A Shared Decision-Making Toolkit for Mode of Birth After Cesarean

This study evaluated a shared decision-making (SDM) Toolkit (decision aid, counseling guide, and provider scripts) designed to prepare and engage racially diverse women in shared decision-making discussions about the mode of birth after cesarean. The pilot study, involving 27 pregnant women and 63 prenatal providers, assessed women's knowledge, preferences, and satisfaction with decision making, as well as provider perspectives on the Toolkit's acceptability. Most women experienced knowledge improvement, felt more in control and that providers listened to their concerns and supported them. Providers reported that the Toolkit helped women understand their options and supported their counseling. The SDM Toolkit could be used to help women and providers improve their SDM regarding mode of birth after cesarean.

Testing the assumptions of an indicator of unmet need for obstetric surgery in Ghana: A cross-sectional study of linked hospital and population-based delivery data

BACKGROUND

The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life-saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%-2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications.

METHODS

We used linked hospital and population-based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education.

RESULTS

A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI-related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post-secondary education (P < .001). However, there was no association between AMI-related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%-0.92%), below the assumed 1% minimum threshold.

DISCUSSION

Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life-saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.

Outcomes of women age 40 or more undergoing repeat cesarean or trial of labor after cesarean. J Matern Fetal Neonatal Med 2019;34:3750-3755. [PMID: 31709871 DOI: 10.1080/14767058.2019.1691989]

Aim: Despite the increasing trend in delayed childbirth and the known associated complications in advancing maternal age, limited information exists regarding outcomes in very advanced maternal age by delivery type. This study aims to evaluate maternal and neonatal outcomes in women age 40 or more undergoing cesarean delivery or trial of labor after cesarean delivery.Materials and methods: We performed a secondary analysis of the Cesarean Section Registry Maternal-Fetal Medicine Units (MFMU) Network data, which was a prospective study of women undergoing repeat cesarean delivery or trial of labor after cesarean delivery from 1 January 1999 to 31 December 2002. Women age 40 years or more at the time of delivery were compared to the control group of women less than 40 years of age.Results: There were 67,389 cases identified that met inclusion criteria. 2,436 (3.6%) were age ≥40 years old, and 65,403 (97.05%) were <40 at delivery. The >40 group had a higher rate of PRBC transfusion (aRR 1.75; 95% CI 1.20-2.56), maternal ICU admission (aRR 2.02; 1.41-2.89), bowel injury (aRR 3.65; 1.43-9.31), placenta accreta (aRR 1.92; 1.09-3.38) and classical uterine incision (aRR 1.59; 1.43-9.31) compared to the control group. Maternal death rates were similar in both groups (p = .30).Conclusion: Women aged 40 or more undergoing repeat cesarean delivery or trial of labor after cesarean delivery are more likely to have maternal complications including intraoperative transfusion, maternal ICU admission, abnormal placentation and surgical complications in comparison to women under age 40.

Target populations to reduce cesarean rates after induced labor: A national population-based cohort study

INTRODUCTION

Great variations in cesarean rates after induction of labor exist and reasons for these disparities remain unclear. They may be explained by individual characteristics or obstetric practices. Ten-group classification systems have proved their utility to monitor cesarean rates in general population. We aimed to identify groups of women that account for most cesareans after induction of labor using the Nippita reproducible 10-group classification, specifically designed for induced population.

MATERIAL AND METHODS

A prospective population-based cohort study was performed in 94 French maternity units, including 3042 women undergoing induction of labor. Women were sorted according to 10 mutually exclusive groups based on parity, weeks of gestation, number of fetuses, fetal presentation and previous cesarean delivery. Relative size, cesarean delivery rate and contribution to the overall cesarean rate were described for each group. Cesarean rates were compared according to the Bishop score at the onset of labor induction. Indications for cesarean delivery were also described in the groups that contributed most to the overall cesarean rate. The MEDIP protocol was registered in ClinicalTrial (NCT02477085).

RESULTS

The overall cesarean rate was 21.0% among this population of induced women. Nulliparous women with a term singleton cephalic fetus (groups 1, 2 and 3; at 37-38, 39-40 and ≥41 weeks of gestation, respectively) accounted for two-thirds of the overall cesarean rate because they were the largest group (relative size of 10.6, 16.6 and 18.1%, respectively) and had higher cesarean rates (27.2, 30.9 and 33.0%, respectively). When the Bishop score was <6 (n = 2270/3042), cesarean delivery rates were higher (24.1 vs 10.7% if Bishop score ≥6, P < 0.01), in particular for group 1 (29.1 vs 12.5%, P = 0.02), and group 2 (33.3 vs 19.3%, P = 0.01). In groups 1, 2 and 3, which contributed most to the overall cesarean rate, a significant part of the cesareans were performed before 6 cm of cervical dilation for dystocia only (40.0, 16.7 and 17.6%, respectively).

CONCLUSIONS

Nulliparous women with a term singleton cephalic fetus and an unfavorable cervix represent the population to target for auditing induction practices. Specific actions could be implemented among this population to weigh the benefits and risks of induction and improve the management of labor induction.

Safety of salpingectomy at time of delivery

OBJECTIVE

The most common methods of sterilization during cesarean delivery rely on excision of a mid-segment of the fallopian tube. Contemporary data suggest ovarian cancers may originate in the fimbriae of the fallopian tube; therefore, a strategy of prophylactic salpingectomy (SL) has been adopted during gynecologic surgery. The purpose of this study was to evaluate the safety of SL compared to traditional mid-segment excision at time of cesarean and after vaginal delivery through change in perioperative hemoglobin (Hgb).

STUDY DESIGN

We retrospectively evaluated patients undergoing sterilization concurrent with cesarean delivery or in the post-vaginal delivery period between 1 January 2015 and 31 December 2017 in the Mayo Clinic Health System; a community-based practice. In order to test for non-inferiority, 30 patients in each arm (tubal ligation (TL) and SL) were required to detect a pre- and post-operative Hgb difference of 0.5 mg/dL between groups with a power of 80%. Exclusion criteria included: age  <18 years, BMI >50 kg/m², endometriosis, other concurrent surgical procedures, bleeding disorders, postpartum hemorrhage due to atony, trial of labor after cesarean (TOLAC), and the presence of ovarian masses.

RESULTS

One hundred fifty-two patients met inclusion criteria. There was no evidence of inferiority in either the post-vaginal delivery or the cesarean groups with a mean difference in pre- and post-op Hgb of 0.18 mg/dL (p = .99) post-cesarean and 0.04 mg/dL post-vaginal delivery with less reduction in Hgb from SL. The mean length of the procedure was 10.0 and 9.9 min (p = .005) longer for SL procedures amongst cesarean and postpartum procedures, respectively. Subgroup analyses did not demonstrate differences in blood loss between different techniques. Clamp-cut-tie techniques took longer than all other procedures in both groups.

CONCLUSION

This study provides evidence that the practice of salpingectomy at the time of cesarean and post-vaginal delivery may be safe and should form the basis of prospective trials.

Efficacy of striae gravidarum extension and localization on predicting intraperitoneal adhesion risk

AIM

To evaluate the diagnostic value of striae gravidarum (SG) presence and localization in predicting the intraperitoneal adhesion (IPA) risk in pregnant women with a history of at least one previous cesarean delivery (CD).

METHODS

A total of 100 pregnant women with repeated CD were included in this prospective observational study. Patients were divided into three groups according to severity of SG with Davey scoring system. Intraoperative adhesion severity and extension were evaluated by using Nair classification system. Moreover, operation duration and neonatal outcomes were analyzed.

RESULTS

Demographic features were comparable between the groups. Adhesion scores were significantly higher in mild and severe SG groups (for mild SG: 1.93 ± 0.99, for severe SG: 2.81 ± 0.88 and for no SG: 1.4 ± 0.57; P < 0.001). Analysis revealed a positive correlation between IPA and severity of SG (P < 0.001). There was a correlation between increased striae density and adhesion severity especially in the right and left upper quadrants of the abdomen (for right quadrant: r = 0.515, P < 0.001; for left quadrant: r = 0.359, P = 0.005).

CONCLUSION

Our results suggest that preoperative evaluation of SG severity and extend particularly in upper quadrants is a feasible option to predict IPA risk in patients with repeated CD.

[Effect of auricular acupuncture on postpartum rehabilitation of primipara with cesarean]

OBJECTIVE

To explore the postoperative effect of auricular acupuncture on primipara with cesarean in order to promote postpartum rehabilitation.

METHODS

A total of 120 primiparas with cesarean were randomly divided into an observation group and a control group, 60 cases in each group. The routine treatment and care after surgery were given in the two groups. On the basis treatment, auricular acupuncture was applied at penqiang (TF₅), shenmen (TF₄), jiaogan (AH_6a), pizhixia (AT₄), neishengzhiqi(TF₂), pi(CO₁₃), wei(CO₄) in the observation group, even-needling technique at all points. The needles were retained for 30 min, 3 times a day, the acupuncture was alternately every other day for 5 days continuously. The postpartum pain, anus exhaust time, incidence of postpartum hemorrhage, urinary retention and constipation, and postpartum average hospitalization day were recorded and compared between the two groups.

