Is planned cesarean childbirth a safe alternative?

The value of routine hemoglobin level evaluation following elective cesarean section: Is it worthwhile?

OBJECTIVE

The aim of this study was to assess the usefulness of routine hemoglobin testing following elective and urgent cesarean section (CS) in patients without primary postpartum hemorrhage (PPH).

METHODS

This retrospective cohort study included women who underwent vaginal delivery (VD), elective CS, and urgent CS at Carmel Medical Center from 2015 to 2020. Data were extracted from the obstetric database, excluding deliveries with PPH. Demographic and obstetric variables were recorded. Primary outcomes were the need for packed red blood cell transfusion.

RESULTS

A total of 19 446 women were included, with five (0.3%) requiring a blood transfusion in the elective CS group, 27 (0.17%) in the VD group, and eight (0.4%) in the urgent CS group. Urgent CS was associated with a higher risk of blood transfusion, but there was no significant difference between elective CS and VD. Elective CS showed the lowest rates of post-delivery hemoglobin below 7 g/dL 1 (0.1%) compared to VD 16 (0.6%) and urgent CS 13 (0.7%).

CONCLUSION

Routine postoperative hemoglobin testing following elective CS in asymptomatic patients without PPH appears unnecessary. This study supports reconsidering routine hemoglobin testing following elective CS, aligning with the goal of optimizing resource utilization while maintaining patient quality.

Risks of urgent cesarean delivery preceding the planned schedule: A retrospective cohort study

PURPOSE

The aim of the study was to ascertain risk factors and outcomes of elective cesarean deliveries performed urgently prior to their scheduled date.

METHODS

Women carrying a viable singleton fetus who were scheduled for elective cesarean delivery at a tertiary medical center between 2012-2020 were identified by retrospective database. Differences in maternal and neonatal parameters between those who ultimately required urgent cesarean delivery and those who underwent the procedure as scheduled were analyzed.

RESULTS

Of 4403 women who met the inclusion criteria, 559 underwent urgent cesarean delivery before the scheduled date. On multivariate analysis, factors significantly associated with a risk of transformation to an urgent cesarean delivery were chronic hypertension (aOR 1.92, 95% CI 1.30-2.83 P = 0.001), antenatal corticosteroids administration (aOR 3.26, 95% CI 2.38-4.47, P <0.001), and contraindication for vaginal delivery as the reason for elective cesarean delivery (aOR 1.67, 95% CI 1.32-2.12, P <0.001). Neonates born via urgent cesareans had an increased risk of 1-minute Apgar <7 (6% vs. 1.7%, P <0.001), intensive care unit admission (6.6% vs. 2.5%, P <0.001); their mothers were at risk of postpartum hemorrhage (5.9% vs. 3%, P = 0.001).

CONCLUSIONS

The present study sheds light on the risk factors and maternal and fetal morbidities associated with elective cesarean deliveries that become urgent before the originally scheduled date. Physicians should take this information into account when planning an optimal date for elective cesarean delivery.

Awareness and Knowledge of Caesarean Section Complications Among Women in Jeddah, Saudi Arabia

OBJECTIVES

 To assess the awareness about and attitude towards the complications of Cesarean section in the antenatal and postnatal period among women in Jeddah, Saudi Arabia.

METHODS

 This cross-sectional study was conducted between January 2020 and September 2020, involving 507 women in the antenatal and postnatal period in Jeddah, Saudi Arabia. Data were obtained via online surveys. The questionnaire addressed the knowledge about short and long-term complications.  Results: Most participants received a poor knowledge score for the awareness of Cesarean section complications (45.4%), and only 12.6% had good knowledge. Most participants were in the age group of 32-42 years. Most participants were university-educated and had an excellent socioeconomic status. A statistically significant relationship was detected between the age group and the participant's level of knowledge regarding Cesarean sections (P = 0.030) and between the level of knowledge and experiencing Cesarean delivery by maternal request (P = 0.029).

CONCLUSION

 The study concluded that pregnant women had poor awareness regarding the complications of Cesarean sections. Most participants had a negative attitude toward Cesarean deliveries and preferred vaginal delivery.

The effect of walking during late pregnancy on the outcomes of labor and delivery: A randomized clinical trial

BACKGROUND

Exercising during pregnancy has various benefits for the mother and the fetus, but there are controversial results about its effect on labor and delivery. Therefore, the present study was conducted to evaluate the effect of walking during late pregnancy on the outcomes of labor and delivery.

