Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term

Impact of Gestational Weight Gain Recommendations for Obese Women on Neonatal Morbidity

INTRODUCTION

 In 2013, the American College of Obstetricians and Gynecologists (ACOGs) developed gestational weight gain guidelines to minimize the risks associated with obesity during pregnancy. However, a growing body of evidence suggests that current recommendations should be revised for obese women.

OBJECTIVE

 The objective of this study is to assess the impact of gestational weight gain recommendations for obese women (body mass index ≥ 30 kg/m2) on neonatal and maternal outcomes in Quebec.

STUDY DESIGN

 Secondary analysis of the QUARISMA trial was performed including obese women who delivered a full-term singleton in cephalic presentation from 2008 to 2011 in Quebec. Outcomes assessed were composite risks of major neonatal and maternal complications, minor neonatal and maternal complications, as well as obstetrical interventions. Outcomes were compared between weight gain recommendations (reference group) and three weight gain/loss categories using logistic regressions. In second analysis, obese women were stratified by obesity class.

RESULTS

 Among the 16,808 eligible obese women, 605 lost weight during pregnancy, 2,665 gained between 0 and 4.9 kg, 4,355 gained weight within the recommendations (5-9.09 kg), and 9,183 gained at least 9.1 kg. Results showed a significant reduction in major neonatal morbidity (adjusted odds ratio [aOR] = 0.69, 95% confidence interval [CI] = 0.51-0.94), minor maternal morbidity (aOR = 0.79, 95%CI = 0.67-0.93), and assisted vaginal delivery (aOR = 0.82, 95%CI = 0.68-0.99) among women who gained 0 to 4.9 kg compared with the reference group. Cesarean delivery and preeclampsia/eclampsia were significantly reduced with weight loss (aOR = 0.76, 95%CI = 0.64-0.89 and 0.58, 95%CI = 0.42-0.78) compared with the reference group. Weight gain above recommendations was associated with an increased risk of minor neonatal morbidity, major and minor maternal morbidity, as well as cesarean delivery.

CONCLUSION

 Compared with a weight gain within the recommendations, a gestational weight gain/loss of less than 5 kg in obese women is associated with a reduced risk of major neonatal morbidity, minor maternal morbidity, preeclampsia/eclampsia, cesarean delivery, and assisted vaginal delivery. Guidelines on gestational weight gain for obese women should be updated.

KEY POINTS

· Gestational weight gain/loss of less than 5 kg reduces the risk of perinatal complications.. · As suggested by ACOG recommendations, guidelines for obese women should be updated.. · Recommendations stratified by obesity class should be included in revised guidelines..

Do all patients with history of pelvic ring injuries need a cesarean section? - A survey of orthopaedic and obstetric providers

OBJECTIVE(S)

The recommended mode of delivery following pelvic ring fractures with surgical fixation is unclear. The objective of this study was to assess expert opinions from orthopaedic surgeons and obstetrician gynecologists on their recommended delivery recommendations for pregnant individuals with a history of pelvic ring injury, and to see if there was any difference in recommendations between the two specialties, and what factors influenced recommendations.

STUDY DESIGN

An electronic, web-based survey was administered to a convenience sample of orthopaedic surgeons and obstetrician gynecologists, via advertisement to members of the Orthopaedic Trauma Association (OTA), the Society for Maternal Fetal Medicine, and querying obstetrician gynecologists practicing within the Military Health System. The survey was administered from November 2021 to December 2022. A two-proportion z-test, Chi-square or Fisher's Exact Test, and descriptive statistics were used to analyze data.

RESULTS

Survey respondents included 44 orthopaedic surgeons and 37 obstetricians. A total of 74 % obstetricians would recommend a trial of labor with hardware in place, while orthopaedic surgeon's recommendations varied based on the type of fixation. Forty four, 100 % of orthopaedic surgeons, recommended trial of labor if non-operative pelvic injury or unilateral posterior fixation only, 88 % recommended trial of labor if bilateral posterior fixation only, and 47.7 % for anterior trans-symphyseal plating only, 50 % for unilateral posterior and trans-symphyseal plating, and 43.2 % for bilateral posterior fixation with trans-symphyseal plating.

CONCLUSIONS

The results of these surveys demonstrate the lack of consensus as to the most appropriate birth plan for patients with a history of pelvic ring injuries. Vaginal delivery following pelvic ring fracture and fixation is possible, yet these patients are significantly more likely to undergo cesarean section than the general population. As such, we recommend that women who become pregnant after operative treatment of a pelvic ring injury develop an in-depth birthing plan with their obstetrician to determine the best course.

Associations between the Safe Prevention of Primary Cesarean Delivery Care Consensus and Maternal/Neonatal Outcomes

OBJECTIVE

 This study aimed to compare cesarean delivery (CD) rates and maternal/neonatal outcomes before and after the 2014 ACOG/SMFM Obstetric Care Consensus for Safe Prevention of Primary CD.

STUDY DESIGN

 This retrospective study compared unscheduled CD rates and outcomes of singleton, cephalic, term pregnancies at a tertiary-care teaching maternity hospital. Births 5 years before (March 2009-February 2014) and after (June 2014-May 2019) release of the consensus were included. Chi-square and t-test were used to compare outcomes and logistic regression to adjust for confounders.

RESULTS

 In this study, 44,001 pregnancies were included, 20,887 before and 23,114 after the consensus. Unscheduled CD rates increased after the consensus (12.9 vs. 14.3%, p < 0.001); however, there was no difference after adjustment (adjusted odds ratio [aOR], 0.97; 95% confidence interval [CI], 0.91-1.03). Vaginal birth after cesarean (VBAC) deliveries increased among multiparas (4.8 vs. 7.2%, p < 0.001), which remained significant after adjustment (aOR, 1.51; 95% CI, 1.37-1.66). Postpartum hemorrhage, blood transfusion, and chorioamnionitis were modestly increased, while third-degree perineal lacerations decreased. Uterine rupture and neonatal outcomes were unchanged after adjustment.

CONCLUSION

 At our tertiary-care maternity hospital, the Safe Prevention of Primary CD Care Consensus was not associated with a change in unscheduled CD, though VBAC deliveries increased. We did not demonstrate improved neonatal outcomes and showed increased maternal morbidity that warrants further study.

KEY POINTS

· Consensus did not change unscheduled cesarean rates.. · Consensus associated with increased hemorrhage.. · Institutional outcomes can assist implementing changes..

Maternal Morbidity in the Second Stage of Labor: Analysis to Simulate the Clinical Choice

OBJECTIVE

 The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice.

STUDY DESIGN

 The study design comprises secondary analysis of the Consortium for Safe Labor, which included 228,688 deliveries at 19 hospitals between 2002 and 2008. We included the 107,675 women who were undergoing a trial of labor without a prior uterine scar or history of substance abuse, who reached the second stage, with a liveborn, nonanomalous, vertex, singleton, at term of at least 2,500 g. Maternal complications included postpartum fever, hemorrhage, blood transfusion, thrombosis, intensive care unit (ICU) admission, hysterectomy, and death. For maternal complications, we simulated the clinical choice by comparing operative vaginal or cesarean deliveries to continued expectant management at every hour in the second stage. For neonatal complications, we modeled the risk of severe neonatal complication by second stage duration for spontaneous vaginal deliveries only, adjusting for maternal demographics, comorbidities, and delivery hospital. Severe neonatal complications included death, asphyxia, hypoxic-ischemic encephalopathy (HIE), seizure, sepsis with prolonged stay, need for mechanical ventilation, and 5-minute Apgar score <4.

RESULTS

 Maternal morbidity was higher with operative vaginal/cesarean delivery versus continued expectant management for every hour in the second stage, a difference that was statistically significant at hour 2 (18.4 vs. 14.7%; p <0.01). Overall, 951 (0.88%) deliveries were complicated by a severe neonatal complication. A second stage over 4 hours was associated with an adjusted odds of severe neonatal complication of 2.10 (95% confidence interval [CI]: 1.32-3.34) as compared with women who delivered in the first hour.

CONCLUSION

 There is a trade-off between maternal and neonatal morbidity in the second stage of labor. Serious neonatal complications rise throughout, however, there is no time at which maternal morbidity is improved with a cesarean or operative vaginal delivery. Strategies are needed to identify neonates at highest risk of complication for targeted intervention.

KEY POINTS

· Severe neonatal complications increase with every hour in the second stage.. · Shortening the second stage is associated with higher maternal complications at every hour.. · There is a trade-off between maternal and neonatal morbidity in the second stage..

Maternal outcomes of planned mode of delivery for term breech in nulliparous women

OBJECTIVE

To estimate short- and long-term maternal complications in relation to planned mode of term breech delivery in first pregnancy.

DESIGN

Register-based cohort study.

SETTING

Denmark.

POPULATION

Nulliparous women with singleton breech delivery at term between 1991 and 2018 (n = 30,778).

