Elective Cesarean Research Articles

English

BACKGROUND Pregnancy with one prior Caesarean section (CS) constitutes a high-risk group with associated medical and legal implications. The dictum ‘once a Caesarean always a Caesarean’ has now judiciously been replaced with ‘once a Caesarean, trial of labour after selection’ because low transverse uterine incision has much lesser chance of scar rupture. Though vaginal birth after Caesarean (VBAC) or trial of scar (TOS) brings a significant change in modern obstetric practice in terms of lower maternal and perinatal morbidities, apprehension of accidental scar rupture during trial of labour with its undesirable consequences still prevents a good number of obstetricians adopting this process. The purpose of the study was to determine the outcome of pregnancy in relation to mode of delivery, i.e., either elective repeat Caesarean section (ERCS) or vaginal birth after Caesarean (VBAC) with maternal and perinatal complications in each mode. METHODS A hospital based prospective, longitudinal, and observational study of 300 pregnant women with previous one Caesarean delivery attended labour emergency or out-patient department (OPD) at Midnapore Medical College of West Bengal, was carried out, approved by the institutional ethical committee. Gestational age < 37 weeks and > 42 weeks and h\o previous uterine surgery like myomectomy, hysterotomy, classical CS were excluded from the study. Data collected was analysed using statistical package for the social sciences (SPSS) software version 20. Descriptive statistics were used to analyse the continuous and categorical data and expressed in the form of mean and percentage whereas proportions were analysed using chi-square test. A P - value ≤ 0.05 was considered statistically significant. RESULTS Out of 300 pregnancies, 140 subjects were given trial of labour (TOL). Of which 89 subjects (63.6 %) had successful VBAC and 51 subjects (36.4 %) had repeat Caesarean sections. Among 211 subjects of repeat Caesarean section, 53 subjects (25.12 %) had indicated for scar tenderness and 73 subjects (34.59 %) had elective repeat Caesarean section (ERCS) due to protracted or arrested cervical dilatation. Those having previous vaginal delivery (VD), had more incidences of VBAC in present pregnancy than those who had no previous VD (P ≤ 0.005); Maternal morbidity (33.65 % ERCS versus 10.11 % VD group, P ≤ 0.05) and neonatal morbidity (12.3 % ERCS versus 2.46% VD group, P ≤ 0.05) was significantly higher in ERCS group. CONCLUSIONS Trial of labour (TOL) should be given in well-equipped hospital. In carefully selected cases, it is a safe procedure and often rewarding, thus incidence of repeat CS can be reduced. Those who had a history of vaginal delivery, VBAC often successful. KEYWORDS VBAC, Trial of Scar, Elective Repeat Caesarean Section, Trial of Labour

A retrospective review of clinical and non-clinical factors associated with unscheduled cesarean deliveries at one urban medical center.

To investigate factors associated with unscheduled cesarean delivery at one urban tertiary medical center. A retrospective chart review was performed on 11162 deliveries between 2009 and 2019. The dependent variable was unscheduled cesarean delivery. Covariates examined included time of delivery, as well as several maternal and pregnancy-related factors. There were a total of 7037 (63.1%) vaginal, 1133 (10.1%) elective cesarean, and 2992 (26.8%) unscheduled cesarean deliveries. Independent factors associated with increased odds for unscheduled cesarean delivery included daytime delivery (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.42, P<0.001); advanced maternal age (OR 1.40, 95% CI 1.26-1.56, P<0.001); obesity (OR 1.04, 95% CI 1.03-1.05, P<0.001); history of previous cesarean delivery (OR 2.77, 95% CI 1.91-4.01, P<0.001); hypertension (OR 1.72, 95% CI 1.27-2.32, P<0.001); multiparity (OR 3.99, 95% CI 2.82-5.64, P<0.001); pre-eclampsia (OR 1.96, 95% CI 1.33-2.89, P=0.001); and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome (OR 5.45, 95% CI 1.13-26.28, P=0.035). Factors associated with unscheduled cesarean delivery in this study cohort included daytime delivery, advanced maternal age, obesity, hypertension, previous cesarean delivery, multiparity, preterm labor, pre-eclampsia, and HELLP syndrome.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BackgroundA high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the “Two-child Policy” in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.MethodsData were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.ResultsThe rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984–9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116–14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311–0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007–16.455).Conclusions“Maternal request” has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme.