RESULTS

Twenty-seven cases of postpartum uterine contraction pain (45.0%), 25 cases of wound pain (41.7%), 19 cases of breast distending pain (31.7%) and 11 cases of muscle soreness (18.3%) in the observation group, which was significantly lower than 38 cases (63.3%), 36 cases (60.0%), 30 cases (50.0%) and 21 cases (35.0%) respectively in the control group (P<0.05). The anus exhaust time in the observation group was earlier than that in the control group (P<0.05), and the average hospitalization time was shorter than that in the control group (P<0.05). The incidence of postpartum hemorrhage, urinary retention and constipation in the observation group was lower than that in the control group (P<0.05).

CONCLUSION

Auricular acupuncture can effectively relieve postpartum pain in primipara with cesarean, promote postpartum exhaust and shorten hospitalization days, and reduce the incidence of postpartum complications such as postpartum hemorrhage, urinary retention and constipation, it is conducive to postpartum rehabilitation.

Point-of-care HIV viral load in pregnant women without prenatal care: a cost-effectiveness analysis

BACKGROUND

Routine cesarean delivery has been shown to decrease mother-to-child-transmission of HIV in women with high viral load greater than 1000 copies/mL; however, women presenting late in pregnancy may not have viral load results before delivery.

OBJECTIVE

Our study investigated the costs and outcomes of using a point-of-care HIV RNA viral load test to guide delivery compared with routine cesarean delivery for all in the setting of unknown viral load.

STUDY DESIGN

A decision-analytic model was constructed using TreeAge software to compare HIV RNA viral load testing vs routine cesarean delivery for all in a theoretical cohort of 1275 HIV-positive women without prenatal care who presented at term for delivery, the estimated population of HIV-positive women without prenatal care in the United States annually. TreeAge Pro software is used to build decision trees modeling clinical problems and perform cost-effectiveness, sensitivity, and simulation analysis to identify the optimal outcome. The average cost per test was $15.22. To examine the downstream impact of a cesarean delivery and because most childbearing women in the United States will deliver 2 children, we incorporated a second pregnancy and delivery in the model. Primary outcomes were mother-to-child transmission, delivery mode, cesarean delivery-related complications, cost, and quality-adjusted life years. Model inputs were derived from the literature and varied in sensitivity analyses. The cost-effectiveness threshold was $100,000/quality-adjusted life year.

RESULTS

Measuring viral load resulted in more HIV-infected neonates than routine cesarean delivery for all due to viral exposure during more frequent vaginal births in this strategy. There were no observed maternal deaths or differences in cesarean delivery-related complications. Quantifying viral load increased cost by $3,883,371 and decreased quality-adjusted life years by 63 compared with routine cesarean delivery for all. With the threshold set at $100,000/quality-adjusted life year, the viral load test is cost-effective only when the vertical transmission rate in women with high viral load was below 0.68% (baseline: 16.8%) and when the odds ratio of vertical transmission with routine cesarean delivery for all compared with vaginal delivery was above 0.885 (baseline: 0.3).

CONCLUSIONS

For HIV-infected pregnant women without prenatal care, quantifying viral load to guide mode of delivery using a point-of-care test resulted in increased costs and decreased effectiveness when compared with routine cesarean delivery for all, even after including downstream complications of cesarean delivery.

Comparing pregnancy outcomes and loss rates in elective twin pregnancy reduction with ongoing twin gestations in a large contemporary cohort

BACKGROUND

As compared with singleton gestations, twin pregnancies are associated with a significantly higher risk of preterm birth and maternal complications as well as fetal and neonatal morbidity and mortality. Multifetal pregnancy reduction is a technique developed in the 1980s to reduce the fetal number in higher-order multiple pregnancies to reduce the risk of adverse pregnancy outcomes, most importantly preterm birth.

OBJECTIVE

The objective of the study was to compare pregnancy outcomes and loss rates in elective twin pregnancy reduction to ongoing twin gestations in a large contemporary cohort.

STUDY DESIGN

This was a retrospective review of dichorionic diamniotic twin gestations that underwent first-trimester ultrasound at our institution from January 2008 to September 2016. Planned elective 2-to-1 multifetal pregnancy reductions at less than 15 weeks' gestation were compared with ongoing dichorionic diamniotic twin gestations. Data were collected via chart review. Demographics between 2-to-1 reduced singletons and ongoing twins were assessed using a Student t test or a Wilcoxon rank-sum test, as appropriate, for continuous variables and χ² or Fisher exact tests, as appropriate, for categorical variables. Univariable and multivariable logistic regressions were used to compare pregnancy outcomes between ongoing twins and reduced singletons adjusting for maternal age, body mass index, race, in vitro fertilization, use of chorionic villus sampling, prior term birth, and prior preterm birth.

RESULTS

Of 1070 dichorionic diamniotic twin pregnancies identified, completed follow-up data were available and analyzed for 855 patients (79.9%). Among those, 250 (29.2%) were 2-to-1 singletons and 605 (70.8%) were ongoing twins. Reduced singleton patients were slightly older, more likely white, and had lower body mass index. They were also more likely to have undergone in vitro fertilization (63.6% vs 48.8%), had chorionic villus sampling (92% vs 37.5%), and had prior term births (54% vs 35.7%). Compared with 2-to-1 singletons, the adjusted odds of having preterm delivery at 37 weeks for ongoing twins were 5.62 times (95% confidence interval, 3.67-8.61; P < .001) and 2.22 times (95% confidence interval, 1.20-4.11; P < .001) at 34 weeks. While intrauterine growth restriction, placental abruption, and gestational diabetes were not significant, ongoing twins were more likely to have a cesarean delivery (odds ratio, 5.53, 95% confidence interval, 3.60-8.49; P < .001) and preeclampsia (odds ratio, 3.33, 95% confidence interval, 1.60-6.96; P < .001) after adjusting for maternal characteristics. There were also significant differences between groups for preterm premature rupture of membranes and low birthweight at less than the fifth and 10th percentiles. Total pregnancy loss (at 24 and 20 weeks) was similar between singleton and ongoing twins (4% vs 2.5%, P = .23, and 3.6% vs 1.7%, P = .09 for respective weeks). There were no significant differences in the rate of unintended pregnancy loss (2.4% vs 2.3%; P = .94) and the rate of intrauterine fetal death greater than 24 weeks (1.2% vs 0.7%; P = .43) in reduced singleton versus ongoing twin group, respectively.

CONCLUSION

In our study, patients who elected to reduce to a singleton pregnancy had a higher gestational age of delivery and lower rates of preterm birth and pregnancy complications without an increased risk of pregnancy loss.

Postdates induction with an unfavorable cervix and risk of cesarean. J Matern Fetal Neonatal Med 2019;32:2874-2878. [PMID: 29562794 PMCID: PMC6636843 DOI: 10.1080/14767058.2018.1450861]

Objective: To determine the risk of cesarean delivery associated with postdates induction (≥41 weeks) compared to term induction (37-40w6d) among women with an unfavorable cervix, and to examine the risk factors associated with cesarean among women undergoing postdates induction. Methods: A planned secondary analysis of a large prospective cohort study on induction (n = 854) was performed. Women with a singleton gestation, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) who were undergoing a term (≥37 weeks) induction for any indication were included. Women with a prior cesarean were excluded. The primary outcome was cesarean delivery. Relative risk of cesarean was estimated using a modified Poisson's regression model. Results: There was a significantly increased risk of cesarean for women undergoing postdates induction (n = 154) compared to women 37-40w6d (n = 700), (46.8 versus 26.0%, p < .001). This increased risk of cesarean remained after adjustment for race, parity, and pregnancy-related hypertension (aRR 1.70 [1.39-2.09], p < .001). Risk factors independently associated with cesarean among women ≥41 weeks included nulliparity (aRR 3.38 95%CI (2.42-4.74)), BMI ≥30 (aRR 1.72 95%CI (1.34-2.21)), and starting cervical dilation <1 cm (aRR 1.37 95%CI (1.11-1.70)). Conclusions: Women ≥41 weeks undergoing an induction with an unfavorable cervix are at a significantly increased risk of cesarean compared to women 37-40w6d, with nulliparity, obesity, and cervical dilation <1 cm being independent risk factors. These data can be used to augment patient counseling and support the ongoing discussion regarding the risk of post dates induction.

Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study

BACKGROUND

The presence of midwives in a health system may affect perinatal outcomes but has been inadequately described in United States settings. Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only).

METHODS

We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to compare outcomes.

RESULTS

There was concordance across logistic regression models, the most restrictive and conservative of which were propensity-matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled.

CONCLUSIONS

The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study

BACKGROUND

Sixty percent of United States births are to multiparous women. Hospital-level policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women.

METHODS

We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes.

RESULTS

There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes.