METHODS

We used data from the Danish national health registries to identify nulliparous women with singleton breech presentation at term and their subsequent pregnancies. We performed logistic regression to compare the risks of maternal complications by planned mode of delivery. All data were proceeded and statistical analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA).

MAIN OUTCOME MEASURES

Postpartum hemorrhage, operative complications, puerperal infections in first pregnancy and uterine rupture, placenta previa, post-partum hemorrhage, hysterectomy and stillbirth in the subsequent two pregnancies.

RESULTS

We identified 19,187 with planned cesarean and 9,681 with planned vaginal breech delivery of which 2,970 (30.7%) delivered vaginally. Planned cesarean significantly reduced the risk of postoperative infections (2.4% vs 3.9% adjusted odds ratio (aOR): 0.54 95% confidence interval (CI) 0.44-0.66) and surgical organ lesions (0.06% vs 0.1%; (aOR): 0.29 95% CI 0.11-0.76) compared to planned vaginal breech delivery. Planned cesarean delivery in the first pregnancy was associated with a significantly higher risk of uterine rupture in the subsequent pregnancies but not with risk of postpartum hemorrhage, placenta previa, hysterectomy, or stillbirth.

CONCLUSION

Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications but a higher risk of uterine rupture in their subsequent pregnancies.

Does structured obstetric management play a role in the delivery mode and neonatal outcome of twin pregnancies?

PURPOSE

While the optimal delivery method of twin pregnancies is debated, the rate of cesarean deliveries is increasing. This retrospective study evaluates delivery methods and neonatal outcome of twin pregnancies during two time periods and aims to identify predictive factors for the delivery outcome.

METHODS

553 twin pregnancies were identified in the institutional database of the University Women's Hospital Freiburg, Germany. 230 and 323 deliveries occurred in period I (2009-2014) and period II (2015-2021), respectively. Cesarean births due to non-vertex position of the first fetus were excluded. In period II, the management of twin pregnancies was reviewed; adjusted and systematic training with standardized procedures was implemented.

RESULTS

Period II showed significantly lower rates of planned cesarean deliveries (44.0% vs. 63.5%, p < 0.0001) and higher rates of vaginal deliveries (68% vs. 52.4%, p = 0.02). Independent risk factors for primary cesarean delivery were period I, maternal age > 40 years, nulliparity, a history with a previous cesarean, gestational age < 37 completed weeks, monochorionicity and increasing birth weight difference (per 100 g or > 20%). Predictive factors for successful vaginal delivery were previous vaginal delivery gestational age between 34 and 36 weeks and vertex/vertex presentation of the fetuses. The neonatal outcomes of period I and II were not significantly different, but planned cesareans in general were associated with increased admission rates to the neonatal intensive care units. Inter-twin interval had no significant impact on neonatal outcome.

CONCLUSION

Structured regular training of obstetrical procedures may significantly reduce high cesarean rates and increase the benefit-risk ratio of vaginal deliveries.

Socioeconomic inequalities in skilled attendance at birth and caesarean section rates in Myanmar 2015-2016: a cross-sectional study

OBJECTIVES

This study aims to assess inequalities in skilled birth attendance and utilisation of caesarean section (CS) in Myanmar.

STUDY DESIGN

Cross-sectional study design.

SETTING AND POPULATION

We used secondary data from the Myanmar Demographic and Health Survey (2015-2016). Our outcome measures of skilled birth attendance and utilisation of CS were taken from the most recent birth of interviewed women. Absolute and relative inequalities across several sociodemographic characteristics were assessed and evaluated by calculating rate differences, rate ratio and concentration indexes.

RESULTS

More than one-third (36%, 95% CI 32.5% to 39.4%) of women gave birth without a skilled birth attendant present at their most recent birth. 40.7% (95% CI 37.8% to 43.7%) gave birth in healthcare facilities, and the CS rate was 19.7% (95% CI 17.9% to 21.8%) for their most recent birth. The highest proportion of birth without a skilled provider was found in the hilly regions and rural residents, poorest and less educated women, and those with less than four antenatal care visits. Inequalities in birth without a skilled provider were observed across regions, place of residence, wealth quintile, education level and number of antenatal care taken. The highest rate of CS was found among plain regions and urban residents, richest women, more than secondary education, those with more than four antenatal care visits and in private health facilities. Inequalities in CS utilisation were observed across place of residence, wealth quintiles, education level, number of antenatal care taken and type of health facilities.

CONCLUSION

This study provides evidence regarding inequalities in maternal health service utilisation in Myanmar. Increasing maternal health service availability and accessibility, promoting quality of care and health education campaigns to increase maternal health services utilisation are recommended.

Obstetric outcomes of nulliparous women with pelvic pain undergoing fertility treatment

RESEARCH QUESTION

Is there any association between pelvic pain and primary caesarean delivery for patients undergoing assisted reproductive technology (ART) treatment?

DESIGN

Retrospective cohort study of nulliparous patients with singleton pregnancies who underwent ART treatment and achieved a live birth between 2012 and 2020. Cases included patients diagnosed with pelvic pain. A 3:1 ratio propensity-score-matched population of patients without a history of pelvic pain was included as the control group. Comparative statistics were performed using chi-squared test and Student's t-test. A multivariate regression analysis was conducted to evaluate the association between pelvic pain and mode of delivery.

RESULTS

One hundred and seventy-four patients with pelvic pain were compared with 575 controls. Patients with pelvic pain reported a significantly longer duration of infertility compared with controls (18.98 ± 20.2 months versus 14.06 ± 14.06 months; P = 0.003). Patients with pelvic pain had a significantly higher rate of anxiety disorders (115 ± 21.9 versus 55 ± 31.6; P = 0.009) and use of anxiolytics at embryo transfer (17 ± 3.2 versus 12 ± 6.9; P = 0.03) compared with controls. In addition, patients with pelvic pain had a higher rate of primary caesarean delivery compared with controls (59.8% versus 49.0%; P = 0.01). After adjusting for multiple variables, a significant association was found between pelvic pain and increased odds of primary caesarean delivery (adjusted OR 1.48, 95% CI 1.02-2.1).

CONCLUSION

Patients with pelvic pain have significantly higher odds of primary caesarean delivery compared with patients without a history of pelvic pain. The infertility outpatient setting may be uniquely positioned to identify patients at risk for undergoing primary caesarean delivery, and could facilitate earlier intervention for pelvic floor physical therapy during the preconception and antepartum periods.

Surgical Management of Airway Stenosis During Pregnancy: A Scoping Review

OBJECTIVE

There are several options for surgical management of subglottic stenosis, including endoscopic and open procedures. However, treatment algorithms, outcomes, and anesthetic management of subglottic stenosis during pregnancy are not well described.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane databases.

REVIEW METHODS

A scoping review of management of subglottic stenosis during pregnancy was performed, and then reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of those with subglottic or tracheal stenosis aged greater than 18 years, those in whom management was performed during pregnancy, and those who reported delivery related outcomes.

RESULTS

After systematic review and detailed search of 330 identified articles, 15 articles met inclusion criteria and were included in the final analysis. All studies were case reports or case series (level 4 evidence). This study identified 27 patients. The median age was 29 and the median gestational age at intervention was 28 weeks. Left lateral positioning and fetal heart rate monitoring were used in nearly every case. The most common intervention performed was endoscopic balloon dilation. In many cases, jet ventilation or transnasal humidified rapid insufflation ventilatory exchange was satisfactory for maintenance of the airway. Three women ultimately required tracheostomy prior to labor and delivery. There was no fetal death or complications reported in these studies, and all but one woman proceeded to deliver at term.

CONCLUSION

Endoscopic balloon dilation during pregnancy is safe and effective, resulting in optimized respiratory outcomes for the mother and safe delivery of the fetus. The third trimester appears to be safe for airway intervention. Laryngoscope, 134:1014-1022, 2024.

Racial Disparities in Cesarean Delivery Rates: Do Hospital-Level Factors Matter?

OBJECTIVE

 This study aimed to assess whether racial disparities in nulliparous, term, singleton, vertex cesarean delivery rates vary among hospitals of different type (academic vs. nonacademic), setting (urban vs. rural), delivery volume, and patient population.

STUDY DESIGN

 This is a retrospective cohort study including singleton term vertex live births in nulliparous Black and non-Hispanic White birthing people in California between 2011 and 2017. Cesarean delivery rates were obtained using birth certificate data and International Classification of Diseases, 9th/10th Revision codes. Risk of cesarean delivery was compared among Black versus White birthing people by hospital type (academic, nonacademic), setting (rural, suburban, urban), volume (< 1,200, 1,200-2,300, 2,400-3,599, ≥3,600 deliveries annually), and patient population (proportion Black-serving). Federal Information Processing codes were used to designate hospital setting. Risks were calculated using univariable and multivariable logistic regression and adjusted for birthing person age, body mass index, medical comorbidities, gestational age, labor type (spontaneous vs. induction), and infant birthweight.

