Indications for, and timing of, planned caesarean section: A systematic analysis of clinical guidelines

Association between mode of delivery and early neurodevelopment: A prospective birth cohort study

Previous research has assessed the effects of caesarean delivery (CD) on child neurodevelopment; however, whether the effects stem from the surgical procedure itself or its related medical conditions has not been conclusively determined. This study aimed to evaluate the associations among delivery mode, CD-related medical conditions and early childhood neurodevelopment. A total of 3829 maternal-infant pairs from a longitudinal birth cohort in Wuhan City, China, were included in the primary analysis. The neurodevelopment of the children was assessed by the Bayley Scales of Infant Development (BSID), the Conners Comprehensive Behaviour Rating Scale and the Chinese version of the Autism Behavior Checklist. Data on delivery mode and medical conditions were collected via medical records from the study hospital. Among the 3829 children for whom the BSID test was completed at two years of age, 50%, 27%, and 23% were delivered vaginally, by necessary CD, and by elective CD, respectively. Compared with vaginally delivered children, Necessary CD was associated with a 16.67% decrease in Mental Development Index (MDI) scores and a 13.37% decrease in Psychomotor Development Index (PDI) scores, while elective CD showed a 20.63% and 20.99% decrease after FDR correction, respectively. Similarly, among the 2448 children for whom the CBRS was completed, necessary CD was found to be associated with conduct disorders (adjusted β: 0.06; 95% CI: 0.02, 0.09), hyperactivity (adjusted β: 0.06; 95% CI: 0.02, 0.11), and hyperactivity index (adjusted β: 0.07; 95% CI: 0.03, 0.11), while elective CD was significantly associated with hyperactivity problem scores (adjusted β: 0.08, 95% CI: 0.03, 0.13). However, no significant association was found between CD and symptoms of autism in children, as assessed by the Autism Behavior Checklist (ABC).

CONCLUSION

This study suggested that the adverse impact of CD on child neurodevelopment stems from the procedure itself rather than CD-related medical conditions. It is important to minimize the use of CD when there is no medical necessity.

WHAT IS KNOWN

• Caesarean delivery (CD) may influence child neurodevelopment and other long-term outcomes. • In China, approximately one-quarter of CD are performed due to maternal request without medical indications.

WHAT IS NEW

• The negative impact of CD on the neurodevelopmental outcomes of children may be primarily attributed to the procedure itself, as opposed to related medical conditions. • In the absence of medical indications, unnecessary CD may have adverse impacts on children's neurodevelopment.

Association of gestational hepatitis B virus infection and antiviral therapy with pregnancy outcomes: A retrospective study

OBJECTIVE

To explore the relationships between gestational hepatitis B virus (HBV) infection, antiviral therapy, and pregnancy outcomes.

METHODS

We retrospectively selected hepatitis B surface antigen (HBsAg)-positive pregnant women hospitalized for delivery at Fujian Medical University Affiliated Hospital from October 1, 2016 to October 1, 2020. The control group included randomly selected healthy pregnant women hospitalized for delivery during the same time.

RESULTS

Overall, 1115 participants were enrolled and grouped into control (n = 380) and HBsAg-positive groups (n = 735), which were further divided into groups I (n = 407; low viral load), II (n = 207; high viral load without antiviral therapy), and III (n = 121; high viral load with antiviral therapy). Pregnant women with HBV were positively correlated with the incidence of intrahepatic cholestasis of pregnancy (ICP) (adjusted odds ratio [aOR] 5.1, 95% confidence interval [CI] 2.62-9.92, P < 0.001), neonatal jaundice (aOR 10.56, 95% CI 4.49-24.83, P < 0.001), and neonatal asphyxia (aOR 5.03, 95% CI 1.46-17.27, P = 0.01). Aspartate aminotransferase (AST) greater than the upper limit of normal (ULN) was an independent risk factor for increased ICP incidence (aOR 3.49, 95% CI 1.26-9.67, P = 0.019). Antiviral therapy considerably reduced HBV DNA and improved liver function. High viral load and antiviral therapy did not correlate significantly with adverse pregnancy outcomes (P < 0.05).