MATERIALS AND METHODS

The present randomized clinical trial was conducted on 102 pregnant women who were referred to the comprehensive health service centers of Rafsanjan and were selected using convenient sampling method and randomly were allocated into two groups from August 2018 to February 2019. The intervention group performed walking from the 34^th week of pregnancy until the time of delivery 4 times per week, each time for 40 min. The control group just received the routine prenatal care. Information about the outcomes of delivery were gathered from the participants' medical files in the hospital and were analyzed using SPSS software version 22 and Chi-square and independent t-tests.

RESULTS

The results indicated that the Bishop score of the intervention group was significantly higher than the control group (P < 0.05). Furthermore, regarding the duration of the third phase of delivery, spontaneous labor, induced labor, cesarean section , and instrumental delivery, a statistically significant difference was observed between the intervention and the control groups (P < 0.05). There was no statistically significant difference between both the groups regarding the duration of the first and the second stages of delivery and Apgar score at 1^st and 5^th min (P > 0.05).

CONCLUSIONS

Walking during late pregnancy could improve Bishop score, increase spontaneous onset of labor, and decrease induction, cesarean, and instrumental delivery without having any adverse effect on the neonate's Apgar score.

A comparison of the risk of cesarean section in gestational diabetes mellitus patients supplemented antenatally with vitamin D containing supplements versus placebo: A systematic review and meta-analysis of double-blinded randomized controlled trials

The aim of this study was to study the role of vitamin D containing supplements in the risk of cesarean section (CS), a common complication in gestational diabetes mellitus (GDM) patients. An additional objective was to assess the risk of developing pre-eclampsia, preterm delivery, macrosomia, and polyhydramnios in these participants. Various electronic databases were searched for double-blinded parallel-arm randomized controlled trials that reported the incidence of CS in adult, non-insulin treated GDM patients who received vitamin D and placebo in different treatment arms, respectively. Next, each eligible trial’s risk of bias was assessed, and the effects of the above interventions on the respective outcomes were compared meta-analytically across the trials. This review included five Iranian trials sourcing data from nearly 380 participants. The risk of bias in the trials was primarily low. In contrast to the placebo group, the risk of CS [risk ratio (RR): 0.61, p=0.002, 95% confidence interval (CI): 0.44,0.83; I²=0%, p-value of Cochrane’s Q: 0.373) and macrosomia (RR: 0.31, p=0.006, 95% CI: 0.13,0.72; I²=0%, p-value of Cochrane’s Q: 0.935] was less in the vitamin D supplemented group. The remaining outcomes did not differ between the intervention groups. The antenatal use of vitamin D containing supplements in non-insulin treated GDM patients might reduce the risk of CS and macrosomia.

Still No Substantial Evidence to Use Prophylactic Antibiotic at Operative Vaginal Delivery: Systematic Review and Meta-Analysis

Background

Postpartum maternal infection is still a common problem worldwide, mainly due to obstetric risk factors. The use of prophylactic antibiotic at operative vaginal delivery (OVD), taking it as a standalone risk factor, has been controversial. The purpose of this review was to rigorously evaluate the association of OVD with postpartum infection and shed light on such highly controversial issue.

Methods

A computer-based literature search was done mainly in the databases of PUBMED, HINARI health research, and the Cochrane library. Systematic review and meta-analysis were done by including 14 articles published between 1990 and August 2019.

Results

The average absolute risk of postpartum infection at OVD from seven large cohort studies was 1%. Few studies showed a weak association of OVD with postpartum infection without being adjusted to perineal wound, but the pooled meta-analysis showed statistically significant association with non-OVD. In the included randomized trial, 97% of the study participants had perineal wound for whom repairs were performed; the risks of maternal infection and perineal wound breakdown were comparable, and maternal infections other than perineal wound infection did not show significant difference between prophylactic antibiotic and placebo groups. The majority of included studies demonstrated a strong association of postpartum infection and perineal wound dehiscence with episiotomy and perineal tear.

Conclusion

Both the relative and absolute risks of postpartum infection at OVD are extremely low unless accompanied by episiotomy and 3^rd/4^tht degree perineal tear. From previous studies, there is no substantial evidence to use prophylactic antibiotic at OVD, but episiotomy and perineal tear.

Maternal motives behind elective cesarean sections

OBJECTIVES

The World Health Organization recommends a target cesarean section rate of 10-15%. In recent years, the US has had a nation-wide rate of 30.3% and some developed countries are even higher. Many factors account for this high rate, but our hypothesis is that women who elect cesarean section do so at least in part because of unallayed fear.