RESULTS

 The sample included 59,441 Black (cesarean delivery rate: 30.2%) and 363,624 White birthing people (cesarean delivery rate: 26.1%). Black birthing people were significantly more likely than White birthing people to have a cesarean delivery across nearly all hospital-level factors considered with adjusted relative risks ranging from 1.1 to 1.3. The only exception was rural settings in which the adjusted relative risk was 1.3 but did not reach statistical significance.

CONCLUSION

 Black-White disparities in nulliparous, term, singleton, vertex cesarean delivery rates were persistent across all hospital-level factors we considered: academic status, rurality, delivery volume, and patient population. Furthermore, disparities existed at roughly the same magnitude regardless of hospital characteristics. These global increased risks likely reflect structural inequities in care, which contribute to disparities in pregnancy-related morbidity and mortality. These data should encourage providers, hospital systems, and quality collaboratives to further investigate racial disparities in cesarean delivery rates and develop strategies for eliminating them.

KEY POINTS

· Nulliparous Black birthing people are more likely than White to undergo cesarean delivery.. · This persists across hospitals of all academic status, rurality, delivery volume, and patient population.. · These findings likely reflect structural rather than institutional inequities in obstetric care..

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) EUROPEAN MIDWIVES ASSOCIATION (EMA) Joint position statement: Caesarean delivery rates at a country level should be in the 15-20 % range

While cesarean deliveries performed for health indications can save lives, unnecessary cesareans cause unjustifiable health risks for the mother, newborn, and for future pregnancies. Previous recommendations for cesarean delivery rates at a country level in the 10-15% range are currently unrealistic, and the proposed concept that striving to achieve specific rates is not important has resulted in a confusing message reaching healthcare professionals and the public. It is important to have a clear understanding of when cesarean delivery rates are deviating from internationally acceptable ranges, to trigger the implementation of healthcare policies needed to correct this problem. Based on currently existing scientific evidence, we recommend that cesarean delivery rates at a country level should be in the 15-20% range. This advice is based on the demonstration of decreased maternal and neonatal mortalities when national cesarean delivery rates rise to circa 15%, but values exceeding 20% are not associated with further benefits. It is also based on real-world experiences from northern European countries, where cesarean delivery rates in the 15-20% range are associated with some of the best maternal and perinatal quality indicators in the world. With the increase in cesarean delivery rates projected for the coming years, experience in provision of intrapartum care may come under threat in many hospitals, and recovering from this situation is likely to be a major challenge. Professional and scientific societies, together with healthcare authorities and governments need to prioritize actions to reverse the upward trend in cesarean delivery rates observed in many countries, and to strive to achieve values as close as possible to the recommended range.

The association between musculoskeletal pain during pregnancy and pregnancy outcomes: A systematic review and meta-analyses

OBJECTIVE

To systematically investigate the association between musculoskeletal pain during pregnancy and birth outcomes including caesarean section, newborn birthweight, newborn birth length, and gestational age at birth.

METHODS

Medline, Embase, Web of Science, Cinahl and Scopus were systematically searched to identify eligible studies. Odds ratios, mean differences, and confidence intervals were used to describe results. Risk of Bias was assessed using the Newcastle-Ottawa Scale for observational studies. GRADE (The Grading of Recommendation Assessment, Development, and Evaluation) was used to assess the quality of each outcome.

RESULTS

Seven studies were included with a total population of 85,991 participants. There is low- quality evidence that pregnant women with musculoskeletal pain had 1.59 greater odds to experience delivery by caesarean section compared to those without musculoskeletal pain ([OR] 1.59, 95 % confidence interval [CI] 1.09 to 2.31). Both newborn birth weight (Mean Difference [MD] 77.79 g, 95 % [CI] -23.09 to 178.67) and newborn birth length ([MD] 0.55 cm, 95 % [CI] -0.47 to 1.56) were not affected by musculoskeletal pain, with very low-quality and low-quality evidence, respectively. There was moderate evidence that pregnant women with musculoskeletal pain had shorter gestational age (weeks), although the effect was small and possibly not clinically relevant ([MD] -0.41, 95 % [CI] -0.41 to -0.07).

CONCLUSION

Pregnant women experiencing musculoskeletal pain are at greater odds of delivering their babies via caesarean than those without musculoskeletal pain, however, musculoskeletal pain during pregnancy does not appear to affect newborn birth weight, length, or gestational age at birth.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

The impact of fear of childbirth on mode of delivery, postpartum mental health and breastfeeding: A prospective cohort study in Shanghai, China

BACKGROUND

The prevalence and impact of fear of childbirth (FOC) has not been sufficiently understood. We aimed to investigate the prevalence of FOC among Chinese population and its impact on mode of delivery, postpartum mental health and breastfeeding.

METHODS

We conducted a prospective cohort study, wherein pregnant women in their third trimester who underwent antenatal assessments at Shanghai Changning Maternity and Infant Health Hospital between September 2020 and March 2021 were recruited. Sociodemographic data of the participants were gathered by self-administered questionnaire, and their FOC was assessed using the Wijma Delivery Expectancy Questionnaire. Participants were followed up to 42 days postpartum. Information regarding their modes of delivery was retrieved from medical records, and data regarding postpartum mental health symptoms and one-month postpartum breastfeeding were obtained through self-administered questionnaires.

RESULTS

Among 1287 participants, 461 (35.8 %) had high-level FOC (W-DEQ ≥ 66). Logistic regressions showed that women with high-level of FOC had higher rates of caesarean delivery on maternal request (CDMR) (aOR = 1.55, 95 % CI: 1.00-2.41, p = 0.049), a higher incidence of postpartum mental health symptoms (aOR = 1.68, 95 % CI: 1.09-2.59, p = 0.018), lower rates of one-month postpartum exclusive breastfeeding (aOR = 0.33, 95 % CI: 0.16-0.69, p = 0.003) and mixed feeding (aOR = 0.44, 95 % CI: 0.21-0.91, p = 0.028).

LIMITATIONS

The long-term implications of FOC beyond the immediate postpartum period were not explored in the study.

CONCLUSIONS

High-level FOC during the third trimester was associated with increased CDMR and postpartum mental health symptoms and reduced breastfeeding establishment. These results underscore the significance of FOC screening and tailored interventions for affected women.

To Determine the Quality of Life in Indian Women After Peripartum Hysterectomy Using a Hindi Version of the SF-36 Questionnaire

Objective

The objective of the study was to determine the quality of life in women after peripartum hysterectomy using a Hindi version of the SF-36 questionnaire.

Background

There are long-term effects on quality of life in women after peripartum hysterectomy. The effects on physical, mental, and social functioning have a prolonged recovery. No studies have been done in Indian women after peripartum hysterectomy to evaluate quality of life.

Methods

Patients who underwent peripartum hysterectomy from January 2017 to May 2021 were contacted to participate in the study. To determine the quality of life post-surgery, a Hindi version of the 36-item Short-Form Health Survey (SF-36) was used for a face-to-face personal interview-based assessment. The participants were divided into two groups based on the duration between surgery and the interview. The aggregate scores for the eight components of SF-36 were calculated, and responses were analyzed.

Results

Out of the 138 post-hysterectomy women, 118 were enrolled in the study. Women who could not be contacted [14 (10.14%)] and those who died post-procedure [6 (4.35%)] were excluded. Out of the total, 43 assessed participants were within 2 years of surgery, and 75 were after 2 years of surgery. The group that was assessed after 2 years of surgery had a significantly lower quality of life in six, out of the eight aspects of SF-36 domains.

Conclusion

Women after peripartum hysterectomy undergo a prolonged recovery phase with effects on physical, mental, and social functioning. A multi-disciplinary long-term follow-up including physiotherapy and psychotherapy is required and that should be guided by a dedicated clinical team.

L, Agiwal V, Angaali N, A. Y. N, D. S, Haggerty C, Reddy PS. Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

BACKGROUND

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

MAIN OBJECTIVES

To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India.

METHODS

A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity.

RESULTS

The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%).

