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PubMed2006

Trends in maternal request cesarean delivery from 1991 to 2004.

OBJECTIVE: To review definitions and terminology for and to estimate percentages of maternal request cesarean deliveries in the United States between 1991 and 2004. METHODS: National Hospital Discharge Survey data 1991-2004 (N=458,767) were used to identify maternal request cesarean deliveries. After excluding women with a history of cesarean delivery, women who labored, and women with indicated risks against labor, 2,394 potential maternal request cesarean deliveries remained. Indicated risks were identified with a recognized protocol. RESULTS: Maternal request cesarean deliveries have two properties: 1) cesarean delivery before labor and 2) cesarean delivery in the absence of medical conditions presenting a risk for labor. Risk is either absolutely absent or it is relatively absent. In 1991-2004, 0.20% of women who delivered live infants and 1.34% of women who delivered by primary cesarean delivery did so without any medical conditions listed on their hospital discharge record. Estimates for maternal request cesarean deliveries without certain indicated risks were 0.75% for women who delivered live infants and 5.03% for women who delivered by primary cesarean delivery. Maternal request cesarean deliveries without any indicated risk peaked in 1999 for women who delivered live infants. Maternal request cesarean deliveries without certain indicated risks crested in 2004. CONCLUSION: Our estimates were affected by three factors: 1) lack of agreement on a definition of maternal request cesarean deliveries, 2) changes in medical coding practices, and 3) changes in physician response to medical conditions. To validly and reliably estimate maternal request cesarean deliveries requires an empirically tractable, standard definition. LEVEL OF EVIDENCE: III.

Adolescent↗
PubMed2004

Factors associated with preterm delivery in women with type 1 diabetes: a cohort study.

OBJECTIVE: The reported rate of preterm delivery in women with type 1 diabetes ranges from 22 to 45%, but the reasons are unclear. The purpose of this study was to identify factors associated with preterm delivery in these women. RESEARCH DESIGN AND METHODS: We studied the influence of maternal and diabetes-related factors on the occurrence of preterm delivery in 168 single pregnancies occurring in 127 women with type 1 diabetes. Women with spontaneous or indicated preterm delivery were compared with those who delivered after 37 weeks of gestation using polytomous logistic regression. RESULTS: The overall rate of preterm delivery was 24%, fivefold higher than the French prematurity rate in single pregnancy. Preterm delivery was spontaneous in 9% and indicated in 15%. HbA1c > or =7% at delivery was associated with spontaneous preterm delivery (odds ratio [OR] 5.3 [95% CI 1.1-26.8]). Nulliparity (12.0 [2.3-64.1]), progression of nephropathy (7.7 [1.3-46.9]), preeclampsia (12.0 [3.1-47.1]), and HbA1c > or =7% (7.5 [1.5-37.9]) at delivery were all associated with indicated preterm delivery. Preterm delivery was associated with significant neonatal morbidity as the risks for neonatal hypoglycemia and respiratory distress syndrome were increased by three- to sixfold compared with the reference group. CONCLUSIONS: The rate of preterm delivery remains high in women with type 1 diabetes. Different factors were associated with spontaneous and indicated preterm delivery, respectively. Because poor glycemic control was a risk factor for both outcomes, part of preterm delivery might be preventable.

Adult↗
PubMed2003

Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery.

