Cesarean Risk Research Articles

Cesarean delivery rates and indications in pregnancies complicated by diabetes

Objective Rates of pregestational (PGDM) and gestational diabetes (GDM), and their associated pregnancy complications, are rising. Pregnancies complicated by diabetes have increased cesarean delivery (CD) rates; however, there are limited data regarding the current rates of, and contributing factors to, these deliveries. The Robson Ten Group Classification System (TGCS) is a clinically relevant, standardized framework that can be used to evaluate and analyze cesarean rates. The objective of this study was to evaluate rates of, and indications for, intrapartum, unplanned CD among pregnancies complicated by diabetes, compared to normoglycemic (NG) pregnancies, in a large United States birth cohort. Methods This retrospective cohort study used chart-abstracted data on births between 24 and 42 weeks’ gestation at 17 hospitals that contributed to the Obstetrical Care Outcome Assessment Program database between 01/2016 and 03/2019. The CD rate for NG pregnancies, and pregnancies complicated by gestational and PGDM was calculated and compared using the Robson TGCS. The indications for intrapartum CD in patients with term, singleton, vertex gestations without a prior cesarean were then analyzed. Univariate and multivariate logistic regression models were used to compare the cesarean rate and indications for CD, between the diabetic groups and the NG group. Results were adjusted for maternal age, BMI, neonatal birth weight, and insurance status, as well as clustering by hospital. Results A total of 86,381 pregnant people were included in the study cohort. Of these 76,272 (88.3%) were NG, 8591 (9.9%) had GDM, and 1518 (1.8%) had PGDM. Compared to NG patients, overall cesarean rates were higher in patients with GDM (40.3% vs. 29.7%; aOR 1.25, 95%CI 1.18–1.31) and PGDM (60.0% vs. 29.7%; aOR 2.53, 95%CI 2.04–3.13). This finding remained true when the cohort was restricted to term, singleton, vertex laboring patients without a prior cesarean; compared to NG patients, the cesarean rate was higher in patients with GDM (17.4% vs. 12.2%, aOR 1.37, 95%CI 1.29–1.45) and PGDM (26.0% vs. 12.2%, aOR 2.55, 95%CI 2.00–3.25). The cesarean rate for fetal indications was similar in the GDM (5.7%) and NG (4.4%) groups, while those patients with PGDM had a significantly higher rate (10.4%; aOR 2.01, 95%CI 1.43–2.83). Similarly, the rate of cesarean for labor dystocia in patients with PGDM was significantly higher than in NG patients (16.9% vs. 7.0%, and aOR 2.28, 95%CI 1.66–3.13) while patients with GDM had an intermediate rate (10.6% vs. 7.0%, aOR 1.49, 95%CI 1.40–1.57). Conclusions The CD rate is significantly higher in pregnancies complicated by diabetes, particularly pregestational, compared to NG pregnancies. Despite controlling for maternal factors and birth weight, pregnancies complicated by diabetes are more likely to undergo an unplanned intrapartum cesarean secondary to labor dystocia than their NG counterparts, but only pregnancies complicated by PGDM have an increased risk of cesarean for fetal indications. More research is needed to understand whether this higher cesarean rate is due to factors intrinsic to diabetes in laboring patients or is due to a difference in the way clinicians manage diabetics in labor.

Sublingual misoprostol vs. oral misoprostol solution for induction of labor: A retrospective study.