CONCLUSIONS

Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Retained bones of the second twin following a cesarean section: a case report

Twin pregnancies are increasing due to assisted reproductive techniques. Following the death of one twin in-utero, the surviving and dead twin are removed from the uterine cavity at delivery. This is a report of a 38-year-old para 0⁺³ woman who experienced fetal demise of one of a set of twins at 20 weeks of gestation. She had an elective cesarean section during which the dead twin was forgotten in the uterine cavity. She presented with profuse vaginal discharge that was sterile on culture. An ultrasound scan showed the presence of several echogenic substances within the endometrial cavity. These substances were hysteroscopically removed and confirmed by histology to be fetal bones. The vaginal discharge subsequently stopped. In conclusion, uterine revision should always be performed during cesarean section to prevent such an occurrence.

Estimating the Financial Impact of Reducing Primary Cesareans

INTRODUCTION

Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women's Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative.

METHODS

All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings.

RESULTS

For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were $4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of $280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged.

DISCUSSION

Participation in ACNM's RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors.

Meconium-stained amniotic fluid and the risk of postcesarean surgical site infection

OBJECTIVE

To investigate the association between meconium-stained amniotic fluid (MSAF) and postcesarean surgical site infections.

METHODS

This was a secondary analysis of the Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry. Women with a singleton pregnancy attempting labor or induction of labor, who ultimately had a cesarean delivery, were included in the study. Pregnancies complicated by MSAF (n = 4262) and those who did not have MSAF (n = 13,850) were compared. The primary outcome was the incidence of SSI.

RESULTS

A total of 18,112 patients were included in the study. 4262 (38%) had meconium-stained amniotic fluid. After accounting for potential confounders in a multivariable logistic regression, meconium-stained amniotic fluid was associated with an increased risk of postoperative surgical site infection (odds ratio 1.16, 95% CI 1.03-1.30).

CONCLUSIONS

Meconium-stained amniotic fluid may be associated with an increased risk of postoperative surgical site infection.

The ARRIVE Trial: Interpretation from an Epidemiologic Perspective

The findings of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) were recently published. This multisite randomized trial was designed to provide evidence regarding whether labor induction or expectant management is associated with increased adverse perinatal outcomes and risk of cesarean birth among healthy nulliparous women at term. The trial reported that the primary outcome, a composite of adverse neonatal outcomes, was not significantly different between the 2 groups; the principal secondary outcome, cesarean birth, was significantly more common among women whose pregnancy was expectantly managed than among women whose labor was induced at 39 weeks. These results have the potential to change existing practice. Several aspects of the study design may influence its potential internal and external validity and should be considered in order to make sound causal inferences from this trial, which will in turn affect how its findings are translated to practice. Although chance and confounding are of minimal concern, given the sample size and randomization used in the study, selection bias may be a concern. Studies are vulnerable to selection bias when the sample population differs from eligible nonparticipants, including in randomized controlled trials. External validity is defined as the extent to which the study population and setting are representative of the larger source population the study intends to represent. External validity may be limited given the characteristics of the women enrolled in the ARRIVE trial and the practice settings where the study was conducted. This brief report provides concrete suggestions for further analyses that could help solidify conclusions from the trial, and for further research questions that will continue advancement toward answering this complex question of how best to manage labor and birth decisions at full term among low-risk women.

Effect of using silver nylon dressings to prevent superficial surgical site infection after cesarean delivery: a randomized clinical trial

BACKGROUND

Surgical site infections are associated with significant healthcare cost and burden. Silver-impregnated dressings have been associated with a decrease in surgical site infections in select populations, but it is unknown whether the benefit can be observed after cesarean deliveries.

OBJECTIVE

We sought to evaluate the impact of silver nylon dressings in reducing superficial surgical site infections after cesarean delivery.

MATERIALS AND METHODS

A blinded randomized clinical trial of women undergoing scheduled or unscheduled cesarean delivery at a single site was conducted. Women were recruited for participation from September 2013 to June 2016. Women with vertical skin incisions were excluded. Enrolled participants were randomized to silver nylon dressing or an identical-appearing gauze wound dressing. Wounds were evaluated in the outpatient office at 1 week and 6 weeks after delivery. The primary outcome was superficial surgical site infection as defined by Centers for Disease Control criteria at any time within the first 6 weeks after cesarean delivery. A sample size of 330 per group (n = 660) was planned to compare the 2 arms. Data were analyzed using the χ², Fisher exact test, Student t test, Mann-Whitney U test, and logistic regression where appropriate, and a value of P < .05 was considered significant.

RESULTS

Among the 657 participants, overall, the primary outcome was similar between the 2 groups (4.6% in the silver nylon group vs 4.2% in the gauze group, P = .96). Women allocated to silver nylon, when compared to those who were allocated to gauze, had similar rates of superficial surgical site infection within 1 week (1.2% vs 0.9%) and within 6 weeks ( 4.6% vs 4.2%) after delivery (P >.99). The 2 groups were similar in age (30.9 ± 5.6 vs 31.0 ± 5.5 years, P = .95), body mass index (36.2 ± 8.7 vs 35.3 ± 8.2 kg/m², P = .19), pregestational diabetes (6.2% vs 3.4%, P = .14), gestational diabetes (7.9% vs 7.3%, P = .88), cesarean delivery after labor (31.9% vs 31.1%, P = .86), presence of chorioamnionitis (5.2% vs 2.1% P = .06), and operative time (56.4 ± 20.6 vs 55.9 ± 17 minutes, P = .69). After adjusting for clinical and sociodemographic confounding variables, current smoking (adjusted odds ratio, 4.9; 95% confidence interval, 1.8-13.4) body mass index ≥40 kg/m² (adjusted odds ratio, 3.08; 95% confidence interval, 1.3-6.8), and surgery length (minutes) (adjusted odds ratio, 1.02; 95% confidence interval, 1.002-1.04), but not use of gauze dressing, were associated with superficial surgical site infections.

CONCLUSION

Among women undergoing cesarean delivery, silver nylon dressing was not more effective than gauze in reducing the risk of superficial surgical site infections.

Women's Prenatal and Labor Experiences in a Hospital With an Early-Labor Lounge

OBJECTIVE

To evaluate the information that women with low-risk pregnancies received during the prenatal period about latent labor and the early-labor lounge (ELL) and their subsequent use of the ELL.

DESIGN

Cross-sectional design with survey.

SETTING/LOCAL PROBLEM

Community hospital in the northeastern United States with a low-risk cesarean birth rate of 33%, which exceeds the national target rate of 23.9%.

PARTICIPANTS

Low-risk, nulliparous, pregnant women with a term singleton vertex fetus at hospital admission (N = 67).

INTERVENTION/MEASUREMENTS

An electronic survey was administered before hospital discharge following birth. The survey assessed prenatal education, use of the ELL, admission characteristics, and birth satisfaction. Descriptive analysis was used.

RESULTS

Nearly half (43.9%) of the women surveyed used the ELL. ELL users received prenatal care (72.3%), knew signs of active labor (93.1%), and had a cesarean birth rate of 7.1%. Significantly greater proportions of women prenatally cared for by midwives reported knowledge of the signs of early labor (100% vs. 80%; χ² = 4.4, p = .04) and of the availability of the ELL (18.2% vs. 70.6%; χ² = 15.2, p < .001). A range of activities were offered in the ELL, and at least 75% of women indicated that all activities were helpful during latent labor. Birth satisfaction scores, measured on a scale of 0 to 40, with 40 indicating greatest satisfaction, ranged from 22 to 35 among ELL participants.

CONCLUSION

An ELL is a care innovation that hospitals can consider for providing support to women with low-risk pregnancies during the latent phase of labor. Women who used the ELL reported feeling that it provided guidance and support. An ELL is a woman-centered option for delayed admission.

The Robson 10-group classification in Iceland: Obstetric interventions and outcomes

BACKGROUND

Rising cesarean rates call for studies on which subgroups of women contribute to the rising rates, both in countries with high and low rates. This study investigated the cesarean rates and contributing groups in Iceland using the Robson 10-group classification system.

METHODS

This study included all births in Iceland from 1997 to 2015, identified from the Icelandic Medical Birth Registry (81 839). The Robson distribution, cesarean rate, and contribution of each Robson group were analyzed for each year, and the distribution of other outcomes was calculated for each Robson group.

RESULTS

The overall cesarean rate in the population was 16.4%. Robson groups 1 (28.7%) and 3 (38.0%) (spontaneous term births) were the largest groups, and groups 2b (0.4%) and 4b (0.7%) (prelabor cesareans) were small. The cesarean rate in group 5 (prior cesarean) was 55.5%. Group 5 was the largest contributing group to the overall cesarean rate (31.2%), followed by groups 1 (17.1%) and 2a (11.0%). The size of groups 2a (RR 1.04 [95% CI 1.01-1.08]) and 4a (RR 1.04 [95% CI 1.01-1.07]) (induced labors) increased over time, whereas their cesarean rates were stable (group 2a: P = 0.08) or decreased (group 4a: RR 0.95 [95% CI 0.91-0.98]).

CONCLUSIONS

In comparison with countries with high cesarean rates, the prelabor cesarean groups (singleton term pregnancies) in Iceland were small, and in women with a previous cesarean, the cesarean rate was low. The size of the labor induction group increased, yet the cesarean rate in this group did not increase.

Effect of Peanut Ball and Position Changes in Women Laboring With an Epidural

OBJECTIVE

To examine the effect of a nurse-driven intervention using a peanut ball (PB) with position changes on length of labor and incidence of cesarean birth among women who receive epidural anesthesia.