OBJECTIVE: To compare, in a prospective, randomised controlled trial, differences in anal sphincter function following forceps or vacuum assisted vaginal delivery in an institution practising standardised management of labour. DESIGN: Prospective, randomised controlled trial. SETTING: Tertiary-referral maternity teaching hospital. POPULATION: One hundred and thirty women. METHODS: Primiparous women were recruited antenatally and if an instrumental delivery was indicated, were randomised to either a vacuum or low-cavity, non-rotational forceps assisted delivery. Follow up consisted of a symptom questionnaire, anal manometry and endoanal ultrasound at three months postpartum. MAIN OUTCOME MEASURES: Faecal continence scores, anal manometry, endoanal ultrasound. RESULTS: Sixty-one women delivered with forceps assistance (40 for failure to progress in the second stage) and 69 with vacuum assistance (33 for failure to progress); 16/69 vacuum deliveries proceeded to a forceps assisted delivery (23%). There were no statistical differences in the antecedent antenatal factors between the two groups. A third degree perineal tear followed 10 (16%) forceps and 5 (7%) vacuum deliveries. Based on intention-to-treat analysis, 36 (59%) women complained of altered faecal continence after forceps delivery compared with 23 (33%) following vacuum delivery three months postpartum (RR 2.88, 95% CI 1.41-5.88). Endoanal ultrasound was reported as abnormal following 34 (56%) forceps deliveries and 34 (49%) vacuum deliveries (RR 1.3, 95% CI 0.65-258). After exclusion of 'failed vacuum', median anal canal resting pressure was significantly lower following forceps delivery compared with vacuum delivery alone (P = 0.004). There were no significant differences in degree of ultrasound abnormality between the two groups. CONCLUSIONS: Symptoms of altered faecal continence are significantly more common following forceps assisted vaginal delivery. Based on continence outcome, when circumstances allow, vacuum should be the instrument of first choice in assisted delivery.

Adult↗
PubMed2005

[Rupture of the uterus as a complication in delivery after cesarean section].

INTRODUCTION: In present clinical practice there is an increasing number of patients with delivery with previous cesarean section which is frequent reason for the repeated one. The most serious complication in labour with previous cesarean section is the rupture of the uterus which is as frequent in labour by natural way as in repeated cesarean section. This is a reason that many of obstetricians do not support attitude "Once cesarean section, always a cesarean". THE AIM: In a retrospective study in five years period beginning January 1, 1998, we analyzed total number of deliveries, total number of cesarean section, way of deliveries with previous cesarean section and frequency of complications. METHODS: We used Chi2 test and Contigency table. RESULTS: In analyzed period from January 1, 1998 through December 31, 2002, we completed 24,194 deliveries at Ob/Gyn Clinic in Tuzla. Out of this number we performed 4073 cesarean sections or 16.83%. Out of 24,194 deliveries we had 1328 (5.49% of all deliveries) deliveries after performed cesarean in previous pregnancy. Out of 1328 deliveries following cesarean we completed by natural way 323 pregnancies or 24.33% and by repeated cesarean 1005 or 75.67%. Previous one cesarean had 1191, previous two cesarean 126, and previous three cesarean had 11 women. Out of 1328 deliveries by previous cesarean we had 12 (0.90%) or 1:111 cases, complicated by intrapartum rupture of the uterus. It was significantly more than in group of deliveries by unscarred uterus (1:16,849 deliveries). Three of 12 ruptures of the uterus were in group by natural way of delivery and 9 cases in group by repeated cesarean, no statistical difference (p>0.05). Out of 12 cases complicated by rupture of the uterus, ten cases were incomplete and two complete rupture of the uterus. CONCLUSION: Repeated cesarean section by his complications imposes the careful choice of indication for primary cesarean section and by this way make maternal mortality and morbidity significantly lower, specially in the light of the fact that only 24.33% deliveries following cesarean is completed vaginally. The most frequent complication was rupture of the uterus in relation 1:111 deliveries.

Cesarean Section, Repeat↗
PubMed1994

Cesarean delivery in the United States, 1990.

Information now available on method of delivery from birth certificates confirms past findings on the groups at highest risk of cesarean delivery and greatly expands our knowledge of the demographic and health characteristics associated with cesarean delivery. Mothers who live in the South, who are in the oldest years of childbearing, having their first birth, married, or who have high educational attainment are all at increased risk of a cesarean delivery. Very short gestations, low or high birthweights, multiple delivery, the presence of certain complications of pregnancy, labor and/or delivery, abnormal conditions of the newborn, and the use of some obstetric procedures are also associated with elevated cesarean rates. Several recent studies (28,29) have concluded that advanced maternal age in and of itself may be an independent risk factor for cesarean delivery, due to physician and patient concern over pregnancy outcome for older women. Many of the characteristics examined in this study are highly related to maternal age (for example, marital status and educational attainment). Therefore, for these variables, mother's age is also taken into account to determine if age itself is the underlying reason for differences in rates of cesarean delivery. The importance of the role of maternal age in the risk of cesarean delivery is clearly demonstrated throughout this report: Older mothers are more likely to deliver by cesarean regardless of race, Hispanic origin, parity, marital status, or educational attainment. The overall rate of cesarean delivery is only slightly lower for black than for white mothers (22.1 percent compared with 23.0 percent), despite the generally lower educational attainment of black mothers and the higher percentage who are unmarried or in their teen years, all factors that tend to substantially lower the risk of cesarean delivery. However, there are many offsetting factors that tend to raise the cesarean rate for black mothers. A relatively high proportion of black births occur in the South, which has the highest cesarean rate of all regions; the incidence of low and very low birthweight is far higher for black births; and premature delivery is twice as frequent for black babies. Also, although rates of cesarean delivery for most medical risk factors, complications of labor and or delivery, and abnormal conditions of the infant are about the same for both races, the incidence of a number of these conditions is substantially higher for black mothers and babies, and that has the effect of increasing the overall cesarean rate for black mothers.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed2000