IntroductionInduction of labor (IOL) is one of the most common obstetrical procedures, with an increasing rate. The prostaglandin E1 analogue misoprostol is frequently used as a primary method of labor induction. The optimal dose and route of administration is yet to be ascertained.AimTo compare efficiacy and safety between a regimen of sublingually administered misoprostol and a regimen of orally administered misoprostol, with cesarean delivery as primary outcome.MethodsA retrospective study was conducted including women carrying a live, singleton fetus in a cephalic position with labor induced at >37 + 0 gestational weeks at Skåne University hospital, Lund, between January 1st 2013 to December 31st 2017. Data was obtained from computerized obstetrical charts.ResultsTotally 2,404 women were included; 974 induced with sublingual misoprostol and 1,430 with oral solution. In primiparous women the cesarean delivery rate was lower in primiparous women induced with oral compared to sublingual misoprostol (20.5% vs. 28.6%, p < 0.001), whereas in parous women the rates did not differ significantly 4.9% vs. 7.5%; NS). The increased risk of caesarean remained after controlling for potential confounding factors (adjusted odds ratio 1.49 (1.14–1.95). Women induced with sublingual misoprostol had a shorter time to vaginal delivery when compared to oral solution (primiparous median 16.7 h vs. 21.7 h; p < 0.001, parous median 9.9 h vs. 13.3 h; p = 0.01), and a higher rate of vaginal delivery within 24 h (primiparas 77.7% vs. 63.3%, p < 0.001, parous 93.2% vs. 84.2%; p = 0.01).ConclusionIOL with oral misoprostol solution was associated with a significantly higher vaginal delivery rate when compared to sublingual misoprostol, whereas sublingual misoprostol was associated with a significantly shorter time from induction to vaginal delivery. Oral administration is considered the most safe and efficient administration of misoprostol, although more studies are needed to find the optimal route and dosage of misoprostol for IOL.

Deriving a prediction model for emergency cesarean delivery following induction of labor in singleton term pregnancies.

To derive a prediction model combining various clinical factors associated with increased risk of emergency cesarean section following induction of labor in women with unfavorable cervix. All women with singleton term pregnancies undergoing induction of labor and fulfilling inclusion criteria were included in this cross-sectional study after supplying consent. Women with a Bishop score of 6 or less were induced with dinoprostone gel. Multiple regression analysis was used to find the most significant independent predictive factors and these factors were used to develop the predictive model and calculator. After multiple logistic regression, risk of emergency cesarean after induction of labor was significantly associated with the following variables: height (adjusted odds ratio [aOR] 0.955, P= 0.033), nulliparity (aOR 3.987, P< 0.001), closed cervix (aOR 2.030, P= 0.030), fetal station -3 above ischial spine (aOR 2.719, P= 0.043), firm or medium cervical consistency (aOR 2.028, P= 0.004), cervical length 3cm or longer (aOR 3.090, P= 0.015), posterior cervix (aOR 2.112, P= 0.002). Use of a prediction model would help to reduce the number of emergency cesarean sections secondary to unsuccessful inductions and help in the reduction of maternal and perinatal morbidity.

Labor Diet and the Effects on Energy and the Birth Experience

The labor process is both physical and emotional. Patients who are in labor frequently are offered only clear liquids, regardless of cesarean risk. Laboring patients often complain of hunger, and not being able to eat can result in decreased energy and increased emotional stress. Pregnant women deserve safe care that meets their physical and emotional needs during birth.

Development and Validation of a Nomogram to Estimate Risk of Cesarean After Induction of Labor in Term Pregnancies with an Unfavorable Cervix in Iran

This study aimed to develop and validate a labor induction nomogram for nulliparous and multiparous women who were 38 weeks pregnant or more and had their labor induced by an unfavorable cervix. This prospective study was conducted on 300 individuals (200 for nomogram development and 100 for nomogram validation). Height, body mass index at delivery, parity, gestational age, adjusted bishop score, and cesarean section risk assessment were all recorded on a checklist. Participants were followed until they gave birth, and the type of delivery was noted in the checklist. Out of 300 labor inductions, 80 (26.7%) underwent a cesarean section. Cesarean risk estimation was the only predictor of delivery type based on multivariate logistic regression. The AUC (Area Under the Curve) in development group was 0.68 and in validation group was 0.71. The developed nomogram for predicting of cesarean section risk following labor induction has a relatively good predictive value among women.

P.7 Elective caesarean section risk rating: a quality improvement project

P.7 Elective caesarean section risk rating: a quality improvement project

P.53 Elective caesarean section risk scoring at booking - is there a correlation with theatre time?

P.53 Elective caesarean section risk scoring at booking - is there a correlation with theatre time?

Reducing surgical complications after cesarean section: Vaginal birth after cesarean section. Identifying the ideal candidate

Vaginal birth after cesarean section (VBAC) is worldwide accepted and encouraged. Currently, in Romania due to increased cesarean section rate especially for maternal request, a high number of patients with scarred uterus is seeking for VBAC at subsequent pregnancies. Because of specific complications of trial of labor after cesarean section (TOLAC), risks and benefits need to be individualized for each specific candidate. This study is about VBAC in Filantropia Clinical Hospital from Bucharest and how we are selecting the ideal candidate.

