Changes in indications for cesarean delivery: United States, 1985 and 1994

A predictive model for successfully inducing active labor among pregnant women: Combining cervical status assessment and clinical characteristics

Objective

To develop a predictive model for successfully inducing active labor by using a combination of cervical status and maternal and fetal characteristics.

Study design

A retrospective cohort study was conducted among pregnant women who underwent labor induction between January 2015 and December 2019. Successfully inducing active labor was defined as achieving a cervical dilation > 4 cm within 10 h after adequate uterine contractions. The medical data were extracted from the hospital database; statistical analyses were performed using a logistic regression model to identify the predictors associated with the successful induction of labor. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to assess the accuracy of the model.

Results

In total, 1448 pregnant women were enrolled; 960 (66.3 %) achieved successful induction of active labor. Multivariate analysis revealed that maternal age, parity, body mass index, oligohydramnios, premature rupture of membranes, fetal sex, dilation, station, and consistency were significant factors associated with successful labor induction. The ROC curve of the logistic regression model had an AUC of 0.7736. For the validated score system to predict the probability of success, we found that a total score > 60 has a 73.0 % (95 % CI 59.0-83.5) probability of successful induction of labor into the active phase stage within 10 h.

Conclusions

The predictive model for successfully achieving active labor using the combination of cervical status and maternal and fetal characteristics had good predictive ability.

Identification of shared bacterial strains in the vaginal microbiota of related and unrelated reproductive-age mothers and daughters using genome-resolved metagenomics

It has been suggested that the human microbiome might be vertically transmitted from mother to offspring and that early colonizers may play a critical role in development of the immune system. Studies have shown limited support for the vertical transmission of the intestinal microbiota but the derivation of the vaginal microbiota remains largely unknown. Although the vaginal microbiota of children and reproductive age women differ in composition, the vaginal microbiota could be vertically transmitted. To determine whether there was any support for this hypothesis, we examined the vaginal microbiota of daughter-mother pairs from the Baltimore metropolitan area (ages 14-27, 32-51; n = 39). We assessed whether the daughter's microbiota was similar in composition to their mother's using metataxonomics. Permutation tests revealed that while some pairs did have similar vaginal microbiota, the degree of similarity did not exceed that expected by chance. Genome-resolved metagenomics was used to identify shared bacterial strains in a subset of the families (n = 22). We found a small number of bacterial strains that were shared between mother-daughter pairs but identified more shared strains between individuals from different families, indicating that vaginal bacteria may display biogeographic patterns. Earlier-in-life studies are needed to demonstrate vertical transmission of the vaginal microbiota.

Effect of Intravenous Ketamine on Hypocranial Pressure Symptoms in Patients with Spinal Anesthetic Cesarean Sections: A Systematic Review and Meta-Analysis

Background: Pregnant women are more likely to suffer post-puncture symptoms such as headaches and nausea due to the outflow of cerebrospinal fluid after spinal anesthesia. Because ketamine has the effect of raising intracranial pressure, it may be able to improve the symptoms of perioperative hypocranial pressure and effectively prevent the occurrence of hypocranial pressure-related side effects. Method: Keywords such as ketamine, cesarean section, and spinal anesthesia were searched in databases including Medline, Embase, Web of Science, and Cochrane from 1976 to 2021. Thirteen randomized controlled trials were selected for the meta-analysis. Results: A total of 12 randomized trials involving 2099 participants fulfilled the inclusion criteria. There was no significant association between ketamine and the risk of headaches compared to the placebo (RR = 1.12; 95% CI: 0.53, 2.35; p = 0.77; I² = 62%). There was no significant association between ketamine and nausea compared to the placebo (RR = 0.66; 95% CI: 0.40, 1.09; p = 0.10; I² = 57%). No significant associations between ketamine or the placebo and vomiting were found (RR = 0.94; 95% CI: 0.53, 1.67; p = 0.83; I² = 72%). Conclusion: Intravenous ketamine does not improve the symptoms caused by low intracranial pressure after spinal anesthesia in patients undergoing cesarean section.

The Influence of Cesarean Delivery on Ovarian Reserve: a Prospective Cohort Study

To assess the association between cesarean delivery and ovarian reserve, as compared to vaginal delivery. A prospective case control study conducted at a single tertiary medical center between June 2018 and June 2019. Study population included women with singleton pregnancy that underwent first cesarean delivery that were compared to women undergoing normal vaginal delivery. Women with low ovarian reserve, endometriosis, previous pelvic surgery, chronic maternal disease, and active labor were excluded. Ovarian reserve was estimated by Anti-Mullerian hormone (AMH) levels that was determined twice for each participant: up to a week before and 3 months after delivery. Primary outcome was defined as the delta in AMH levels. Data were analyzed by non-parametric tests. During the study period, 135 women were enrolled, of them 63 (47%) underwent cesarean delivery and 72 (53%) had vaginal delivery. Women in the cesarean delivery group were older (34 (31-38) vs. 32 (29-35); p = 0.001); nevertheless, AMH levels measured before delivery were comparable between the two groups (0.92 (0.51-1.79) vs. 0.95 (0.51-1.79) pg/mL; p = 0.42). AMH levels measured after delivery were more than doubled in the study and control groups (2.15 (1.24-3.05) vs. 2.62 (1.05-5.09); p = 0.50), and delta AMH levels were also found comparable (1.25 (0.61-2.22) vs. 1.59 (0.63-3.41), respectively; p = 0.43). Linear regression analysis including age, mode of delivery, gestational age at delivery, and delta hemoglobin levels revealed that only maternal age was significantly associated with delta in AMH levels (B =  - 0.09, p = 0.04). Cesarean delivery does not decrease ovarian reserve as estimated by AMH.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Guidelines for labor assessment: failure to progress?

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits.

Maternal and Fetal Outcomes of Admission for Delivery in Women With Congenital Heart Disease

Background

Women with congenital heart disease (CHD) may be at increased risk for adverse events during pregnancy and delivery.

Objective

To compare delivery outcomes between women with and without CHD.

