Indication For Cesarean Delivery Research Articles

Analysis of caesarean delivery rates using Robson ten group classification system in North West Amhara referral hospitals, Ethiopia, 2022: A cross-sectional study

IntroductionThe cesarean delivery rate has been consistently rising over time and differs among different hospitals. In order to understand the specific factors contributing to this rapid increase beyond the recommended levels, it is necessary to continuously monitor and evaluate cesarean deliveries using the Robson ten-group classification system. Consequently, the objective of this study was to evaluate the rate of cesarean deliveries within each group by employing the Robson ten-group classification system. MethodA cross-sectional study design was conducted in referral hospitals in the North West Amhara region, involving 721 mothers who gave birth between January and February 2022. Participants were selected using systematic random sampling. Data collection involved an interviewer-administered, pretested, semi-structured questionnaire, as well as a review of medical charts. The women were allocated into one of the ten Robson groups. The proportion of each group, the contribution of each group to the total caesarean delivery rate, and the caesarean delivery rate within each group were all calculated. ResultThe overall caesarean delivery rate was 277 (38.3 %). The primary factors contributing to the overall cesarean delivery rate were found to be group 1 (23.9 %), group 5 (21 %), group 3 (11.6 %), and group 10 (11%). The most common indication for caesarean delivery included an abnormal fetal heart rate pattern, the presence of meconium in the amniotic fluid, a history of previous cesarean delivery, fetal-pelvic disproportion, and breech presentation. ConclusionGroup 1, 5, 3, and 10 emerged as the major contributor to the overall cesarean delivery rate. Interestingly, this study also unveiled a significant prevalence of cesarean delivery among low-risk groups. These specific groups warrant further investigation to identify potential factors that can be modified and implement targeted interventions to decrease the cesarean delivery rate. It is crucial to evaluate existing management protocols in the study area.

Neurologic Complication Rates in Obstetric Patients With Chiari Malformation Based on Mode of Delivery [ID 2683669

INTRODUCTION: Chiari malformation (CM) describes inferior displacement of hindbrain structures. Because of the theoretical effects of labor on cerebrospinal fluid dynamics, CM alone has historically been suggested as a sufficient indication for cesarean delivery because of concern for herniation. However, existing literature is limited and does not demonstrate increased adverse outcomes of vaginal delivery in this population. This novel work utilizes a national dataset to describe neurologic complication rates in CM parturients in relation to mode of delivery. METHODS: The 2016–2018 Nationwide Readmissions Datasets were queried for obstetric patients with and without documented CM. ICD-10 codes were used to identify parturients who experienced neurologic complications relevant to CM. Univariate and multivariate analyses were performed to assess associations between CM and mode of delivery. RESULTS: 11,021,188 parturients were identified, including 1,210 with preexisting CM. The primary cesarean rate was 50.7% (n=479) in CM parturients compared to 20% (n=1,823,650) in the general population and CM independently predicted cesarean delivery (OR 3.8, CI, 3.1–4.7). There was no significant difference (P=.87) in the rate of herniation based on delivery method in CM parturients. The incidence of stroke, myelopathy, and hydrocephalus was zero regardless of delivery method. CONCLUSION: There is no significant difference in neurological complication rates in CM patients based on delivery method, yet CM patients are more than twice as likely to undergo cesarean delivery. Data suggest that vaginal delivery carries minimal risk to CM patients and should be considered during clinical decision making. Future studies should stratify risk based on type and severity of CM.

Rates of Cesarean Delivery and Neurologic Complications in Parturients With Cerebrospinal Fluid Shunts [ID 2683661

INTRODUCTION: The effect of parturition on neurologic status in CSF shunt-dependent patients is poorly understood. Cesarean delivery has been proposed as a safer alternative to labor in this population based on limited case reports and retrospective data in the literature; however, the true risk of vaginal delivery has not been adequately described. To our knowledge, this is the first study to estimate national incidence of neurologic complications based on delivery mode in shunt-dependent parturients. METHODS: The Nationwide Readmissions Database (NRD) was queried for obstetric patients undergoing delivery between 2016 and 2018. ICD-10 codes were used to identify delivery mode, preexisting CSF shunt-dependence, obstetric comorbidities, and neurologic complications. Data were weighted per NRD specifications. RESULTS: Of 11,021,188 total deliveries, 1,856 were in shunt-dependent patients. The primary cesarean rate was 41.2% (n=613) versus 20.1% (n=1,823,517) for shunted and non-shunted parturients, respectively. Multivariate analysis confirmed that presence of a shunt independently predicted cesarean delivery (OR 2.4; CI, 2.0–2.9). Intrapartum shunt complication rates were low regardless of delivery mode (vaginal:0.5%, cesarean:0.5%). Additionally, there was no significant difference in rates of brain herniation (P=.82) or CNS infection (P=.15). CONCLUSION: There is no difference in neurologic complication rates between CSF shunt-dependent patients undergoing cesarean and vaginal delivery; however, cesarean delivery is performed at more than twice the rate of the general population. CSF-shunt dependence alone may not be an independent indication for cesarean delivery in the absence of other obstetric indications.