Theoretical and experimental comparison of constant inspired concentration and pulsed delivery in NO therapy.

OBJECTIVE: Inhaled NO therapy of artificially ventilated patients has been established as being based on constant inspired concentration of NO. In this study a new volumetrically controlled pulsed NO delivery mode is compared with the established concentration-based concept. DESIGN: To evaluate the relationship between NO delivery parameters, alveolar NO fraction, and patient uptake, a mathematical lung model was created where NO delivery can be simulated in varying ventilator settings, delivery modes, and lung properties. This model and the efficacy of pulsed delivery in inducing pulmonary capillary vasodilatation were examined experimentally. SETTING: Animal laboratory, Department of Medical Sciences, Clinical Physiology. SUBJECTS: The experimental study was performed with nine pigs of mixed breed weighing 25-35 kg. INTERVENTIONS: The pigs were anaesthetised and artificially ventilated. Pulmonary vasoconstriction was induced by hypoxia. NO was delivered periodically in the various delivery modes. MEASUREMENTS AND RESULTS: In simulation, in all delivery modes the NO uptake was found to be dependent on the ventilator settings and the volume of the dead space. Measured from pulmonary artery pressure, the pulsed delivery was as effective in reducing the induced pulmonary vasoconstriction as the constant inspired concentration delivery. The amount of NO that could reduce the vasoconstriction back to baseline was 105 nmol x min(-1). By delivering in the early part of the inspiration, ambient contamination by the exhaust gas is avoided. The expired NO values obtained in the simulation and the experiments were equal. Based on the simulation, the alveolar NO fraction and the NO uptake depend on the ventilator settings and the dead space in both volumetric- and concentration-based delivery. CONCLUSIONS: With pulsed delivery, a therapeutic effect comparable to constant inspired concentration delivery is achieved, NO gas is used more effectively, and environmental exhausts are reduced. The theoretical model shows that the NO delivery does not predict alveolar NO fraction and the NO uptake. However, it still remains an open question if the online measurement of these parameters would provide useful information, having added value in predicting and controlling the efficacy of the NO treatment.

Animals↗
PubMed1998

Severe preeclampsia remote from term: labor induction or elective cesarean delivery?