Design, Setting, and Participants

This retrospective study of inpatient delivery admissions in the Healthcare Cost and Utilization Project's California State Inpatient Database compared maternal and fetal outcomes between women with and without CHD by using multivariate logistic regression. Female patients with codes for delivery from the International Classification of Diseases, Ninth Revision, from January 1, 2005, through December 31, 2011, were included. The association of CHD with readmission was assessed to 7 years after delivery. Cardiovascular morbidity and mortality were hypothesized to be higher among women with CHD. Data were analyzed from April 4, 2014, through January 23, 2017.

Exposures

Noncomplex and complex CHD.

Main Outcomes and Measures

Maternal outcomes included in-hospital arrhythmias, eclampsia or preeclampsia, congestive heart failure (CHF), length of stay, preterm labor, anemia complicating pregnancy, placental abnormalities, infection during labor, maternal readmission at 1 year, and in-hospital mortality. Fetal outcomes included growth restriction, distress, and death.

Results

Among 3 642 041 identified delivery admissions, 3189 women had noncomplex CHD (mean [SD] age, 28.6 [7.6] years) and 262 had complex CHD (mean [SD] age, 26.5 [6.8] years). Women with CHD were more likely to undergo cesarean delivery (1357 [39.3%] vs 1 164 509 women without CHD [32.0%]; P < .001). Incident CHF, atrial arrhythmias, ventricular arrhythmias, and maternal mortality were uncommon during hospitalization, with each occurring in fewer than 10 women with noncomplex or complex CHD (<0.5% each). After multivariate adjustment, noncomplex CHD (odds ratio [OR], 9.7; 95% CI, 4.7-20.0) and complex CHD (OR, 56.6; 95% CI, 17.6-182.5) were associated with greater odds of incident CHF. Similar odds were found for atrial arrhythmias in noncomplex (OR, 8.2; 95% CI, 3.0-22.7) and complex (OR, 31.8; 95% CI, 4.3-236.3) CHD, for fetal growth restriction in noncomplex (OR, 1.6; 95% CI, 1.3-2.0) and complex (OR, 3.5; 95% CI, 2.1-6.1) CHD, and for hospital readmission in both CHD groups combined (OR, 3.6; 95% CI, 3.3-4.0). Complex CHD was associated with greater adjusted odds of serious ventricular arrhythmias (OR, 31.8; 95% CI, 4.3-236.3) and maternal in-hospital mortality (OR, 79.1; 95% CI, 23.9-261.8).

Conclusions and Relevance

In this study of hospital admissions for delivery in California, CHD was associated with incident CHF, atrial arrhythmias, and fetal growth restriction and complex CHD was associated with ventricular arrhythmias and maternal in-hospital mortality, although these outcomes were rare, even in women with complex CHD. These findings may guide monitoring decisions and risk assessment for pregnant women with CHD at the time of delivery.

Primary and Repeat Cesarean Deliveries: A Population-based Study in the United States, 1979-2010

BACKGROUND

Despite the temporal increase in cesarean deliveries, the extent to which maternal age, period, and maternal birth cohorts may have contributed to these trends remains unknown.

METHODS

We performed an analysis of 123 million singleton deliveries in the United States (1979-2010). We estimated rate ratio (RR) with 95% confidence interval (CI) for primary and repeat cesarean deliveries. We examined changes in cesarean rates with weighted Poisson regression models across three time-scales: maternal age, year of delivery, and birth cohort (mother's birth year).

RESULTS

The primary cesarean rate increased by 68% (95% confidence interval [CI]: 67%, 69%) between 1979 (11.0%) and 2010 (18.5%). Repeat cesarean deliveries increased by 178% (95% CI: 176, 179) from 5.2% in 1979 to 14.4% in 2010. Cesarean rates increased with advancing age. Compared with 1979, the RR for the period effect in primary and repeat cesarean deliveries increased up to 1990, fell to a nadir at 1993, and began to rise thereafter. A small birth cohort effect was evident, with women born before 1950 at increased risk of primary cesarean; no cohort effect was seen for repeat cesarean deliveries. Adjustment for maternal BMI had a small effect on these findings. Period effects in primary cesarean were explained by a combination of trends in obesity and chronic hypertension, as well as demographic shifts over time.

CONCLUSIONS

Maternal age and period appear to have important contributions to the temporal increase in the cesarean rates, although the effect of parity on these associations remains undetermined.

Accelerated Titration of Oxytocin in Nulliparous Women with Labour Dystocia: Results of the ACTION Pilot Randomized Controlled Trial

OBJECTIVE

The primary objective was to determine the feasibility of a large RCT assessing the effectiveness of an accelerated oxytocin titration (AOT) protocol compared with a standard gradual oxytocin titration (GOT) in reducing the risk of CS in nulliparous women diagnosed with dystocia in the first stage of labour. The secondary objective was to obtain preliminary data on the safety and efficacy of the foregoing AOT protocol.

METHODS

This was a multicentre, double-masked, parallel-group pilot RCT. This study was conducted in three Canadian birthing centres. A total of 79 term nulliparous women carrying a singleton pregnancy in spontaneous labour, with a diagnosis of labour dystocia, were randomized to receive either GOT (initial dose 2 mU/min with increments of 2 mU/min) or AOT (initial dose 4 mU/min with increments of 4 mU/min), in a 1:1 ratio. An intention-to-treat analysis was applied.

RESULTS

A total of 252 women were screened and approached, 137 (54.4%) consented, and 79 (31.3%) were randomized. Overall protocol adherence was 76 of 79 (96.2%). Of the women randomized, 10 (25.6%) allocated to GOT had a CS compared with six (15.0%) allocated to AOT (Fisher exact test P = 0.27).

CONCLUSION

This pilot study demonstrated that a large, multicentre RCT is not only feasible, but also necessary to assess the effectiveness and safety of an AOT protocol for labour augmentation with regard to CS rate and indicators of maternal and perinatal morbidities.

The Effect of Clinical Chorioamnionitis on Cesarean Delivery in the United States

OBJECTIVE

To examine the association of clinical chorioamnionitis on cesarean delivery in a national sample of hospital discharges.

DATA SOURCE

Hospital discharge data from the 1998-2010 Nationwide Inpatient Sample.