CONCLUSION

Pregnant women with HBV have significantly elevated incidence of ICP, neonatal jaundice, and neonatal asphyxia not significantly correlated with viral load. AST greater than ULN independently increases the risk of ICP. Antiviral therapy effectively reduces viral replication and improves liver function without increasing the risk of adverse outcomes.

Likelihood of primary cesarean section following induction of labor in singleton cephalic pregnancies at term, compared with expectant management: An Australian population-based, historical cohort study

INTRODUCTION

There has been increased use of both induction of labor (IOL) and cesarean section for women with term pregnancies in many high-income countries, and a trend toward birth at earlier gestational ages. Existing evidence regarding the association between IOL and cesarean section for term pregnancies is mixed and conflicting, and little evidence is available on the differential effect at each week of gestation, stratified by parity.

MATERIAL AND METHODS

To explore the association between IOL and primary cesarean section for singleton cephalic pregnancies at term, compared with two definitions of expectant management (first: at or beyond the week of gestation at birth following IOL; and secondary: only beyond the week of gestation at birth following IOL), we performed analyses of population-based historical cohort data on women who gave birth in one Australian state (Queensland), between July 1, 2012 and June 30, 2018. Women who gave birth before 37+0 or after 41+6 weeks of gestation, had stillbirths, no-labor, multiple births (twins or triplets), non-cephalic presentation at birth, a previous cesarean section, or missing data on included variables were excluded. Four sub-datasets were created for each week at birth (37-40). Unadjusted relative risk, adjusted relative risk using modified Poisson regression, and their 95% confidence intervals were calculated in each sub-dataset. Analyses were stratified by parity (nulliparas vs. parous women with a previous vaginal birth). Sensitivity analyses were conducted by limiting to women with low-risk pregnancies.

RESULTS

A total of 239 094 women were included in the analysis, 36.7% of whom gave birth following IOL. The likelihood of primary cesarean section following IOL in a Queensland population-based cohort was significantly higher at 38 and 39 weeks, compared with expectant management up to 41+6 weeks, for both nulliparas and paras with singleton cephalic pregnancies, regardless of risk status of pregnancy and definition of expectant management. No significant difference was found for nulliparas at 37 and 40 weeks; and for paras at 40 weeks.

CONCLUSIONS

Future studies are suggested to investigate further the association between IOL and other maternal and neonatal outcomes at each week of gestation in different maternal populations, before making any recommendation.

Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study

PROBLEM

Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions.

BACKGROUND

Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth.

AIM

We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians.

METHODS

The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews.

FINDINGS

The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process.

DISCUSSION

The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice.

CONCLUSION

Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.

Association of Maternal Risk Factors with the Prevalence of Caesarean Section Deliveries: A Cross-Sectional Study

In the last few years, there has been a gradually increasing rate of caesarean section deliveries worldwide that negatively affects both mothers' and children's health. The present survey intended to explore the relations of common maternal risk factors with the prevalence of caesarean sections. This is a cross-sectional study including 5182 healthy mothers from geographically diverse regions of Greece, which has applied relevant inclusion and exclusion criteria. An elevated 56.4% incidence of caesarean sections was noted. The prevalence of caesarean section deliveries was estimated to be 51.5% in private hospitals and 48.5% in public hospitals. Maternal age, pre-pregnancy overweight/obesity, excess gestational weight gain, preterm birth, financial status, smoking habits, and private type of birth hospital were considerably associated with a high probability of caesarean section, regardless of several confounders. In conclusion, caesarean section rates are constantly increasing, and various maternal risk factors additively elevate its incidence, which additionally enhances the likelihood of postpartum complications for both the mothers and their infants. Public health procedures and approaches are strongly recommended to notify future mothers of the potential risk factors that may result in adverse pregnancy outcomes of caesarean section delivery, highlighting its use only for emergency medical reasons and also promoting healthier nutritional and lifestyle habits that may reduce the increasing prevalence of caesarean section deliveries.

Pregnancy associated cancer, timing of birth and clinical decision making-a NSW data linkage study

BACKGROUND

The incidence of pregnancy-associated cancer (PAC), comprising cancer diagnosed during pregnancy or within one year postpartum, is increasing. We investigated the obstetric management and outcomes of women with PAC and their babies.

