Cesarean Delivery Rate Research Articles

Is there any materno- foetal risks in mothers with gestational weight gain (WHO & IOM) based on their pre-pregnancy body mass indices? Our experience in a tertiary care teaching institution in North Kerala

: This research was done to learn the impact of pre-pregnancy BMI and gestational weight gain (GWG) on subsequent risks of adverse pregnancy outcomes in a tertiary care teaching institution in North Kerala, India. A descriptive study in a tertiary care teaching institution in Kozhikode, North Kerala. : 296 singleton pregnant women with BMI categorised as per Asian Standards and adverse maternal outcomes were looked out for. Pregnant women were underweight (82.8%) achieved less than recommended weight during pregnancy as compared to 18.4% obese mothers. Mothers with high BMI gained more than recommended weight during pregnancy as compared to the underweight and normal weight woman. GDM was 3.03 times(p=0.019)and Hypertensive disorders of pregnancy was 1.116 times more common in higher pre-pregnancy BMI mothers. In the present study, gestational weight gain had no impact on maternal anaemia, Gestational diabetes, Gestational hypertension, foetal growth restriction and rate of caesarean deliveries. A statistically significant positive correlation was obtained between pre-pregnancy BMI and baby weight, p<0.001. A statistically significant positive correlation was obtained between gestational weight gain and baby weight, p=0.005. Weight gain during pregnancy had no significant impact on maternal pregnancy outcomes and caesarean delivery.

Buccal versus Vaginal Misoprostol Combined with a Foley Catheter among Individuals with Obesity Undergoing Induction.

Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 μg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m2) was stratified. The primary outcome was time to delivery. A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m2 (vaginal misoprostol-FC: 21.3 hours vs. buccal misoprostol-FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1-1.7). There were no significant differences in maternal and neonatal outcomes. We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. · Vaginal misoprostol was superior to buccal route among patients with obesity.. · There was no difference in the cesarean delivery rate between the two groups.. · Vaginal misoprostol should be the preferred route of administration among patients with obesity..

Transcutaneous Discrimination of Fetal Heart Rate from Maternal Heart Rate: A Fetal Oximetry Proof-of-Concept.

Intrapartum care uses electronic fetal heart rate monitoring (EFHRM) for over 50years to indirectly assess fetal oxygenation. However, this approach has been associated with an increase in cesarean delivery rates and limited improvements in neonatal hypoxic outcome. To address these shortcomings, a novel transabdominal fetal pulse oximeter (TFO) is being developed to provide an objective measurement of fetal oxygenation. Previous studies have evaluated the performance of TFO on pregnant ewe. Building on the animal model, this study aims to determine whether TFO can successfully capture human fetal heart rate (FHR) signals during non-stress testing (NST) as a proof-of-concept. Eight ongoing pregnancies meeting specific inclusion criteria (18-40years old, singleton, and at least 36weeks' gestation) were enrolled with consent. Each study session was 15 to 20min long. Reference maternal heart rate (MHR) and FHR were obtained using finger pulse oximetry and cardiotocography for subsequent comparison. The overall root-mean-square error was 9.7BPM for FHR and 4.4 for MHR, while the overall mean-absolute error was 7.6BPM for FHR and 1.8 for MHR. Bland-Altman analysis displayed a mean bias ± standard deviation between TFO and reference of -3.9 ± 8.9BPM, with limits of agreement ranging from -21.4 to 13.6 BPM. Both maternal and fetal heart rate measurements obtained from TFO exhibited a p-value < 0.001, showing significant correlation with the reference. This proof-of-concept study successfully demonstrates that TFO can accurately differentiate maternal and fetal heart signals in human subjects. This achievement marks the initial step towards enabling fetal oxygen saturation measurement in humans using TFO.