Risk of Cesarean Delivery Among People With Inflammatory Bowel Disease According to Disease Characteristics: A Population-Based Study

ObjectivesIt is unclear if use of cesarean delivery in people with inflammatory bowel disease (IBD) is guideline-concordant. We compared the odds of cesarean delivery among primiparous individuals with IBD versus without, overall, and by disease characteristics, as well as time to subsequent delivery. MethodsRetrospective matched population-based cohort study between 1 April 1994 and 31 March 2020. Primiparous individuals aged 15–55 years with IBD were matched to those without IBD on age, year, hospital, and number of newborns delivered. Primary outcome was cesarean delivery versus vaginal delivery. Multivariable conditional logistic regression analyses were performed to estimate the odds of cesarean delivery among individuals with and without IBD as a binary exposure, and a categorical exposure based on IBD-related indications for cesarean delivery. Time to subsequent delivery was evaluated using a Cox proportional hazard model. ResultsWe matched 7472 individuals with IBD to 37 360 individuals without (99.02% match rate). Individuals with IBD were categorised as having perianal (PA) disease (IBD-PA, n = 764, 10.2%), prior ileal pouch-anal anastomosis (n = 212, 2.8%), or IBD-Other (n = 6496, 86.9%). Cesarean delivery rates were 35.4% in the IBD group versus 30.4% in their controls (adjusted odds ratio 1.27; 95% CI 1.20–1.34). IBD-ileal pouch-anal anastomosis had a cesarean delivery rate of 66.5%, compared to 49.9% in IBD-PA and 32.7% in IBD-Other. There was no significant difference in the rate of subsequent delivery in those with and without IBD (adjusted hazard ratio 1.03,;95% CI 1–1.07). ConclusionsThe higher risk of cesarean delivery in people with IBD reflects guideline-concordant use. Individuals with and without IBD were equally likely to have a subsequent delivery with similar timing.

Cardiovascular and obstetrical outcomes among delivering patients with Marfan or Loeys-Dietz syndrome: a retrospective analysis by hospital delivery setting