STUDY DESIGN

We performed a cross-sectional study and general linear modeling was used to determine the association of clinical chorioamnionitis on risk of cesarean delivery.

PRINCIPAL FINDINGS

A total of 10,843,682 deliveries and 51,799,431 nationally weighted deliveries were identified. Clinical chorioamnionitis was present in 2.9 percent of cesarean and 1.3 percent of vaginal deliveries (p < .001). In multivariate analysis, clinical chorioamnionitis was associated with a 1.39-fold increased risk of cesarean delivery. Compared with women without clinical chorioamnionitis at an urban/teaching hospital, women with clinical chorioamnionitis at an urban/teaching, urban/nonteaching, and rural hospital were 1.4-1.5 times more likely to have cesarean delivery. Compared with women without clinical chorioamnionitis in the Midwest, the relative risk for cesarean in women with clinical chorioamnionitis was 1.54 for women in the South, 1.47 in the Northeast, 1.39 in the Midwest, and 1.34 in the West.

CONCLUSIONS

Women with clinical chorioamnionitis were more likely to have cesarean delivery than those without clinical chorioamnionitis, and the risk of cesarean delivery varied significantly by hospital location, teaching status, and U.S. region.

Relative Risk of Postpartum Complications in the Ohio Medicaid Population: Vaginal Versus Cesarean Delivery

The objective of this study was to estimate the relative risk of postpartum complication by type of delivery among Ohio Medicaid beneficiaries. The study uses the linked Medicaid and Ohio birth certificate data for births occurring from July 1991 through April 1996 (N = 168,736). The results indicate that the incidence of major puerperal infection, thromboembolic events, anesthetic complications, and obstetrical surgical wound infection was higher among women undergoing a C-section as compared to those with vaginal delivery, even after limiting the analysis to elective cesarean deliveries and uncomplicated vaginal deliveries. On the other hand, women with C-sections were less likely to experience obstetrical trauma, and results on postpartum hemorrhage were inconclusive. Aside from obstetrical trauma, the relative risk of postpartum complications remains significantly higher among women undergoing C-section. These findings are of particular relevance in light of the substantial proportion of repeat C-sections performed on an elective basis.

Gestational Age at Term, Delivery Circumstance, and Their Association with Childhood Attention Deficit Hyperactivity Disorder Symptoms

BACKGROUND

Perinatal characteristics may identify subgroups of term-born children at risk for academic and behavioural difficulties. Using follow-up data from the Pregnancy Outcomes and Community Health Study, we subdivided term births according to two potential markers of perinatal risk (gestational age, delivery circumstance) and evaluated their association with attention deficit hyperactivity disorder (ADHD) symptoms.

METHODS

We included children born at term whose mothers completed the Conners' Parent Rating Scales-Revised-Short Form (CPRS-R-S) (n = 610; ages: 3-9 years). The CPRS-R-S yields age and sex-referenced T-scores for the two primary dimensions of ADHD (inattention, hyperactivity) and an ADHD Index that reflects both dimensions. Using general linear models, we evaluated whether: (1) term delivery defined by gestational week (reference: 39-40 weeks), or (2) term delivery circumstance defined by labour onset type and mode of delivery (reference: spontaneous labour, vaginal delivery) was associated with these problems.

RESULTS

Following adjustment for parity, sociodemographics, and maternal mental health both during pregnancy and at the child follow-up survey, the induced labour plus caesarean group exhibited higher inattention and ADHD Index scores relative to the spontaneous labour, vaginal delivery group (inattention: mean difference = 5.1, 95% CI 0.6, 9.7; ADHD Index: mean difference = 4.1, 95% CI 0.5, 7.8). Findings were primarily driven by male children.

CONCLUSIONS

Among term-born children, only those whose mothers experienced induction of labour that culminated in caesarean delivery exhibited higher levels of ADHD symptoms. Prenatal, antepartum, and/or postnatal factors associated with this delivery profile may reflect increased risk for such problems.

Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term

PURPOSE

Dystocia is the leading indication for primary caesarean sections. Our aim is to compare two approaches in the management of dystocia in labor in nulliparous women with a singleton fetus in cephalic presentation at term in spontaneous or induced labor.

METHODS

Prospective cohort study. Four hundred and nineteen consecutive patients were divided into two groups: the standard management group (SM), in acceleration of labor was commenced at the "action line" in the case of arrested or protracted labor, and the comprehensive management group (CM) in which arrested or protracted labor was considered as a warning sign promoting further diagnostic assessment prior to considering intervention.

RESULTS

Caesarean sections rate was 22.2 % in the SM group (216 patients) and 10.3 % in the CM group (203 patients) (p = 0.001). The rate of oxytocin use decreased from 33.3 % in SM group to 13.8 % in the CM group (p < 0.0005). The rate of amniotomy decreased from 41.7 % in the SM group to 7.4 % in the CM group (p < 0.0005). The percentage of newborns with 5-min Apgar score <7 and/or umbilical cord arterial pH ≤ 7.00 decreased from 2.3 % in SM cohort to 0.5 % in CM cohort (p = ns). The average length of labor did not differ between the two groups of patients (264 vs 277 min; p = ns).

CONCLUSION

Comprehensive management of dystocia enabled us to achieve a reduction in iatrogenic interventions in labor while maintaining good neonatal outcomes.

Outcome of deliveries in healthy but obese women: obesity and delivery outcome

Background

Obesity among fertile women is a global problem. 25% of pregnant Swedish women are overweight at admission to the antenatal clinic and 12% of them are considered as obese. Previous studies have shown an increased risk of delivery complications with an elevated maternal BMI. The aim of this study was to evaluate delivery outcomes in relation to maternal BMI on admission to the antenatal clinic.

A healthy group of 787 women with full-term pregnancies and spontaneous onset of labor were included in the study. Delivery outcome was assessed in relation to maternal BMI when attending the antenatal clinic.

Results

The results indicated that in deliveries where the maternal BMI was >30 a high frequency of abnormal CTG trace during the last 30 minutes of labor was shown. A blood sample for evaluation of risk of fetal hypoxia was performed in only eight percent of these deliveries. A spontaneous vaginal delivery without intervention was noted in 85.7%, and 12% of neonates were delivered with an adverse fetal outcome compared to 2.8% in the group with a maternal BMI<30 (p<0.001).