Perinatal outcomes among pregnant patients with peripartum coronavirus disease 2019 infection

PurposeEvaluate maternal and neonatal outcomes in peripartum coronavirus disease 2019 (COVID-19) positive women.MethodsA retrospective cohort study was conducted, comparing outcomes between women with and without peripartum COVID-19. All singleton deliveries from June 2020 to January 2022 were included. Univariate analysis was followed by multivariate analysis.ResultsOf 26,827 singleton deliveries, 563 women had peripartum COVID-19, associated with preterm deliveries both near-term and remote from term [adjusted odds ratio (aOR) 1.6 and 2.0, respectively, p = 0.007 and 0.003]. Women with peripartum COVID-19 had a significantly higher rate of disseminated intravascular coagulation (DIC) (aOR 23.0, p < 0.001). Conversely, peripartum COVID-19 peripartum COVID-19 was negatively associated with premature rupture of membranes and prolonged maternal length of stay (aOR 0.7 and 0.5, respectively, p = 0.006 and <0.001).In cesarean delivery (CDs), patients with COVID-19 had higher rate of urgent CDs (75.5 vs. 56.1%, p < 0.001), higher rate of regional anesthesia (74.5 vs. 64.9%, p = 0.049), and longer anesthesia duration (86.1 vs. 53.4 min, p < 0.001). CD rate due to non-reassuring fetal heart rate (NRFHR) was significantly higher in women with COVID-19 (29.6 vs. 17.4%, p = 0.002). Conversely, CDs rate due to history of previous single CD was significantly higher in patients without COVID-19 diagnosis (13.6 vs. 4.1%, p = 0.006).Concerning neonatal outcomes, an association has been observed between COVID-19 and low one-minute APGAR score <5, as well as neonatal COVID-19 infection (aOR 61.8 and 1.7 respectively, p < 0.001 and p = 0.037).ConclusionsPeripartum COVID-19 is associated with preterm deliveries, urgent CDs and DIC, potentially aligning with the infection’s pathophysiology and coagulation alterations.

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.

The Impact on Birth Outcomes of Sonographic Fetal Weight Estimation in Neonatal Macrosomia.

Our objective was to examine the association between sonographic estimated fetal weight (EFW) and obstetrical and neonatal outcomes in women with neonatal macrosomia. This study, conducted at a tertiary university-affiliated hospital from 2017 to 2021, compared obstetrical and neonatal outcomes between two groups of women who delivered macrosomic newborns (actual birthweight ≥ 4,000 g): (1) those with EFW ≥ 3,800 g (suspected impending macrosomia) and (2) those with EFW < 3,800 g (unsuspected impending macrosomia). During the study period, 854 women with neonatal macrosomia attempted vaginal delivery. Only 9.2% had a sonographic EFW ≥ 4,000 g. Among women with EFW ≥ 3,800 g (n = 317) compared with EFW < 3,800 g (n = 537), the cesarean delivery (CD) rate was higher (17.0 vs. 10.5%, p = 0.004) and the operative delivery rate was lower (3.2 vs. 0.6%, p = 0.015). Among primiparous women, the CD rate was higher among those with EFW ≥ 3,800 versus <3,800 g (37.3 vs. 23.2%, p = 0.033). EFW ≥3,800 g was associated with CD, regardless of predelivery body mass index, parity, diabetes mellitus, maximal fetal weight at previous deliveries, actual birthweight, and labor induction (p = 0.014). EFW ≥ 3,800 g and diabetes mellitus were independent predictors of CD. Among women with EFW ≥3,800 g and diabetes mellitus, the risk of CD was double that of those without diabetes and with EFW ≥ 3,800 g (31.4% vs. 15.2%, p = 0.02), although their actual birthweights were similar. Obstetrical and neonatal outcomes were similar between those with sonographic EFW ≥ 3,800 and < 3,800 g. Larger EFW increased CD risk among pregnancies with actual neonatal macrosomia. Antenatally suspected macrosomia might alter labor management due to concerns for potential complications, especially when associated with primiparity, diabetes mellitus, or maternal obesity. The increase in the CD rate did not show an association with improved maternal and neonatal outcomes. · Antenatally suspected macrosomia might alter labor management due to concerns about complications.. · Larger EFW increased cesarean delivery risk among pregnancies with actual neonatal macrosomia.. · The increase in the cesarean delivery rate was not associated with improved outcomes..