DESIGN

Quasiexperimental comparison group design.

SETTING/LOCAL PROBLEM

A 407-bed, nonprofit, Magnet-designated, Baby-Friendly Hospital Initiative-designated hospital with 8 labor and delivery suites and an average of 100 births per month.

PARTICIPANTS

A total of 343 participants were included, with 164 women in the PB group.

INTERVENTION/MEASUREMENTS

The PB was placed after epidural administration; women were repositioned a minimum of every 1 to 2 hours, and the PB was removed at second stage of labor; duration was recorded.

RESULTS

Overall, women in the PB group were 50% less likely to have cesarean birth. For women with cervical dilation of 4 cm or less, rates of vaginal birth were 61% with use of the peanut ball. A multivariate analysis of outcomes was used. A multiple linear regression model showed, after adjusting for other variables, that PB placement alone did not shorten labor length (p = .4684). However, a stratified analysis indicated that for women with cervical dilation of 4 cm or less, length of the first stage of labor was affected by parity (p = .0042) and frequency of position change (p < .001). For women with cervical dilation greater than 4 cm, length of the first stage of labor was influenced by frequency of position changes (p = .0130) and effacement (p = .0050). Length of the second state of labor was affected by the frequency of position change (p = .0416).

CONCLUSION

The PB may be an effective intervention to reduce the incidence of cesarean birth. Changing position frequently was associated with reduced length of first and second stages of labor.

An Optimal Uterine Closure Technique for Better Scar Healing and Avoiding Isthmocele in Cesarean Section: A Randomized Controlled Study

Objective: The aim of this study is to compare the effects of two different uterine closure techniques, used during cesarean section (CS) operations on isthmocele formation. Material and Methods: This prospective, randomized, controlled study was performed on 138 patients in a university hospital between the dates December 2016 and August 2017. Uterine closures were performed using the double-layer, far-far-near-near (FFNN) unlocked technique, in the study group (n = 70) and using a single-layer continuous locked (SLL) technique in the control group (n = 68). The presence of isthmocele, residual myometrial thickness (RMT), postmenstrual spotting, dysmenorrhea, chronic pelvic pain and uterus position were evaluated in postoperative sixth month. Results: Isthmocele formation was less frequent and RMT was greater in the study group when compared to the control group (p < 0.001 and p < 0.001, respectively). Duration of operation, amount of blood loss and additional hemostatic suture requirement were not significantly different between the two groups (p = 0.221, p = 0.520 and p = 0.930, respectively). Postmenstrual spotting was less common in FFNN group, while the rates of chronic pelvic pain and dysmenorrhea were not significantly different between the groups (p = 0.002, p = 0.205 and p = 0.490, respectively). Conclusion: The findings of the present study demonstrate that uterine closure using the FFNN technique is beneficial in terms of providing protection from isthmocele formation and ensuring sufficient RMT. This method has the potential to become the optimal uterine closure technique, but the findings of the present study should be supported by large-scale studies in the future.

The Association between Maternal Height, Body Mass Index, and Perinatal Outcomes

OBJECTIVE

To test the hypothesis that maternal height is associated with adverse perinatal outcomes, controlling for and stratified by maternal body mass index (BMI).

STUDY DESIGN

This was a retrospective cohort study of all births in California between 2007 and 2010 (n = 1,775,984). Maternal height was categorized into quintiles, with lowest quintile (≤20%) representing shorter stature and the uppermost quintile (≥80%) representing taller stature. Outcomes included gestational diabetes mellitus (GDM), preeclampsia, cesarean, preterm birth (PTB), macrosomia, and low birth weight (LBW). We calculated height/outcome associations among BMI categories, and BMI/outcome associations among height categories, using various multivariable logistic regression models.

RESULTS

Taller women were less likely to have GDM, nulliparous cesarean, PTB, and LBW; these associations were similar across maternal BMI categories and persisted after multivariable adjustment. In contrast, when stratified by maternal height, the associations between maternal BMI and birth outcomes varied by specific outcomes, for example, the association between morbid obesity (compared with normal or overweight) and the risk of GDM was weaker among shorter women (adjusted odds ratio [aOR], 95% confidence interval [CI]: 3.48, 3.28-3.69) than taller women (aOR, 95% CI: 4.42, 4.19-4.66).

CONCLUSION

Maternal height is strongly associated with altered perinatal risk even after accounting for variations in complications by BMI.

Time from neuraxial anesthesia placement to delivery is inversely proportional to umbilical arterial cord pH at scheduled cesarean delivery

BACKGROUND

Neuraxial block-related hypotension and maternal obesity contribute to uterine hypoperfusion and decreased umbilical arterial pH at cesarean delivery. Between the time of anesthesia placement and delivery, the fetus may be exposed to a hypoperfused uterine environment without surgeon awareness of fetal compromise.

OBJECTIVE

We sought to evaluate neonatal umbilical arterial pH according to predelivery time intervals at scheduled term cesarean.

STUDY DESIGN

We performed a retrospective cohort study of cesarean deliveries between September 2014 and February 2017. Singleton gestations undergoing scheduled cesarean delivery under spinal anesthesia between 37 and 41 weeks with a reassuring preoperative nonstress test were included. Time intervals between operative room entry, spinal anesthesia placement, skin incision, uterine incision, and delivery were calculated. The primary outcome was umbilical arterial pH. Demographic data, maternal blood pressures, predelivery time intervals, and delivery outcomes were analyzed according to umbilical arterial pH intervals of <7.0, 7.01-7.10, 7.11-7.20, 7.21-7.30, and >7.30. Umbilical cord gas analytes and neonatal outcomes were analyzed by spinal to delivery time. Stepwise linear regression was performed to identify predictors of decreasing umbilical arterial pH. Receiver-operator characteristic curves were calculated for spinal to delivery time and umbilical arterial pH <7.0 and 7.1.

RESULTS

Among 527 included participants, median umbilical arterial pH was 7.27 [interquartile range, 7.23-7.29] and body mass index was 35 kg/m² [interquartile range, 30-41]. Both maternal body mass index and hypotensive episodes increased with decreasing umbilical arterial pH (P <.001, P ≤ .02). All predelivery time intervals (operative room to delivery, spinal to skin, spinal to delivery, and uterine incision to delivery) increased as umbilical arterial pH interval decreased (P < .05 for all). In a stepwise linear regression, maternal body mass index, noncephalic presentation, spinal start to delivery interval, uterine incision to delivery interval, and maximum reduction in blood pressure from baseline were predictive of decreasing umbilical arterial pH after controlling for confounding variables (F [5,442] = 17.7, P = .0001], adjusted R² of 0.157. When evaluated by spinal to delivery time, both umbilical arterial and venous pH and partial pressure of carbon dioxide decreased (P < .001 for all), but base deficit and neonatal outcomes were similar (P ≥ .7 for all). There were 2 cases of hypoxic-ischemic encephalopathy (0.38%). A receiver-operating characteristic curve demonstrated that a spinal start to delivery time greater than 27 minutes was associated with an umbilical arterial pH <7.1 (area under the curve, 0.74, 100% sensitivity, 21% specificity), and an interval greater than 30 minutes was associated with an umbilical arterial pH <7.0 (area under the curve, 0.80, 100% sensitivity, 33% specificity).

CONCLUSION

Longer spinal-to-delivery and uterine incision-to-delivery time intervals were associated with decreasing umbilical arterial pH at scheduled term cesarean delivery. Efforts to minimize predelivery time following spinal placement could reduce the frequency of unanticipated neonatal acidemia.

Safe Childbirth: A Call to Action

Since the publication of Lamaze's Six Healthy Birth Practice papers in 2014, there has been increasing concern with the safety of the current maternity care system. A doubling of the maternal mortality rate in the United States and the continued high cesarean rate, as well as ongoing research that supports physiologic birth and identifies the risks of interfering with the physiologic process, has resulted in updated guidelines for care and has spurred advocacy efforts to transform maternity care. This article presents a number of these advocacy efforts.

Association between gestational age and severe maternal morbidity and mortality of preterm cesarean delivery: a population-based cohort study

BACKGROUND

Cesarean delivery rates at extreme prematurity have regularly increased over the past years, and few previous studies have investigated severe maternal morbidity associated with extreme preterm cesarean delivery.

OBJECTIVE

The aim of this study was to evaluate whether gestational age <26 weeks of gestation (weeks) was associated with severe maternal morbidity and mortality (SMMM) of preterm cesarean deliveries in comparison with cesarean deliveries between 26 and 34 weeks.

MATERIALS AND METHODS

The Etude Epidémiologique sur les petits âges gestationnels (EPIPAGE) 2 is a national prospective population-based cohort study of preterm births in 2011. We included mothers with cesarean deliveries between 22 and 34 weeks, excluding those who had a cesarean delivery for the second twin only and those with pregnancy terminations. SMMM was analyzed as a composite endpoint defined as the occurrence of at least 1 of the following complications: severe postpartum hemorrhage defined by the use of a blood transfusion, intensive care unit admission, or death. To assess the association of gestational age <26 weeks and SMMM, we used multivariate logistic regression and a propensity score-matching approach.