METHODS

Our sample was comprised of American women of childbearing age who have not given birth but may in the near future. We received 368 online survey responses with a 92% completion rate. Responses were categorical and hypotheses tested with non-parametric statistics.

RESULTS

Those who reported a preference for cesarean section were significantly more likely to be extremely fearful of birth (43.9%) than those who reported a preference for vaginal delivery (20.6%). 73.2% of the cesarean section group state that fear is what influenced their birth preference, 9.8% said their fear had no influence, while in the vaginal birth group 18.9% said fear influenced their birth preference and 53.7% said it did not.

CONCLUSIONS

In our sample, women likely to elect cesarean sections are motivated at least in part by fear. They report both more extreme levels of fear than the group anticipating non-surgical delivery and they more often say that this fear influences their birth decision. This study offers productive, non-interventional, and inexpensive ways to address women's fears in the hope of reducing unnecessary cesarean sections.

Is Vaginal Birth without an Episiotomy a Rarity in the 21st Century? Cross-Sectional Studies in Southern Poland

Purpose: The objective of this study was to analyze the birth methods (vaginal, with medical intervention, or by Cesarean Section, CS) predominant in the Malopolska province, to describe the risk factors for non-physiologically normal births, and to characterize the demographics of women who give birth and selected parameters of maternity care. Methods: The retrospective analysis was conducted on data collected in 2013⁻2014 in the framework of the current activity of the Polish National Health Fund and encompassed 68,894 childbirths from 29 hospitals in 21 towns in the south of Poland. Results: In the study period, 38,366 (56.5%) of the births in Malopolska were vaginal, and only 22,839 (22.9%) of births were considered 'normal', without an episiotomy. The remaining were births by CS (29,551; 43.5%). Factors increasing the chances of having a normal childbirth in comparison with birth by CS were as follows: days free from work, living in a village, woman's age > 35 years, and the hospital's referral level (primary or secondary). Women aged 18⁻34 years and those living in a village/town were more frequently admitted directly into the birth room without a stay in the maternity units. There was a high level of medicalization of births in Malopolska: natural labour and childbirth were rare. It seems that efforts to increase natural birth rates should be directed toward both reducing the CS rate as well as increasing vaginal birth without an episiotomy.

A randomized controlled double blind trial comparing the effects of the prophylactic antibiotic, Cefazolin, administered at caesarean delivery at two different timings (before skin incision and after cord clamping) on both the mother and newborn

BACKGROUND

Caesarean delivery (CD) increases the risk of postpartum infection by 5 to 20 fold. Prevention of surgical site infection (SSI) is the goal of antibiotic prophylaxis. This study was carried out to assess the optimum timing for prophylactic antibiotic administration and to assess the amount of the antibiotic crossing the placental barrier.

METHODS

Eligible mothers were recruited, after informed consent, once the decision for CD was made. Each mother received two injections, one prior to skin incision and one after cord clamping, (one being the study drug Cefazolin, and the other, a placebo) based on the randomization code. Demographic, maternal and neonatal monitoring data until discharge from hospital, and at the 6 weeks postpartum visit were collected. Levels of the prophylactic antibiotic were measured from the cord blood in every 8th neonate. The objective of the study was to compare the effects of the prophylactic antibiotic, intravenous Cefazolin 1 g, administered at Caesarean delivery (CD) at two different timings (before skin incision and after cord clamping) on both the mother and newborn. The secondary outcomes that were followed up were the number of maternal and neonatal readmissions. An appropriate test for significance, Fisher's exact test was used to find the association between risk variables and outcome.

RESULTS

The total numbers of mothers enrolled were 1106, of whom 553 mothers received antibiotic prior to skin incision (pre-incision) and 543 mothers received antibiotic after cord clamping (post-incision). The pre-incision group had significantly less febrile illness (RR = 0.48, 95% CI: 0.29 - 0.80) and SSI (RR = 0.14, 95% CI: 0.04 - 0.53) when compared with the post- incision group. The post-incision group significantly had >7 days hospital stay when compared to the 4-7 days stay of the pre-incision group (p = 0.005).There were no differences in any of the neonatal outcomes. The quantity of the antibiotic in the cord blood was only 2-3%.

CONCLUSIONS

Pre incision prophylactic antibiotic protected the mother from SSI and febrile illness and decreased the hospital stay significantly.

TRIAL REGISTRATION

The Clinical Trials Registry India (CTRI) was [ CTRI/2016/03/006710 dated, 04/03/2016].