BackgroundPregnancy is a high-risk time for patients with Marfan syndrome (MFS) or Loeys-Dietz (LDS) syndrome due to risk for cardiovascular complications including risk of aortic dissection. Little is known about differences in obstetric and cardiac outcomes based on delivery hospital setting (academic/academic-affiliated versus community medical centers). ObjectiveThis study aimed to evaluate obstetric and cardiac outcomes of patients with MFS or LDS based on delivery hospital setting. Study DesignThis is a secondary analysis of a retrospective, observational cohort study of singleton pregnancies among patients with a diagnosis of MFS or LDS from 1990 to 2016. Patients were identified through the Marfan Foundation, Loeys-Dietz Syndrome Foundation, or Cardiovascular Connective Tissue Clinic at Johns Hopkins Hospital. Data were obtained via self-reported obstetric history and verified by review of medical records. Nonparametric analysis was performed via Fisher's Exact Test and Wilcoxon rank-sum tests. Results273 deliveries among patients with MFS or LDS were included in this analysis. More patients who had a known diagnosis prior to delivery for either MFS or LDS delivered at an academic hospital as compared community hospital (78.6% vs. 59.9%, p=0.001). Patients with MFS or LDS who delivered at academic centers were more likely to have an operative vaginal delivery compared to those at community centers (23.7% vs 8.6%, p=0.002). When indications for cesarean delivery were assessed, connective tissue disease was the primary reason for indication for mode of delivery at community centers compared to academic centers (55.6% vs 43.5%, p=0.02). There were higher rates of cesarean for arrest of labor and/or malpresentation at community hospitals compared to academic centers (23.6% vs 5.3%, p=0.01). There were no differences between groups in regards to method of anesthesia for delivery. Among those with a known diagnosis of MFS or LDS prior to delivery, there were increased operative vaginal delivery rates at academic hospitals compared to community hospitals (27.2% vs 15.1%, p=0.03; Table 2). More patients with an aortic root measuring ≥4 cm pre-pregnancy or postpartum delivered at academic centers compared to community centers (33.0% vs. 10.2%, p=0.01), but there were no significant differences in median size of the aortic root during pregnancy or on postpartum assessment between delivery locations. Cardiovascular complications were rare: eight patients who delivered at academic centers and seven patients who delivered at community centers had an aortic dissection either in pregnancy or the postpartum period (p=0.79). ConclusionPatients with MFS/LDS and more severe aortic phenotypes were more likely to deliver at academic hospitals. Those who delivered at academic hospitals had higher rates of operative vaginal delivery. Despite lower frequencies of aortic root diameter >4.0 cm, those delivered at community hospitals had higher rates of cesarean delivery for the indication of MFS/LDS. Optimal delivery management of these patients requires further prospective research.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BackgroundAn increased risk of preterm birth has been observed among individuals with a previous second stage cesarean delivery compared with a previous vaginal delivery. One mechanism that may contribute to the increased risk of preterm birth following second stage cesarean delivery is the increased risk of cervical injury due to extension of the uterine incision (hysterotomy) into the cervix. Investigating the contribution of hysterotomy extension to the rate of preterm birth has not been well-studied and may shed light on the mechanisms underlying the observed relationship between mode of delivery and subsequent preterm birth. ObjectiveWe aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. Study designWe performed a retrospective cohort study using electronic perinatal data collected in two university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks; secondary outcomes included subsequent preterm birth <34, <32 and <28 weeks. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios (RRs) and 95% confidence intervals (CIs). Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labour, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. ResultsA total 4,797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labour, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses controlling for several confounders showed that a history of hysterotomy extension is not associated with a higher risk of preterm birth <37 weeks gestation (adjusted RR 1.55, 95% CI 0.98-2.47), but is associated with preterm birth <34 weeks gestation (adjusted RR 2.49, 95% CI 1.06-5.42). ConclusionPatients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks compared with patients who do not sustain this injury. This association was not observed for preterm birth <37 weeks. Future research should aim to replicate our analyses while incorporating additional data to minimize the potential for residual confounding.

Evaluation of cesarean delivery rates and factors associated with cesarean delivery among women enrolled in a pregnancy cohort study at two tertiary hospitals in Thailand.

Cesarean delivery rates have increased globally resulting in a public health concern. We estimate rates of cesarean deliveries among Thai women using the World Health Organization(WHO) Robson Classification system and compare rates by Robson group to the Robson guideline for acceptable rates to identify groups that might benefit most from interventions for rate reduction. In 2017 and 2018, we established cohorts of pregnant women aged ≥ 18 years seeking prenatal care at two tertiary Thai hospitals and followed them until 6-8 weeks postpartum. Three in-person interviews (enrollment, end of pregnancy, and postpartum) were conducted using structured questionnaires to obtain demographic characteristics, health history, and delivery information. Cesarean delivery indication was classified based on core obstetric variables (parity, previous cesarean delivery, number of fetuses, fetal presentation, gestational week, and onset of labor) assigned to 10 groups according to the Robson Classification. Logistic regression was used to identify factors associated with cesarean delivery among nulliparous women with singleton,cephalic, term pregnancies. Of 2,137 participants, 970 (45%) had cesarean deliveries. The median maternal age at delivery was 29 years (interquartile range, 25-35); 271 (13%) participants had existing medical conditions; and 446 (21%) had pregnancy complications. The cesarean delivery rate varied by Robson group. Multiparous women with > 1 previous uterine scar, with a single cephalic pregnancy, ≥ 37 weeks gestation (group 5) contributed the most (14%) to the overall cesarean rate, whereas those with a single pregnancy with a transverse or oblique lie, including women with previous uterine scars (group 9) contributed the least (< 1%). Factors independently associated with cesarean delivery included age ≥ 25 years, pre-pregnancy obesity, new/worsen medical condition during pregnancy, fetal distress, abnormal labor, infant size for gestational age ≥ 50th percentiles, and self-pay for delivery fees. Women with existing blood conditions were less likely to have cesarean delivery. Almost one in two pregnancies among women in our cohorts resulted in cesarean deliveries. Compared to WHO guidelines, cesarean delivery rates were elevated in selected Robson groups indicating that tailored interventions to minimize non-clinically indicated cesarean delivery for specific groups of pregnancies may be warranted.