Conclusion

These results indicate an increased risk at delivery for healthy, but obese women in labor. Furthermore, the delivery management may not always be optimal in these deliveries.

Physiologic partograph to improve birth safety and outcomes among low-risk, nulliparous women with spontaneous labor onset

Oxytocin augmentation and cesarean rates among low-risk, term, nulliparous women with a spontaneous onset of labor in the United States approximate 50% and 26.5%, respectively. This indicates that the quality of obstetrical care is less than optimal in this nation. Exorbitant oxytocin use, the intervention most commonly associated with preventable adverse perinatal outcomes, jeopardizes birth safety while the high cesarean rate in this high-volume group compromises population health and increases health care costs. Dystocia, characterized by the slow, abnormal progression of labor, is the most commonly reported indication for primary cesareans, accounting directly for approximately 50% of all nulliparous cesareans and indirectly for most repeat cesareans. Diagnoses of dystocia are most often based on ambiguously defined delays in cervical dilation beyond which labor augmentation is deemed justified. Dystocia is known to be over-diagnosed which undoubtedly contributes to contemporary oxytocin augmentation and primary cesarean rates. Labor attendants would benefit from an evidence-based framework for homogenous labor assessment. To this end, we present a physiologically-based partograph for 'in-hospital' use in assessing the labors of low-risk, term, nulliparous women with spontaneous labor onset. This tool incorporates several evidence-based labor principles that combine to give needed clinical meaning to 'dystocia' as a diagnosis. It is hypothesized that our partograph will safely limit diagnoses of dystocia to only the slowest 10% of low-risk, nulliparous women. This should, in turn, safe-guard against unnecessary, injudicious, and potentially harmful use of oxytocin when labor is already adequately progressing while also indicating when its use may be justified. We further hypothesize that cesareans performed for dystocia in this population will decrease by ≥ 50%. No significant influence on other labor process or labor outcome variables is expected with partograph use. Widespread use of this physiologically-based partograph will be warranted if our hypotheses are supported.

Beta-2 adrenoceptor genotype and progress in term and late preterm active labor

OBJECTIVE

We sought to evaluate whether beta-2 adrenoceptor (β2AR) genotype at a functional polymorphic site encoding for amino acid residue 16 influences rate of cervical dilatation in term and late preterm active labor.

STUDY DESIGN

Subjects who underwent vaginal delivery at ≥34 weeks' gestational age from May 2006 through August 2007 were identified. Each subject had provided venous blood from which DNA was extracted for β2AR genotyping. Digital cervical examinations with paired examination times were collected from intrapartum records. Rate of cervical dilatation in active labor was determined using linear regression. Rates were compared between genotype groups.

RESULTS

Among 401 subjects with satisfactory genotype and intrapartum data, overall rate of active labor was 0.76±0.01 cm/h. When labor was compared by genotype, homozygous Arg/Arg16 subjects progressed at a slower rate (0.64±0.03 cm/h) than all other pooled genotypes (0.8±0.02 cm/h, P<.001).

CONCLUSION

Homozygous β2AR genotype encoding for Arg/Arg16 was associated with slower progress in active labor.

Trends in cesarean delivery at preterm gestation and association with perinatal mortality

OBJECTIVE

We sought to examine the extent to which a temporal increase in preterm cesarean delivery is associated with gestational age-specific changes in perinatal survival in preterm gestations.

STUDY DESIGN

We utilized data on singleton births in the United States (1990 through 2004) delivered between 24-36 weeks' gestation. Associations between changes in cesarean delivery at preterm gestations and trends in the risk of preterm stillbirth, and neonatal and perinatal mortality were estimated before and after adjustments for a variety of potential confounders.

RESULTS

From 1990 through 2004, cesarean delivery rates increased by 50.6%, 40.7%, and 35.8% at 24-27, 28-33, and 34-36 weeks, respectively. The largest incremental effect of cesarean was associated with a reduction in stillbirths by 5.8%, 14.2%, and 23.1% at 24-27, 28-33, and 34-36 weeks, respectively, leading to an 11.4%, 4.9%, and 0.6% reduction in perinatal deaths at 24-27, 28-33, and 34-36 weeks, respectively.

CONCLUSION

Increasing rates of preterm cesarean were associated with improved perinatal survival. This association was evident largely because of dramatic incremental declines in stillbirths.

Labor Dystocia as First Presentation of Pelvic Malignancy

The underlying causes of labor dystocia can be various. Lack of expulsive forces or fetal malpresentation are amongst the most common ones. However, pelvic masses are described as well. Here we describe two cases of labor dystocia as first presentation of pelvic malignancy.

Racial and ethnic disparities in the trends in primary cesarean delivery based on indications

OBJECTIVE

To examine trends in primary cesarean deliveries by indications and race/ethnicity.

STUDY DESIGN

We examined temporal trends in primary cesarean deliveries from 1991 through 2008 among singleton births (n = 540,953) in Kaiser Permanente Southern California hospitals using information from maternal hospitalizations and infant birth certificates. In addition, relative increases and 95% confidence intervals (CIs) were used to estimate differences in primary cesarean section rates by indication for the earliest (1991-1992) and most recent (2007-2008) periods. Racial/ethnic disparities in primary cesarean deliveries were examined by comparing the relative risks from multiple logistic regression models.

RESULTS

The rate of primary cesarean section among white, African American, Hispanic, and Asian/Pacific Islander women increased by 61.6%, 64.1%, 62.4%, and 70.2%, respectively, between 1991 and 2008. In comparison to the primary cesarean section rate for white women, the rate was 25% (95% confidence interval [CI], 22-29%) higher for African American women, 19% (95% CI, 16-23%) higher for Asian/Pacific Islander women, but 14% (95% CI, 13-16%) lower for Hispanic women. After adjustment for confounding factors, primary cesarean section rates remained significantly higher for African American women but lower for Hispanic women compared with white women. Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity.

