 from 21% (95% confidence interval [CI] 16%, 25%) to 2% (95% CI -2%, 7%). Additional adjustment for obstetric practice factors further reduced period effects. Midpelvic forceps delivery was significantly and negatively associated with primary cesarean delivery (P =.001). CONCLUSION: Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery.

Adult↗
PubMed1999

Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study.

BACKGROUND: Because obstetric injury to the anal sphincters may be occult, and because the mechanism of injury differs between first and subsequent deliveries, we prospectively assessed the effects of first and second vaginal deliveries on anal physiology and continence. METHODS: We undertook a prospective observational study of 59 previously nulliparous women through two successive vaginal deliveries by means of a bowel-function questionnaire, and an anorectal-physiology assessment, both antepartum and 6-12 weeks post partum. FINDINGS: 13 (22%) women reported altered faecal continence after their first vaginal delivery: eight had persistent symptoms during their second pregnancy, of whom seven deteriorated after the second delivery; five regained continence before their second pregnancy, but two became incontinent again after the second delivery. Five women developed incontinence for the first time after their second vaginal delivery, of whom three had occult primiparous sphincter injury. 20 (34%) women, seven of whom had no symptoms, had anal-sphincter injury as a result of their first delivery, but only two new injuries occurred after the second vaginal delivery (p=0.013). Although pudendal neuropathy was no more common after the second than after the first vaginal delivery (15 vs 19%, p=0.8), pudendal-nerve latency was longer after the second delivery (p=0.02). INTERPRETATION: Primiparous women with persistent symptoms of altered faecal continence experience deterioration after a second vaginal delivery. Women with transient faecal incontinence or occult anal-sphincter injury after their first vaginal delivery are at high risk of faecal incontinence after a second vaginal delivery. The risk of mechanical anal sphincter injury is greatest after the first delivery.

Adult↗
PubMed2005

Cesarean delivery in the United Kingdom: time trends in the general practice research database.

OBJECTIVE: To estimate recent temporal trends in delivery by cesarean during the past decade and the proportion of vaginal deliveries after prior caesarean in the United Kingdom. METHODS: We conducted a cohort study using information from the General Practice Research Database. We identified all women with 1 or more deliveries between January 1990 and December 1999 and determined the method(s) of delivery. We estimated the proportion of women with vaginal delivery after cesarean in a subcohort who had at least 3 years of follow-up. RESULTS: We identified 39,938 cesareans among 271,663 deliveries (14.7%), with an increase from 12.5% in 1990 to 18.3% in 1999. The proportion of cesarean deliveries increased with age and increased over time in all age groups except women aged younger than 20 years. Among 26,480 women with a caesarean delivery between 1990 and 1996, 7,649 (28.9%) had a subsequent delivery. The proportion of vaginal delivery after prior cesarean decreased from 45% in 1991 to 37% in 1999. CONCLUSION: Cesarean deliveries increased as a proportion of all deliveries in the United Kingdom during the past decade, and the proportion of vaginal delivery after prior cesarean decreased. Still, the proportion of cesarean deliveries is lower and the proportion of vaginal deliveries after prior cesarean is higher in the United Kingdom than in the United States. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2004

Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study.

OBJECTIVE: To evaluate the reproductive outcome and the mode of delivery in subsequent pregnancies after instrumental vaginal delivery in theatre or caesarean section at full dilatation. DESIGN: Prospective cohort study. SETTING: Two urban hospitals with a combined total of 10 000 deliveries a year. PARTICIPANTS: A cohort of 393 women with term, singleton, cephalic pregnancies who needed operative delivery in theatre during the second stage of labour from February 1999 to February 2000. Postal questionnaires were received from 283 women (72%) at three years after the initial delivery. MAIN OUTCOME MEASURE: Mode of delivery in the subsequent pregnancy. RESULTS: 140 women (49%) achieved a further pregnancy at three years. 91/283 (32%) women wished to avoid a further pregnancy. Women were more likely to aim for vaginal delivery (87% (47/54) v 33% (18/54); adjusted odds ratio 15.55 (95% confidence interval 5.25 to 46.04)) and more likely to have a vaginal delivery (78% (42/54) v 31% (17/54); 9.50 (3.48 to 25.97)) if they had had a previous instrumental vaginal delivery rather than a caesarean section. There was a high rate of vaginal delivery after caesarean section among women who attempted vaginal delivery 17/18 (94%). In both groups, fear of childbirth was a frequently reported reason for avoiding a further pregnancy (51% after instrumental vaginal delivery, 42% after caesarean section; 1.75 (0.58 to 5.25)). CONCLUSION: Instrumental vaginal delivery offers advantages over caesarean section for future delivery outcomes. The psychological impact of operative delivery requires urgent attention.

Cesarean Section↗
PubMed1999

[Comparison of blood loss during cesarean section and during vaginal delivery with episiotomy].

OBJECTIVE: The aim of our study was to compare blood loss during vaginal delivery with episiotomy and during cesarean section, to determine risk factors, and to determine whether clinical assessment of blood loss at delivery is well-evaluated. PATIENTS AND METHODS: We retrospectively matched 97 vaginal deliveries with episiotomy with 97 cesarean deliveries which has occurred between 1 November 1991 and 30 April 1993. Matching criteria were age, parity, term and birth weight. Blood loss at delivery was defined by a drop in hematocrit greater than 10% between the pre-delivery anesthesia work-up and the laboratory results 3 days post-partum. RESULTS: We found that hemoglobin and hematocrit fell more after vaginal deliveries than after cesarean section (p < 0.05 and p < 0.01). The fall in hemoglobin level and hematocrit were significantly greater after forceps delivery with episiotomy than after spontaneous vaginal delivery (p < 0.01 and p < 0.01). Among the vaginal deliveries, 11 showed laboratory criteria corresponding to blood loss at delivery despite clinical diagnosis in only 2 of them. Unwarranted clinical diagnosis of blood loss at delivery was however made 11 times after vaginal delivery and 19 times after cesarean (20%). CONCLUSION: Our findings demonstrate that blood loss during vaginal delivery with episiotomy is greater than during cesarean section and affirms the determining role of forceps use in association with episiotomy in this blood loss. Clinical assessment of blood loss at delivery lacks precision.

Adult↗
PubMed2006

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.

OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.

Adult↗