The Relationship of Patient/Provider Racial Concordance to Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rates [ID 2683595

INTRODUCTION: Prior studies have explored factors affecting nulliparous, term, singleton, vertex cesarean (NTSV-C) delivery rates, such as induction, provider type, and racial disparities. Some studies have shown higher NTSV-C rates among non-White patients compared to their White counterparts. Our aim was to study the influence of racial concordance between patient and provider on NTSV outcomes. METHODS: A retrospective analysis of 315 NTSV pregnancies at an urban hospital from January to March 2023 was performed. The NTSV outcomes by racial concordance were examined using χ2 and Fisher exact tests with alpha &lt;.05. Logistic regression analysis was used to adjust for high-risk maternal comorbidities. The race of patients and delivering providers was based on self-identification. RESULTS: A majority of patient–provider dyads were concordant for race (199/315 [63.2%]). Racial concordance was associated with a lower NTSV-C rates (23.1 versus 33.6%; P=.04). This association persisted after adjusting for maternal comorbidities (P=.003). When NTSV outcomes were stratified by patient race, significant differences in cesarean delivery rates by patient race were observed for White providers (P=.02). No significant differences between races were observed for Asian (P=.93) or Black providers (P=.82). CONCLUSION: These results emphasize the significant effect of racial concordance between patients and providers on cesarean delivery rates, highlighting the need for further examination of health care disparities and tailored interventions to promote equitable maternal care.

COVID-19's Effect in Pregnancy and Vertical Transmission: A Systematic Review.

The COVID-19 pandemic has significantly impacted public health and the global economy. It has also been found to have potential effects on pregnancy, neonatal outcomes, and mother-to-infant transmission. This systematic review aims to provide an overview of the maternal and perinatal outcomes associated with pregnancy. A systematic review study was conducted by searching the PubMed, MEDLINE, Embase, and Web of Science databases according to PRISMA guidelines from December 1, 2019, to December 23, 2022. The results indicate that there was an increase in the rate of cesarean delivery among mothers infected with SARS-CoV-2. However, the study found that the mode of delivery for pregnant women infected with SARS-CoV-2 did not increase or decrease the risk of infection for newborns. During the COVID-19 pandemic, there has been an increase in maternal and infant mortality rates, as well as stillbirths and ruptured ectopic pregnancies. Research has shown that SARS-CoV-2 can potentially be transmitted during pregnancy, although vertical transmission is rare. However, additional data are needed to investigate this adverse effect, especially regarding reports of disease recurrence in mothers infected with SARS-CoV-2.

Prevalence of Large for Gestational Age and Polyhydramnios on Late Third-Trimester Ultrasound and Associated Adverse Pregnancy Outcomes [ID 2683531

INTRODUCTION: The objective of this study was to evaluate the prevalence of large for gestational age (LGA) and polyhydramnios found on ultrasound performed between 34 and 38 weeks of gestation and investigate the prevalence of gestational diabetes and delivery outcomes in this population. METHODS: A retrospective cross-sectional study (IRB #4869) was performed including chart review of late third-trimester ultrasounds performed on singleton pregnancies between 34 and 38 weeks of gestation from April 2020 to April 2022 at a hospital-owned private practice. Patients were grouped as no LGA (estimated fetal weight &gt;90%) or polyhydramnios (amniotic fluid index ≥25 or maximum vertical pocket ≥8) or LGA and/or polyhydramnios. Differences in cesarean delivery (CD), gestational diabetes diagnosis, and macrosomia between groups were assessed via χ2 and Fisher's exact tests. RESULTS: Of 1,510 pregnancies, 15.0% (227/1,510) were diagnosed with LGA and/or polyhydramnios on late third-trimester ultrasound. The overall prevalence of CD in the group without LGA and/or polyhydramnios was 25.5%, whereas the rate of CD in patients having LGA and/or polyhydramnios was 44.1% (P&lt;.001). The overall prevalence of macrosomia in the group without LGA and/or polyhydramnios was 8.8%, whereas the rate of macrosomia in patients having LGA and/or polyhydramnios was 17.2% (P&lt;.001). The prevalence of diabetes in pregnancy was not significantly different between groups (without LGA and/or polyhydramnios 12.2% versus having LGA and/or polyhydramnios 16.7%; P=.081). CONCLUSION: Patients with LGA and/or polyhydramnios on late third-trimester ultrasound had significantly higher rates of CD and macrosomia. They were not more likely to have a diagnosis of diabetes during pregnancy. Late third-trimester ultrasound findings of LGA and/or polyhydramnios could be useful in detecting undiagnosed and/or missed diabetes. Future work will evaluate the timing of gestational diabetes screening and subsequent testing for diabetes if findings suggest LGA and/or polyhydramnios.