Background: To test the feasibility of benchmarking the care of women with pregnancies complicated by hyperglycaemia. Methods: A retrospective audit of volunteer diabetes services in Australia and New Zealand involving singleton pregnancies resulting in live births between 2014 and 2020. Ranges are shown and compared across services. Results: The audit included 10,144 pregnancies (gestational diabetes mellitus (GDM) = 8696; type 1 diabetes (T1D) = 435; type 2 diabetes (T2D) = 1013) from 11 diabetes services. Among women with GDM, diet alone was used in 39.4% (ranging among centres from 28.8–57.3%), metformin alone in 18.8% (0.4–43.7%), and metformin and insulin in 10.1% (1.5–23.4%); when compared between sites, all p < 0.001. Birth was by elective caesarean in 12.1% (3.6–23.7%) or emergency caesarean in 9.5% (3.5–21.2%) (all p < 0.001). Preterm births (<37 weeks) ranged from 3.7% to 9.4% (p < 0.05), large for gestational age 10.3–26.7% (p < 0.001), admission to special care nursery 16.7–25.0% (p < 0.001), and neonatal hypoglycaemia (<2.6 mmol/L) 6.0–27.0% (p < 0.001). Many women with T1D and T2D had limited pregnancy planning including first trimester hyperglycaemia (HbA1c > 6.5% (48 mmol/mol)), 78.4% and 54.6%, respectively (p < 0.001). Conclusion: Management of maternal hyperglycaemia and pregnancy outcomes varied significantly. The maintenance and extension of this benchmarking service provides opportunities to identify policy and clinical approaches to improve pregnancy outcomes among women with hyperglycaemia in pregnancy.

Birth outcomes following cesarean delivery on maternal request: a population-based cohort study.

BACKGROUND:Data on the effect of cesarean delivery on maternal request (CDMR) on maternal and neonatal outcomes are inconsistent and often limited by inadequate case definitions and other methodological issues. Our objective was to evaluate the trends, determinants and outcomes of CDMR using an intent-to-treat approach.METHODS:We designed a population-based retrospective cohort study using data on low-risk pregnancies in Ontario, Canada (April 2012–March 2018). We assessed temporal trends and determinants of CDMR. We estimated the relative risks for component and composite outcomes used in the Adverse Outcome Index (AOI) related to planned CDMR compared with planned vaginal delivery using generalized estimating equation models. We compared the Weighted Adverse Outcome Score (WAOS) and the Severity Index (SI) across planned modes of delivery using analysis of variance.RESULTS:Of 422 210 women, 0.4% (n = 1827) had a planned CDMR and 99.6% (n = 420 383) had a planned vaginal delivery. The prevalence of CDMR remained stable over time at 3.9% of all cesarean deliveries. Factors associated with CDMR included late maternal age, higher education, conception via in vitro fertilization, anxiety, nulliparity, being White, delivery at a hospital providing higher levels of maternal care and obstetrician-based antenatal care. Women who planned CDMR had a lower risk of adverse outcomes than women who planned vaginal delivery (adjusted relative risk 0.42, 95% confidence interval [CI] 0.33 to 0.53). The WAOS was lower for planned CDMR than planned vaginal delivery (mean difference −1.28, 95% CI −2.02 to −0.55). The SI was not statistically different between groups (mean difference 3.6, 95% CI −7.4 to 14.5).Interpretation:Rates of CDMR have not increased in Ontario. Planned CDMR is associated with a decreased risk of short-term adverse outcomes compared with planned vaginal delivery. Investigation into the long-term implications of CDMR is warranted.