New labor curves of dilation and station to improve the accuracy of predicting labor progress

BackgroundThe diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references of expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making. ObjectiveTo compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using 2 modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method. Study designThis was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex presenting fetus at ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first exam in the 20 hours before delivery; dilation, effacement and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, we calculated the differences between each model’s predicted value and its corresponding observed value. These prediction errors were summarized using mean absolute error and root mean squared error statistics. Results(1) Dilation curves based on multiple parameters were more accurate than those derived from time alone. (2) The mean absolute error with the multifactor methods were better (lower) than those from the single-factor methods [0.826 cm (95% CI, 0.820–0.832) for the multifactor machine learning and 0.893 cm (95% CI, 0.885–0.901) for the multifactor mixed-effects method and 2.122 cm (95% CI, 2.108–2.136) for the single-factor methods; P<0.0001 for both comparisons]. (3) The root mean squared errors with the multifactor methods were also better (lower) than those from the single-factor methods [1.126 cm (95% CI, 1.118–1.133) P<0.0001 for the machine learning and 1.172cm (95% CI, 1.164–1.181) for the mixed-effects method and 2.504 cm (95% CI, 2.487–2.521) for the single-factor; P<0.0001 for both comparisons]. (4) The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<0.0001). (5) The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% CI, 0.509–0.515) and a root mean squared error of 0.660 cm (95% CI, 0.655–0.666). (6) External validation using independent data produced similar findings. Conclusions(1) Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone; (2) the mean prediction errors were reduced by more than 50%; and (3) a more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Cesarean delivery. The rate of general anesthesia for cesarean delivery by race and ethnicity. Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Cesarean section prior to 28 weeks’ gestation: which type of uterine incision is optimal?

Objective The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy. Methods This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery. Results There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 – 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03. Conclusion In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.

Obstetrical and perinatal consequences of childbirth in women with antenatally undiagnosed fetal growth restriction

Fetal growth restriction (FGR) is one of the most studied topics in the medicine of the mother and fetus. However, not identified antenatally FGR can have an increased risk of both perinatal morbidity and mortality, as well as adverse long-term consequences. The identification of FGR during pregnancy will contribute to the reduction of both perinatal morbidity and perinatal mortality.&#x0D; Aim. Based on a retrospective analysis, assess the obstetric and perinatal consequences of childbirth in women with antenatally undiagnosed fetal growth restriction.&#x0D; Materials and methods. An analysis of 488 cases of childbirth in women with singleton pregnancy, who gave birth to a live child, was conducted. In all cases, the gestational age was ≥22 weeks with a fetal weight less than the 10th percentile for the corresponding gestational age. Depending on the antenatally established diagnosis of FGR, two study groups were formed: group I consisted of 204 (41.8 %) cases with antenatally diagnosed FGR, group II – 284 (58.2 %) cases in which signs of FGR were identified after the birth of the child. Maternal characteristics, neonatal outcomes, and evaluation of short-term infant outcomes were analyzed.&#x0D; Results. Both groups were dominated by women with first births, the number of which was almost the same. Somatic pathology was almost 2 times more common in women of group I, 17.2 %, compared to 9.2 % of women in group II (p &lt; 0.01), this indicates that the majority of women who were not diagnosed with FGR during pregnancy belong to the low-risk group. Fetuses with impaired blood flow in the umbilical cord arteries were twice as common in group I, 49.5 % versus 23.9 % in group II (p &lt; 0.0001), and the frequency of absent/reversible end flow in the umbilical arteries in group I compared to group II, prevailed 3 times (p &lt; 0.0001), indicating more serious lesions of the placenta and, as a result, early manifestation of the fetal condition disorder. The frequency of premature abdominal delivery was 3.75 times higher in group I compared to group II. The most frequent indication for cesarean delivery in both groups was signs of fetal distress syndrome. Analysis of neonatal outcomes showed that the average birth weight was significantly lower in group I and was 2180 ± 55 g against 2420 ± 61 g in group II (p &lt; 0.0001). The need for hospitalization of newborns in the intensive care unit had no statistical difference between the groups (p &gt; 0.05). However, the complications of the early neonatal period and the total length of stay in the hospital were greater in children of the I group, compared to the II group (p &lt; 0.0001).&#x0D; Conclusions. The results of the conducted research indicate a low level of prenatal diagnosis of fetal growth restriction. Most pregnant women with antenatally undiagnosed fetal growth restriction belong to the group of low perinatal risk. The most frequent indication for cesarean section operation, regardless of the date of delivery, in both groups were signs of fetal distress, the frequency of which was 1.5 times higher in the antenatally diagnosed fetal growth retardation group. Newborns with an undetected growth anomaly before delivery have an increased risk of fetal distress, the severity of which is determined by the degree of deterioration of fetal oxygenation, and not by weight percentile, which requires more careful observation of fetuses with signs of growth restriction.