Inflammatory Bowel Disease and Associated Placental Histopathology [ID 2683599

INTRODUCTION: Inflammatory bowel disease (IBD) has been associated with adverse obstetric outcomes, but its effect on placental histopathology is not well studied. We sought to determine the placental histopathology findings associated with maternal IBD. METHODS: This is an IRB-approved retrospective cohort study of patients with IBD who delivered singleton live births at a single institution from October 2019 to April 2023 and had placental pathology available. Participants were identified using an ultrasound query for “Crohn’s” or “ulcerative colitis” (UC). Cases with fetal aneuploidy or major anomalies were excluded. Controls were matched 2:1 for maternal age, gestational age at delivery, and medical comorbidities. Demographics, pregnancy outcomes, and pathology findings were obtained from the electronic medical record. Mann–Whitney and Fisher's exact tests were used with significance set at P&lt;.05. RESULTS: Placental pathology was compared between 18 IBD participants (11 Crohn's, seven UC) and 36 controls. Of 18 IBD participants, three were treated with sulfasalazine, seven with TNF-α inhibitors, and eight used no medication. Baseline demographics and cesarean delivery rates were similar between groups. Five participants per group had histologic evidence of acute chorioamnionitis and/or funisitis (27.8% versus 13.9%; P=.27). Three IBD participants demonstrated maternal vascular malperfusion (MVM) versus 15 controls (16.7% versus 41.7%; P=.07). There were no differences in placental weight, meconium, or fetal vascular malperfusion. CONCLUSION: Inflammatory bowel disease was not associated with adverse placental histopathology. Decreased incidence of MVM may result from IBD medications reducing systemic inflammation. Larger studies are warranted to further evaluate the effect of IBD on placental pathology.

Exploring Effect of Patient Counseling on Mode of Delivery After Cesarean Section [ID 2683575

INTRODUCTION: Increasing vaginal birth after cesarean (VBAC) may help lower national cesarean delivery rates in the United States. This study aims to evaluate factors that affect counseling practices and trial of labor after cesarean (TOLAC). METHODS: All term repeat cesarean deliveries (rCDs) and VBACs from September 2018 to February 2020 were reviewed. Antepartum counseling on mode of delivery, demographic, and obstetrical data were collected. Patients who were not TOLAC candidates were excluded. This study was IRB approved. RESULTS: Six hundred thirty-five patients met inclusion criteria. 304 (47.72%) of these patients had rCD, 65 (10.20%) attempted TOLAC with subsequent rCD, and 268 (42.07%) had VBAC. Of the 635 patients, 470 (74.02%) patients had documentation of TOLAC counseling prior to admission for delivery, whereas 165 (25.98%) did not. TOLAC counseling documentation was not associated with age, race, ethnicity, body mass index (BMI), insurance type, or history of vaginal delivery (VD). Prior VBAC increased the odds of documented TOLAC counseling (odds ratio [OR] 2.36; 95% CI, 1.29–4.63). Medicaid insurance (OR 2.18; 95% CI, 1.29–3.73), history of VD (OR 2.28; 95% CI, 1.16–4.68), history of VBAC (OR 269.0; 95% CI, 50.2–5079), and documented TOLAC counseling (OR 21.12; 95% CI, 11.0–45.10) increased the odds of TOLAC. Increasing BMI decreased the odds of TOLAC (OR 0.91; 95% CI, 0.89–0.95). CONCLUSION: Documented TOLAC counseling increased the odds of attempting TOLAC. As only 74.02% of patients had documented counseling prior to admission for delivery, an effort to increase TOLAC counseling and documentation may increase TOLAC and subsequent VBAC rates, decreasing the cesarean delivery rate.