Effect of Anesthesia Methods During Elective Cesareans on Neonates: Ordu Province Example

Objective: To research the short-term effects on neonates of different anesthesia methods administered for elective cesareans.Methods: Data obtained from files and electronic medical records of 157 singleton cesarean cases and neonates from January 2018 to December 2019 were retrospectively analyzed and 6 cases were excluded from the study. A total of 151 cases were divided into general anesthesia-propofol (n=30), spinal (n=100) and general anesthesia-pentothal (n=21) groups.Results: A total of 151 cesarean cases that meet the inclusion criteria in the date interval of the study were assessed. Of cases, 100 (66%) were in the spinal anesthesia group, 30 (20%) were in the general anesthesia-propofol group and 21 (14%) were in the general anesthesia-pentothal group. There was no significant difference between the study groups in terms of demographic data. The umbilical cord pCO2 value was significantly low in the spinal anesthesia group (43.60±5.52) compared to the general-pentothal group (47.38±5.71). The umbilical cord HCO3 value was lower in the spinal anesthesia group (22.69±1.62) compared to the general-pentothal (23.48±1.53) and general-propofol groups (23.49±1.83). There was a significant variation in postnatal treatment types according to anesthesia method (p=0.012). The rate not requiring treatment was lowest in the general-propofol group (46.7%), while the rate of balloon-valve mask use (46.7%) was highest compared to the other groups. In terms of 5th minute Apgar scores, there was a significant difference between the groups (p=0.024). Patients in the general-propofol group had significantly lower 5th minute Apgar scores compared to patients in the spinal group.Conclusion: The balloon-valve mask rate was highest for those with propofol general anesthesia. Additionally, it was identified that neonates in both general anesthesia groups had higher neonatal intensive care unit requirements compared to the spinal anesthesia group.

Elective versus Emergency Cesarean Sections : Mother and Fetal Outcome

Objective: To compare the outcomes of mothers and newborns in emergency cesarean section and elective cesarean section.Methods: A prospective cohort study included 120 pregnant women consists of 60 women who performed an emergency cesarean section and 60 women who underwent elective cesarean section. Age, education level, occupation, income, history of comorbidities, history of abortion or miscarriage, antenatal care history, decision-making time until surgery is performed along with other components required, duration of operation, outcome of mother and fetal were obtained through interviews and questionnaires. Data were analyzed regarding fetal outcome and cesarean sections indications.Results: The maternal and fetal outcome between emergency and elective cesarean section were not significantly different regarding on hospital stay, dehiscence, NICU admission, Apgar score and newborn status (dead or alive). Blood transfusion is the main difference signifi cant indication for maternal outcome between emergency and elective procedure (p less than 0.05). The total duration of procedure less than 60 or more than 60 minutes and maternal-fetal outcome not signifi cantly different between two type of procedures.Conclusions: Emergency cesarean section at preterm gestational age with an operating time less than equal to 60 minutes leads to greater transfusion blood requirements compared with elective cesarean section.Keywords: emergency cesarean section, elective cesareansection, mother-infant outcome.&#x0D; AbstrakTujuan: Membandingkan luaran ibu dan bayi baru lahir di seksio sesarea emergensi dan elektif.Metode: Penelitian kohort prospektif melibatkan 120 perempuan hamil terdiri atas 60 perempuan yang melakukan operasi seksio sesarea emergensi dan 60 perempuan melakukan operasi elektif. Usia, tingkatpendidikan, pekerjaan, pendapatan, riwayat komorbiditas, riwayat aborsi atau keguguran, riwayat asuhan antenatal, waktu pengambilan keputusan sampai operasi dilakukan bersamaan dengan komponen lain yang diperlukan, lamanya operasi, luaran ibu dan bayi diperoleh melalui wawancara dan kuesioner. Data yang dianalisis mengenai luaran ibu dan bayinya.Hasil: Luaran ibu dan bayi antara seksio sesarea emergensi dan elektif tidak berbeda bermakna dalam hal lama rawat inap, dehisensi, admisi, skor Apgar dan status bayi baru lahir (meninggal atau hidup). Transfusi darah adalah indikasi penting utama yang berbeda untuk luaran ibu antara prosedur emergensi dan elektif (p kurang dari 0,05). Durasi total prosedur kurang dari 60 atau lebih dari 60 menit dan luaran ibu tidak berbeda secara signifikan antara kedua jenis seksio sesarea.Kesimpulan: Tindakan seksio sesarea emergensi pada usia gestasi prematur dengan waktu operasi kurang dari sama dengan 60 menit menyebabkan kebutuhan transfusi darah lebih besar dibandingkan seksio sesarea elektif.Kata kunci: luaran ibu-bayi, seksio sesarea elektif, seksio sesarea emergensi.