METHODS

A population-based observational study of all women who gave birth between 1994 and 2013 in New South Wales, Australia. Women were stratified into three groups: those diagnosed during pregnancy (gestational cancer group), those diagnosed within one year of giving birth (postpartum cancer group), and a no-PAC group. Generalized estimating equations were used to examine the association between PAC and adverse maternal and neonatal outcomes.

RESULTS

One million seven hundred eighty-eight thousand four hundred fifty-onepregnancies were included-601 women (614 babies) were in the gestational cancer group, 1772 women (1816 babies) in the postpartum cancer group, and 1,786,078 women (1,813,292 babies) in the no-PAC group. The overall crude incidence of PAC was 132.7/100,000 women giving birth. The incidence of PAC increased significantly over the twenty-year study period from 93.5/100,000 in 1994 to 162.5/100,000 in 2013 (2.7% increase per year, 95% CI 1.9 - 3.4%, p-value < 0.001). This increase was independent of maternal age. The odds of serious maternal complications (such as acute abdomen, acute renal failure, and hysterectomy) were significantly higher in the gestational cancer group (adjusted odds ratio (AOR) 5.07, 95% CI 3.72 - 6.90) and the postpartum cancer group (AOR 1.55, 95% CI 1.16 - 2.09). There was no increased risk of perinatal mortality in babies born to women with PAC. However, babies of women with gestational cancer (AOR 8.96, 95% CI 6.96 - 11.53) or postpartum cancer (AOR 1.36, 95% CI 1.05 - 1.81) were more likely to be planned preterm birth. Furthermore, babies of women with gestational cancer had increased odds of a severe neonatal adverse outcome (AOR 3.13, 95% CI 2.52 - 4.35).

CONCLUSION

Women with PAC are more likely to have serious maternal complications. While their babies are not at increased risk of perinatal mortality, they are more likely to experience poorer perinatal outcomes associated with preterm birth. The higher rate of birth intervention among women with gestational cancers reflects the complexity of clinical decision-making in this context.

From data to practice change - exploring new territory for atlases of clinical variation

Despite decades of atlas production and use within multiple healthcare systems, and consistent reporting of geographical differences in the utilisation of services, significant levels of clinical variation persist. Drawing on over forty years of combined experience using atlases of clinical variation, we reflect on why that might be the case and explore the role of atlases have played in efforts to reduce inappropriate overuse, underuse and misuse of healthcare services. We contend that atlases are useful but, on their own, are not enough to drive change in clinical practice and improvement in patient outcomes. Building on four conceptual models we have published since 2017, we argue that atlases, with their focus on measuring healthcare utilisation by residents in different geographies, generally fail to provide sufficient information and statistical analyses to truly assess the nature of the variation and support action for change. They seldom use structures such as hospitals or teams as the unit of analysis to understand variation; they rarely feature the key elements of healthcare performance which underlie variation; they are mostly silent about how to assess whether the variation measured is warranted or truly unwarranted; nor do they identify evidence-based levers for change. This means that a stark choice confronts producers of atlases - to either continue with the current model and more explicitly rely on other players to undertake work to complete the 'data to action' cycle that is necessary to secure improvement; or to refine their offering - including more sophisticated performance measurement approaches, nuanced guides for interpretation of any differences found, support for the selection and application of levers for change that align with local context, and provision of evidence-based options for implementation.

Mapping of high-risk detection of women pregnancy on antenatal care in Talise Health Center, Palu City, Indonesia

OBJECTIVE

This study aimed to map pregnant women with high-risk pregnancies based on age, parity, pregnancy history, childbirth history, illness history, and CED status history as well as the relationship between the six factors.

METHOD

This study utilized a survey method with descriptive data without the intervention of variables but observed phenomena or sought the relationship between phenomena and other variables. The survey was conducted with an approach using Geographic Information Systems (GIS). There were 243 respondents obtained using the Lemeshow formula, while the data were analyzed using spatial techniques and Chi-Square test with p>0.05.

RESULTS

The results of spatial analysis using a 1: 50,000 scale map showed that; (1) high-risk and very high-risk pregnancies dominated Talise, (2) based on age, parity, pregnancy history, childbirth history, illness history, and CED status, cases of high-risk pregnancies were all detected in Talise, (3) age (p=0.000). Furthermore, pregnancy history (p=0.004) correlated with a high-risk pregnancy. Besides, parity, childbirth history, illness history, and CED status did not correlate with high-risk pregnancy since the p-value>0.05; (4) age and pregnancy history influenced the high-risk pregnancy.