Comparative Study of Amoxicillin and Multiple Antibiotics in Caesarean Section

Background: Prophylactic antibiotic usage is important for preventing surgical site wound infections and related complications following caesarean delivery, which can lead to maternal morbidity, prolonged hospital stays, and increased treatment costs. Despite the recommendation for a single dose of preoperative antibiotic prophylaxis, clinicians are hesitant to adopt this approach due to variations in patient characteristics and concerns about aseptic techniques. Objective: To compare the efficacy of a single-antibiotic regimen versus multiple antibiotics in caesarean section procedures. Materials and Methods: It was a randomized clinical trial study. It was carried out in Obs and Gynae, North East Medical College, Sylhet, Bangladesh during the period of January 2022 to June 2022. The study included pregnant women above 34 weeks of gestation admitted to the hospital undergone elective or emergency caesarean delivery for singleton pregnancy. Total 92 sample patients with 46 patients in each group. Study involved two groups. Group A received Amoxicillin single antibiotic. Group B received multiple antibiotics. Statistical data calculations were done using Statistical Package for the Social Science (SPSS Inc., Version 25.0, Chicago, IL, USA) and Chi-square test was done. The p- value &lt;0.05 was considered significant. Results: There were 46 patients in each group. Baseline characteristics, indications for caesarean delivery, duration of operation, duration of hospital stay and difficulties were similar. Post- operative morbidities like wound infection did not differ significantly (P&gt;0.05). None of the women needed prolong hospital stay. Conclusion: The current study found no statistically significant difference in the outcome measures among the two study groups receiving different prophylactic regimens for caesarean delivery. Therefore, it can be concluded that both single and multiple antibiotics provide equally effective protection in reducing maternal .......

Comparison of Umbilical Cord Arterial Blood Gas and Neonatal Outcomes in Women with and without Meconium-Stained Amniotic Fluid During Labor

Introduction: Meconium-stained amniotic fluid (MSAF) may increase maternal and neonatal complications. The favorable mode of delivery is controversial in women with MSAF. This study aimed to compare umbilical cord arterial blood gas (ABG) and neonatal outcomes in deliveries complicated by meconium and clear amniotic fluid during the active phase of labor. Materials and Methods: This observational study was performed on 144 term pregnant women (72 with MSAF and 72 with clear amniotic fluid) during the active phase of labor with ruptured membranes admitted to Al-Zahra and Taleghani hospitals in Tabriz, Iran, from June 2019 to June 2020. A checklist was used to record the ABG and neonatal outcomes. Results: The frequency of cesarean delivery in the MSAF group (25%) was significantly higher than in the women with clear amniotic fluid (20%) (P = 0.006). There was no statistically significant difference between the groups regarding pH, base excess, PCO2, 1- and 5- minute Apgar scores, and neonatal intensive care unit (NICU) admission of the newborn due to MSAF (P&gt; 0.05). There was no incidence of hypoxic-ischemic encephalopathy, sepsis, and seizure. Conclusion: Given the non-significant difference between two groups of women with and without MSAF during labor in terms of neonatal outcomes and umbilical cord ABG, it seems that MSAF alone is not an indication for cesarean delivery. Thus, vaginal delivery is recommended in pregnant women with MSAF.

Misoprostol with balloon vs oxytocin with balloon in high-risk pregnancy induction: a randomized controlled trial