Effect of amino acid infusion during cesarean delivery on newborn temperature: a randomized controlled trial

BackgroundThe effect of maternal amino acid (AA) infusion before and during cesarean delivery on neonatal temperature remains unknown. We hypothesized that thermogenic effects of AA metabolism would help maintain body temperature of newborn babies and their mothers.MethodsSeventy-six parturients scheduled for elective singleton term cesarean delivery were equally randomized to receive intravenous 200 ml of AA or placebo approximately 1 h before subarachnoid block (infusion rate:100 ml/h). The primary outcome was the newborn rectal temperature at 0, 5 and 10 min after birth. The secondary outcomes included the maternal rectal temperature at six time-points: T0 = before starting study solution infusion, T1 = 30 min after starting infusion, T2 = one hour after starting infusion, T3 = during spinal block, T4 = half an hour after spinal block, T5 = at the time of birth and T6 = at the end of infusion, as well as maternal thermal discomfort and shivering episodes.ResultsThere were no differences in newborn temperature between the two groups at any of the time-points (intervention-time-interaction effect, P = 0.206). The newborn temperature (mean [95%CI] °C) at birth was 37.5 [37.43–37.66] in the AA and 37.4 [37.34–37.55] in the placebo group. It showed a significant (P < 0.001) downward trend at 5 and 10 min after birth (time effect) in both groups. One neonate in the AA and five in the placebo group were hypothermic (temperature < 36.5 °C) (P = 0.20). There was a significant difference in the maternal temperature at all time points between the two groups (Intervention-time interaction effect, P < 0.001). However, after adjustment for multiplicity, the difference was significant only at T6 (P = 0.001). The mean difference [95%CI] in temperature decline from baseline (T0) till the end of infusion (T6) between the two groups was − 0.39 [− 0.55;− 0.22] °C (P < 0.0001). Six mothers receiving placebo and none receiving AA developed hypothermia (temperature < 36 °C) (P = 0.025). Maternal thermal discomfort and shivering episodes were unaffected by AA therapy.ConclusionsUnder the conditions of this study, maternal AA infusion before and during spinal anesthesia for cesarean delivery did not influence the neonatal temperature within 10 min after birth. In addition, the maternal temperature was only maintained at two hours of AA infusion.Trial registrationClinicalTrials.government, Identifier NCT02575170. Registered on 10th April, 2015 - Retrospectively registered.

Mental health problems and fear of childbirth: A cohort study of women in an inner‐city maternity service

AbstractObjectivesTo estimate the population prevalence of severe fear of childbirth (FOC) during pregnancy and investigate its association with: (a) antenatal common mental disorders (depression and anxiety disorder) and (b) elective cesarean birth.Methods545 participants from an inner‐city London maternity population were interviewed soon after their first antenatal appointment (mean gestation: 14 weeks). Current mental disorders were assessed using the Structured Clinical Interview DSM‐IV. FOC was measured using the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ‐A) at approximately 28 weeks gestation (n = 377), with severe FOC defined using a cutoff of WDEQ‐A ≥ 85. Birth mode information was collected at 3 months post‐delivery using an adapted Adult Service Use Schedule. Linear regressions were used to model associations, adjusting for the effects of covariates (age, parity, relationship status, education, and planned pregnancy). Sampling weights were used to adjust for bias introduced by the stratified sampling. We also accounted for missing data within the analysis.ResultsThe estimated population prevalence of severe FOC was 3% (95% CI: 2%‐6%) (n = 377). Depression and anxiety were significantly associated with severe FOC after adjustment for covariates (45% vs 11%; coefficient: 15.75, 95% CI: 8.08‐23.42, P &lt; .001). There was a weak association between severe FOC and elective cesarean birth.ConclusionsSevere FOC occurs in around 3% of the population. Depression and anxiety are associated with FOC. Pregnant people with depression and anxiety may be at increased risk of experiencing severe FOC. Attitudes toward childbirth should be assessed as part of routine clinical assessment of pregnant people in contact with mental health services.

Association of cesarean delivery on maternal request with neonatal iron stores at birth.