CONCLUSION

We found that the overall primary cesarean section rate has increased over time. In addition, there is a wide variability in rate of indications for primary cesarean section by race/ethnicity.

Prevalence and determinants of caesarean section in a teaching hospital of Pakistan

A retrospective analysis of 10 863 caesarean sections was carried out at a teaching hospital in Pakistan to examine the factors responsible for the high caesarean section rate. The caesarean section rate (CSR) during the study period (1985-1996) was 24.1/100 births and 78% of the caesareans were emergency procedures. The caesarean section rate was significantly higher among primigravida (27.26%) compared with 22.31% in multipara (P<0.01). Even for each indication, the frequency of caesarean section was higher among prinigravida (P<0.05). The three leading indications were dystocia (6.32%), repeat section (5.8%) and fetal distress (3.5%). Specific socio-demographic and child bearing patterns of our women, flaws in antenatal surveillance, ineffective working of the referral chain and departmental polices regarding management of cases with dystocia, Previous, abdominal delivery and fetal distress seem to be the major underlying causes of the high CSR.

Identifying women most likely to benefit from prevention strategies for postpartum hemorrhage

OBJECTIVE

To identify women who are most likely to benefit from primary prevention strategies for postpartum hemorrhage (PPH).

STUDY DESIGN

In a retrospective patient cohort, we applied recursive partitioning algorithms to identify the most discriminant risk factors and their interactions, and calculated the 'number needed to treat' to prevent a single case of PPH (estimated blood loss >1000 ml).

RESULT

By delivery category, the highest risk groups with 'number needed to treat' ranging from 4 to 7 were: (1) vaginal delivery (PPH=0.7% of 16 218)-macrosomia with gestational diabetes and manual removal of the placenta; (2) primary cesarean (PPH=18.7% of 2696)-macrosomia and multiparity; and (3) repeat cesarean (PPH=16.0% of 1832)-uterine incision other than low transverse and failed vaginal birth after cesarean.

CONCLUSION

Clinical profiles that identify women at risk for PPH can provide a foundation for the development of primary prevention strategies.

Timing of elective repeat cesarean delivery at term and neonatal outcomes

BACKGROUND

Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes.

METHODS

We studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU).

RESULTS

Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.

CONCLUSIONS

Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes.

Primary cesarean delivery among parous women in the United States, 1990-2003

OBJECTIVE

To explore trends in primary cesarean delivery rates among parous women with singleton pregnancies in the United States between 1990 and 2003.

METHODS

The analysis used data from national birth files based on U.S. birth certificates between 1990 and 2003. The primary cesarean delivery rate was defined as the number of primary cesarean deliveries per 100 deliveries among parous women with singleton pregnancies who have not had a previous cesarean delivery. A stratified analysis was employed to investigate whether trends varied by maternal age, gestational age, race/ethnicity, or region.

RESULTS

In the United States, the primary cesarean delivery rate among parous women decreased modestly from 7.1% in 1990 to 6.6% in 1996 but increased progressively to 9.3% in 2003. The increase in cesarean rates from 1996 to 2003 varied substantially by race/ethnicity: Hispanic and non-Hispanic white women exhibited lower and similar rates, whereas rates for non-Hispanic black women were consistently higher and rose by a far greater extent across the years. There were substantial differences in cesarean delivery trends across geographic divisions, with greatest increases observed in the mid-Atlantic, South Central, and South Atlantic areas of the United States. Primary cesarean rates also declined considerably with increasing gestational age.

CONCLUSION

Similar to the overall cesarean delivery rate, primary cesarean rates among parous women with singleton pregnancies have increased substantially in the United States since 1996.

LEVEL OF EVIDENCE

III.

Minimizing perinatal neurologic injury at term: is cesarean section the answer?

Despite advances in obstetric and neonatal care, the last several decades have not witnessed an improvement in the prediction or prevention of term cerebral palsy. Obstetric interventions such as electronic fetal heart rate monitoring and cesarean delivery, although biologically plausible as intervention strategies, do not improve perinatal outcomes in clinical practice. In reaction to mounting medicolegal pressure, obstetricians continue to increase the number of cesarean deliveries they perform as a form of defensive medicine, despite evidence that this practice is not associated with improved perinatal outcomes. The current standard for expeditious delivery in a case of potential fetal compromise is described by the "30-minute rule." However, obstetricians' determinations of the need for expedited delivery may be a preferable guide for appropriate delivery timing.

Factors affecting Taiwanese women's choice of Cesarean section

The rising rate of cesarean section (CS) is a subject of concern, intensive discussion, and investigation. However, few, if any, systematic studies of this trend have been recorded among the oriental populations. This study examines factors that may contribute to the high incidence of CS in Taiwan, where the rate of CS is among the highest in the world. Multiple logistic regression and stratified analyses were used to determine the association between CS and various factors, including provider and patient parameters. Our study sample of 2,497 cases was drawn from a total of 10,654 in-patient deliveries in Chang Gung Memorial Hospital of Taiwan. A number of factors associated with the use of CS were explored, including maternal age, occupation, education and marital status of the mother, sex and body weight of the infant at birth, parity, insurance status, source of admission, and time of birth. Our study also shows that CS in Taiwan is affected by the folk belief of Pe-Ji, which influences the preference of some patients for delivery at a specific time. Such a preference reflects a unique right of choice by women in Taiwan.

Cesarean section in term breech presentations: do rates of adverse neonatal outcomes differ by hospital birth volume?

AIM

To determine if risk of adverse neonatal outcomes among term breech infants delivered by cesarean section differs by volume of such births at the delivering hospital.

METHODS

We conducted a population-based cohort study using Missouri linked birth and death certificate files. The study population included 10,106 singleton, term, normal birth weight infants in breech presentation delivered by cesarean section. Infants were linked to hospitals where delivered. These hospitals were divided into terciles (low, medium, and high volume) based on the median number of annual deliveries during 1993-1999. The primary outcome was presentation of at least one adverse neonatal outcome. Adjusted odds ratios and 95% confidence intervals (CI) were calculated using logistic regression analysis.