OBJECTIVES: The study's objectives were as follows: (1) to determine the rate of vaginal delivery after labor induction in severe preeclampsia remote from term and (2) to determine potential predictors of success. STUDY DESIGN: Retrospective chart review was conducted on live-born singleton pregnancies complicated by severe preeclampsia and delivered at 24 to 34 weeks' gestation from January 1, 1992, to December 31, 1996. Exclusion criteria included eclampsia, presence of labor or spontaneous rupture of membranes on admission, and complication of pregnancy by an ultrasonographically detected fetal congenital anomaly. Patients were divided into 3 groups: elective cesarean delivery without labor, cesarean delivery after labor induction, and vaginal delivery after labor induction. Statistical analyses included multiple logistic regression, the Student t test, the chi2 test, and the Mann-Whitney test. P </=.05 was considered significant. RESULTS: A total of 306 charts were reviewed. Among these, 161 patients (52.6%) underwent elective cesarean delivery without labor; the 2 most common indications were unfavorable cervix (33.5%) and malpresentation (22.4%). The remaining 145 patients (47.4%) underwent labor induction with a 48. 3% rate of vaginal delivery after induction, ranging from 31.6% at </=28 weeks' gestation to 62.5% at >32 weeks' gestation. The most common indication for cesarean delivery after induction, in 50.7% of the cases, was nonreassuring fetal heart rate. The median Bishop score was significantly higher (3 vs 2, P =.004) and the total hospital stay was significantly shorter in the vaginal delivery after induction group than in the cesarean delivery after induction group. However, there were no significant differences between the 2 groups in use of cervical ripening agents, gestational age at delivery, birth weight, 5-minute Apgar score, or postpartum endometritis. After exclusion of cesarean deliveries performed for malpresentation, there was no statistically significant difference in classic incision rates between the elective cesarean delivery without labor and cesarean delivery after induction groups (13.6% vs 6.8%; P =.137). According to logistic regression analysis, only the Bishop score was significantly associated with a successful induction (odds ratio 1.38, 95% confidence interval 1.11-1.71). Gestational age reached marginal significance (odds ratio 1.30, 95% confidence interval 0.89-1.89). CONCLUSIONS: (1) Labor induction should be considered a reasonable option for patients with severe preeclampsia at </=34 weeks' gestation because 48% of patients given the chance were successfully delivered vaginally. (2) The Bishop score on admission is the best predictor of success, although the chance of successful labor induction increases with advancing gestational age.

Adult↗
PubMed2002

The likelihood of placenta previa with greater number of cesarean deliveries and higher parity.

OBJECTIVE: To examine the relationship between prior cesarean delivery and placenta previa. METHODS: A hospital-based, case-control study was conducted in which 316 multiparous women with placenta previa were identified. Controls consisted of 2051 multiparous women with spontaneous vaginal deliveries. Information on prior cesarean delivery was examined in three forms: as a dichotomous variable, as an ordinal variable, and as a set of three indicator variables for one, two, and three or more cesarean deliveries. Multivariable logistic regression modeling was used to obtain an adjusted estimate of this association. RESULTS: Women with a prior cesarean delivery were more likely to have a placenta previa than those without (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.21, 2.08). The likelihood of placenta previa increased as both parity and number of cesarean deliveries increased. Thus, the adjusted OR for a primiparous woman with one cesarean delivery was 1.28 (95% CI 0.82, 1.99). For a woman who has four or more deliveries with only a single cesarean delivery, the OR increases to 1.72 (95% CI 1.12, 2.64). This trend continues with greater parity and a greater number of cesarean deliveries such that the likelihood of placenta previa for a woman with parity greater than four and greater than four cesarean deliveries was OR 8.76 (95% CI 1.58, 48.53). CONCLUSION: This study supports the association between prior cesarean delivery and placenta previa and demonstrates that the joint effect of parity and prior cesarean delivery is greater than that of either variable alone.

Adult↗
PubMed1998

Factors affecting home delivery in the Kathmandu Valley, Nepal.

This nested case-control study compares the characteristics of mothers having home or institutional deliveries in Kathmandu, Nepal, and explores the reasons given by mothers for a home delivery. The delivery patterns of mothers were identified in a cross-sectional survey of two communities: an urban area of central Kathmandu (Kalimati) and a peri-urban area (Kirtipur and Panga) five kilometres from the city centre. 357 pregnant women were identified from a survey of 6130 households: 183 from 3663 households in Kirtipur and Panga, 174 from 2467 households in Kalimati. Methods involved a structured baseline household questionnaire and detailed follow-up of identified pregnant women with structured and semi-structured interviews in hospital and the community. The main outcome measures were social and economic household details of pregnant women; pregnancy and obstetric details; place of delivery; delivery attendant; and reasons given for home delivery. The delivery place of 334/357 (94%) of the pregnant women identified at the survey was determined. 272 (81%) had an institutional delivery and 62 (19%) delivered at home. In univariate analysis comparing home and institutional deliverers, maternal education, parity, and poverty indicators (income, size of house, ownership of house) were associated with place of delivery. After multivariate analysis, low maternal educational level (no education, OR 5.04 [95% CI 1.61-15.8], class 1-10, OR 3.36 [1.04-10.8] compared to those with higher education) and multiparity (OR 3.1 [1.63-5.74] compared to primiparity) were significant risk factors for a home delivery. Of home deliverers, only 24% used a traditional birth attendant, and over half were unplanned due to precipitate labour or lack of transport. We conclude that poor education and multiparity rather than poverty per se increase the risk of a home delivery in Kathmandu. Training TBAs in this setting would probably not be cost-effective. Community-based midwife-run delivery units could reduce the incidence of unplanned home deliveries.