CONCLUSION

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Pregnancy-induced remodeling of the murine reproductive tract: a longitudinal in vivo magnetic resonance imaging study

Mammalian pregnancy requires gradual yet extreme remodeling of the reproductive organs to support the growth of the embryos and their birth. After delivery, the reproductive organs return to their non-pregnant state. As pregnancy has traditionally been understudied, there are many unknowns pertaining to the mechanisms behind this remarkable remodeling and repair process which, when not successful, can lead to pregnancy-related complications such as maternal trauma, pre-term birth, and pelvic floor disorders. This study presents the first longitudinal imaging data that focuses on revealing anatomical alterations of the vagina, cervix, and uterine horns during pregnancy and postpartum using the mouse model. By utilizing advanced magnetic resonance imaging (MRI) technology, T1-weighted and T2-weighted images of the reproductive organs of three mice in their in vivo environment were collected at five time points: non-pregnant, mid-pregnant (gestation day: 9-10), late pregnant (gestation day: 16-17), postpartum (24-72 h after delivery) and three weeks postpartum. Measurements of the vagina, cervix, and uterine horns were taken by analyzing MRI segmentations of these organs. The cross-sectional diameter, length, and volume of the vagina increased in late pregnancy and then returned to non-pregnant values three weeks after delivery. The cross-sectional diameter of the cervix decreased at mid-pregnancy before increasing in late pregnancy. The volume of the cervix peaked at late pregnancy before shortening by 24-72 h postpartum. As expected, the uterus increased in cross-sectional diameter, length, and volume during pregnancy. The uterine horns decreased in size postpartum, ultimately returning to their average non-pregnant size three weeks postpartum. The newly developed methods for acquiring longitudinal in vivo MRI scans of the murine reproductive system can be extended to future studies that evaluate functional and morphological alterations of this system due to pathologies, interventions, and treatments.

Rate and direct medical costs of cesarean sections among supplementary health plan holders living in the state of São Paulo, Brazil: 2015-2021

Brazil has the second largest cesarean section rate in the world. Differences in rates exist between the public and private health sectors. This study used data on admissions of supplementary health plan holders aged between 10 and 49 years living in the state of São Paulo admitted between 2015 and 2021 to determine cesarean section rates and costs in the private health sector. We conducted a partial economic analysis in health from a supplementary health perspective focusing on the direct medical costs of admissions. A total of 757,307 admissions were analyzed with total costs amounting to R$7.701 billion. The cesarean section rate over the period was 80%. Rates were lowest in young women (69%) and highest in the oldest age group (86%), exceeding 67% across all groups. The rate was 71% higher than in public services. The proportion of admissions with use of the intensive care unit was higher among cesarian deliveries. The median cost of a cesarean was 15% higher than that of a normal delivery and twice as high in insurance companies than healthcare cooperatives. There is an opportunity to apply policies that are widely used in public services to the private sector with the aim of reducing cesarean rates in private services, direct costs of admission, and the cost of supplementary health plans.

Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time?

OBJECTIVE

 The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017.

METHODS

 This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders.

RESULTS

 A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2-1.3). From 2011 to 2017, the CD rate fell 11% (26.4-23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4-30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1-1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9-0.9 and 0.3-0.5).

CONCLUSION

 The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people.

PRECIS

 Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017.

KEY POINTS

· Black birthing people are more likely to undergo CD than White despite controlling for confounders.. · There are unexplained differences in CD indication among Black and White birthing people.. · These disparities persisted from 2011 to 2017 despite increasing efforts to decrease CD rates in CA..

SARS-CoV-2-Infected Pregnant Woman Requiring 38 Days of Extracorporeal Membrane Oxygenation Experiences Rectal Ulcer Bleeding: A Case Report

Pregnancy has been shown to be associated with an adverse clinical course and symptomatic patients with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. Extracorporeal membrane oxygenation (ECMO) is rarely used in pregnant or postpartum women with severe coronavirus disease 2019 (COVID-19). Here, we report the rare case of a pregnant woman diagnosed with SARS-CoV-2 infection placed on ECMO postpartum who subsequently received treatment for active rectal ulcer bleeding. Despite being placed on ECMO for 38 days and receiving a massive transfusion of 95 packs of red blood cells, she recovered and was discharged on hospital day 112. ECMO can be used in most patients with severe COVID-19, including pregnant patients, although potential coagulopathy complications must be considered.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

Perinatal Outcomes of Pregnancy in Women with Scarred Uteri

Objective

Uterine scarring is risky for the pregnancy and is closely associated with adverse pregnancy outcomes. Here, we investigated risk factors and associated perinatal outcomes in singleton pregnant women with uterine scars.

Methods

This retrospective cohort study was conducted on singleton pregnant women who delivered at the West China Second University Hospital between January 1, 2021, and December 31, 2021.

Results

The control group included 13,433 cases without uterine scars. The study group involved 2397 cases with one previous cesarean delivery (PCD), 163 cases with two PCDs, 12 cases with three PCDs, and 184 cases with non-cesarean uterine scars. The study group had a significantly higher incidence of placenta previa (6.4%), placenta percreta (5.3%), preterm delivery (10.3%), postpartum hemorrhage (3.4%), uterine rupture (9.4%), hysterectomy (0.18%), and bladder injury (0.4%) when compared with the control group (P <0.05). The scarred uterus cases with 1, 2, or 3 PCDs had significantly different complications, with the higher PCD frequency correlating with increased rates of placenta previa, placenta percreta, postpartum hemorrhage, uterine rupture, and uterine resection. Moreover, the hospitalization time, cesarean operation time, and intrapartum bleeding in the current pregnancy significantly increased with increasing PCD frequency (P <0.05). Analysis of the association between the duration of the interval between PCD and re-pregnancy and pregnancy complication revealed that the incidence of pernicious placenta previa was statistically higher in cases with intervals of <2 years or ≥5 years (4.7%) than in cases with 2 years ≤ interval time <5 years (2.5%) (P <0.05).

Conclusion

Pregnancies with uterine scars may experience higher rates of adverse perinatal outcomes. This calls for increased observation during pregnancy and delivery to reduce maternal and fetal complications.

Despite Increased Disease Activity, Women who Attended a Dedicated Inflammatory Bowel Disease and Pregnancy Clinic Had Infants With Higher Apgar Scores: A Population-Based Study

BACKGROUND

Attendance at a subspecialty pregnancy clinic for women with inflammatory bowel disease (IBD) improves disease-specific pregnancy knowledge. We examined the impact of attendance at a dedicated IBD-pregnancy clinic on IBD and perinatal outcomes.

METHODS

Using linked administrative databases in Alberta, Canada (2012-2019), we identified 1061 pregnant women with IBD who delivered singleton liveborn infants in-hospital who did (n = 314) and did not attend (n = 747) the clinic. Propensity score weighted multivariable log-binomial and multinomial logistic regression models were used to determine the risk of IBD and perinatal outcomes.

RESULTS

The median number of clinic visits was 3 (Q1-Q3, 3-5), with 34.7% completing a preconception consultation. A greater proportion of women who attended lived near the clinic, were nulliparous, had a disease flare prior to pregnancy, and were on maintenance IBD medication (P < .05). Women who attended had increased risks of a disease flare during pregnancy (adjusted risk ratio [aRR], 2.02; 95% CI, 1.45-2.82), an IBD-related emergency department visit during pregnancy (aRR, 2.66; 95% CI, 1.92-3.68), and cesarean delivery (aRR, 1.78; 95% CI, 1.23-2.57). Despite this, clinic attendees had a decreased risk of delivering an infant with a low Apgar score at 1 minute (risk ratio [RR], 0.49; 95% CI, 0.32-0.76) and 5 minutes (RR, 0.32; 95% CI, 0.12-0.87).

CONCLUSIONS

Women who attended a dedicated IBD-pregnancy clinic were more likely to have a disease flare prior to pregnancy, reflecting a more severe disease phenotype, but had similar perinatal outcomes and infants with better Apgar scores at birth. Our study suggests the value of these subspecialty clinics in providing enhanced IBD-specific prenatal care.

Prevalence of Breech Presentation and Other Gestational/Delivery Characteristics Among Patients Born With Developmental Dysplasia of the Hip

Introduction Developmental dysplasia of the hip (DDH) is the most common congenital disability in newborns. The condition can range from a slight laxity in the hip joint to secondary femoral head injury, early osteoarthritis (OA), and mobility issues. There are several risk factors for DDH, including positive family history, female sex, breech presentation, and the presence of clubfoot. Early detection and treatment are crucial to avoid long-term hip dysplasia and arthritis, which can cause difficulty in walking and discomfort. Breech presentation, in particular, is a significant risk factor for DDH, with spontaneous vaginal birth increasing the risk of hip pathology and instability compared to elective Caesarean section. However, whether breech presentation continues to be a risk factor for DDH in preterm children is unknown. Objective and methods This study aimed to investigate the prevalence of breech presentation and other gestational/delivery characteristics among newborns diagnosed with DDH. This retrospective study was conducted at Abha Maternity and Children Hospital, Abha, Saudi Arabia, over a period of six months. Data were collected from medical records of DDH cases diagnosed between 2016 and 2023. Data analysis was performed using Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States) and IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). Descriptive statistics and statistical tests were used to analyze the data. Results Most of the diagnosed children were female (86.7%), and bilateral hip dislocation (40%) was the most common presentation. X-ray was the most common diagnostic tool (48.3%), and operative management was the most common management strategy (73.3%). A positive family history of DDH was reported in more than one-third of cases. The study also analyzed the association between complications during pregnancy and various factors such as mode of delivery, presentation at delivery, gestational age at delivery, and associated maternal diseases. The difference in complication rates between women who delivered via C-section and those who delivered vaginally was insignificant (p = 0.14). Similarly, the difference in complication rates between women with breech and cephalic presentation was not statistically significant (p = 0.094). The difference in complication rates between women who delivered preterm, at term, or post-term was also not statistically significant (p = 0.578). Furthermore, the association between complications during pregnancy and pregnancy-associated maternal diseases was not statistically significant (p = 1.00). Conclusion DDH is a significant health issue in newborns, leading to long-term mobility problems and discomfort. Positive family history of DDH is a significant risk factor. Breech presentation was not significantly associated with DDH in preterm children, and no significant associations were found between complications during pregnancy and various factors. Early detection and treatment of DDH are crucial for preventing long-term complications. Family history should be considered an important risk factor, emphasizing the need for screening programs in families with a history of DDH.