Women's Experiences and Involvement in Decision-Making in Relation to Planned Cesarean Birth: An Interview Study

Actively engaging women in decision-making about their own care is critical to providing woman-centered maternity care. The aim was to understand women's mode-of-birth preferences and shared decision-making experiences during planned cesarean birth (CB). Semi-structured telephone interviews were conducted with 33 women who had planned CB at eight Australian metropolitan hospitals. Inductive thematic analysis was conducted using NVivo-12. Many women preferred a vaginal birth but were willing to have a CB if the clinician recommended. Most women looked to their clinicians for information and guidance. Although many women reported receiving enough information to make informed decisions, others felt pressured into having or not having a CB, or expected to make decisions themselves. Women wished for longer consultation times, more information, and care continuity.

What are the causes for low birthweight in Japan? A single hospital-based study

Low-birthweight (LBW; <2,500 g) babies are at a higher risk of poor educational achievement, disability, and metabolic diseases than normal-birthweight babies in the future. However, reliable data on factors that contribute to LBW have not been considered previously. Therefore, we aimed to examine the distribution of the causes for LBW. A retrospective review of cases involving 4,224 babies whose mothers underwent perinatal care at Keio University Hospital between 2013 and 2019 was conducted. The LBW incidence was 24% (1,028 babies). Of the 1,028 LBW babies, 231 babies were from multiple pregnancies. Of the 797 singleton LBW babies, 518 (65%) were born preterm. Obstetric complications in women with preterm LBW babies included premature rupture of membrane or labor onset (31%), hypertensive disorders of pregnancy (HDP, 64%), fetal growth restriction (24%), non-reassuring fetal status (14%), and placental previa/vasa previa (8%). Of the 279 term LBW babies, 109 (39%) were small for gestational age. Multiple logistic regression analyses revealed the following factors as LBW risk factors in term neonates: low pre-pregnancy maternal weight, inadequate gestational weight gain, birth at 37 gestational weeks, HDP, anemia during pregnancy, female sex, and neonatal congenital anomalies. HDP was an LBW risk factor not only in preterm births but also in term births. Our results suggest that both modifiable and non-modifiable factors are causes for LBW. It may be appropriate to consider a heterogeneous rather than a simple classification of LBW and to evaluate future health risks based on contributing factors.

Inter-hospital and inter-disciplinary variation in planned birth practices and readiness for change: a survey study

BACKGROUND

How the application of evidence to planned birth practices, induction of labour (IOL) and prelabour caesarean (CS), differs between Australian maternity units remains poorly understood. Perceptions of readiness for practice change and resources to implement change in individual units are also unclear.

AIM

To identify inter-hospital and inter-professional variations in relation to current planned birth practices and readiness for change, reported by clinicians in 7 maternity units.

METHOD

Custom-created survey of maternity staff at 7 Sydney hospitals, with questions about women's engagement with decision making, indications for planned birth, timing of birth and readiness for change. Responses from midwives and medical staff, and from each hospital, were compared.

FINDINGS

Of 245 completed surveys (27% response rate), 78% were midwives and 22% medical staff. Substantial inter-hospital variation was noted for stated planned birth indication, timing, women's involvement in decision-making practices, as well as in staff perceptions of their unit's readiness for change. Overall, 48% (range 31-64%) and 64% (range 39-89%) agreed on a need to change their unit's caesarean and induction practices respectively. The three units where greatest need for change was perceived also had least readiness for change in terms of leadership, culture, and resources. Regarding inter-disciplinary variation, medical staff were more likely than midwifery staff to believe women were appropriately informed and less likely to believe unit practice change was required.

CONCLUSION

Planned birth practices and change readiness varied between participating hospitals and professional groups. Hospitals with greatest perceived need for change perceived least resources to implement such change.

Quality assessment of evidence-based clinical practice guidelines for the management of pregnant women with sickle cell disease using the AGREE II instrument: a systematic review

BACKGROUND

The management of pregnant women with sickle cell disease (SCD) poses a major challenge for maternal healthcare services owing to the potential for complications associated with morbidity and mortality. Trustworthy evidence-based clinical practice guidelines (CPGs) have a major impact on the positive outcomes of appropriate healthcare. The objective of this study was to critically appraise the quality of recent CPGs for SCD in pregnant women.