Adult↗
PubMed2001

Mode of delivery and postpartum morbidity among HIV-infected women: the women and infants transmission study.

Cesarean delivery before onset of labor and rupture of membranes (i.e., scheduled cesarean delivery) is associated with a lower risk of vertical transmission of HIV. The following a priori hypotheses were tested: among HIV-infected women, scheduled cesarean delivery is associated with a higher risk of postpartum morbidity, longer hospitalization, and a higher risk of rehospitalization than spontaneous vaginal delivery. Postpartum morbidity occurred following 178 of 1,186 (15%) of deliveries during 1990 to 1998 in The Women and Infants Transmission Study. The most commonly reported postpartum morbidity events were: fever without infection, hemorrhage or severe anemia, endometritis, urinary tract infection, and cesarean wound complications. Several time trends were observed: the median duration of ruptured membranes decreased (p < .001), intrapartum antibiotic use increased (p < .001), the median antepartum plasma HIV RNA concentration decreased (p < .001), and the incidence of any postpartum morbidity decreased (p = .02). With spontaneous vaginal delivery as the reference category, both scheduled (odds ratio [OR] = 4.69; 95% confidence interval [95% CI], 2.03-10.84), and nonscheduled (OR, 2.50; 95% CI, 1.24-5.04) cesarean deliveries were associated with fever without infection; with urinary tract infection (OR, 3.79; 95% CI 1.04-13.85; OR, 3.86; 95% CI, 1.55-9.60, respectively), and with any postpartum morbidity (OR, 3.19; 95% CI 1.69-6.00; OR, 4.10; 95% CI, 2.71-6.19, respectively). Nonscheduled cesarean deliveries were more likely to be complicated by endometritis (OR, 6.98; 95% CI, 3.53-13.78). Adjusted ORs relating mode of delivery and each of the outcomes (fever without infection, urinary tract infection, endometritis, and any postpartum morbidity) were similar to unadjusted ORs. Results of this analysis indicate scheduled cesarean delivery is associated with an increased risk of any postpartum morbidity and, specifically, postpartum fever without infection. The potential for postpartum morbidity with scheduled cesarean delivery should be considered in light of possible adverse events associated with other interventions to decrease the risk of vertical transmission of HIV. Counseling of HIV-infected pregnant women regarding scheduled cesarean delivery as a possible intervention to decrease maternal-infant transmission of HIV should include discussion of these results, as well as new data as they become available, regarding the incidence and severity of postpartum morbidity events among HIV-infected women according to mode of delivery.

Cesarean Section↗
PubMed2004

Twin deliveries in the United States over three decades: an age-period-cohort analysis.

OBJECTIVE: Time is an important variable in understanding the recent increase in twin deliveries in the United States. Therefore, this study was designed to estimate the influences of maternal age, period (year) of delivery, and maternal-birth-year cohort on trends in rates of twin deliveries. METHODS: United States natality data were used to assess trends in twin pregnancies resulting in live births. This age-period-cohort analysis included 7, 5-year maternal-age groups (15-19 through 45-49 years), 6 twin delivery periods (1975, 1980, 1985, 1990, 1995, and 2000), and 12, 5-year maternal birth cohorts (1926-1930 through 1981-1985). The independent effects of maternal age, twin delivery period, and maternal birth cohort on twin delivery rates for blacks and whites were modeled using Poisson regression techniques. RESULTS: Our study assessed 95,042 blacks and 401,989 whites with twin deliveries. Twin deliveries increased by 46% for blacks and 62% for whites from 1975 to 2000, with the largest increase occurring in the year 2000. For blacks, maternal age had the strongest impact on the increasing twin delivery rates, followed by period of delivery. For whites, the greatest effect was due to period of delivery, followed by maternal birth year cohort and, lastly, maternal age. CONCLUSION: Our data confirm the importance of nature's biologic contribution of maternal aging to twin delivery rates, but suggest that recent changes in the environment surrounding pregnancy (nurture) also influence twin delivery rates. The relative contributions of biologic versus environmental influences appear to differ among blacks and whites.