RESULTS

The rate of any adverse outcome was 17.8, 15.0, and 5.9 cases per 1,000 deliveries at low-, medium-, and high-volume hospitals, respectively. All component adverse outcomes occurred more frequently in low- or medium-volume hospitals than in high-volume hospitals. Compared to breech infants delivered at high-volume hospitals, those delivered at low-volume and medium-volume hospitals were 2.7 (CI 1.6, 4.5) and 2.4 (CI 1.4, 4.1) times, respectively, more likely to experience an adverse outcome after adjusting for significant confounders.

CONCLUSIONS

Prospective studies should explore the source of these risk differences.

What Is A Failed Labor Induction?

Criteria for failed labor induction have not been standardized. The increasing prevalence of labor induction and the lack of a definition for failed induction contribute to unnecessary abdominal deliveries. Labor duration, cervical dilation, and uterine activity necessary to attain the active phase are reviewed. A practical definition of failed induction of labor is suggested.

Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002

OBJECTIVES

We examined factors contributing to shifts in primary cesarean rates in the United States between 1991 and 2002.

METHODS

US national birth certificate data were used to assess changes in primary cesarean rates stratified according to maternal age, parity, and race/ethnicity. Trends in the occurrence of medical risk factors or complications of labor or delivery listed on birth certificates and the corresponding primary cesarean rates for such conditions were examined.

RESULTS

More than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates. There was a steady decrease in the primary cesarean rate from 1991 to 1996, followed by a rapid increase from 1996 to 2002. In 2002, more than one fourth of first-time mothers delivered their infants via cesarean. Changing primary cesarean rates were not related to general shifts in mothers' medical risk profiles. However, rates for virtually every condition listed on birth certificates shifted in the same pattern as with the overall rates.

CONCLUSIONS

Our results showed that shifts in primary cesarean rates during the study period were not related to shifts in maternal risk profiles.

Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service?

BACKGROUND

Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations. Native American women have among the lowest cesarean delivery rates of all United States populations, yet few studies have focused on Native Americans. The study purpose was to determine the rate and risk factors for cesarean delivery in a Native American population.

METHODS

We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999. Data were abstracted from the labor and delivery logbook, the hospital's primary source of birth certificate data. Univariate and multivariate analyses examined demographic, prenatal, obstetric, intrapartum, and fetal factors associated with cesarean versus vaginal delivery.

RESULTS

The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03).

CONCLUSIONS

Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.

Rethinking the cesarean rate: how pregnancy complications may affect interhospital comparisons

BACKGROUND

The cesarean rate has served an integral role in the monitoring of obstetrical care, and in 2002, the national rate reached 26.1%, the highest ever reported.

OBJECTIVE

We sought to describe the effect of clinical complications on hospital cesarean rates.

RESEARCH DESIGN

This was a population-based cohort study.

SUBJECTS

All laboring women without a previous cesarean who delivered in California in 1995 as reported through public-use hospital discharge data were included.

MEASURES

Women with and without maternal, fetal, or placental complications were compared with respect to cesarean use. Using recursive partitioning algorithms, women with complications were stratified into clinically homogeneous categories, which were analyzed separately with respect to cesarean use.

RESULTS

The 443,532 women delivered at 288 hospitals and included 116,170 women (26.2%) in the complicated group (cesarean rate 22.6%); and 327,362 women (73.8%) in the uncomplicated group (cesarean rate 6.7%). At the hospital level, the cesarean rates among the complicated and uncomplicated patients respectively were: median 23.5% (range, 2.2-9.9%); and median 6.5% (range, 1.8-18.2%). Recursive partitioning algorithms suggested 16 distinct clinical categories, with cesarean rates varying from 8.9% for women with asthma to 84.5% for women with an unengaged fetal head.

CONCLUSIONS

Cesarean rates varied widely across complication types, and complication-specific rates varied widely among hospitals. Although the presence of pregnancy complications upon hospital admission comprised the strongest factor affecting first-time cesarean use among laboring women, the importance and interdependence of these clinical conditions has yet to be incorporated into commonly used models for cesarean rate comparisons.

Rupture of the uterine scar during term labour: contractility or biochemistry?

OBJECTIVE

Vaginal birth after a prior low transverse caesarean section (VBAC) is advocated as a safe and effective method to reduce the total caesarean section rate. However, the risk of uterine rupture has dampened the enthusiasm of practising clinicians for VBAC. Uterine rupture occurs more frequently in women receiving prostaglandins in preparation for the induction of labour. We hypothesised that similar to the cervix, prostaglandins induces biochemical changes in the uterine scar favouring dissolution, predisposing the uterus to rupture at the scar of the lower segment as opposed to elsewhere.

DESIGN

We tested aspects of this hypothesis by investigating the location of uterine rupture associated with prostaglandins and compared it with the sites of rupture in the absence of prostaglandins.

SETTINGS

Two North American University Hospitals.

POPULATION

Twenty-six women with a prior caesarean section, experiencing uterine rupture in active labour.

METHODS

Retrospective review of all pregnancies complicated by uterine rupture at two North American teaching hospitals from 1991 to 2000.

MAIN OUTCOME MEASURE

Site of the uterine rupture.

RESULTS

Thirty-four women experienced rupture after a previous caesarean section with low transverse uterine incision. Ten of the women who ruptured (29%) received prostaglandins for cervical ripening (dinoprostone: n= 8 or misoprostol: n= 2) followed by either spontaneous contractions (n= 3) or oxytocin augmentation during labour (n= 7). In 16 women (47%), oxytocin alone was sufficient for the induction/augmentation of labour. Eight (23%) women ruptured at term before reaching the active phase of labour in the absence of pro-contractile agents or attempted VBAC. There were no differences among the groups in terms of age, body mass index, parity, gestational age, fetal weight or umbilical cord pH measurements. Women treated with prostaglandins experienced rupture at the site of their old scar more frequently than women in the oxytocin-alone group whose rupture tended to occur remote from their old scar (prostaglandins 90%vs oxytocin 44%; OR: 11.6, 95% CI: 1.2-114.3).

CONCLUSION

Women in active labour treated with prostaglandins for cervical ripening appear more likely to rupture at the site of their old scar than women augmented without prostaglandins. We propose that prostaglandins induce local, biochemical modifications that weaken the scar, predisposing it to rupture.