Cesarean has been suggested to decrease neonatal iron stores at birth. However, few studies have differentiated the effect induced by cesarean operation from that related to medical indications. We aimed to estimate the association of cesarean delivery on maternal request (CDMR), a subtype of cesarean without any medical indications, with a spectrum of indicators reflecting iron stores at birth. This prospective cohort study involved 288 term singleton neonates born to women without any complications by CDMR or spontaneous vaginal delivery (SVD). Measured hematological iron-related indicators in cord blood included serum ferritin (SF), hemoglobin (Hb), red blood cell (RBC), and hematocrit (Hct). Blood flow volume (BFV) of cord vein when clamping was measured to reflect placental transfusion status during birth. Quantile regression was used to assess the association between delivery mode and the iron store indicators. CDMR (n = 154) versus SVD group (n = 134) had lower conditional median cord blood SF (-34.80; 95% CI -64.70, -4.90 μg/L; P = 0.02), Hb (-10.67; 95% CI -18.87, -2.47 g/L; P = 0.01), RBC (-0.30; 95% CI -0.48, -0.12 ×1012/L; P = 0.002), and Hct (-3.06; 95% CI -6.08, -0.04 %; P = 0.047). The BFV was higher in CDMR than SVD group at the 25th centile (0.51; 95% CI 0.19, 0.82 ml/cm3; P = 0.002), median (0.49; 95% CI 0.04, 0.95 ml/cm3; P = 0.03) and the 75th centile (0.54; 95% CI 0.06, 1.03 ml/cm3; P = 0.03). The cesarean operation per se likely hampered placental transfusion from mother to neonate and decreased iron stores at birth.

Comparative Study of USG and MRI in Evaluation of Isthmocele.

To study the presence of isthmocele in post-cesarean women using USG and MRI and its correlation with risk factors. This was a prospective observational study. A total of 90 patients were enrolled at the time of discharge of cesarean delivery and were advised to come for follow-up at 3-4months for detection of isthmocele. A total of 82 patients reported for follow-up, and TVS and MRI Pelvis were done for visualization of isthmocele. If isthmocele was diagnosed, its correlation with risk factors was studied. On TVS isthmocele was present in 11 patients and on MRI in 16 patients. Detection rate was 77.07% in comparison with previous studies. Compared to MRI, sensitivity of USG was 68.75%; however, the specificity and positive predictive value for both were 100%. The negative predictive value for USG compared to MRI was 92.96%. Shape of the isthmocele was triangular in most women. Obesity, prior history of cesarean delivery, elective cesarean, gestational diabetes, preeclampsia and prolonged active labor were associated with development of isthmocele. The study concluded that yield of diagnosis of isthmocele by MRI was better than TVS but not statistically significant. Further study with large sample size is needed to identify the best tool for diagnosis of isthmocele. Obesity, gestational diabetes, preeclampsia, prior history of cesarean, elective cesarean and prolonged active labor were associated with development of isthmocele.

156 Trends in cesarean delivery on maternal request in the United States from 1999 to 2015

The rate of cesarean delivery has increased in the United States over the last several decades. The rate of cesarean delivery on maternal request (CDMR) however remains uncertain. The objectives of this study were to describe the prevalence and temporal trends of CDMR in the United States, and to characterize the population of patients who elect to undergo a CDMR. A retrospective cohort study was conducted using data from The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999 to 2015. An algorithm based on International Classification of Diseases, Ninth Revision (ICD-9) codes was created to identify patients who delivered by primary elective cesarean section in the absence of fetal or maternal indications. Maternal demographic characteristics between patients who delivered by CDMR and patients who did not were compared. Of the 13,698,836 deliveries included over the study period, 221,310 were identified as potential CDMR. CDMR rates peaked in 2009, and varied from 1% to 1.98% of all live births and 4.53% to 5.88% of all cesarean deliveries over the study period. Overall, the rate of CDMR among all live births increased over the study period, from 1% in 1999 to 1.56% in 2015 (p <0.0001). Patients who elected to deliver by CDMR were more likely to be over the age of 35, in the highest income quartile, and have private insurance, and were less likely to be African American (p <0.0001). Our findings indicate that CDMR accounts for a small proportion of all deliveries in the United States. Furthermore, rates of CDMR have increased only slightly since 1999. CDMR is more prevalent among patients with certain demographic characteristics. These results may indicate that the option of CDMR is more appealing or more frequently offered to a certain population of patients.