RESULTS

Among 2525 women having preterm cesarean deliveries, 116 before 26 weeks and 2409 between 26 and 34 weeks, 407 (14.4%) presented with SMMM. The SMMM occurred in 31 mothers (26.7%) who were at gestational age <26 weeks vs 376 (14.2%) between 26 and 34 weeks (P < .001). Cluster multivariate logistic regression showed significant association of gestational age <26 weeks and SMMM (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.42-4.40) and propensity score-matching analysis was consistent with these results (aOR, 2.27; 95% CI, 1.31-3.93).

CONCLUSION

Obstetricians should know about the higher SMMM associated with cesarean deliveries before 26 weeks, integrate this knowledge into decisions regarding cesarean delivery, and be prepared to manage the associated complications.

Opioid prescribing after childbirth: overprescribing and chronic use

PURPOSE OF REVIEW

Overprescribing opioids contributes to the epidemic of drug overdoses and deaths in the United States. Opioids are commonly prescribed after childbirth especially after caesarean, the most common major surgery. This review summarizes recent literature on patterns of opioid overprescribing and consumption after childbirth, the relationship between opioid prescribing and chronic opioid use, and interventions that can help reduce overprescribing.

RECENT FINDINGS

It is estimated that more than 80% of women fill opioid prescriptions after caesarean birth and about 54% of women after vaginal birth, although these figures vary greatly by geographical location and setting. After opioid prescriptions are filled, the median number of tablets used after caesarean is roughly 10 tablets and the majority of opioids dispensed (median 30 tablets) go unused. The quantity of opioid prescribed influences the quantity of opioid used. The risk of chronic opioid use related to opioid prescribing after birth may seem not high (annual risk: 0.12-0.65%), but the absolute number of women who are exposed to opioids after childbirth and become chronic opioid users every year is very large. Tobacco use, public insurance and depression are associated with chronic opioid use after childbirth. The risk of chronic opioid use among women who underwent caesarean and received opioids after birth is not different from the risk of women who received opioids after vaginal delivery.

SUMMARY

Women are commonly exposed to opioids after birth. This exposure leads to an increased risk of chronic opioid use. Physician and providers should judiciously reduce the amount of opioids prescribed after childbirth, although more research is needed to identify the optimal method to reduce opioid exposure without adversely affecting pain management.

Determinants of in-hospital feeding practices in Shiraz, Iran: Results of a prospective cohort study

BACKGROUND

In-hospital feeding practices have been shown negatively to affect breastfeeding exclusivity and duration. The purpose of this study was to report the prevalence and determinants of delayed breastfeeding, provision of traditional prelacteal foods, and use of infant formula in hospital.

METHODS

Between June 2014 and March 2015, 700 women were recruited from three public and two private maternity hospitals in Shiraz, Iran. Data were collected at recruitment via face-to-face interviews and extracted from medical records. Multivariable logistic regression was used to explore the association of feeding practices with a variety of maternal characteristics and hospital practices.

RESULTS

Only 32.2% of infants were breastfed within 1 hour of birth, with 40.8% receiving a traditional prelacteal food, and 34.9% given formula during their hospital stay. Compared with infants delivered vaginally, those delivered by cesarean were more likely to have experienced delayed breastfeeding and received formula, but less likely to have received traditional prelacteal foods. Infants who did not experience skin-to-skin contact were more likely to have experienced delayed breastfeeding and received traditional prelacteal foods and formula in hospital.

CONCLUSIONS

Although four out of the five hospitals were designated as Baby-Friendly, several of the 10 Steps to Successful Breastfeeding were not adhered to. The high rate of cesarean delivery was a barrier to the early initiation of breastfeeding and the majority of infants did not experience early skin-to-skin contact. Maternity care practices should be reviewed and include a clear breastfeeding care plan for women who undergo a cesarean delivery.

Planned cesarean or vaginal delivery for women in spontaneous labor with a twin pregnancy: A secondary analysis of the Twin Birth Study

BACKGROUND

The Twin Birth Study, a multicenter randomized controlled trial, found no differences in neonatal outcomes in women with twins randomized to planned cesarean or vaginal delivery. Nevertheless, women who present in spontaneous labor might expect a better outcome following a trial of vaginal delivery than undergoing cesarean delivery. In this secondary analysis, we aimed to compare neonatal outcomes of women who presented in spontaneous labor in the two arms of the Twin Birth Study.

METHODS

Women in whom the first twin was in the cephalic presentation were randomized between 32 + 0 and 38 + 6 weeks to planned vaginal delivery or cesarean. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity.

RESULTS

Of the 2804 women included in the Twin Birth Study, 823 women in the planned vaginal delivery arm and 612 in the planned cesarean arm presented in spontaneous labor. Although the odds ratio favored planned vaginal delivery, there was no statistically significant difference in the rate of primary outcome between the vaginal delivery and cesarean arms (1.8% vs 2.7%, respectively; P = 0.16; OR 1.49; 95% CI, 0.87-2.55). Similarly, the rates of the individual components of the primary outcome and of maternal adverse outcome were similar between the two arms.

CONCLUSION

In women with twins who present in spontaneous labor between 32 + 0 and 38 + 6 weeks' gestation, where the first twin is cephalic, a policy of planned vaginal delivery or cesarean is not associated with significant differences in neonatal or maternal outcomes.

Comparing the effects of general anesthesia and spinal anesthesia on the serum level of blood sugar in patients undergoing cesarean

Objective

This paper aims to study the influence of both general and spinal anesthesia on blood sugar changes in patients undergoing cesarean.

Methods

This is a single-blind clinical trial study conducted on 60 patients with classes 1 and 2 anesthesia. The patients were divided by chance into the general anesthesia and spinal anesthesia groups (each contains 30 members). The patients in the spinal group were blocked up to the T4 level and similar methods and medicines were also utilized for those in the general anesthesia group.

Results

No significant difference was observed in the blood sugar levels of both groups before and after the operation, but the group, which had utilized the general anesthesia method, had reported with lower levels of blood sugar than the spinal anesthesia group after operation with a significant difference (P < 0.05). A difference has been observed in the levels of blood sugar at 2, 12, and 24 h after the operation in both groups, but it was not a statistically significant difference.

Conclusion

However, none of the mentioned methods had any influence on reduction of blood sugar levels during the recovery or the period after it.

Factors associated with increased odds of cesarean delivery in ART pregnancies

OBJECTIVE

To quantify the effect of medical and obstetrical factors on the odds of cesarean delivery, comparing assisted reproductive technology (ART)-treated women and women with subfertility not treated with ART versus fertile women.

DESIGN

Retrospective cohort.

SETTING

Not applicable.

PATIENT(S)

Singleton deliveries to primiparous women; with the source of this data being the Massachusetts vital and hospital records linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System data (2004-2010).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mode of delivery.

RESULT(S)

The 173,130 deliveries included 5,768 ART-treated, 2,657 subfertile (1,627 non-ART medically assisted reproduction [MAR] and 1,030 unassisted infertile), and 164,705 fertile pregnancies and 117,743 vaginal and 55,387 cesarean deliveries. ART-treated women were older, more often white and non-Hispanic, and with more private insurance, previous uterine surgery, gestational diabetes, pregnancy hypertension, bleeding, and placental complications than fertile women. Overall rates of cesarean delivery were 45.7%, 43.3%, and 31.1% for ART-treated, subfertile, and fertile women and 41.7% and 45.9% for MAR and unassisted infertile deliveries. When adjusted for demographics, underlying medical factors, previous uterine surgery, and placental and delivery complications, adjusted odds ratios (ORs) compared with fertile women were 1.27 for ART-treated and 1.15 for subfertile women, with greater odds among unassisted infertile (OR 1.26) but not MAR (OR 1.09) women. The strongest confounders of odds of cesarean delivery were age and previous uterine surgery.

CONCLUSION(S)

ART and unassisted infertility were associated with greater odds of cesarean compared with fertile women. Underlying medical and obstetrical risks had strong confounding effects strongly attenuating the odds for cesarean delivery.

Hospital variation in utilization and success of trial of labor after a prior cesarean

BACKGROUND

Trial of labor after cesarean delivery is an effective and safe option for women without contraindications.

OBJECTIVES

The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes.

STUDY DESIGN

Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery.

RESULTS

In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P < .001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P < .001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P < .001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P = .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P < .001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P < .001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate.

CONCLUSION

Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).

Obstetric interventions, trends, and drivers of change: A 20-year population-based study from Iceland

BACKGROUND

Population data on obstetric interventions is often limited to cesarean delivery. We aimed to provide a more comprehensive overview of trends in use of several common obstetric interventions over the past 2 decades.

METHODS

The study was based on nationwide data from the Icelandic Medical Birth Register. Incidence of labor induction, epidural analgesia, cesarean, and instrumental delivery was calculated for all births in 1995-2014. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for several maternal and pregnancy-related characteristics. Analyses were stratified by women's parity and diagnosis of diabetes or hypertensive disorder.