"We really are seeing racism in the hospitals": Racial identity, racism, and doula care for diverse populations in Georgia

INTRODUCTION

Poor birth outcomes are more prevalent for Black communities, but strong evidence shows that doula care can improve those outcomes. More evidence is needed to understand racial differences, discrimination, and equity in doula care.

METHODS

The current study's objective was to describe the experiences of Black doulas as well as the challenges and facilitators of providing doula care to communities of color in Georgia. From Fall 2020-Fall 2021, 20 surveys and in-depth interviews were conducted with doulas as part of a community-based participatory study co-led by Healthy Mothers, Healthy Babies Coalition of Georgia and academic researchers.

RESULTS

Doula participants were diverse in age (5% under 25, 40% 25-35, 35% 36-45, and 20% 46+) and race/ethnicity (45% white, 50% Black, 5% Latinx). Most (70%) Black doulas reported that more than 75% of their clientele is Black, while most (78%) white doulas reported that less than 25% of their clientele is Black. Doulas noted the alarming Black maternal mortality rate and how mistreatment causes Black clients to lose trust in medical staff, leaving them in need of advocates. Black doulas were passionate about serving and advocating with Black clients. Participants also described how language and cultural barriers, particularly for Asian and Latinx people, reduce clients' ability to self-advocate, increasing the need for doulas. Doulas also discussed the ways that race influences their connections with clients and their dissatisfaction with the lack of cultural humility or sensitivity training in standard doula training.

CONCLUSION

Our findings indicate that Black doulas provide essential and supportive services to Black birthing people, and those services are more urgently needed than ever following the overturn of Roe v. Wade. Doula training must be improved to address the cultural needs of diverse clients. Increasing access to doula care for Asian and Latinx communities could also address language and cultural barriers that can negatively impact their maternal and child health outcomes.

Global inequities in cesarean section deliveries and required resources persist

OBJECTIVE

The purpose of this study was to estimate the global distribution and financial cost associated with the inequities present in the use of cesarean sections (CS) worldwide.

STUDY DESIGN

We used the latest estimates on CS rates published by WHO and we adopted 10-15 % as the range of CS rates that are considered optimal for adequate use. We calculated the cost (in USD) to achieve CS rates of 10-15 % for countries that reported rates below 10 %. We also calculated the cost of CS rates in excess (>15 % and > 20 %) by estimating how much it would cost to reduce the rates to 10-15 % for each of those countries.

RESULTS

137 countries are included in this analysis with updated data on CS rates between the years 2010 and 2018. Our analysis found that 36 countries reported CS rates < 10 %, whereas 91 countries reported CS rates > 15 % (a majority of which were > 20 %); only 10 countries reported CS rates between 10 and 15 %. The cost of CS exceeding a rate of 15 % is estimated to be $9,586,952,466 including inflation and exceeding 20 % is $7.169.248.033 (USD). The cost of achieving "needed" CS among countries with CS rates < 10 % is $612,609,418 (USD). The cost of cesarean sections exceeding 15 % has increased by 313 % between 2008 and more recent years, accruing $7 billion (USD) more in surplus since 2008. The reallocation of CS funding would save the global economy $9 billion (USD).

CONCLUSION

Global inequities in CS performed and associated costs have increased since 2008, resulting in a disproportionate number of resources allocated.

Cesarean delivery and risk of HIV vertical transmission in Southern Brazil, 2008-2018

BACKGROUND

Childbirth via cesarean delivery can prevent intrapartum vertical transmission for women who are not virally suppressed at the time of delivery. Few studies have compared cesarean delivery trends between women living with HIV and women without HIV and have examined the role of cesarean delivery in the prevention of vertical transmission in the era of potent combination antiretroviral therapy.

OBJECTIVE

We hypothesized that the cesarean delivery rate is high in women living with HIV compared with women without HIV and that cesarean delivery usage decreases over time among women living with HIV with advances in combined antiretroviral therapy in a country with a high national cesarean delivery rate. This study aimed (1) to evaluate cesarean delivery trends in women with and without HIV and (2) to examine its role in preventing vertical transmission among women living with HIV in a setting of free, universal combined antiretroviral therapy coverage in a retrospective cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of maternal HIV in Brazil.

STUDY DESIGN

Data from maternal-infant pairs from January 1, 2008, to December 31, 2018, were extracted. Cesarean delivery rates were compared using the Pearson chi-square test. Cesarean delivery predictors were evaluated by multivariate log-linear Poisson regression using a generalized estimating equations approach. HIV viral suppression was defined as a viral load of <1000 copies/ml at delivery. HIV vertical transmission was determined following national guidelines.

RESULTS

Over 11 years, 48,688 pregnancies occurred in 40,375 women; HIV seroprevalence was 2.7%; 18,886 cesarean deliveries (38.8%) were performed; 47.7% of women living with HIV and 38.6% of women without HIV underwent cesarean delivery (P<.001). Although HIV was associated with cesarean delivery (adjusted relative risk, 1.17 [95% confidence interval, 1.05-1.29]), women living with HIV with vertical transmission achieved similar cesarean delivery rates (36.7%) as women without HIV (39.8%) in 2018. Cesarean delivery in women living with HIV with an unknown viral load at delivery (42.6%) did not increase over time. HIV vertical transmission rate was 2.2%, the highest in women living with HIV with an unknown viral load (8.4%) vs women living with HIV without vertical transmission (4.1%) and women living with HIV with vertical transmission (0.5%) (P<.001).

CONCLUSION

In the HIV epicenter of Brazil, women living with HIV with vertical transmission had fewer surgical deliveries, likely because of the use of potent combination antiretroviral therapy. Nearly half of the women living with HIV with an unknown viral load did not undergo cesarean delivery, a potential missed opportunity for the prevention of HIV vertical transmission.

Global increased cesarean section rates and public health implications: A call to action

Over the years; global caesarian section (CS) rates have significantly increased from around 7% in 1990 to 21% today surpassing the ideal acceptable CS rate which is around 10%-15% according to the WHO. However, currently, not all CS are done for medical reasons with rapidly increasing rate of nonmedically indicated CS and the so-called "caesarian on maternal request." These trends are projected to continue increasing over this current decade where both unmet needs and overuse are expected to coexist with the projected global rate of 29% by 2030. CS reduces both maternal and neonatal morbidity and mortality significantly when it is done under proper indications while at the same time, it can be of harm to the mother and the child when performed contrary. The later exposes both the mother and the baby to a number of unnecessary short and long-term complications and increase the chances of developing different noncommunicable diseases and immune-related conditions among babies later in life. The implications of lowering SC rate will ultimately lower healthcare expenditures. This challenge can be addressed by several ways including provision of intensive public health education regarding public health implications of increased CS rate. Assisted vaginal delivery approaches like the use of vacuum and forceps and other methods should be considered and encouraged during delivery as long as their indications for implementation are met. Conducting frequent external review and audits to the health facilities and providing feedback regarding the rates of CS deliveries can help to keep in check the rising CS trends as well as identifying the settings with unmet surgical needs. Moreover, the public especially expectant mothers during clinic visits and clinicians should be educated and be informed on the WHO recommendations on nonclinical interventions towards reduction of unnecessary CS procedures.

Cervical dilatation at diagnosis of active phase of labour determines the mode of delivery and peripartum outcomes: a retrospective study in a single tertiary centre in Malaysia

BACKGROUND

There is an increasing trend of Caesarean section rate in Malaysia. Limited evidence demonstrated the benefits of changing the demarcation of the active phase of labour.

METHODS

This was a retrospective study of 3980 singletons, term pregnancy, spontaneous labouring women between 2015 and 2019 comparing outcomes between those with cervical dilation of 4 versus 6 cm at diagnosis of the active phase of labour.