Cesarean section and breastfeeding outcomes in an Indigenous Qom community with high breastfeeding support.

Background and objectivesCesarean section may lead to suboptimal breastfeeding outcomes, though evidence has been mixed. Factors, such as premature birth, birth weight and maternal age may independently increase risk of cesarean and hinder breastfeeding initiation, while maternal preferences, support and sociostructural barriers may influence breastfeeding practices beyond the immediate postpartum period.MethodologyWe assessed impacts of cesarean section and gestational factors on breastfeeding duration among Indigenous Qom mothers in Argentina who have strong traditional breastfeeding support. We modeled transitions from exclusive breastfeeding to complementary feeding and from complementary feeding to full weaning in a Bayesian time-to-event framework with birth mode and gestational covariates (n = 89 infants).ResultsEstimated median time to full weaning was 30 months. Cesarean-delivered babies were weaned an average of 5 months later adjusting for gestational age, maternal parity and infant sex. No factors were associated with time-to-complementary feeding, and time-to-complementary feeding was not associated with time-to-full weaning.Conclusions and implicationsAmong Indigenous Qom mothers in Argentina, cesarean section was not associated with suboptimal breastfeeding outcomes. Although some Qom mothers do experience early breastfeeding problems, particularly following first birth, problems are not more frequent following cesarean delivery. Traditional postpartum kin and community support during prolonged postpartum periods may be instrumental in helping mothers to overcome early breastfeeding problems due to cesarean or other risk factors.

The influence of maternal body mass index on oxytocin and prostaglandin signaling in pregnancy

Pregnant women with obesity (body mass index, BMI ≥ 30 kg/m2) are more likely to experience prolonged labor and their risk of cesarean is double, compared with those of normal weight (BMI < 25 kg/m2). Oxytocin and prostaglandin F (PGF) are important mediators of myometrial contractility, and COX-2 is downstream of oxytocin signaling and crucial for production of prostaglandins. Our objective was to compare myometrial gene and protein expression of oxytocin and PGF receptors and their downstream signaling in obese and normal weight pregnant women at term.

Fetal abdominal size and risk of unplanned cesarean in pregnancies complicated by fetal growth restriction

Fetal abdominal size and risk of unplanned cesarean in pregnancies complicated by fetal growth restriction

Obesity and associated outcomes among nulliparas receiving high-dose versus standard-dose oxytocin for labor augmentation

Women with obesity are at increased risk for cesarean and labor complications. In vitro studies suggest that oxytocin receptor expression and function may be affected by maternal body mass index (BMI). We aimed to identify whether a high-dose oxytocin (HDO) regimen reduces the risk of cesarean or other labor complications in women with obesity.

Standardized Cesarean Risk Counseling with Induction: Impact on Racial Disparities in Birth Satisfaction.

Our prior work demonstrated decreased birth satisfaction for Black women undergoing labor induction. We aimed to determine if implementation of standardized counseling around calculated cesarean risk during labor induction could reduce racial disparities in birth satisfaction. We implemented use of a validated calculator that provides an individual cesarean risk score for women undergoing induction into routine care. This prospective cohort study compared satisfaction surveys for 6 months prior to implementation (preperiod: January 2018-June 2018) to 1 year after (postperiod: July 2018-June 2019). Women with full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix undergoing induction were included. In the postperiod, providers counseled patients on individual cesarean risk at the beginning of induction using standardized scripts. This information was incorporated into care at patient-provider discretion. The validated 10-question Birth Satisfaction Scale-Revised (BSS-R) subdivided into three domains was administered throughout the study. Patients were determined to be "satisfied" or "unsatisfied" if total BSS-R score was above or below the median, respectively. In multivariable analysis, interaction terms evaluated the differential impact of the calculator on birth satisfaction by race (Black vs. non-Black women). A total of 1,008 of 1,236 (81.6%) eligible women completed the BSS-R (preperiod: 330 [79.7%] versus postperiod: 678 [82.5%], p = 0.23), 63.8% of whom self-identified as Black. In the preperiod, Black women were 50% less likely to be satisfied than non-Black women, even when controlling for differences in parity (Black: 39.0% satisfied vs. non-Black: 53.9%, adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI]: 0.30-0.79). In the postperiod, there was no difference in satisfaction by race (Black: 43.7% satisfied vs. non-Black: 44.0%, aOR = 0.97. 95% CI: 0.71-1.33). Therefore, disparities in birth satisfaction were no longer present at postimplementation (interaction p = 0.03). Implementation of standardized counseling with a validated calculator to predict cesarean risk after labor induction is associated with a decrease in racial disparities in birth satisfaction. · Preintervention, Black women were less likely to have above-median birth satisfaction.. · We implemented standardized counseling around cesarean risk with labor induction.. · Implementation was associated with reduced racial disparities in birth satisfaction scores..

Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study

PurposeTo evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy.MethodsCases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis.ResultsThree hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22–4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23–3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23–3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49–79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69–38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38–22.09).ConclusionWomen with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery.Trial registrationClinical trial registration number: NCT03354793.

Daily weekday audit and feedback to clinicians for an inpatient intervention in obstetrics: is there sustained impact over the weekend? A secondary analysis of a prospective cohort study

BackgroundAudit and feedback as an implementation strategy leads to small, but potentially important improvements in practice. Yet, audit and feedback is time and personnel intensive. Many interventions designed for inpatient care are meant to be utilized by care teams all days of the week, including weekends when research staff are at a minimum. We aimed to determine if audit and feedback regarding use of an evidence-based inpatient obstetric intervention performed only on weekdays could have a sustained impact over the weekend.MethodsThis study was performed as a secondary analysis of a prospective cohort study examining the impact of implementation of a validated calculator that predicts the likelihood of cesarean delivery during labor induction. During the 1 year postimplementation period, Monday through Friday, a member of the study team contacted clinicians daily to provide verbal feedback. While the same clinician pool worked weekend shifts, audit and feedback did not occur on Saturdays or Sundays. The primary outcome was intervention use, defined as documentation of counseling around the cesarean risk calculator result, in the electronic health record. Intervention use was compared between those with (weekdays) and without (weekends) audit and feedback.ResultsOf the 822 women meeting eligibility criteria during the postimplementation period (July 1, 2018–June 30, 2019), 651 (79.2%) were admitted on weekdays when audit and feedback was occurring and 171 (20.8%) on weekends without audit and feedback. The use of the cesarean risk calculator was recorded in 676 of 822 (82.2%) of eligible patient charts. There was no significant difference in cesarean risk calculator use overall by days when audit and feedback occurred versus days without audit and feedback (weekday admissions 82.0% vs. weekend admissions 83.0%, aOR 0.90 95% CI [0.57–1.40], p = 0.76). There was no significant trend in the relationship between calculator use and weekday versus weekend admission by month across the study period (p = 0.21).ConclusionsDaily weekday audit and feedback for implementation of an evidence-based inpatient obstetric intervention had sustained impact over the weekends. This finding may have implications for both research staffing, as well as sustainability efforts. Further research should determine the lowest effective frequency of audit and feedback to produce implementation success.

618Is mode of first birth a risk factor for subsequent preterm birth?

Abstract Background Previous preterm birth is a strong predictor of subsequent preterm birth but less is known about the causes of preterm birth following a full-term pregnancy. Recent research highlighted previous caesarean as a potential risk factor and we aimed to further explore this risk. Methods This population-based record linkage study included all women in NSW, Australia who had a live singleton first birth at ≥ 37 weeks gestation, followed by a singleton second birth between 2005–2017. Relative risk (RR) and 95%CI of having a subsequent preterm birth, spontaneous preterm birth or preterm pre-labour caesarean was calculated using individual modified Poisson regression models, with mode of first birth as the exposure. Results Women who had an intrapartum (RR:1.26, 95%CI 1.19–1.32) or prelabour caesarean (RR:1.26,95%CI 1.18–1.35) first birth had a higher risk of subsequent preterm birth, than those who birthed vaginally. Those who had a pre-labour caesarean (RR:0.74, 95%CI 0.67–0.82) had a lower risk of subsequent spontaneous preterm birth. However, prior pre-labour caesarean also greatly increased the risk of subsequent preterm prelabour caesarean (RR:5.25, 95%CI 4.65–5.93). Conclusions Pre-labour and intrapartum caesareans have differing effects on the risk of subsequent spontaneous preterm birth and preterm pre-labour caesarean. Key messages The risk of subsequent preterm birth following a first birth caesarean depends on whether the caesarean occurred before or after the onset of labour and whether the subsequent preterm birth is spontaneous or a pre-labour caesarean.