RESULTS

During the study period, there were 81 389 intended vaginal births and 5544 elective cesarean deliveries. Among both primiparous and multiparous women, we observed a marked increase across time for labor induction (RR 1.78 [CI 1.67-1.91] and RR 1.83 [CI 1.73-1.93], respectively) and epidural analgesia (RR 1.40 [CI 1.36-1.45] and RR 1.74 [CI 1.66-1.83], respectively). A similar trend of smaller magnitude was observed among women with hypertensive disorders but no time trend was observed among women with diabetes. Incidence of cesarean and instrumental delivery remained stable across time.

DISCUSSION

The use of labor induction and epidural analgesia increased considerably over time, while the cesarean delivery rate remained low and stable. Increases in labor induction and epidural analgesia were most pronounced for women without a diagnosis of diabetes or hypertensive disorder and were not explained by maternal characteristics such as advanced age.

Longitudinal changes in pelvic floor muscle strength among parous women

BACKGROUND

There is limited knowledge of the effects of time on change in pelvic floor muscle strength after childbirth.

OBJECTIVE

The objectives of this study were to estimate the change in pelvic floor muscle strength in parous women over time and to identify maternal and obstetric characteristics associated with the rate of change.

STUDY DESIGN

This is an institutional review board-approved prospective cohort study of parous women. Participants were recruited 5-10 years after first delivery and followed annually. Pelvic floor muscle strength (peak pressure with voluntary contraction) was measured at 2 annual visits approximately 4 years apart with the use of a perineometer. We calculated the change in peak pressures, which were standardized per 5-year interval. Linear regression was used to identify maternal and obstetric characteristics that are associated with the rate of change in peak pressure. The obstetric variable of greatest interest was delivery group. Participants were classified into 3 delivery groups (considering all deliveries for each multiparous woman). Delivery categories included cesarean only, at least 1 vaginal birth but no forceps-assisted deliveries, and at least 1 forceps-assisted vaginal birth. Statistical analysis was completed with statistical software.

RESULTS

Five hundred forty-three participants completed 2 perineometer measurements with a median 4 years between measures (interquartile range, 3.1-4.8). At initial measurement, women were, on average, 40 years old and 8 years from first delivery. Initial strength was higher in participants who delivered all their children by cesarean (38.5 cm H₂O) as compared with women with any vaginal non-forceps delivery (26.0 cm H₂O) or vaginal forceps delivery (13.5 cm H₂O; P<.001). There was a strong correlation between the first and second perineometry measurement (r=0.84). Median change in pelvic floor muscle strength was small at 1.2 cm H₂O per 5 years (interquartile range, -5.6, 9.9 cm H₂O). In multivariable analysis, women who delivered by cesarean only demonstrated almost no change in strength over 5 years (0.2 increase cm H₂O per 5 years); those who experienced at least 1 vaginal or vacuum delivery increased strength (4.8 cm H₂O per 5 years) as did women with at least 1 forceps delivery (5.0 cm H₂O per 5 years). Additionally, obese women had a significant reduction in strength (-3.1 cm H₂O per 5 years) compared with normal weight participants (0.2 cm H₂O per 5 years).

CONCLUSION

Among parous women, pelvic muscle strength increased minimally over time with an average change of 1.2 cm H₂O per 5 years; change in strength was associated with mode of delivery and obesity.

Length of the second stage of labor and preterm delivery risk in the subsequent pregnancy

BACKGROUND

Cervical injury is regarded as an important risk factor for preterm delivery. A prolonged second stage of labor may increase the risk of cervical injury that, in turn, may be associated with increased risk of spontaneous preterm delivery in the subsequent pregnancy.

OBJECTIVE

We sought to evaluate whether the duration of the second stage of labor in a term primiparous singleton delivery is associated with an increased risk of singleton spontaneous preterm delivery (<37 weeks) in the second pregnancy.

STUDY DESIGN

We carried out a retrospective cohort analysis of women with 2 consecutive pregnancies: a first term (≥37 weeks) delivery and second birth. Data were derived from a single institution's prospectively collected obstetrical database from January 2005 through January 2015. Duration of the second stage of labor was examined as a continuous variable, modeled based on nonparametric restricted cubic regression spline with 4 degrees of freedom. Second-stage duration was also examined as short (<30 minutes), normal (30-179 minutes), and prolonged, defined as ≥180 minutes. The association between the duration of the second stage of labor in the first term pregnancy and the risk for spontaneous preterm delivery in the second pregnancy was evaluated before and after adjusting for potential confounders based on the Cox proportional hazards regression model. Associations were expressed based on the adjusted hazard ratio and 95% confidence interval.

RESULTS

In all, 6715 women met inclusion criteria. The hazard of spontaneous preterm delivery in the second pregnancy trended higher with both shorter and longer second-stage labors. The length of the second stage of labor in the first term delivery was categorized as short (<30 minutes) in 1749 (26.0%), normal (30-179 minutes) in 4551 (67.8%), and prolonged (≥180 minutes), in 415 (6.2%) women. Of these 6715 women with a first term delivery, 4.2% (n = 279) delivered spontaneously preterm in the second pregnancy. The risks of spontaneous preterm delivery among women with prolonged (≥180 minutes) second stage of labor and normal labor duration (30-179 minutes) were 5.4% (n = 22) and 3.5% (n = 158), respectively (adjusted hazard ratio, 1.81; 95% confidence interval, 1.15-2.84). This increased risk for prolonged second stage of labor was primarily seen among women who underwent a cesarean (hazard ratio, 3.38; 95% confidence interval, 1.09-10.49), but was imprecise among women who delivered vaginally (hazard ratio, 1.52; 95% confidence interval, 0.62-3.74). The risk of spontaneous preterm delivery among women with short second stage of labor (<30 minutes) in their first term pregnancy was 5.8% (n = 99; hazard ratio, 1.28; 95% confidence interval, 0.99-1.67).

CONCLUSION

The risk of spontaneous preterm delivery in the second pregnancy was increased in women with a prolonged (≥180 minutes) second stage in the first term pregnancy. This risk was even greater among women who were delivered by cesarean in the first pregnancy.

The Dual Burden of Malnutrition Increases the Risk of Cesarean Delivery: Evidence From India

Background: Among contemporary human populations, rates of cesarean delivery vary substantially, making it difficult to know if the procedure is inadequately available, or used excessively relative to medical need. A much-cited evolutionary hypothesis attributed birth complications to an “obstetric dilemma,” resulting from antagonistic selective pressures acting on maternal pelvic dimensions and fetal brain growth during hominin evolution. However, the childbirth challenges experienced by living humans may not be representative of those in the past, and may vary in association with trends in ecological conditions. We hypothesized that variability in maternal phenotype (height and nutritional status) may contribute to the risk of cesarean delivery. In many populations, high levels of child stunting contribute to a high frequency of short adult stature, while obesity is also becoming more common. The combination of short maternal stature and maternal overweight or obesity may substantially increase the risk of cesarean delivery.

Methods: Using data from two large Indian health surveys from 2005–6 to 2015–2016, we tested associations of maternal somatic phenotype (short stature, overweight) with the risk of cesarean delivery, adjusting for confounding factors such as maternal age, birth order, rural/urban location, wealth and offspring sex.

Results: Secular trends in maternal body mass index between surveys were greater than trends in height. Maternal short stature and overweight both increased the risk of cesarean delivery, most strongly when jointly present within individual women. These associations were independent of birth order, wealth, maternal age and rural/urban location. Secular trends in maternal phenotype explained 18% of the increase in cesarean rate over 10 years.

Conclusion: Our results highlight how the emerging dual burden of malnutrition (persisting short adult stature which reflects persistent child stunting; increasing overweight in adults) is likely to impact childbirth in low and middle-income countries.

Use of a Fibrin Sealant Patch at Cesarean for Conservative Management of Morbidly Adherent Placenta

Background  Morbidly adherent placenta represents a surgical challenge and source of maternal morbidity and mortality. We report the use of a fibrin sealant patch to address hemorrhage associated with a morbidly adherent placenta during cesarean delivery. Case  A patient underwent repeat cesarean delivery with complete anterior placenta previa and anticipated morbidly adherent placenta. Bleeding persisted following delivery and removal of the placenta, despite uterine artery embolization. A fibrin sealant patch was applied as an adjuvant intervention to the placental bed and hemostasis was achieved without resorting to a hysterectomy. Conclusion  Postpartum hemorrhage is an ongoing leading source of maternal morbidity and mortality. A case is presented in which a fibrin sealant patch provided control of focal placental bed bleeding, allowing removal of a focal morbidly adherent placenta and avoidance of hysterectomy.

Progressive Devascularization: A Novel Surgical Approach for Placenta Previa

Background  The gold standard for antenatal diagnosis of placenta previa is the transvaginal ultrasonography. In placenta previa cases, separation of placental and uterine tissues is challenging even for the most experienced surgeons. Life-threatening obstetrical complications from cesarean deliveries with placenta previa include peripartum hemorrhage, coagulopathy, blood transfusion, peripartum hysterectomy, and multiple organ failure. Cases  We detailed the 3 cases of placenta previa that underwent bilateral uterine artery ligation; if hemostasis was not achieved, horizontal mattress sutures were placed in the lower uterine segment. All patients were discharged with minimal morbidity. Conclusion  For patients with placenta previa and low risk for placenta creta, counseling should include the risk for maternal morbidity and criteria for pursuing peripartum hysterectomy. Our devascularization, a stepwise surgical approach, shows promising outcomes in placenta previa cases. Précis  We propose a novel surgical approach, using a progressive devascularization surgical technique, for management of women with placenta previa, undergoing cesarean delivery.