What's in a Name? Provider Type and Delivery Outcomes for Nulliparous, Term, Singleton, Vertex Pregnancies in an Urban Hospital [ID 2683515

INTRODUCTION: Few studies have compared the rates of cesarean section of nulliparous, term, singleton, vertex (NTSV) pregnancies between those managed by physicians and those managed by midwives. Our aim was to compare those rates and to determine whether there were any associated differences in neonatal outcomes. METHODS: This was a retrospective cohort study of NTSV pregnancies at an urban hospital over 3 months. Two groups were compared: patients who were managed by physicians and those managed by midwives. Our primary outcome was the rate of primary cesarean delivery for each group. Patient demographics and outcomes were compared using a χ2 analysis for categorical variables and Mann–Whitney U test for continuous variables, with significance being alpha &lt;.05. Our study was approved by the Maimonides IRB. RESULTS: Between January and March 2023, there were 315 NTSV deliveries. Of these, 230 (73%) were admitted by physicians and 85 by certified nurse-midwives (27%). The NTSV patients admitted and managed by physicians were significantly more likely to undergo cesarean delivery (30.9% versus 16.5%; P=.01). This trend remains significant (P=.04) when adjusted for high-risk maternal comorbidities (ie, diabetes, hypertension, and maternal body mass index). There were no significant differences of neonatal outcomes between physician and midwives groups in Apgar scores (1 minute P=.43, 5 minutes P=.19), neonatal intensive care unit (NICU) admissions (P=.84), or NICU stay length (P=.89). CONCLUSION: The NTSV pregnancies managed by midwives resulted in fewer cesarean deliveries with similar neonatal outcomes. Further investigation is needed to assess causes of the difference between provider types and to develop interventions to address the discrepancy.

ARTERIAL BLOOD PRESSURE PHENOTYPES DEFINED BY AMBULATORY BLOOD PRESSURE MONITORING IN PREGNANCY AND ITS PROGNOSTIC VALUE FOR FUTURE MATERNAL AND NEONATAL EVENTS

Objective: We have previously demonstrated that some ambulatory blood pressure monitoring (ABPM) values can predict maternofoetal evens in hypertensive pregnant women. The analysis of the different blood pressure (BP) phenotypes in pregnant women is still an unknown topic. Design and method: A retrospective cohort study which followed a sequential number of 274 pregnant women referred to Cardiology/Hypertension consult (mean age of 32 years), from 2007 to 2022, who underwent ABPM made with a Spacelabs 90207. Data was collected and analysed in SPSS Statistics through different parametric tests. An event was defined as the composite endpoint of multiple adverse events: preeclampsia or eclampsia, foetal or neonatal death, prematurity, low weight at birth, gestational diabetes, and maternal death. Results: In a survival Kaplan-Meier curve of events, when we compared normal versus hypertensive groups, those with hypertension had worse survival with a log rank of 6.594 (p=0.010). In a further comparison, Kaplan-Meier analysis revealed a worse survival in the hypertensive without medication group, followed by the non-controlled hypertensive and controlled hypertensive groups, with a log rank of 11.737 (p=0.003). (Fig 1) An independent-samples T test followed by a multi-variate analysis was performed, revealing significant differences between the hypertensive and non-hypertensive group for maternal age (p=0.034) and birth weight (p=0.023). In the multi-variate analysis, the hypertensive group was notably associated with a higher rate of caesarean delivery (70.2% versus 34.6%, p=0.007). Further analysis showed significant differences in birth weight between the controlled hypertensive group and the hypertensive without medication (p=0.001) and non-controlled hypertensive (p=0.002) groups. Conclusions: This study further corroborates the importance of ABPM in the diagnosis and follow-up of hypertensive pregnant women, having a major impact in both maternal and neonatal morbidity. Normotensive pregnant women had a better prognosis as compared to hypertensive pregnant women, defined by ABPM values. ABPM should be an essential tool to manage pregnant women.

Are pelvic-abdominal mechanics exercises effective for cesarean delivery rate and postpartum pelvic floor function: A randomized controlled trial

ObjectivesTo examine the effectiveness of pelvic-abdominal mechanics exercise in reducing cesarean section rates and preventing pelvic floor dysfunction in primiparous women. DesignRandomized controlled trial. MethodsA single-center prospective study was conducted among 200 primiparous participants (aged 18–38 years) who undertook formal card-issuing maternity tests between June 1, 2022, and June 30, 2023. Participants were divided into two groups: exercise (intervention) and control using the random number table method. Participants of the intervention group performed pelvic-abdominal mechanics exercise at least 1 h each time per week for three months. Participants of the control group did not perform any pelvic-abdominal mechanics exercise during pregnancy. This study conducted a comprehensive evaluation from three perspectives, including maternal and neonatal health outcomes during delivery, the recovery status of pelvic floor muscles at 42 days postpartum, and the quality of life during late pregnancy (36–38 weeks) and 42 days postpartum. ResultsA significant difference was found in delivery outcomes. The cesarean section rates are significantly higher (p < 0.05) in the control group (36 %) than in the exercise group (19 %). At 42 days postpartum, pelvic floor assessment showed that the exercise group had significantly better results in pelvic floor muscle strength compared to the control group, with statistical significance (p < 0.05). ConclusionsPelvic-abdominal mechanics exercise lowers the rate of cesarean section and improves postpartum pelvic floor function.