Women's knowledge and attitude towards mode of delivery and frequency of cesarean section on mother's request in six public and private hospitals in Tehran, Iran, 2012

AIM

The rate of cesarean section (CS) has been reported to be as high as 40% among Iranian women in the year 2009. The aim of this study was to determine the rate of cesarean delivery on mother's request (CDMR) and to determine maternal attitude and knowledge about various modes of delivery in private and public (university) hospitals in Tehran.

MATERIAL AND METHODS

All primiparous mothers delivering in six selected hospitals between April 2010 and March 2011 were included. Trained investigators handed a predesigned questionnaire to mothers 1 day after delivery to be filled out in the presence of the investigator.

RESULTS

From 600 deliveries, 501 (83.5%) were CS and 99 (16.5%) were normal vaginal delivery. The CS rates in university hospitals versus private hospitals were 78.5% and 91.9%, respectively. In total, mothers' knowledge scores were poor, intermediate, and good in 55.6%, 37.9%, and 6.5% of cases, respectively, and no significant difference in knowledge was observed between mothers attending private or public hospitals. The overall rate of CDMR was 20.8%; and the most frequent reason was fear of pain. Women with CDMR were at higher marital age, education, insurance coverage, and socioeconomic status compared with the women with vaginal delivery.

CONCLUSION

Prompt action is needed to reduce the unacceptably high rate of unwarranted cesarean deliveries. Improving women's knowledge about the risks and benefits of different modes of delivery can lead to a positive maternal attitude towards vaginal delivery.

Elective caesarean section: a case study

Caesarean section as a means of delivering babies has been around for centuries with numerous references to the procedure appearing in ancient writings (Simm & Matthew 2008). It is now the most common major surgical intervention carried out on women in the world, with between 23% and 30% of deliveries in the UK performed by caesarean section (Beech 2004). This rate is all the more surprising when one considers that caesarean section accounted for just 5.3% of UK births in 1973 (Kitzinger 1998). This rising rate has many implications for both clinical practice and the NHS. An Audit Commission report (1997) suggested that each 1% rise in the caesarean section rate would cost the NHS five million pounds per year. However, the increased rate also has clinical implications, with some studies suggesting that maternal mortality is three to seven times greater following abdominal rather than vaginal birth and maternal morbidity is proportionately even greater, even with elective procedures (McCourt et al 2004).

Preferência pela via de parto nas parturientes atendidas em hospital público na cidade de Porto Velho, Rondônia

As parturientes que procuram o Centro Obstétrico do Hospital de Base de Porto Velho, Rondônia, para terem seus filhos são mulheres provenientes das camadas sociais desfavorecidas, ao contrário das mulheres com níveis de renda diferenciados que procuram os médicos em seus consultórios particulares e parem seus filhos por meio de cesarianas com dia e hora previamente marcados. O artigo aborda a questão do aumento da crescente incidência de cesarianas verificado em vários países latinos e também no mundo desenvolvido onde tem motivado necessárias e inadiáveis discussões no campo da Bioética e procura conhecer a opinião das parturientes quanto à via de parto que foram atendidas no Centro Obstétrico do Hospital de Base nos anos de 2006 e 2007.

Why do women request caesarean section in a normal, healthy first pregnancy?

BACKGROUND AND CONTEXT

a growing number of childbearing women are reported to prefer a caesarean section in the absence of a medical reason. Qualitative research describing factors influencing this preference in pregnant women is lacking.

OBJECTIVE

to describe Australian women's request for caesarean section in the absence of medical indicators in their first pregnancy.

DESIGN

advertisements were placed in local newspapers inviting women to participate in a telephone interview exploring women's experience of caesarean section. Thematic analysis was used to analyse data.

SETTING

two states of Australia: Queensland and Western Australia.

PARTICIPANTS

a community sample of women (n=210) responded to the advertisements. This paper presents the findings elicited from interviews conducted with 14 women who requested a caesarean section during their first pregnancy in the absence of a known medical indication.

FINDINGS

childbirth fear, issues of control and safety, and a devaluing of the female body and birth process were the main themes underpinning women's requests for a non-medically-indicated caesarean section. Women perceived that medical discourses supported and reinforced their decision as a 'safe' and 'responsible' choice. KEY CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE: these findings assist women and health professionals to better understand how childbirth can be constructed as a fearful event. In light of the evidence about the risks associated with surgical birth, health-care professionals need to explore these perceptions with women and develop strategies to promote women's confidence and competence in their ability to give birth naturally.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.