Effect of preexisting chronic disease on primary cesarean delivery rates by race for births in U.S. military hospitals, 1999-2002

BACKGROUND

A previous study of the United States Department of Defense healthcare beneficiaries reported elevated cesarean delivery rates for black and Asian women relative to white women that were independent of maternal socioeconomic status. This finding suggests that other maternal factors may explain the elevated rates. The purpose of this study was to examine the prevalence of specific chronic diseases identified as risk factors for complications during pregnancy, labor, and delivery, and to explore the strength of each disease to predict a cesarean outcome.

METHODS

United States military hospital discharge records from 1999 to 2002 for singleton births to women without a previous cesarean were used to calculate primary cesarean and chronic disease rates for diabetes, hypertension, cardiovascular disease, renal disease, anemia, asthma, sexually transmitted diseases, and substance abuse. Stepwise logistic regression was used to calculate adjusted odds ratios for dichotomized race and chronic disease indicators for five maternal age groups using the chi2 difference (p < 0.05) to identify significant variables for inclusion in the model. Primary cesarean delivery rates were then adjusted for the presence of chronic diseases that were significantly associated with a cesarean outcome.

RESULTS

Diabetes, genital herpes, and hypertension were significant predictors of cesarean use among all maternal age groups. Cardiovascular disease, renal disease, asthma, and anemia were predictors in some age groups. The remaining disease conditions were not significant predictors for cesarean delivery. Adjustment of cesarean rates for these chronic diseases did not significantly alter the differences in primary cesarean rates for black and Asian mothers relative to white mothers.

CONCLUSIONS

The presence of certain chronic conditions before pregnancy may increase the likelihood that a woman will deliver by cesarean section. Adjustment of cesarean rates for the presence of these chronic diseases, however, does not account for the difference in cesarean rates observed for white and minority mothers in the study population. The potential for underreporting of chronic diseases complicates a true assessment of the impact of chronic disease on cesarean delivery rate variations between white and minority women.

Recent Trends in Caesarean Delivery Rates and Indications for Caesarean Delivery in Canada

OBJECTIVE

To examine recent trends in Caesarean delivery rates as well as the indications for Caesarean delivery in Canada, excluding the provinces of Manitoba and Quebec.

METHODS

All deliveries (N = 1 807 388) recorded in the Canadian Institute for Health Information's Discharge Abstract Database for the years 1994/95 to 2000/01 were included in the study (all hospital deliveries in Canada except for those occurring in Manitoba and Quebec). Temporal trends and inter-provincial/territorial variations in Caesarean delivery rates were quantified, and the primary indications for Caesarean delivery during the study period were compared.

RESULTS

The overall Caesarean delivery rate increased from 18.0% in 1994/95 to 22.1% in 2000/01. The primary Caesarean delivery rate increased from 12.7% to 16.3%, while the rate of vaginal birth after Caesarean decreased from 33.3% to 28.5% over the same period. Most of the increase in primary Caesarean deliveries was due to increases in Caesarean deliveries for dystocia, which increased from 6.9% in 1994/95 to 9.2% in 2000/01. The largest increase in repeat Caesarean deliveries was due to elective repeat Caesarean sections, which increased from 37.7% to 40.3%. Approximately 15% of the increase in overall Caesarean delivery rates was explained by increases in maternal age. The rate of vaginal deliveries following forceps rotation declined from 1.9% in 1994/95 to 1.3% in 2000/01.

CONCLUSION

Most of the recent increase in Caesarean delivery rates in Canada was attributed to increases in primary Caesarean delivery for dystocia and elective repeat Caesarean deliveries.

The Effect of Computer-Assisted Evaluation of Labor on Cesarean Rates

Dystocia, or slow labor, is the leading cause of first-time cesarean sections. Current diagnostic guidelines for dystocia are vague, and there is no clear postoperative confirmatory evidence to assess the correctness of this diagnosis. For several decades, various professional organizations have indicated that cesarean rates could be lowered safely and have recommended levels that are far below national averages. The three major factors, of roughly equal importance, associated with cesarean for slow labor are the baby's weight, the mother's height, and the threshold at which the physician believes it is reasonable to intervene. The last is the only modifiable factor, and quality programs are a major part of changing medical behavior. By using two study designs, the effect of a mathematical method for evaluating labor progress on the rate of cesarean section was measured. In the prospective randomized clinical trial, the relative risk of cesarean in the experimental group was unchanged at 1.04. In the pretest-posttest analysis, the rates fell from 19.54% to 17.04% at 6 months and 16.62% at 12 months.

A Native American community with a 7% cesarean delivery rate: does case mix, ethnicity, or labor management explain the low rate?

PURPOSE

Cesarean delivery rates vary widely across populations. Studying communities with low rates of cesarean delivery may identify practices that can lower the cesarean rate.

METHODS

A population-based historical cohort study included all pregnant women (N = 1132) from 1992 through 1996 in a predominantly Native American region of northwestern New Mexico known to have a high prevalence of gestational diabetes and preeclampsia. The outcomes studied included delivery type (eg, cesarean, operative vaginal, spontaneous vaginal), indication for cesarean delivery, presence of obstetrical risk factors, and use of labor induction or augmentation.

RESULTS

The cesarean delivery rate of the study group (7.3%) was only 35% of the 1996 US rate of 20.7%. Among study participants, the relative risk of a primary cesarean delivery for dystocia was 0.22 (95% CI, 0.14, 0.35). Trial of labor after cesarean delivery was attempted by 93% of study participants compared with 42% of women nationwide in 1994. The cesarean delivery rates for women with diabetes in pregnancy (11.5% versus 35.4%) and preeclampsia (14.8% versus 37.4%) were significantly lower than nationwide rates. Case-mix analysis comparison with a standardized population and comparison of standard (ie, term, singleton, vertex) primiparous women demonstrate that the low rate of cesarean delivery was not because of a lower prevalence of risk factors.

CONCLUSIONS

The community's low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.