A Literature Review of Midwifery-Led Care in Reducing Labor and Birth Interventions

Certified nurse-midwives are usually recognized as independently practicing advanced practice registered nurses because they provide maternity care to pregnant women in various states. In the United States, certified nurse-midwives are historically underused. Culture favors physician-led care, with 90% of all births attended by physicians. Midwifery-led care is considered high-touch/low-intervention and is guided by a philosophy of care that regards pregnancy and childbirth as normal life events for most women. Evidence from the literature supports midwifery-led care as being safe, effective, and associated with fewer interventions.

Investigation of cesarean sections at Konya Training and Research Hospital Obstetrics and Gynecology Department between 2010 and 2015

OBJECTIVE

Analysis of the annual distribution of cesarean sections and indications between 2010 and 2015 in our clinic.

MATERIAL AND METHODS

Medical records of 10,437 cesarean section patients from a total number of 24,283 deliveries performed at Department of Obstetrics and Gynecology between 2010-2015 were evaluated retrospectively. The indications for Cesarean section were analyzed and compared based on years.

RESULTS

The lowest cesarean section rate was 18.67% in 2011 and the highest rate was 24.5% in 2013, and the annual rates were close to each other in this 6-year period (p > 0.05). History of uterine surgery was the indication with the highest rate of 49.52%, while fetal distress was the second most frequent with 12.53%; presentation anomalies were observed as the most frequent third indication with 7.55%, and umbilical cord prolapse was the least frequent indication with 0.33%.

CONCLUSIONS

Patient education about normal delivery and providing means for pain control during normal delivery, improvement in physical conditions of the clinics, frequent and regular training of the assisting staff with obstetrics physicians are important to diminish the rates of primary cesarean sections. In addition, a normal delivery after a previous cesarean section must be encouraged.

Intervention thresholds and cesarean section rates: A time-trends analysis

INTRODUCTION

To improve understanding of rising cesarean section (CS) rates in the UK, this study assessed the relation between clinician thresholds for performing CS for delayed labor progress or suspected fetal distress and corresponding CS rates in Aberdeen, UK.

MATERIAL AND METHODS

Time-trends analysis of term births from 1988 to 2012 in a population of nulliparous women (N = 53 745) in Aberdeen, UK, using Chi-square test for trend, and binary logistic regression. Data were obtained from the Aberdeen Maternity and Neonatal Databank.

RESULTS

Unplanned CS rates per quintile increased from 11.0% (1391/12 686) to 21.1% (2383/11 273) between 1988 and 2012, while planned CS rates increased from 2.7% (338/12 686) to 5.2% (591/11 273). The median duration of labor before CS for delayed progress per quintile decreased from 17.2 (IQR 12.5-22.3) to 13.1 hours (9.6-16.9) before first stage CS and from 17.1 (12.6-22.3) to 15.3 (11.5-19.1) hours before second stage CS (P < .001). The proportion of CS for suspected fetal distress performed with evidence of fetal acidosis declined from 23.4% (98/418) to 17.4% (106/608) per quintile (P < .01). Neonatal unit admission (adjusted OR 1.99, 95% CI 1.85-2.14) was more likely following unplanned CS than vaginal births. Birth trauma was less likely following both unplanned (adjusted OR 0.48, 95% CI 0.39-0.60) and planned (adjusted OR 0.33, 95% CI 0.18-0.63) CS.

CONCLUSION

Increased CS rates can be partly attributed to lowered clinical thresholds for intrapartum CS. Higher CS rates are associated with less birth trauma for the offspring.

Ondansetron 8 mg and 4 mg with normal saline against post-operative headache and nausea/vomiting after spinal anesthesia: a randomized double-blind trial

The study aims to evaluate the efficacy of ondansetron in preventing post-spinal headache, considering the high prevalence of the headache in pregnant women and the common use of the adjuvants for prophylaxis against post-operative nausea and vomiting (PONV). This double-blind clinical trial included the 195 patients who were referred to Taleghani Hospital (in Arak, Iran) for cesarean section (C/S) under spinal anesthesia, and then the subjects were assigned to three equally sized groups using block randomization. Participants in the first, second, and control groups received 8 mg, 4 mg of ondansetron, and normal saline, respectively, 5 minutes before surgery. A final volume of 5 cc was prepared by adding normal saline. Participants were examined for headache one week after surgery, and then data analysis was performed using SPSS 20. The incidence of post-spinal headache was significantly higher in the placebo group than in the ondansetron 8-mg and 4-mg groups at 24 hours after surgery (P < 0.010). But, no significant difference was observed between two ondansetron groups (P ≤ 0.05). The overall incidence of the headache was generally lower in ondansetron 8-mg (26.66% vs. 33.68.05%) and 31.66% in ondansetron 4-mg (P < 0.001). Moreover, the PONV incidence was significantly higher in the placebo group than in the other two groups at 24 hours (P < 0.001). The hemodynamic variables were same in three groups. The ondansetron 8-mg dose can be effective to prevent headache after spinal anesthesia for C/S. Moreover, the ondansetron 8-mg and ondansetron 4-mg have same effect in control of PONV after spinal anesthesia for C/S.

Case Report of Spontaneous Skull Fracture in a Newborn With Cesarean Birth for Persistent Occiput Posterior Position

Spontaneous newborn skull fracture is rarely cited in nursing literature as a potential outcome of persistent fetal occiput posterior position. Although most newborns seem unaffected by the condition initially, some may show symptoms several hours after the birth, when nursing assessments are less frequent. This case report illustrates delayed newborn symptoms that led to an unexpected diagnosis of spontaneous skull fracture.

Outcomes of Care for 1,892 Doula-Supported Adolescent Births in the United States: The DONA International Data Project, 2000 to 2013

This is the largest study to-date to report on outcomes of care for a national sample of doula-supported adolescent births (n = 1,892, birth years 2000 to 2013). Descriptive statistics were calculated for maternal demographics, risk profiles, labor/birth interventions and occurrences, and birth outcomes. In this national sample, childbearing adolescents and their neonates experienced improved health outcomes and lower rates of intervention relative to national statistics for adolescent deliveries in the United States. Key findings are consistent with previous studies on the effects of doula care for marginalized and medically underserved communities. Results strengthen the case for doulas as a perinatal care strategy for improving maternal and infant health outcomes and decreasing inequities among childbearing adolescents.

Why do women request an elective cesarean delivery for non-medical reasons? A systematic review of the qualitative literature

BACKGROUND

Cesarean rates have increased significantly over the past decade. The reasons for this are both complex and context specific, and have significant consequences for health resources. The aim of this systematic review was to assess published, peer-reviewed, and gray qualitative literature on the reasons behind cesarean delivery on maternal request (CDMR).

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, LILACS, and PsycINFO databases was performed for all relevant articles published between January 2006 and June 2016. Reference lists of all included studies were also searched in addition to select web-based sources. Studies were included if they qualitatively evaluated women's preferences for CDMR, with no geographic restriction. Findings from the studies were narratively and thematically synthesized.

RESULTS

Sixteen studies were included in this review. Three themes were identified as to why women choose CDMR, which were: social norms, emotional experiences, and personal experiences. A woman's decision was often shaped by various influences including family, friends, and the media. In addition, previous experience of childbirth and interactions with health care professionals contributed to a strong preference for CDMR. CDMR provided women with a sense of control over the birth and diminished feelings of fear.

CONCLUSIONS

The reasons behind CDMR are multifactorial and complex. Situation-specific cultural factors, fear of pain during childbirth, previous experience, and interactions with health care professionals are likely to have led to the increase in CDMR. Multifaceted, context-specific approaches are required if there is to be a reduction in CDMR rates.