RESULTS

A total of 3403 (85.5%) women had cervical dilatation of 4 cm, and 577 (14.5%) at 6 cm upon diagnosis of the active phase of labour. Women in 4 cm group were significantly heavier at delivery (p = 0.015) but significantly more multiparous women were in 6 cm group (p < 0.001). There were significantly fewer women in the 6 cm group who needed oxytocin infusion (p < 0.001) and epidural analgesia (p < 0.001) with significantly lower caesarean section rate (p < 0.001) done for fetal distress and poor progress (p < 0.001 both). The mean duration from diagnosis of the active phase of labour until delivery was significantly shorter in the 6 cm group (p < 0.001) with lighter mean birth weight (p = 0.019) and fewer neonates with arterial cord pH < 7.20 (p = 0.047) requiring neonatal intensive care unit admissions (p = 0.01). Multiparity (AOR = 0.488, p < 0.001), oxytocin augmentation (AOR = 0.487, p < 0.001) and active phase of labour diagnosed at 6 cm (AOR = 0.337, p < 0.001) reduced the risk of caesarean delivery. Caesarean delivery increased the risk of neonatal intensive care admission by 27% (AOR = 1.73, p < 0.001).

CONCLUSIONS

Active phase of labour at 6 cm cervical dilatation is associated with reduced primary caesarean delivery rate, labour intervention, shorter labour duration and fewer neonatal complications.

Breech delivery in low-income settings: A systematic review of perinatal and maternal outcomes in vaginal versus cesarean breech deliveries

Most studies comparing vaginal breech delivery (VBD) with cesarean breech delivery (CBD) have been conducted in high-income settings. It is uncertain whether these results are applicable in a low-income setting. To assess the neonatal and maternal mortality and morbidity for singleton VBD compared to CBD in low- and lower-middle-income settings,the PubMed database was searched from January 1, 2000, to January 23, 2020 (updated April 21, 2021). Randomized controlled trials (RCTs) and non-RCTs comparing singleton VBD with singleton CBD in low- and lower-middle-income settings reporting infant mortality were selected. Two authors independently assessed papers for eligibility and risk of bias. The primary outcome was relative risk of perinatal mortality. Meta-analysis was conducted on applicable outcomes. Eight studies (one RCT, seven observational) (12 510 deliveries) were included. VBD increased perinatal mortality (relative risk [RR] 2.67, 95% confidence interval [CI] 1.82-3.91; one RCT, five observational studies, 3289 women) and risk of 5-minute Apgar score below 7 (RR 3.91, 95% CI 1.90-8.04; three observational studies, 430 women) compared to CBD. There was a higher risk of hospitalization and postpartum bleeding in CBD. Most of the studies were deemed to have moderate or serious risk of bias. CBD decreases risk of perinatal mortality but increases risk of bleeding and hospitalization.

Anesthesia during delivery in pregnant women with dilated cardiomyopathy

Emergency cesarean delivery in patients with heart failure increases maternal and fetal mortality. The present study aimed to identify the relationship between the use of anesthesia for delivery and progressive cardiac deterioration in women with dilated cardiomyopathy (DCM) and to examine its implications on maternal and fetal outcomes. Twenty-nine pregnancies in 25 women with DCM from the National Cerebral and Cardiovascular Center Hospital (Suita, Japan) were included in this retrospective longitudinal study. Fourteen of the patients (48.3%) delivered via cesarean section. Among these, 4 patients (13.8%) experienced heart failure within 42 days of delivery. The indication for cesarean delivery was heart failure in 3 patients and induction failure in 1 patient. The types of anesthesia used for these patients included general (n = 1), combined spinal-epidural (n = 2), and epidural (n = 1). Two of these cesarean deliveries were performed preterm. The left ventricular ejection fraction of patients with heart failure was ≤ 35% before 34 weeks gestation. Among the 25 patients without heart failure, 2 exhibited a left ventricular ejection fraction of ≤ 35% before 34 weeks gestation. Meanwhile, the types of anesthesia used for remaining 10 patients who did not experience heart failure included general (n = 1), combined spinal-epidural (n = 8), and epidural (n = 1). The rate of general anesthesia was 25% in patients who experienced heart failure and 4% in others. There was no incidence of maternal or fetal death. A preterm anesthetic evaluation may be warranted to optimize anesthetic management when the ejection fraction decreases to ≤ 35% before 34 weeks gestation in patients with DCM.

Pregnancy in Patients with Pulmonary Arterial Hypertension in Light of New ESC Guidelines on Pulmonary Hypertension

Pulmonary arterial hypertension (PAH) is defined as an elevated mean pulmonary artery pressure (mPAP) of >20 mmHg together with a pulmonary arterial wedge pressure (PAWP) of ≤15 mmHg and pulmonary vascular resistance (PVR) of>2 Wood units (WU). Although the total mortality of pregnant women with PAH has decreased significantly in recent years and is reported to be around 12% in some databases, total mortality is still at an unacceptably high percentage. Moreover, some subgroups, such as patients with Eisenmenger's syndrome, have a particularly high mortality rate of up to 36%. Pregnancy in patients with PAH is contraindicated; its appearance is an indication for a planned termination. Education of patients with PAH, including counseling on effective contraception, is essential. During pregnancy, blood volume, heart rate, and cardiac output increase, while PVR and systemic vascular resistance decrease. The hemostatic balance is shifted towards hypercoagulability. Among PAH-specific drugs, the use of inhaled or intravenous prostacyclins, phosphodiesterase inhibitors, and calcium channel blockers (in patients with preserved vasoreactivity) is acceptable. Endothelin receptor antagonists and riociguat are contraindicated. Childbirth can take place through either vaginal delivery or caesarean section; similarly, neuraxial and general anesthesia have proven indications. In a situation where all pharmacological options have been used in pregnant or postpartum patients in a serious condition, veno-arterial ECMO is a useful therapeutic option. For PAH patients who want to become mothers, an option that does not endanger their lives is adoption.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis

IMPORTANCE

Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial.

OBJECTIVE

We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective.

STUDY DESIGN

We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios).

RESULTS

Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications.

CONCLUSIONS

Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Association Between Surgeon Gender and Maternal Morbidity After Cesarean Delivery

Importance

The stereotype that men perform surgery better than women is ancient. Surgeons have long been mainly men, but in recent decades an inversion has begun; the number of women surgeons is increasing, especially in obstetrics and gynecology. Studies outside obstetrics suggest that postoperative morbidity and mortality may be lower after surgery by women.

Objective

To evaluate the association between surgeons' gender and the risks of maternal morbidity and postpartum hemorrhage (PPH) after cesarean deliveries.

Design, Setting, and Participants

This prospective cohort study was based on data from the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, a multicenter, randomized, placebo-controlled trial that took place from March 2018 through January 2020 (23 months). It aimed to investigate whether the administration of tranexamic acid plus a prophylactic uterotonic agent decreased PPH incidence after cesarean delivery compared with a uterotonic agent alone. Women having a cesarean delivery before or during labor at or after 34 weeks' gestation were recruited from 27 French maternity hospitals.

Exposures

Self-reported gender (man or woman), assessed by a questionnaire immediately after delivery.

Main Outcomes and Measures

The primary end point was the incidence of a composite maternal morbidity variable, and the secondary end point was the incidence of PPH (the primary outcome of the TRAAP2 trial), defined by a calculated estimated blood loss exceeding 1000 mL or transfusion by day 2.

Results

Among 4244 women included, men surgeons performed 943 cesarean deliveries (22.2%) and women surgeons performed 3301 (77.8%). The rate of attending obstetricians was higher among men (441 of 929 [47.5%]) than women (687 of 3239 [21.2%]). The risk of maternal morbidity did not differ for men and women surgeons: 119 of 837 (14.2%) vs 476 of 2928 (16.3%) (adjusted risk ratio, 0.92 [95% CI, 0.77-1.13]). Interaction between surgeon gender and level of experience on the risk of maternal morbidity was not statistically significant. Similarly, the groups did not differ for PPH risk (adjusted risk ratio, 0.98 [95% CI, 0.85-1.13]).

Conclusions and Relevance

Risks of postoperative maternal morbidity and of PPH exceeding 1000 mL or requiring transfusion by day 2 did not differ by the surgeon's gender.

Predictive factors for successful external cephalic version with regional anesthesia

AIM

We aimed to investigate predictive factors of successful external cephalic version (ECV) using regional anesthesia.

METHODS

In this retrospective study, we included women who underwent ECV at our center from 2010 to 2022. The procedure had been conducted using regional anesthesia and the administration of intravenous ritodrine hydrochloride. The primary outcome was the success of ECV, which was defined as the rotation from a non-cephalic to a cephalic presentation. Primary exposures were maternal demographic factors and ultrasound findings at ECV. To determine predictive factors, we conducted a logistic regression analysis.

RESULTS

Of 622 pregnant women who underwent ECV, missing data on any variables (n = 14) were excluded and the remaining 608 were analyzed. The success rate during the study period was 76.3%. Multiparous women had significantly higher success rates than primiparous women (adjusted odds ratio [OR]: 2.06 [95% confidence interval (CI): 1.31-3.25]). Women with a maximum vertical pocket (MVP) of <4 cm had significantly lower success rates than those with 4 cm < MVP ≤6 cm (OR: 0.56 [95% CI: 0.37-0.86]). The non-anterior placental location was associated with higher success rates than the anterior placental location (OR: 1.46 [95% CI: 1.00-2.17]).