Cesarean delivery for fetal distress: rate and risk factors

The objective of this article was to review the recent English language literature on cesarean delivery for fetal distress to determine its incidence, diagnostic tests, and the contributing factors to this obstetric complications. A PubMed search (1990-2000) with items of "cesarean, fetal distress," "cesarean, non-reassuring fetal heart rate," "cesarean, neonatal acidosis," and "cesarean, umbilical arterial pH," was undertaken. Reports, letters to the editor, focus on anomalous fetuses, and papers not specifically focused on this topic were excluded. Of the 392 articles that the search yielded, 169 met the inclusion criteria. Based on 37 reports with more than 1,000 patients each, the overall risk of prompt cesarean delivery for fetal concern was 3.1% (43,340 of 13,989,74). The risk exceeded 20% in patients with moderate/severe asthma, severe hypothyroidism, severe preeclampsia, and postterm or fetal growth restricted fetuses with abnormal Doppler studies. Use of likelihood ratios suggests that Doppler of the umbilical artery is a superior diagnostic test to amniotic fluid index in identifying parturients at risk for cesarean for non-reassuring fetal heart rate tracing. Although several risk factors increase the need for cesarean delivery for fetal distress, in general, most are unpreventable.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to estimate the incidence of cesarean delivery for non-reassuring fetal heart rate tracing, outline potential diagnostic tests that are useful for the detection of fetal distress, and summarize medical and obstetric conditions that place patients at risk for cesarean delivery for fetal distress.

VBAC--is it worth the risk?

Enthusiasm for vaginal birth after cesarean section has waned. As a result, the cesarean birth rate is again on the rise. As a medical community and society we must decide whether the most appropriate question is "What is safest for my baby?" or "Is the risk associated with vaginal birth after cesarean acceptable?" There are risks associated with vaginal birth after cesarean, but in a hospital setting with appropriate resources these risks are low and would still seem to be acceptable.

The Webster Technique: a chiropractic technique with obstetric implications

OBJECTIVE

To survey members of the International Chiropractic Pediatric Association (ICPA); regarding the use of the Webster Technique for managing the musculoskeletal causes of intrauterine constraint, which may necessitate cesarean section.

METHODS

Surveys were mailed to 1047 US and Canadian members of the ICPA.

RESULTS

One hundred eighty-seven surveys were returned from 1047 ICPA members, constituting a return rate of 17.86%. Seventy-five responses did not meet the study inclusion criteria and were excluded; 112 surveys (11%) provided the data. Of these 112 surveys, 102 (92%) resulted in resolution of the breech presentation, while 10 (9%) remained unresolved.

CONCLUSION

The surveyed doctors reported a high rate of success (82%) in relieving the musculoskeletal causes of intrauterine constraint using the Webster Technique. Although the sample size was small, the results suggest that it may be beneficial to perform the Webster Technique in month 8 of pregnancy, when breech presentation is unlikely to spontaneously convert to cephalic presentation and when external cephalic version is not an effective technique. When successful, the Webster Technique avoids the costs and/or risks of external cephalic version, cesarean section, or vaginal trial of breech.In view of these findings, the Webster Technique deserves serious consideration in the health care management of expectant mothers exhibiting adverse fetal presentation.

Risk-adjustment of cesarean delivery rates: a practical method for use in quality improvement

Risk-adjustment of cesarean birthrates has been hampered by inadequacies in the existing secondary data sources or by the need for extensive chart review. This study presents an efficient risk-adjustment model for cesarean birth, based on easily retrievable ICD-9 codes and clinical risk factors least influenced by physician practice style. Data are presented for mothers undergoing 7322 deliveries from 1997-1998 at a large academic medical center with a cesarean birth rate of 15.9%. Multiple logistic regression was used to predict the likelihood of cesarean delivery controlled for maternal age, 10 risk factors identified through ICD-9 coding, and 3 additional clinical variables (nulliparity, birth weight, and gestational age) derived from a perinatal (birth certificate) database. All risk factors were significant predictors of cesarean birth, producing an area under the receiver-operating characteristic curve of 0.86 and a 60-fold increase in cesarean delivery from highest to lowest deciles of predicted risk. This methodology can be used widely for quality improvement without the need for extensive chart review.

Declining trends in cesarean deliveries, Ohio 1989-1996: an analysis by indications

BACKGROUND

Similar to trends observed nationwide, the rates of cesarean deliveries declined in Ohio during the late 1980s and the early 1990s. This study examined the trends in cesarean deliveries in Ohio from 1989 through 1996, in the presence or absence of indications, and in relation to the use of obstetric procedures.

METHODS

Birth certificate data for all singleton, liveborn infants in Ohio (n = 1,204,859) were used to analyze temporal trends in cesarean sections.

RESULTS

The rates of primary and repeat cesarean deliveries declined, respectively, from 15.7 to 12.4 percent and from 83 to 63.3 percent during the 8-year study period. Significant declines in repeat cesarean deliveries were observed both in the presence and absence of documented medical conditions that could present a potential indication for the procedure. The rates of repeat cesareans remained comparable among women with and without documented indications for cesarean section (64% and 61%, respectively). In addition, 45 and 30 percent of repeat cesareans in 1989 and 1996, respectively, were performed in the absence of any documented indications, or on an elective basis. The declines in cesarean delivery rates during the 8-year study period occurred simultaneously with an increase in the use of electronic fetal monitoring, induction, and stimulation of labor.

CONCLUSIONS

The findings suggest that a sizable proportion of repeat cesarean deliveries in 1996 may be unnecessary, even though a marked decline in the procedure has occurred between 1989 and 1996.

Active management of labor

The active management of labor may be one approach to achieving lower rates of intervention. Numerous institutions have reported lower CS rates since initiating this labor management scheme, and concurrent decreases in the length of labor and infectious morbidity have been demonstrated. Sufficient data now exist to conclude that such programs can be instituted without deleterious effects on neonatal outcomes. Nevertheless, success in decreasing CS rates has not been uniform and may be confined to certain settings. Other approaches to labor management may be as good or better at achieving low rates of intervention with minimum morbidity. Any approach that emphasizes advocacy for vaginal birth is likely to produce some success and should receive support.