Vaginal delivery vs. a 'nice clean cut': giving more attention to mothers' postpartum health

Intrauterine bacterial growth in elective and non-elective caesarean sections

We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS (p < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM (p < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis (p < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statementWhat is already known on this subject? Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section.What do the results of this study add? Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value.What are the implications of these findings for clinical practice and/or further research? Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.

Recovery after caesarean birth: a qualitative study of women's accounts in Victoria, Australia

BACKGROUND

The caesarean section rate is increasing globally, especially in high income countries. The reasons for this continue to create wide debate. There is good epidemiological evidence on the maternal morbidity associated with caesarean section. Few studies have used women's personal accounts of their experiences of recovery after caesarean. The aim of this paper is to describe women's accounts of recovery after caesarean birth, from shortly after hospital discharge to between five months and seven years after surgery.

METHOD

Women who had at least one caesarean birth in a tertiary hospital in Victoria, Australia, participated in an interview study. Women were selected to ensure diversity in experiences (type of caesarean, recency), caesarean and vaginal birth, and maternal request caesarean section. Interviews were audiotaped and transcribed verbatim. A theoretical framework was developed (three Zones of clinical practice) and thematic analysis informed the findings.

RESULTS

Thirty-two women were interviewed who between them had 68 births; seven women had experienced both caesarean and vaginal births. Three zones of clinical practice were identified in women's descriptions of the reasons for their first caesareans. Twelve women described how, at the time of their first caesarean section, the operation was performed for potentially life-saving reasons (Central Zone), 11 described situations of clinical uncertainty (Grey Zone), and nine stated they actively sought surgical intervention (Peripheral Zone).Thirty of the 32 women described difficulties following the postoperative advice they received prior to hospital discharge and their physical recovery after caesarean was hindered by a range of health issues, including pain and reduced mobility, abdominal wound problems, infection, vaginal bleeding and urinary incontinence. These problems were experienced across the three zones of clinical practice, regardless of the reasons women gave for their caesarean.

CONCLUSION

The women in this study reported a range of unanticipated and unwanted negative physical health outcomes following caesarean birth. This qualitative study adds to the existing epidemiological evidence of significant maternal morbidity after caesarean section and underlines the need for caesarean section to be reserved for circumstances where the benefit is known to outweigh the harms.

Cesarean section and postnatal sexual health

BACKGROUND

Cesarean delivery avoids perineal trauma and has therefore often been assumed to protect sexual function after childbirth. We sought to examine this assumption by using data from a study of women's sexual health after childbirth to assess whether women who underwent cesarean section experienced better sexual health in the postnatal period than women with vaginal births.

METHODS

A cross-sectional study was conducted of 796 primiparous women, employing data from obstetric records and a postal survey 6 months after delivery.

RESULTS

Any protective effect of cesarean section on sexual function was limited to the early postnatal period (0-3 months), primarily to dyspareunia-related symptoms. At 6 months the differences in dyspareunia-related symptoms, sexual response-related symptoms, and postcoital problems were much reduced or reversed, and none reached statistical significance.

CONCLUSIONS

Outcomes from this study provide no basis for advocating cesarean section as a way to protect women's sexual function after childbirth.

Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey

OBJECTIVE

To describe the incidence of three conditions of acute severe maternal morbidity in selected regions in nine European countries.

DESIGN

A population-based questionnaire survey.

SETTING

Eleven regions in nine countries of Europe.

POPULATION

All the pregnant women in each region who had delivered during the period covered by the study.

METHODS

Standard definitions of three severe obstetric conditions, pre-eclampsia, postpartum haemorrhage and sepsis were established by a steering committee. A common questionnaire was used in each participating country. The incidence of the three obstetric conditions and characteristics of the study women were compared.

MAIN OUTCOME MEASURES

Incidence of three severe obstetric conditions: pre-eclampsia, postpartum haemorrhage and sepsis.

RESULTS

The study identified 1734 women with at least one of the three conditions, with 847 experiencing severe haemorrhage, 793 experiencing severe pre-eclampsia and 142 experiencing severe sepsis. There were wide variations in incidence of three conditions combined, ranging from 14.7 per thousand deliveries in Brussels, Belgium to 6.0 per thousand deliveries in Upper Austria.

CONCLUSIONS

This study sets a simple and straightforward approach to the definition of three severe obstetric conditions and allows population-based comparisons between developed countries in Europe, even though difficulties may have been present with applying the definition across countries. The reported incidence of these severe obstetric conditions in general and severe haemorrhage varied significantly between countries. Overall, severe haemorrhage in particular was the most common of the three conditions, followed closely by severe pre-eclampsia.

Maternal health outcomes in Europe

OBJECTIVES

To use PERISTAT data on indicators of maternal mortality and morbidity to explore maternal health outcomes in Europe, and to discuss the implications of variations in the data sources for these indicators.

STUDY DESIGN

The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Maternal mortality ratios are calculated, and data to describe maternal mortality by age, cause of death and mode of delivery are pooled for the countries that provided data.

RESULTS

Data presented show an increased risk of maternal death among older mothers and for caesarean sections compared with other modes of delivery, and the three most prevalent causes of maternal deaths reported were embolism, hypertensive diseases of pregnancy, and haemorrhage.

CONCLUSIONS

Variations in maternal mortality ratios reflect different data sources with varying levels of ascertainment in addition to differences in the number of maternal deaths. Further development is needed to construct comparable indicators of maternal morbidity.