Adolescent↗
PubMed2002

Effect of twin-to-twin delivery interval on umbilical cord blood gas in the second twins.

OBJECTIVE: To examine the effect of twin-to-twin delivery interval on the umbilical cord blood gas status of the second twin following vaginal delivery. DESIGN: A retrospective study. SETTING: The department of obstetrics and gynaecology in a university teaching hospital. POPULATION: Twin deliveries at or beyond 34 weeks of gestation over a period of five years, with the first twin delivered vaginally. Twins with any antepartum complications including discordant growth, intrauterine growth restriction, intrauterine death, fetal malformations and pre-eclampsia were excluded. METHODS: The correlation between the twin-to-twin delivery interval, and both the umbilical arterial and venous blood gas parameters of the second twin, including pH, partial pressure of CO2 and base excess, were studied. RESULTS: A total of 118 cases were reviewed. The mean gestation at delivery was 37.1 weeks. The median twin-to-twin delivery interval was 16.5 minutes. There were significant negative correlations between twin-to-twin delivery interval and both the umbilical cord arterial and venous pH and base excess of the second twin (P <0.05). There were also significant positive correlations between both arterial and venous partial pressure of CO2 and the delivery interval (P <0.05). Similar changes were found even if the analyses were limited to those who had normal vaginal deliveries. The umbilical arterial pH of Twin 2 was <7.00 in none of the cases delivered within 15 minutes of the birth of Twin 1, 5.9% if within 16-30 minutes, and 27% if more than 30 minutes. Among those with an inter-twin delivery interval of more than 30 minutes, 73% had cardiotocographic evidence of fetal distress which required operative delivery. CONCLUSIONS: Umbilical cord arterial and venous values of pH, partial pressure of CO2 and base excess of the second twin deteriorate with increasing twin-to-twin delivery interval. Risks of fetal distress and acidosis in the second twin are high when the twin-to-twin delivery interval is beyond 30 minutes.

Adult↗
PubMedDate not supplied

Pediatric coverage of the delivery room: an analysis of manpower utilization.

OBJECTIVES: To determine the frequency and pattern of pediatric calls to the delivery room and the actual type of medical care administered to the newborn in the delivery room. STUDY DESIGN: This was a prospective observational study of 2554 births in a university-affiliated tertiary care hospital. Existing protocols required the attendance of a pediatric resident or neonatal fellow at all deliveries other than uncomplicated vaginal term births. The pediatrician's activity in the delivery room was characterized as either "medical care" or "minimal care." Results were analyzed by diagnostic category. RESULTS: Pediatricians attended 646 of the deliveries (25%). Medical care was administered in 204 of the deliveries, representing 31% of the time they were at a delivery and 8% of all deliveries. The three major indications for pediatric delivery room attendance were cesarean sections (n = 253; 39%), presence of meconium in amniotic fluid (n = 117; 18%), and vacuum deliveries (n = 117; 18%). Medical care was required only in 1 of 56 cases of elective repeat cesarean sections, in 1 of 20 cases of a cesarean section for nonprogress of labor, and in 1 of 38 cases when thin meconium was present. In contrast, medical care was needed in 52 of 81 (64%) cases of cesarean sections for fetal distress, in 11 of 11 (100%) of the cesarean sections for multiple births, and in 67 of 89 (85%) cases of thick meconium (p < 0.05). There was a need for medical attendance after the birth in less than 1% of 1908 cases for which the pediatrician was not initially called to delivery room. CONCLUSION: Because their medical skills were needed only one of three times that pediatricians were called to the delivery room, and then mostly in specific risk situations, more selective use of pediatric manpower for delivery room coverage may lead to a more efficient use of medical resources without any apparent increase in patient morbidity.

Cost-Benefit Analysis↗
PubMed1996

An ethically justified algorithm for offering, recommending, and performing cesarean delivery and its application in managed care practice.