Pregnancies at high risk for maternal, fetal, or placental complications often necessitate induction of labor in the late preterm or early term period for delivery. Limited data exist on the safest method of induction to use in this specific patient population. This study aimed to compare the combination of oxytocin plus a Cook balloon vs misoprostol plus a Cook balloon for induction of labor in high-risk pregnancies. We conducted an open-label, randomized controlled trial at a single institution from July 2020 to May 2022. The study was approved by the institutional review board and registered with ClinicalTrials.gov (NCT04492072). Individuals with a high-risk pregnancy, at least ≥22 weeks' gestation, with a singleton in cephalic presentation, Bishop score ≤6, and intact membranes were offered enrollment. A high-risk pregnancy was defined as a pregnancy with any of the following complications: hypertensive disease of pregnancy, fetal growth restriction, oligohydramnios, suspected placental abruption requiring delivery, uncontrolled pregestational diabetes, or abnormal biophysical profile or nonstress test requiring delivery. The primary outcome was the rate of cesarean delivery. Secondary maternal outcomes included induction to delivery interval, number of vaginal deliveries within 24 hours, rates of uterine tachysystole, intraamniotic infection, operative vaginal delivery, and postpartum hemorrhage. Secondary fetal outcomes included fetal heart rate abnormalities, stillbirth, Apgar scores <7 at 5 minutes, admission to the neonatal intensive care unit, arterial umbilical blood pH <7.1, sepsis, and neonatal death. A subgroup analysis was planned for the primary outcome to assess the different indications for cesarean delivery. An intent-to-treat analysis was performed. During the 22 months of the trial, a total of 150 patients were randomized, and 73 (49%) of those were induced with oxytocin and a Cook balloon and 77 (51%) were induced with misoprostol and a Cook balloon. There was no significant difference in the overall rate of cesarean delivery between the study groups, (21.9% vs 31.1%; relative risk, 0.70; 95% confidence interval, 0.41-1.21), nor among those for which the cesarean delivery was performed for a specific indication. There were no differences in the secondary maternal and fetal or neonatal adverse outcomes. In high-risk pregnancies, the rate of cesarean delivery and adverse maternal and fetal outcomes were similar for induction of labor with oxytocin and a Cook balloon and for induction with misoprostol and a Cook balloon.

Factors Associated with Cesarean Operations of Gestational Diabetic Mellitus and Diabetes Complications

Objective: To identify risk factors of cesarean delivery in pregnant women with diabetes mellitus and complications caused by gestational diabetes. Materials and Methods: A retrospective cohort study was conducted at the Department of Obstetrics and Gynecology, Phatthalung Hospital. The participants consisted of pregnant women who labored at Phatthalung Hospital between 2017 and 2021. The inclusion criteria comprised women who labored from 28 to 42 weeks and had complete medical records. Patients having previous cesarean sections, cesarean section on maternal demand, and twin pregnancy were excluded. The study group was diabetic mellitus pregnant women, while non-diabetic pregnant women was generated by random numbers at ratio of 1:1 as control group. The data collected were demographic data, age, body mass index (BMI), number of gestations, parity, abortion, type of diabetic mellitus, underlying disease, route of delivery, indications for cesarean delivery, and maternal and neonatal outcomes. Results: Two thousand twelve pregnant women consisted of 1,006 pregnancies with diabetes and 1,006 non-diabetic pregnancies. Pregnant women with diabetes significantly increased the risk of cesarean section 1.42 time (95% CI 1.19 to 1.70, p&lt;0.001). The greatest indication for cesarean section of both groups was cephalopelvic disproportion, but failure for induction of labor and macrosomia were found in the study group more than in the control group. Logistic regression analysis, adjusted for age group, number of gestations, and BMI, showed that pregnancy-induced hypertension and newborn weight of 4,000 g or more were risk factors for cesarean section among diabetic pregnancies. The maternal complications of the study group were preeclampsia, indicated preterm labor, and premature rupture of membranes. The common fetal complications were macrosomia and birth asphyxia. Conclusion: Risk factors of cesarean section among pregnant women with diabetes included preeclampsia and newborn weight of 4,000 g or more. Gestational diabetes increased significantly the maternal and fetal complications. Keywords: Gestational diabetic mellitus; Cesarean section; Complications

Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000–2019

ABSTRACT Cesarean delivery is a method of improving outcomes for both mothers and neonates when there are medical complications to vaginal delivery. When used unnecessarily, however, it causes increased risks for adverse outcomes as a major surgery. Limited data and investigations have prevented some previous analyses of trends in cesarean deliveries, especially when classifying them as necessary or unnecessary. This study was designed to determine temporal trends in cesarean deliveries among low-risk patients over a 20-year period and to analyze trends in specific cesarean delivery indications. This study was designed as a repeated cross-sectional analysis among patients at low risk for cesarean delivery. The authors utilized the National Inpatient Sample data set, and then patients with conditions previously associated with an increased risk of cesarean delivery (eg, obesity) were excluded. Primary outcomes included temporal trends in the number of cesarean deliveries, as well as trends related to diagnoses of nonreassuring fetal status, labor arrest, or obstructed labor (including disproportion). Between 2000 and 2019, 40,517,867 eligible low-risk deliveries were identified. Of these, 4,885,716 were cesarean deliveries. The overall rate of cesarean delivery increased between 2000 and 2009 (from 9.7% to 13.9%) and then decreased between 2012 and 2019 (from 13% to 11.1%). The average annual percentage change (AAPC) from 2000 to 2005 was 6.4% (95% confidence interval [CI], 5.2%–7.6%), with a plateau from 2005 to 2009 (AAPC, 1.2%; 95% CI, −1.2% to 3.7%) and then a decrease from 2009 to 2019 (AAPC, −2.2%; 95% CI, −2.7% to −1.8%). Deliveries associated with the diagnosis of nonreassuring fetal status increased between 2000 and 2019 (AAPC, 2.1%; 95% CI, 1.7%–2.5%); those associated with labor arrest peaked in 2009 at 4.8% and then decreased to 2.7% in 2019 (AAPC 2009–2019, −5.6%; 95% CI, −6.6% to −4.6%). In contrast, cesarean deliveries due to obstructed labor continuously decreased from 2000 to 2019 (AAPC, −8.6%; 95% CI, −10.0% to −7.1%). After accounting for demographic and hospital characteristics, analysis showed that patients were at increased risk of cesarean delivery if they were between 35 and 39 years of age compared with the younger group of 25 to 29 years (adjusted odds ratio [aOR], 1.27; 95% CI, 1.25–1.28), if they delivered at a hospital in the South versus the Northeast (aOR, 1.11; 95% CI, 1.07–1.15), and if they were non-Hispanic Black versus non-Hispanic White (aOR, 1.23; 95% CI, 1.20–1.25). Overall trends showed increasing rates of cesarean delivery in the first 10 years of the study, but then decreasing rates for the final 10 years. Rates associated with diagnoses of nonreassuring fetal status increased over the study period, and those associated with labor arrest or obstruction decreased. The increase of cesarean delivery due to nonreassuring fetal status when compared with the overall trend of decreasing cesarean deliveries indicates a possible clinical oversight as the interpretation of nonreassuring fetal status can differ based on provider and facility. Some guidelines are in place for determining nonreassuring fetal status, but interpretation of the guidelines and sometimes the guidelines themselves have changed over the time period of this study. This increase is potentially attributable to the changes in requirements or the interpretation of them and should be more fully investigated. Future research should focus on more accurately identifying diagnoses of nonreassuring fetal status to reduce the number of unnecessary cesarean deliveries while improving the outcomes of those that truly need cesarean deliveries.

Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates

Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate. This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity. A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients. Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity. The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.

Six vs 12 hours of Foley catheter balloon placement in the labor induction of multiparas with unfavorable cervixes: a randomized controlled trial

Planned 6- vs 12-hour placement of the double-balloon catheter for cervical ripening in labor induction hastens delivery. The Foley catheter is low-priced and typically performs at least as well as the proprietary double-balloon devices in labor induction. Maternal satisfaction with labor induction is usually inversely related to the speed of the process. This study aimed to compare Foley balloon placement for 6 vs 12 hours in the labor induction of multiparas with unfavorable cervixes. A randomized controlled trial was conducted in a university hospital in Malaysia from January to October of 2022. Eligible multiparous women admitted for induction of labor for various indications were enrolled. Participant inclusion criteria were multiparity (at least 1 previous vaginal delivery of ≥24 weeks' gestation), age ≥18 years, term pregnancy >37 weeks' gestation, singleton pregnancy, cephalic presentation, intact membranes, normal fetal heart rate tracing, no significant contractions (< 2 in 10 minutes), and unfavorable cervix (Bishop score < 6). Participants were randomized after successful Foley balloon insertion for the balloon to be left in place for 6 or 12 hours of passive ripening before removal to check cervical suitability for amniotomy. The primary outcomes were the induction-to-delivery interval and maternal satisfaction with the allocated intervention assessed using a visual numerical rating scale (0-10). Secondary outcomes were derived in part from the core outcome set for trials on induction of labor (Core Outcomes in Women's and Newborn Health [CROWN]). Maternal outcomes were change in first Bishop score after intervention, use of additional method for cervical ripening, time to delivery after balloon removal, mode of delivery, indication for cesarean delivery, duration of oxytocin infusion, blood loss during delivery, presence of third- or fourth-degree perineal tear, maternal infection, use of regional analgesia in labor, length of hospital stay, intensive care unit (ICU) admission, cardiorespiratory arrest, and need for hysterectomy. The secondary neonatal outcomes were Apgar score at 1 and 5 minutes, neonatal intensive care unit (NICU) admission, cord blood pH, neonatal sepsis, birthweight, birth trauma, hypoxic-ischemic encephalopathy, or need for therapeutic hypothermia. Analyses were conducted with the t-test, Mann-Whitney U test, chi-square test, and Fisher exact test, as appropriate. A total of 220 women were randomized (110 to each intervention). Regarding the 2 primary outcomes, the induction-to-delivery intervals were a median (interquartile range) of 15.9 (12.0-24.0) and 21.6 (17.3-26.0) hours (P<.001), and maternal satisfaction scores were 7 (6-8) and 7 (6-8) (P=.734) for 6- and 12-hour placement, respectively. The following rates were observed for 6- and 12-hour placement, respectively: sequential use of additional cervical ripening agent (Foley reinsertion)-29 per 110 (26.4%) and 13 per 110 (11.8%) (relative risk, 2.23; 95% confidence interval, 1.23-4.10; P=.006); spontaneous balloon expulsion-22 per 110 (20.0%) and 37 per 110 (33.6%) (relative risk, 0.60; 95% confidence interval, 0.38-0.94; P=.022); and recommendation of the allocated intervention to a friend-61 per 110 (73.6%) and 87 per 110 (79.1%) (relative risk, 0.90; 95% confidence interval, 0.80-1.08; P=.341). Other secondary outcomes, including cesarean delivery, were not significantly different. Foley balloon placement for 6 hours for cervical ripening in parous women hastens birth but does not increase maternal satisfaction relative to 12-hour placement. Foley reinsertion for additional ripening was more frequent in the 6-hour group.