CONCLUSIONS

Multiparity, MVP >4 cm, and non-anterior placental locations were associated with successful ECV. These three factors could be useful for patient selection for successful ECV.

Incidence and risk factors of bladder injury during cesarean delivery: a cohort study

PURPOSE

To identify risk factors associated with bladder injury during cesarean delivery, and to determine the frequency of associated morbidities.

METHODS

Data obtained from the United States' Health Care Cost and Utilization Project-Nationwide Inpatient Sample were used to conduct a retrospective population-wide cohort study. ICD-9 codes were used to identify women who underwent a cesarean delivery between 1999 and 2015. Subsequently, women were classified based on whether or not they experienced a bladder injury during delivery. Multivariate logistic regression was used to determine predictors of bladder injury in cesarean deliveries and to examine the associated morbidities while adjusting for baseline maternal demographics and clinical characteristics.

RESULTS

Of 4,169,681 cesarean deliveries identified, there were 7,627 (0.2%) bladder injuries for an overall incidence of 18 per 10,000. Women ≥ 35 years were at greater risk of bladder injury 1.5 (1.4-1.6), as were women with endometriosis 2.0 (1.5-2.7) and Crohn's disease 2.7 (1.7-4.2). Risk of bladder injury increased if the cesarean delivery was associated with placenta previa 2.2 (1.9-2.4), previous cesarean delivery 4.3 (4.1-4.6), failed instrumental delivery 4.1 (3.5-4.8), fetal distress 1.7 (1.6-1.8), failed trial of labor after cesarean delivery 1.3 (1.2-1.4), and labor dystocia 1.7 (1.6-1.8). Cesarean hysterectomies presented the greatest risk for bladder injury 37.0 (33.7-40.6). Bladder injury was associated with an increased frequency of sepsis, venous thromboembolism, peritonitis, blood transfusions and longer hospital stays.

CONCLUSION

Bladder injury during cesarean deliveries is a rare outcome but it is more common among women with certain demographic and clinical characteristics. Among these cases, strategies to prevent sepsis and venous thromboembolism should be considered.

Readiness for Hospital Discharge After a Cesarean Section and Associated Factors Among Chinese Mothers: A Single Centre Cross-Sectional Study

Purpose

Knowledge of the readiness for hospital discharge can help health care professionals accurately determine the patients' discharge time. However, few studies were on the readiness for discharge and its related factors among mothers with cesarean sections. Thus, this study aims to examine the readiness for hospital discharge and its associated factors among Chinese mothers with cesarean sections.

Patients and Methods

A single-centre cross-sectional study was conducted from September 2020 to March 2021 in Guangzhou, China. Three hundred thirty-nine mothers with cesarean sections completed the questionnaires on demographic and obstetric characteristics, readiness for hospital discharge, quality for discharge teaching, parenting sense of competence, family function, and social support. Multiple linear regression analysis was used to identify independent factors influencing readiness for hospital discharge among mothers with cesarean sections.

Results

The total score of readiness for hospital discharge was 136.47 ± 25.29. The quality of discharge teaching, parenting sense of competence, number of cesareans, family function, and attending antenatal classes were independent factors influencing the readiness for hospital discharge (P < 0.05) among mothers with cesarean sections.

Conclusion

The readiness for hospital discharge of mothers with cesarean sections need to be improved. Improving the quality of discharge teaching, parenting sense of competence, and family function may help improve the readiness for hospital discharge of mothers with cesarean sections.

Physician cesarean delivery rates and severe perinatal morbidity among low-risk nulliparas

OBJECTIVE

To estimate the individual physician cesarean delivery rate associated with serious perinatal morbidity.

STUDY DESIGN

Study of nulliparous, term, singleton, vertex deliveries with maternal-neonatal dyad data (2015-2017) in the MarketScan Research Database. An individual cesarean delivery rate was calculated for all delivering physicians. The primary maternal outcome included transfusion of ≥4 units of blood, intensive care unit (ICU) admission, venous thromboembolism, or hysterectomy. The primary neonatal outcome included hypoxic ischemic encephalopathy, seizure, cardiopulmonary resuscitation or ventilator use (within 24 h), or ICU admission. Multivariable modeling of the association between physician cesarean delivery rate and each outcome was performed.

RESULTS

Among 77,058 maternal-neonatal dyads, the maternal composite occurred in 1.3% of deliveries and neonatal composite in 3.6% of deliveries. The likelihood of the maternal (aOR 1.03 for each 3% increase in physician cesarean delivery rate, 95% CI 1.021-1.043) and neonatal (aOR 1.02 for each 3% increase, 95% CI 1.014-1.027) composite outcome increased linearly with increasing physician cesarean delivery rate.

CONCLUSIONS

Severe perinatal morbidity was associated with increasing individual physician cesarean delivery rates.

Risk factors of caesarean deliveries in urban-rural areas of Bangladesh

Background and aims

The key interest of this research is to identify the causes of the ongoing increasing trends in caesarean section or C-section (CS) deliveries in both urban and rural areas of Bangladesh.

Methods

This study analyzed all Bangladesh Demographic and Health Survey (BDHS) datasets through Chi-square and z tests and the multivariable logistic regression model.

Results

CS deliveries were found to be more prevalent in urban than in rural areas of Bangladesh. Mothers above 19 years, above 16 years at first birth, overweight mothers, those with higher educational levels, those who received more than one antenatal care (ANC) visit, fathers having secondary/higher education degrees and employed as workers or in business, and mothers living in wealthy households in the cities of Dhaka, Khulna, Mymensingh, Rajshahi, and Rangpur divisions had a significantly higher likelihood of CS deliveries in urban areas. Contrastingly, mothers with ages between 20 and 39 years, above 20 years at first birth, normal weight/overweight mothers, those with primary to higher level of education, those in the business profession, fathers who also received primary to higher education, mothers who received more than one ANC visit, and those living in wealthy households in Dhaka, Khulna, Mymensingh, Rajshahi, and Rangpur divisions were more likely to have CS deliveries in rural areas. The 45-49 age group mothers had a five times higher likelihood of CS deliveries [odds ratio (OR): 5.39] in urban areas than in rural areas. Wealthy mothers were more likely to be CS-delivered in urban (OR: 4.84) than in rural areas (OR: 3.67).

Conclusion

The findings reveal a gradual upward alarming trend in CS deliveries with an unequal contribution of significant determinants in urban and rural areas of Bangladesh. Therefore, integrated community-level awareness programs are an urgent need in accordance with the findings on the risks of CS and the benefits of vaginal deliveries in this country.

Mode of delivery in the context of periviable birth: informed deference and shared decision-making

OBJECTIVE

To qualitatively evaluate women's perspectives on shared decision-making for periviable (22-25 weeks' gestational age) mode of delivery (MOD).

STUDY DESIGN

Interviews were conducted at two Midwestern academic hospitals with 30 women hospitalized for threatened periviable delivery between September 2016 and January 2018. Prior to delivery (T1) and at 3-months postpartum (T2), MOD-related decision-making was explored using prompts. Interviews were coded and analyzed using NVivo 12.

RESULT

The majority of women perceived the MOD options as cesarean section or vaginal delivery. Most ultimately preferred "whatever's best for baby." Understanding of MOD risks was limited, and physicians recommended each option equally. Sixteen participants perceived themselves as decision-makers at T1, while at T2, only nine participants identified themselves as such.

CONCLUSION

Informed deference is introduced as a novel concept in the setting of periviable MOD decision-making, whereby the mother defers decisional authority to the provider, the baby, a higher power, or the circumstance itself.

Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study

Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.

Outcome of Pregnancy in Women With D-Transposition of the Great Arteries: A Systematic Review

Background Information on maternal and fetal outcomes of pregnancy in women with D-transposition of the great arteries is limited. We conducted a systematic literature review on pregnancies in women with transposition of the great arteries after atrial and arterial switch operations to better define maternal and fetal risk. Methods and Results A systematic review was performed on studies between 2000 and 2021 that identified 676 pregnancies in 444 women with transposition of the great arteries. A total of 556 pregnancies in women with atrial switch operation were tolerated by most cases with low mortality (0.6%). Most common maternal complications, however, were arrhythmias (9%) and heart failure (8%) associated with serious morbidity in some patients. Worsening functional capacity, right ventricular function, and tricuspid regurgitation occurred in ≈20% of the cases. Rate of fetal and neonatal mortality was 1.4% and 0.8%, respectively, and rate of prematurity was 32%. A total of 120 pregnancies in women with arterial switch operation were associated with no maternal mortality, numerically lower rates of arrhythmias and heart failure (6% and 5%, respectively), significantly lower rate of prematurity (11%; P<0.001), and only 1 fetal loss. Conclusions Pregnancy is tolerated by most women with transposition of the great arteries and atrial switch operation with low mortality but important morbidity. Most common maternal complications were arrhythmias, heart failure, worsening of right ventricular function, and tricuspid regurgitation. There was also a high incidence of prematurity and increased rate of fetal loss and neonatal mortality. Outcome of pregnancy in women after arterial switch operations is more favorable, with reduced incidence of maternal complications and fetal outcomes similar to women without underlying cardiac disease.