When cesarean delivery is substantively supported and vaginal delivery is not supported in beneficence-based clinical judgment, the physician should offer and recommend only cesarean delivery. When both cesarean and vaginal delivery are substantively supported in beneficence-based clinical judgment, the physician should offer both, discuss any controversy, and make a recommendation. When cesarean delivery is substantively supported and vaginal delivery is more substantively supported in beneficence-based clinical judgment, the physician should offer both and recommend vaginal delivery. If cesarean delivery is not supported and vaginal delivery is substantively supported in beneficence-based clinical judgment, the physician should offer only vaginal delivery. When cesarean delivery is requested and well supported solely in autonomy-based clinical judgment, the physician should repeat the recommendation for vaginal delivery and either perform cesarean delivery or make a referral. Physicians may use this algorithm in negotiating managed care contracts.

Algorithms↗
PubMed2005

Perimortem cesarean delivery: were our assumptions correct?

OBJECTIVE: The recommendation to perform a perimortem cesarean delivery within 4 minutes of maternal cardiac arrest was introduced in 1986. This recommendation was based on the assumptions that cardiopulmonary resuscitation is ineffective in the third trimester because of aortocaval compression, and that fetal and perhaps maternal outcomes would be optimized by timely delivery. Our objective was to review the outcomes of perimortem cesarean deliveries to attempt to validate those assumptions. STUDY DESIGN: Ovid MEDLINE searches using maternal mortality, cardiopulmonary resuscitation, perimortem cesarean delivery, heart attack, and cardiac arrest from 1985 until 2004. Citations from bibliographies of identified publications were perused and cross-referenced for other potential articles. Case reports were included for analysis when mothers had complete cardiopulmonary arrest, and cardiopulmonary resuscitation had been initiated before cesarean delivery. RESULTS: There were 38 cases of perimortem cesarean delivery identified; 34 infants survived (3 sets of twins, 1 set of triplets); 4 other infants survived initially, but died several days after the deliveries from complications of prematurity and anoxia. Of the 34 infants (25-42 weeks' gestation), time of delivery after maternal cardiac arrest was available for 25. Eleven infants were delivered within 5 minutes, 4 were delivered from 6 to 10 minutes, 2 were delivered from 11 to 15 minutes, and 7 were delivered more than 15 minutes. Of 20 perimortem cesarean deliveries with potentially resuscitatable causes, 13 mothers were resuscitated and discharged from the hospital in good condition. One other mother was successfully resuscitated after the delivery, but died within 24 hours from complications related to her amniotic fluid embolism. In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery. We wish to emphasize the large selection bias in this data. CONCLUSION: Published reports from 20 years support, but fall far from proving, that perimortem cesarean delivery within 4 minutes of maternal cardiac arrest improves maternal and neonatal outcomes.

Cardiopulmonary Resuscitation↗
PubMed2006

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study.

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.

Adult↗
PubMed1997

The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis.