Maternal and fetal outcome among pregnant women with jaundice and deranged LFTs attending a tertiary care institute: a prospective study

Background: This was a prospective study to analyses the maternal and fetal outcome among pregnant women with jaundice and deranged LFTs in a tertiary care hospital. Methods: This was a prospective observational study conducted in the department of Obstetrics and Gynaecology at SLBSGMC Nerchowk for a period of 6 months. The pregnant women with jaundice and deranged LFTs were included in the study after fulfilling inclusion and exclusion criteria. History, clinical examination and relevant investigations done. All patients followed till seven days in post-partum period. The maternal and fetal outcomes were noted. Results: During study period we encountered 59 pregnant women with deranged LFTs. Majority of women were in primigravida (74.6%) in 20-30 years (55.9%) of age group. Most common symptom was pruritus in 59.3% of women. ICP was the most common cause amongst 64.4% of women. 40.7% 0f women had FTVD and 40.6% had cesarean delivery. AFD with MSL (87.5%) being the most common indication for cesarean delivery amongst these women. A total of 49 (83.1%) of newborn were delivered alive with good Apgar score, 1 (1.7%) was premature, 1 (1.7%) had respiratory distress syndrome (RDS). Conclusions: In contrary to older Indian studies our study concluded that though liver disease is less common, but on evaluation we found that intra-hepatic cholestasis being the number one cause of deranged LFTs in pregnancy in our hospital. Amongst these patients with high index of suspicion, prompt investigations, early diagnosis and timely management can improve the maternal and perinatal outcome.

Labor induction with a combined method (pharmacologic and mechanical): A randomized controlled trial

IntroductionThe aim of this study was to compare the effectiveness of a combined misoprostol-Foley catheter induction of labor protocol against the current guidelines of our department. Material and methodsA randomized trial was conducted comparing two cervical ripening study groups: combined misoprostol-cervical Foley and the current department practice (misoprostol alone or dinoprostone alone). Women were stratified randomly according to parity for the two intervention groups. The primary outcome was defined as time to delivery (in hours). Secondary outcomes were cesarean delivery rate, time to active labor (defined as dilatation 6 cm or greater), delivery within 12 h, delivery within 24 h, maternal length of stay and indication for cesarean delivery. A composite of maternal morbidity and neonatal morbidity were also analyzed. Results142 women were randomized into one of the two groups (74 for treatment group and 68 for control group). Demographic and clinical characteristics were similar among the two groups. The primary outcome, the average time to delivery, was faster in the treatment group (22.7 h vs 27.2 h, p = 0.03) and this difference was higher in the nulliparous subgroup (24.2 h vs 29.2 h, p = 0.03). Active phase of labor was achieved faster in the treatment group (17.9 h vs 22.7 h, p = 0.008). The risk for cesarean section was similar in both groups (OR 0.801 (0.527–1.217) vs OR 1.203 (0.871–1.662), p = 0.278). ConclusionsOur study suggests that the combined method of cervical Foley with vaginal misoprostol for women presenting to induction of labor with unfavorable Bishop scores reduces time to delivery safely. The risk for cesarean section was similar in both groups.