Continuous local bupivacaine wound infusion with neuraxial morphine reduces opioid consumption after cesarean delivery

Background: As a part of a quality improvement program, maternal postoperative opioid use and pain scores were compared between those receiving continuous infusion of bupivacaine for local incisional pain control with multimodal pain management and neuraxial morphine versus multimodal pain management with neuraxial morphine alone. Objective: We compared postoperative opioid use and pain scores between the multimodal pain management group with neuraxial morphine and the group receiving multimodal pain management, neuraxial morphine, and continuous infusion of bupivacaine for local incisional pain control. Study design: A retrospective cohort analysis of cesarean deliveries from January of 2015 through March of 2016 was undertaken. Deliveries were grouped by utilization of continuous infusion of bupivacaine for local incisional pain control. For each postoperative day, the average daily opioid use, antiemetic use and pain scores were determined. Patients received 1-2 tablets oxycodone-acetaminophen (5-325 mg) every 4 h as needed with oxycodone 5-10 mg immediate release tablets every 4 h as needed for breakthrough pain in addition to acetaminophen and ibuprofen. Total dose of narcotic, antiemetic use, and pain scores was compared between groups utilizing t-test for continuous variables and chi square for categorical data. A linear mixed model with unstructured covariance was utilized to analyze the daily dose of narcotic and pain scores from postoperative day 1 through day 4. Results: Patients in the standard multimodal group with neuraxial morphine used more opioids versus those receiving continuous wound infusion of bupivacaine in total postoperative dosing (122.79 ± 61.92 mg versus 89.88 ± 51.38 mg, p = .0063). There was a statistically significant difference between the standard group and local infusion of bupivacaine group on postoperative days 1 and 2 (32.79 ± 15.56 mg versus 22.13 ± 15.73 mg, p = .0011 and 40.25 ± 19.84 mg versus 29.13 ± 14.58 mg, p = .0018, respectively). There was no difference in narcotic use for postoperative days 3 and 4. There was a higher mean number of antiemetic doses in the standard group (0.31 ± 0.70 versus 0.10 ± 0.30, p = .0396). Pain scores did not differ between groups, although there was a correlation between opioid dosing and pain scores. The standard group received more IV ketorolac (87.72 ± 42.01 mg versus 64.50 ± 53.3 mg, p = .0165) and more IV acetaminophen (634.89 ± 706.42 mg versus 375.0 ± 490.29 mg, p = .0315) within the first 24 h postoperatively. In addition, the standard group received more oral acetaminophen (6969.67 ± 3230.14 mg versus 5248.75 ± 2711.71 mg, p = .0064). No difference was seen in regard to ibuprofen between groups. These results remained constant when adjusted for differences in gestational age, variation in intraoperative opioid dosing, as well as differences in uterine incision type. Conclusion: We found a significant reduction in postoperative opioid use when continuous infusion of bupivacaine for local incisional pain control was added to our standard pain management with neuraxial morphine after cesarean delivery. As a result of this quality improvement initiative, we have implemented this intervention universally as a part of our multimodal postoperative pain management strategy.

Gestation at birth, mode of birth, infant feeding and childhood hospitalization with infection

INTRODUCTION

Infections are a leading cause of mortality and morbidity in preschool children. We aimed to assess the impact of the co-occurrence of cesarean section, early birth and formula feeding on hospitalization with infection in early childhood.

MATERIAL AND METHODS

Population-based retrospective record-linkage cohort study of 488 603 singleton livebirths ≥32 weeks' gestational age in New South Wales, Australia, 2007-2012. Multivariable Cox-regression was used to estimate independent and combined adjusted associations of gestational age, mode of birth (vaginal or cesarean section by labor onset) and formula feeding with time to first and repeat hospitalization with infection for children less than five years of age.

RESULTS

In all, 95 346 (19.5%) children were hospitalized with infection, and of these 24.8% (23 615) more than once. Median age at first and repeat hospitalization was 1.1 and 1.7 years, respectively. Earlier gestation, modes of birth other than spontaneous vaginal, and formula feeding were independently associated with an increased risk of first and repeat hospitalization with infection. At 32-36 weeks' gestation, co-occurrence of perinatal factors (cf. spontaneous vaginal birth at 39+ weeks without formula feeding) was associated with a 2-fold and 1.5-fold increased risk of first and repeat hospitalization, respectively. For births at 37-38 weeks, the increased risk was 1.5-fold and 1.25-fold for first and repeat hospitalization, respectively.

CONCLUSIONS

Cesarean section, labor induction, birth at <39 weeks and formula feeding increase the risk of infection-related hospitalization in childhood, which increases further when these factors co-occur. Reducing early planned birth and supporting breastfeeding are potentially cost-effective approaches to reducing the risk of hospitalization.

Postpartum infection in relation to maternal characteristics, obstetric interventions and complications

The purpose was to evaluate the association between maternal characteristics, obstetrical interventions/complications and postpartum wound infections (WI), urinary tract infection (UTI) and endometritis. Furthermore, this study aimed to determine the time from delivery to onset of infections after discharge from the hospital. Three large Swedish Medical Health Registers were scrutinized for the period 2005-2012. A total of 582,576 women had 795,072 deliveries. Women with diagnosis codes for WIs, UTIs or endometritis, from delivery to 8 weeks postpartum, were compared to non-infected women. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Increasing age and body mass index (BMI) were both associated with increasing prevalence of postpartum infections. WIs were most strongly associated with cesarean section (CS) (OR 17.2; 95%CI 16.1-18.3), 3rd and 4th degree tears (OR 10.7%; 95%CI 9.80-11.9) and episiotomy (OR 10.2; 95%CI 8.94-11.5). Endometritis was associated with anemia (OR 3.16; 95%CI 3.01-3.31) and manual placental removal (OR 2.72; 95%CI 2.51-2.95). UTI was associated with emergency CS (OR 3.46; 95%CI 3.07-3.89) and instrumental delivery (OR 3.70; 95%CI 3.29-4.16). For women discharged from the delivery hospital the peak occurrence of UTI was 6 days postpartum, while for WIs and endometritis it was 7 days postpartum.

Factors Associated With Improvements in Mortality and Morbidity Rates of Very-Low-Birth-Weight Infants: A Cohort Study

Objective. The objective of this study was to determine factors contributing to improvements in infant mortality rates (IMR) and composite morbidity-mortality in very-low-birth-weight (VLBW) infants after initiating a new perinatal program in 2009 at Regional One Health (ROH). VLBW infants account for 67% of infant deaths. Design. This is a pre-/postintervention cohort study of prospectively gathered data. Population. VLBW infants delivered at ROH during the 2004 to 2015 study period. Setting. ROH is a Regional Perinatal Center affiliated with the University of Tennessee Health Science Center. Methods. We studied 2364 consecutive VLBW infants. Multivariate models were applied to determine factors contributing significantly to the reduction in the outcome measures as well as trends over time. Main Outcome Measures. Primary outcomes were IMR and composite morbidity-mortality rates. Standardized, risk-adjusted mortality and composite morbidity ratios were also reported as defined by the Vermont Oxford Network. Results. Mortality declined from 15.5% in Pre-Implementation to 13.1% in Post-Implementation (P = .093), corresponding to an 18% reduction in odds. The combined factors of composite morbidity-mortality rate decreased from 55.7% in Pre-Implementation to 43.9% in Post-Implementation (P < .0001), representing a 38% reduction in odds. Standardized, risk-adjusted mortality and composite morbidity ratios improved during the study period from 20% above to 20% below the expected rate. Increases in the administration of antenatal steroids, surfactant administration, cesarean delivery, and perhaps other programmatic changes that were observational and unaccounted in the model were associated with improvements in outcome measures. Conclusions. Decreased mortality and composite morbidity-mortality in VLBW infants delivered at ROH were found following the initiation of a new perinatal program.

Predictors of Cesarean Delivery in Pregnant Women with Inflammatory Bowel Disease

Aim

Pregnant women with Crohn’s disease (CD) or ulcerative colitis (UC) are likelier to undergo Cesarean delivery than women without IBD. Active perianal disease is the only IBD-related indication for Cesarean delivery. We sought to identify clinical factors contributing to these high rates.

Methods

We conducted a retrospective cohort study of 369 pregnant women with IBD who delivered at our institution between 2006 and 2014. We used logistic regression to identify clinical predictors of Cesarean delivery.

Results

The Cesarean delivery rate among women with CD and UC were 52% and 48%, respectively. Thirty of Cesarean deliveries (54%) in CD and UC patients were performed emergently, respectively. Among those with CD, the strongest predictors of Cesarean delivery were history of perianal disease (adjusted odds ratio [aOR), 13.6; 95% CI: 3.87–47.5) and prior Cesarean delivery (aOR, 22.2; 95% CI: 6.16–80.2). Among women who underwent Cesarean delivery because of perianal disease, only 42% had active perianal symptoms during pregnancy. In UC patients, history of colectomy was a predictor of Cesarean delivery (aOR, 5.08; 95% CI: 1.95–13.2). Cesarean delivery increased the postpartum length of stay by 1.1 days on average for both CD and UC patients, reflecting a 57% and 90% increase over vaginal delivery after adjusting for confounders.

Conclusions

The decision to perform Cesarean delivery for women with IBD is complex involving IBD-related and obstetric factors and is ideally made by a multidisciplinary team that includes input from a gastroenterologist and obstetrician.

Retrospective Chart Review of Skin-to-Skin Contact in the Operating Room and Administration of Analgesic and Anxiolytic Medication to Women After Cesarean Birth

Transporting a newborn out of the operating room after cesarean birth can contribute to maternal awareness of discomfort, anxiety, and the need for administration of analgesics and anxiolytics for relief. This retrospective study analyzed the association between skin-to-skin contact in the operating room and administration of analgesics and anxiolytics to women in the operating and recovery rooms after cesarean birth. Our results indicated a trend toward decreased medication administration for women who experienced skin-to-skin contact and add to evidence supporting the incorporation of skin-to-skin contact in the operating room as the standard of care for cesarean birth. This practice has the potential to enhance the birth experience, promote breastfeeding, and provide greater safety with less exposure to opioids and benzodiazepines for women and their newborns.