OBJECTIVE: Our purpose was to determine the incidence of placenta previa based on the available epidemiologic evidence and to quantify the risk of placenta previa based on the presence and number of cesarean deliveries and a history of spontaneous and induced abortion. STUDY DESIGN: We reviewed studies on placenta previa published between 1950 and 1996 on the basis of a comprehensive literature search with use of MEDLINE and by identifying studies cited in the references of published reports. Studies were chosen for inclusion in the metaanalysis if the incidence of placenta previa and its cross-classification with either prior cesarean delivery or abortions (both spontaneous and induced) or both were available. We also extracted details about the study design (case-control or cohort study) and place where they were conducted (United States or other countries). Published case reports dealing with placenta previa and studies relating to abruptio placentae were excluded from this review. We also restricted the search to studies published in English. No attempts were made to locate any unpublished studies. Data from studies identified during the literature search were reviewed and abstracted by a single author. In case of discrepancies or when the information presented in a study was unclear, abstraction by a (blinded) second reviewer was sought to resolve the discrepancy. RESULTS: Data on the incidence of placenta previa and its associations with previous cesarean delivery and abortions were abstracted. Subgroup analyses were performed to identify potential sources of heterogeneity by study design and place where they were conducted. Statistical methods used for the metaanalysis included the fixed-effects logistic regression model, whereas potential sources of heterogeneity among studies were evaluated by fitting random-effects models. The tabulation of 36 studies identified a total of 3.7 million pregnant women, of whom 13,992 patients were diagnosed with placenta previa. The reported incidence of placenta previa ranged between 0.28% and 2.0%, or approximately 1 in 200 deliveries. Women with at least one prior cesarean delivery were 2.6 (95% confidence interval 2.3 to 3.0) times at greater risk for development of placenta previa in a subsequent pregnancy. The results varied by study design, with case-control studies showing a stronger relative risk (relative risk 3.8, 95% confidence interval 2.3 to 6.4) than cohort studies did (relative risk 2.4, 95% confidence interval 2.1 to 2.8). Four studies, encompassing 170,640 pregnant women, provided data on the number of previous cesarean deliveries. These studies showed a dose-response pattern for the risk of previa on the basis of the number of prior cesarean deliveries. Relative risks were 4.5 (95% confidence interval 3.6 to 5.5) for one, 7.4 (95% confidence interval 7.1 to 7.7) for two, 6.5 (95% confidence interval 3.6 to 11.6) for three, and 44.9 (95% confidence interval 13.5 to 149.5) for four or more prior cesarean deliveries. Women with a history of spontaneous or induced abortion had a relative risk of placenta previa of 1.6 (95% confidence interval 1.0 to 2.6) and 1.7 (95% confidence interval 1.0 to 2.9), respectively. Substantial heterogeneity in the results of the metaanalysis was noted among studies. CONCLUSION: There is a strong association between having a previous cesarean delivery, spontaneous or induced abortion, and the subsequent development of placenta previa. The risk increases with number of prior cesarean deliveries. Pregnant women with a history of cesarean delivery or abortion must be regarded as high risk for placenta previa and must be monitored carefully. This study provides yet another reason for reducing the rate of primary cesarean delivery and for advocating vaginal birth for women with prior cesarean delivery.

Abortion, Induced↗
PubMed2000

Reactive thrombocytosis after caesarean section and vaginal delivery: implications for maternal thromboembolism and its prevention.

OBJECTIVE: To assess the duration and severity of reactive thrombocytosis after caesarean section and vaginal delivery. DESIGN: A prospective cohort study. SETTING: A large teaching hospital. METHODS: Women admitted for delivery at the Leicester Royal Infirmary were recruited into the study. The platelet count was measured before delivery and postnatally on days 3, 8, 12, 16, 20 and 24. Women who had antepartum haemorrhage, postpartum haemorrhage and those delivered by instrumental delivery were excluded from the study. Sixty-five were recruited, and 45 completed the study, 20 of whom were delivered by a normal vaginal delivery and 25 by caesarean section. A random effects model was used to compare platelet counts within and between the two groups to assess the severity and the timing of reactive thrombocytosis. RESULTS: There were no statistically significant differences in booking and pre-delivery platelet counts between the two groups (mean values 248.4 x 10(9)/L and 245 x 10(9)/L in the normal vaginal group and 269.4 x 10(9)/L and 251.6 x 10(9)/L in the caesarean section group, respectively). Postnatally, a rise in the platelet count was noted in the normal vaginal delivery group, reaching statistically significant peak values, compared with booking and pre-delivery at days 8 and 12 of the postnatal period (mean value 365.8 x 10(9)/L; P < 0.001 and 369.4 x 10(9)/L; P < 0.001 respectively). In the caesarean section group, the platelet count was raised to a statistically significant high value, compared with booking and pre-delivery at day 8 of the postnatal period. The platelet count peaked at days 12 and 16 of the postnatal period (mean value 522.5 x 10(9)/L; P < 0.0001 and 526.5 x 10(9)/L; P < 0.0001, respectively) and remained significantly higher than booking and predelivery values for 24 days after the caesarean section. There was a greater rise in the platelet count in the caesarean section group compared with the vaginal delivery group. The platelet counts in the caesarean section group were significantly higher than these in the normal vaginal delivery group from day 12 to day 24 of the postnatal period. CONCLUSION: A significant rise in platelet count occurred eight to twelve days after normal vaginal delivery and caesarean section. The increase in platelet count continued to rise for 16 days after caesarean section, and it stayed significantly higher for more than 24 days after the delivery.

Cesarean Section↗