Comparison of pregnancy outcomes between women of advanced maternal age (≥35 years) versus younger women in a tertiary care center in Saudi Arabia.

BACKGROUND: Pregnancy in women aged 35 years or above is generally considered an advanced maternal age (AMA). AMA is associated with an increased rate of maternal and neonatal complications.OBJECTIVES: Assess the effect of AMA on maternal and neonatal outcomes.DESIGN: Analytical cross-sectional study of medical records.SETTINGS: In-patient hospital tertiary care setting in Jeddah.PATIENTS AND METHODS: All women who attended antenatal care and delivered at King Abdulaziz Medical City in Jeddah in the first half of 2018 were included in the study. Outcomes for women 35 years of age or older were compared with younger women. Significant factors in a univariate analysis were entered in a multiple logistic regression model to assess the association between AMA and outcomes.MAIN OUTCOME MEASURES: Rates of maternal neonatal complications, analysis of factors associated with advanced maternal, gestational diabetes mellitus (GDM), cesarean delivery.SAMPLE SIZE: 1586 women.RESULTS: Of the 1586 women, 406 were 35 years of age or older (25.6%), and 1180 were younger than 35 years. The AMA group had a significantly higher proportion of GDM (32.0% versus 13.2%, P<.001). The adjusted odds ratio (OR) for GDM was 2.6 (95% CI 2–3.5, P<.001.) compared with younger women in the multivariate logistic regression analysis. Older women had a higher rate of cesarean delivery (43.6% versus 30.8%, P<.001). The adjusted OR for cesarean vs. vaginal delivery was 1.5 (CI 1.2–1.9, P=.002).CONCLUSION: Pregnancy in women 35 years or older was associated with an increased risk of GDM and cesarean delivery.LIMITATIONS: Cross-sectional design, small sample size, single hospital.CONFLICT OF INTEREST: None.

Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol

We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m2) and nonobese (<30 kg/m2) women. Indication for cesarean was also evaluated. A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol. Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. · Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction..

Caesarean delivery is associated with increased blood pressure in young adult offspring

We examined the associations between caesarean section (CS) delivery and cardiovascular risk factors in young adults in Thailand. Participants were 632 offspring from a birth cohort in Chiang Mai (Northern Thailand), born in 1989–1990 and assessed in 2010 at a mean age of 20.6 years, including 57 individuals (9.0%) born by CS and 575 born vaginally. Clinical assessments included anthropometry, blood pressure (BP), carotid intima-media thickness, and fasting blood glucose, insulin, and lipid profile. Young adults born by CS had systolic BP (SBP) 6.2 mmHg higher (p < 0.001), diastolic BP 3.2 mmHg higher (p = 0.029), and mean arterial pressure (MAP) 4.1 mmHg higher (p = 0.003) than those born vaginally. After covariate adjustments, SBP and MAP remained 4.1 mmHg (p = 0.006) and 2.9 mmHg (p = 0.021) higher, respectively, in the CS group. The prevalence of abnormal SBP (i.e., pre-hypertension or hypertension) in the CS group was 2.5 times that of those born vaginally (25.0% vs 10.3%; p = 0.003), with an adjusted relative risk of abnormal SBP 1.9 times higher (95% CI 1.15, 2.98; p = 0.011). There were no differences in anthropometry (including obesity risk) or other metabolic parameters. In this birth cohort in Thailand, CS delivery was associated with increased blood pressure in young adulthood.

Obstetric Outcome in Adolescents-(A Single Centre Experience Over 10 Years from Jan 2006-Dec 2015)

The aim of this study is to determine whether young adolescents aged 11-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20- 24 years in the tertiary hospital Royal Hospital in period from January 2006 to December 2015. It is a retrospective cohort study and we include all women delivered in royal hospital in that period of time and aged from 14 to 25 years and gestational age more than 24 week’s singleton pregnancy and cephalic presentation during labour. We exclude maternal Age &gt; 25 years and Gestation age ≤24 weeks, Non-cephalic presentation and Multiple pregnancy. By this study, there is no significant outcome complication among adolescent age group pregnancy compare to adult group except IUGR and NICU admissions.