METHODS

Clinical questions were identified and the relevant CPG and bibliographic databases were searched and screened for eligible CPGs. Each CPG was appraised by four independent appraisers using the AGREE II Instrument. Inter-rater analysis was conducted.

RESULTS

Four eligible CPGs were appraised: American College of Obstetricians and Gynecologists (ACOG), National Heart, Lung, and Blood Institute (NHLBI), National Institute of Health and Care Excellence (NICE), and Royal College of Obstetricians and Gynaecologists (RCOG). Among them, the overall assessments of three CPGs (NICE, RCOG, NHLBI) scored greater than 70%; these findings were consistent with the high scores in the six domains of AGREE II, including:[1] scope and purpose,[2] stakeholder involvement,[3] rigor of development,[4] clarity of presentation,[5] applicability, and [6] editorial independence domains. Domain [3] scored (90%, 73%, 71%), domain [5] (90%, 46%, 47%), and domain [6] (71%, 77%, 52%) for NICE, RCOG, and NHLBI, respectively. Overall, the clinical recommendations were not significantly different between the included CPGs.

CONCLUSIONS

Three evidence-based CPGs presented superior methodological quality. NICE demonstrated the highest quality followed by RCOG and NHLBI and all three CPGs were recommended for use in practice.

Women's experiences of decision-making and beliefs in relation to planned caesarean section: A survey study

BACKGROUND

The caesarean section (CS) rate is over 25% in many high-income countries, with a substantial minority of CSs occurring in women with low-risk pregnancies. CS decision-making is influenced by clinician and patient beliefs and preferences, and clinical guidelines increasingly stipulate the importance of shared decision-making (SDM). To what extent SDM occurs in practice is unclear.

AIMS

To identify women's birth preferences and SDM experience regarding planned CS.

MATERIAL AND METHODS

Survey of women at eight Sydney hospitals booked for planned CS. Demographic data, initial mode of birth preferences, reason for CS, and experiences of SDM were elicited using questions with multiple choice lists, Likert scales, and open-ended responses. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Responses of women who perceived their CS as 'requested' vs 'recommended' were compared.

RESULTS

Of 151 respondents, repeat CS (48%) and breech presentation (14%) were the most common indications. Only 32% stated that at the beginning of pregnancy they had a definite preference for spontaneous labour and birth. Key reasons for wanting planned CS were to avoid another emergency CS, prior positive CS experience, and logistical planning. Although 15% of women felt pressured (or were unsure) about their CS decision, the majority reported positive experiences, with over 90% indicating they were informed about CS benefits and risks, had adequate information, and understood information provided.

CONCLUSIONS

The majority (85%) of women appeared satisfied with the decision-making process, regardless of whether they perceived their CS as requested or recommended.

Neonatal effect of remifentanil in cesarean section with general anesthesia: A protocol of systematic review and meta-analysis

BACKGROUND

Although several previous studies have reported the efficacy of remifentanil in cesarean section (CS) under general anesthesia, no study has specifically addressed its neonatal effect (NE) in CS under general anesthesia systematically. Thus, this study will systematically investigate the NE of remifentanil in CS under general anesthesia.

METHODS

Electronic databases including MEDLINE, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be systematically retrieved with the assistance of a specialist librarian to check randomized controlled trials reporting NE in CS under general anesthesia. We will retrieve all electronic databases from their initial time to March 20, 2020 without restrictions of language. All process of study selection, data extraction, and risk of bias evaluation will be carried out by 2 independent authors. We will invite another senior expert to solve the problems that arise between 2 authors. Data will be pooled and analyzed using RevMan V.5.3 software.

RESULTS

Outcomes consist of assessment of neonatal adaptation, requirements for postoperative respiratory support of neonates, systolic and diastolic noninvasive blood pressure, mean blood pressure, heart rate, electrocardiography, umbilical cord blood gas analysis, and adverse events.

CONCLUSION

This study will present evidence of the NE of remifentanil in CS under general anesthesia. This information may inform benefits of intervention to guide the usage of remifentanil in CS under general anesthesia.

STUDY REGISTRATION

INPLASY202040028.