Risk of intrapartum cesarean delivery in twin pregnancies: A retrospective cohort study.

To compare the risk of intrapartum cesarean delivery (CD) between patients with twin and singleton pregnancies undergoing a trial of labor and identify risk factors for intrapartum CD in twin pregnancies. The present study was a retrospective cohort study of patients with a twin or singleton pregnancy who underwent a trial of labor at ≥340/7 weeks in a single center (2015-2022). The primary outcome was the rate of intrapartum CD. In twin pregnancies, this outcome was limited to CD of both twins. The association of plurality with intrapartum CD was estimated using multivariable Poisson regression. A total of 20 754 patients met the study criteria, 669 of whom had a twin pregnancy. Patients with twins had a greater risk of intrapartum CD (of both twins) than those with singleton pregnancies (22.1% vs 15.9%, respectively; aRR 1.38 [95% CI: 1.15-1.66]), primarily due to a greater risk of failure to progress. In addition, 4.1% of the twin pregnancies had a CD for the second twin, resulting in an overall CD rate in twin pregnancies of 26.2%. Variables associated with intrapartum CD in twin pregnancies included nulliparity (aOR 3.50, 95% CI: 2.34-5.25), birthweight discordance >20% (aOR 2.47, 95% CI: 1.27-4.78), and labor induction (aOR 1.64, 95% CI: 1.07-2.53). The rate of intrapartum CD was highest when all three risk factors were present (67% [95% CI: 41%-87%]). Twin pregnancies are associated with a greater risk of intrapartum CD than singleton pregnancies. Information on the individualized risk of intrapartum CD may be valuable when counseling patients with twins regarding mode of delivery.

A Simple Risk Adjustment for Hospital-Level Nulliparous, Term, Singleton, Vertex, Cesarean Delivery Rates and Its Implications for Public Reporting

The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals' perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system. Included were all consecutive NTSV pregnancies from January 2019 to April 2023 across 10 hospitals in one health system. Logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders. was used to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed vs. expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. The authors calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate. Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across 10 hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5%. Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted vs. unadjusted rates ranging from -1.33% (indicating lower rate after risk adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of 10 (30.0%) hospitals qualified for different reporting statuses after risk adjustment. Risk adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.

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.

Intrahepatic cholestasis of pregnancy and its association with preeclampsia and gestational diabetes: a retrospective analysis.

To evaluate maternal and neonatal outcomes in patients with intrahepatic cholestasis of pregnancy (ICP). Patients who gave birth in our hospital between January 2018 and March 2022 were retrospectively reviewed from the hospital database and patient file records. The study comprised 1686 patients, 54 in the ICP group and 1632 controls. Patients who had ICP after 20weeks of gestation and were monitored and delivered at our facility were enrolled. Maternal demographic and obstetric characteristics data were examined. Perinatal outcomes were also assessed. Logistic regression analysis was used to determine adverse maternal outcomes. The mean age was 29years. ART, GDM, and preeclampsia were significantly higher in the ICP group. The mean serum bile acid level was 19.3 ± 3μmol/L in the ICP group. There was a higher risk of GDM and pre-eclampsia in women with ICP compared with those without and a significant association between ICP and adverse perinatal outcomes. There was a statistically significant relation between the presence of ICP and spontaneous preterm delivery, iatrogenic preterm delivery, 5th-minute Apgar scores < 7, and NICU requirement. No significant relationship was found between the presence of ICP and SGA and meconium. There was a significant relationship between the presence of ICP, mode of delivery, and PPH (p < 0.05). Those with ICP had a lower gestational week and birth weight, and higher rates of cesarean delivery and PPH. ICP should prompt close monitoring and management to mitigate the potential exacerbation of adverse outcomes, including preeclampsia, GDM, and preterm birth.