Time series analysis of in-hospital maternal case fatality ratio in the postpartum period according to pregnancy risks and route of delivery in the regions of Brazil, 2010-2019

OBJECTIVE

to analyze in-hospital maternal case fatality ratio in the postpartum period according to pregnancy risks and route of delivery, within the Brazilian National Health System, Brazil and macro-regions, 2010-2019.

METHODS

this was an ecological time-series study, using data from the Hospital Information System; in-hospital maternal case fatality ratio in the postpartum period took into consideration maternal hospitalizations with outcome 'death' over the total number of hospitalizations per year, according to pregnancy risks and route of delivery, in the regions.

RESULTS

there were 19,158,167 hospitalizations for childbirth and 5,110 deaths in the period analyzed; maternal case fatality ratio increased from 1.1 (2010) to 1.9 death/10,000 hospitalizations (2019), in usual-risk pregnancies after vaginal deliveries, and decreased from 10.5 (2010) to 7.0 deaths/10,000 hospitalizations (2019) in high-risk pregnancies after cesarean sections; the Midwest region presented the highest and the South region the lowest case fatality ratio for high-risk pregnancies.

CONCLUSION

in-hospital case fatality ratio was higher for high-risk pregnancies, showing differences according to route of delivery and regions.

An intrapartum calculator for predicting cesarean birth due to dystocia: Preliminary findings from a single-center study in Korea

BACKGROUND

Previous calculators based on antepartum or pre-labor factors preclude intrapartum counseling. We aimed to develop a reliable, programmable, intrapartum calculator to predict the risk of cesarean birth (CB) due to dystocia and to increase the discriminatory accuracy of the predictive model.

METHODS

Data were obtained retrospectively for 1326 singleton term deliveries with cephalic presentation. Two predictive multivariable logistic regression analysis models were constructed using pre-active labor variables alone (model A) or with active labor variables (model B). The discriminatory accuracies and goodness-of-fit of the models were compared using receiver operating characteristic (ROC) curves or -2log-likelihood ratios, Akaike information criterion (AIC), and Bayesian information criterion (BIC), respectively. Both models were internally validated using a bootstrapping procedure.

RESULTS

Model A yielded an area under the curve (AUC) of 0.859 and adequate goodness of fit (P = 0.970). Model B yielded a significantly higher AUC of 0.887 and adequate goodness of fit (P = 0.624), as well as a significantly lower AIC and BIC (P &lt; 0.001). Internal validation revealed a minimal optimism of 0.0070491 and 0.0068976 for models A and B, respectively. Finally, the logistic regression equations were converted into programmable calculators to yield easy-to-understand basic (model A) and additional intrapartum CB calculators (model B).

CONCLUSIONS

The programmable calculators developed herein can augment intrapartum counseling. Our findings suggest that the risk of CB due to dystocia during labor should be estimated using a calculator that corresponds to labor progression. Further studies should explore external validation of these statistical models before translation to a clinical setting.

Fentanyl for labour pain management: a scoping review

BACKGROUND

Labour pain has been identified as an important reason for women to prefer caesarean section (CS). Fentanyl is one of the short acting opioids recommended by World Health Organization for pain relief during labour. This study aimed to identify and describe the available evidence on the use of fentanyl (monotherapy) for labour pain management by any routes of administration or regime.

METHODS

We included the records published until 31 December 2021 which reported administration of fentanyl to women with normal labour for labour pain relief. Data were extracted by one reviewer and checked by another reviewer using a standardised agreement form. We mapped and presented data descriptively in figure and tabular format.

RESULTS

We included 51 records from 49 studies in our scoping review. The studies were conducted in 12 countries, mostly high-income countries. The study designs of the 51 included records were varied as follows: 38 (74.5%) experimental studies (35 randomised controlled trials and three quasi-experimental studies), and 12 (23.5%) observational studies (five retrospective cohort studies, four prospective cohort studies, two retrospective descriptive studies, and one descriptive study) and one qualitative study. Of the included records, six used intranasal fentanyl, five used subcutaneous fentanyl, 18 (35.3%) used intravenous fentanyl, 18 (35.3%) used intrathecal fentanyl, and nine used epidural fentanyl. Many records compared fentanyl with another analgesic agent while five records (9.8%) had no comparison group and seven records (13.7%) compared with no analgesia group. The doses of fentanyl varied by routes, study and the requirement depended on the women. Pain assessment was the most frequent outcome measure presented in the records (78.4%). Only nine records (17.6%) investigated women's satisfaction about labour pain relief using fentanyl and seven records (13.7%) reported the effect of fentanyl on breastfeeding. The most common reported neonatal outcomes were foetal heart rate (33 records, 64.7%) and Apgar score (32 records, 62.7%).

CONCLUSION

There is limited primary evidence especially randomised controlled trials to evaluate the effectiveness and harms of different routes of fentanyl in low- or middle-income countries. There is a need for high-quality research to establish the most effective route of fentanyl and associated effects for evidence-based international guidelines.

External Cephalic Version-A Chance for Vaginal Delivery at Breech Presentation

Background and Objectives: In recent years, the rate of caesarean section (CS) has increased constantly. Although vaginal breech delivery has a long history, breech presentation has become the third most common indication for CS. This study aims to identify factors associated with the success of external cephalic version (ECV), underline the success rate of ECV for breech presentation and highlight the high rate of vaginal delivery after successful ECV. Material and Methods: This retrospective observational study included 113 patients with singleton fetuses in breech presentation, who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakonieklinikum Schwäbisch Hall, Germany. Maternal and fetal parameters and data related to procedure and delivery were collected. Possible predictors of successful ECV were evaluated. Results: The success rate of ECV was 54.9%. The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The vaginal birth rate after successful ECV was 80.6%. Overall, 79.0% of women with successful ECV delivered spontaneously without complications, 19.4% delivered through CS performed during labor by medical necessity, and 1.6% delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS. Gravidity, parity, maternal age, gestational age, fetal weight, and amniotic fluid index (AFI) were significantly correlated with the outcome of ECV. Conclusions: ECV for breech presentation is a safe procedure with a good success rate, thus increasing the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV.

Impact of an educational program and decision tool on choice of maternity hospital: the delivery decisions randomized clinical trial

Background

Reducing cesarean rates is a public health priority. To help pregnant people select hospitals with lower cesarean rates, numerous organizations publish publically hospital cesarean rate data. Few pregnant people use these data when deciding where to deliver. We sought to determine whether making cesarean rate data more accessible and understandable increases the likelihood of pregnant people selecting low-cesarean rate hospitals.

Methods

We conducted a 1:1 randomized controlled trial in 2019–2021 among users of a fertility and pregnancy mobile application. Eligible participants were trying to conceive for fewer than five months or were 28–104 days into their pregnancies. Of 189,456 participants approached and enrolled, 120,621 participants met entry criteria and were included in analyses. The intervention group was offered an educational program explaining the importance of hospital cesarean rates and an interactive tool presenting hospital cesarean rates as 1-to-5-star ratings. Control group users were offered an educational program about hospital choice and a hospital choice tool without cesarean rate data. The primary outcome was the star rating of the hospital selected by each patient during pregnancy. Secondary outcomes were the importance of cesarean rates in choosing a hospital and delivery method (post-hoc secondary outcome).

Results

Of 120,621 participants (mean [SD] age, 27.8 [7.9]), 12,284 (10.2%) reported their choice of hospital during pregnancy, with similar reporting rates in the intervention and control groups. Intervention group participants selected hospitals with higher star ratings (2.52 vs 2.16; difference, 0.37 [95% CI, 0.32 to 0.43] p < 0.001) and were more likely to believe that the hospitals they chose would impact their chances of having cesarean deliveries (38.5% vs 33.1%, p < 0.001) but did not assign higher priority to cesarean delivery rates when choosing their hospitals (76.2% vs 74.3%, p = 0.05). There was no difference in self-reported cesarean rates between the intervention and control groups (31.4% vs 31.4%, p = 0.98).

Conclusion

People offered an educational program and interactive tool to compare hospital cesarean rates were more likely to use cesarean data in selecting a hospital and selected hospitals with lower cesarean rates but were not less likely to have a cesarean.

Clinical Trial Registration

Registered December 9, 2016 at clinicaltrials.gov, First enrollment November 2019. ID NCT02987803, https://clinicaltrials.gov/ct2/show/NCT02987803

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05087-y.