A simulation study to assess the potential benefits of MRI-based fetal weight estimation as a second-line test for suspected macrosomia

ObjectiveTo simulate the outcomes of Boulvain’s trial by using magnetic resonance imaging (MRI) for estimated fetal weight (EFW) as a second-line confirmatory imaging. Study designData derived from the Boulvain’s trial and the study PREMACRO (PREdict MACROsomia) were used to simulate a 1000-patient trial. Boulvain’s trial compared induction of labor (IOL) to expectant management in suspected macrosomia, whereas PREMACRO study compared the performance of ultrasound-EFW (US-EFW) and MRI-EFW in the prediction of birthweight. The primary outcome was the incidence of significant shoulder dystocia (SD). Cesarean delivery (CD), hyperbilirubinemia (HB), and IOL at < 39 weeks of gestation (WG) were selected as secondary outcomes. A subgroup analysis of the Boulvain’s trial was performed to estimate the incidence of the primary and secondary outcomes in the true positive and false positive groups for the two study arms. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for the prediction of macrosomia by MRI-EFW at 36 WG were calculated, and a decision tree was constructed for each outcome. ResultsThe PPV of US-EFW for the prediction of macrosomia in the PREMACRO trial was 56.3 %. MRI-EFW was superior to US-EFW as a predictive tool resulting in lower rates of induction for false-positive cases. Repeating Boulvain’s trial using MRI-EFW as a second-line test would result in similar rates of SD (relative risk [RR]:0.36), CD (RR:0.84), and neonatal HB (RR:2.6), as in the original trial. Increasing the sensitivity and specificity of MRI-EFW resulted in a similar relative risk for SD as in Boulvain’s trial, but with reduced rates of IOL < 39 WG, and improved the RR of CD in favor of IOL. We found an inverse relationship between IOL rate and incidence of SD for both US-EFW and MRI-EFW, although overall rates of IOL, CD, and neonatal HB would be lower with MRI-derived estimates of fetal weight. ConclusionThe superior accuracy of MRI-EFW over US-EFW for the diagnosis of macrosomia could result in lower rates of IOL without compromising the relative advantages of the intervention but fails to demonstrate a significant benefit to justify a replication of the original trial using MRI-EFW as a second-line test.

Fast Healthcare Interoperability Resources-Based Support System for Predicting Delivery Type: Model Development and Evaluation Study.

The escalating prevalence of cesarean delivery globally poses significant health impacts on mothers and newborns. Despite this trend, the underlying reasons for increased cesarean delivery rates, which have risen to 36.3% in Portugal as of 2020, remain unclear. This study delves into these issues within the Portuguese health care context, where national efforts are underway to reduce cesarean delivery occurrences. This paper aims to introduce a machine learning, algorithm-based support system designed to assist clinical teams in identifying potentially unnecessary cesarean deliveries. Key objectives include developing clinical decision support systems for cesarean deliveries using interoperability standards, identifying predictive factors influencing delivery type, assessing the economic impact of implementing this tool, and comparing system outputs with clinicians' decisions. This study used retrospective data collected from 9 public Portuguese hospitals, encompassing maternal and fetal data and delivery methods from 2019 to 2020. We used various machine learning algorithms for model development, with light gradient-boosting machine (LightGBM) selected for deployment due to its efficiency. The model's performance was compared with clinician assessments through questionnaires. Additionally, an economic simulation was conducted to evaluate the financial impact on Portuguese public hospitals. The deployed model, based on LightGBM, achieved an area under the receiver operating characteristic curve of 88%. In the trial deployment phase at a single hospital, 3.8% (123/3231) of cases triggered alarms for potentially unnecessary cesarean deliveries. Financial simulation results indicated potential benefits for 30% (15/48) of Portuguese public hospitals with the implementation of our tool. However, this study acknowledges biases in the model, such as combining different vaginal delivery types and focusing on potentially unwarranted cesarean deliveries. This study presents a promising system capable of identifying potentially incorrect cesarean delivery decisions, with potentially positive implications for medical practice and health care economics. However, it also highlights the challenges and considerations necessary for real-world application, including further evaluation of clinical decision-making impacts and understanding the diverse reasons behind delivery type choices. This study underscores the need for careful implementation and further robust analysis to realize the full potential and real-world applicability of such clinical support systems.