Newborn infants who received skin-to-skin contact with fathers after Caesarean sections showed stable physiological patterns.

AimSeparating infants and their parents after a Caesarean section is still the routine care worldwide. This study investigated three caregiving models on the wakefulness and physiological parameters of full‐term infants after an elective Caesarean section.MethodsNewborn infants born in a Chilean public hospital in 2009‐12 were randomised to three groups: cot, fathers' arms or skin‐to‐skin contact with their father. They were assessed at 15‐minute intervals, from 45 to 120 minutes after the Caesarean section. Their physiological parameters were measured, and their wakefulness was assessed using the Neonatal Behavioural Assessment Scale.ResultsWe studied 95 infant (53% girls) born at a mean gestational age of 38.9 ± 0.9 weeks. Heart rates were significantly higher in the skin‐to‐skin than cot or fathers' arms groups and showed greater stability over time. Wakefulness was initially higher in the skin‐to‐skin group, but there were no significant differences by the end of the observation. There were no differences between the groups in peripheral oxygen saturation. Skin‐to‐skin contact had no negative impact on the infants.ConclusionThe skin‐to‐skin group showed some advantages over the cot and fathers' arms groups when it came to establishing stable physiological parameters and wakefulness. This approach should be supported during mother‐infant separation.

Quality of Facility-Based Maternal and Newborn Care During the Covid-19 Pandemic: A Multicountry Cross-Sectional Study in the Who European Region Investigating Service Users’ Perspectives

Background: Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic, as defined by WHO Standards, are lacking.Methods Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 to March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based quality measures.Findings: 21,027 women were included in the analysis. Among those who experienced labour (N=18,063), 49·9% (37·2%-60·7%) perceived a reduction in QMNC due to the COVID-19 pandemic, 41·8% (26·1%- 63·5%) experienced difficulties in accessing antenatal care, 62% (12·6%-99·0%) were not allowed a companion of choice, 31·1% (16·5%-56·9%) received inadequate breastfeeding support, 34·4% (5·2%-64·8%) reported health workers not always using protective personal equipment, and 31·8% (17·8%-53·1%) rated the number of health workers as “insufficient”. Episiotomy was performed in 20·1% (6·1%-66·0%) of spontaneous vaginal births and fundal pressure applied in 41·2% (11·5% -100%) of instrumental vaginal births. In addition, 23·9% women felt they were not treated with dignity (12·8%-59·8%), 12·5% (7·0%-23·4%) suffered abuse, and 2·4% (0·1%-26·2%) made informal payments. Findings were significantly worst among women with elective caesarean (CS) and emergency CS during labour (N=2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significant lower QMNC Indexes; younger women and those with operative births also had significant lower QMNC Indexes.Interpretation: Findings reveal large inequities in the QMNC across countries of the WHO European Region. Actions to reduce these inequities and promote high-quality, evidence-based, patient-centred respectful care for all mothers and newborns are urgently needed. Trial Registration: Study registration ClinicalTrials.gov Identifier: NCT04847336. Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.Declaration of Interest: None to declare. Ethical Approval: The study was approved by the Institutional Review Board of the coordinating centre: the IRCCS Burlo Garofolo Trieste (IRB-BURLO 05/2020 15.07.2020). The study protocol was also reviewed and approved by the ethical committees of three other countries to comply with local regulations: Portugal (Instituto de Saúde Pública da Universidade do Porto, CE20159); Norway (Norwegian Regional Committee for Medical Research Ethics, 2020/213047) and Germany (Bielefeld University ethics committee, 2020-176).

The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions.

The global rise in the rate of induction of labor and cesarean birth shows considerable unexplained variation both within and between countries. Prior research suggests that the extent to which women are engaged in the decision-making process about birth options, such as elective cesarean, induction of labor, or use of fetal monitoring, is heavily influenced by clinician beliefs and preferences. The aim of this study was to investigate the beliefs about labor interventions and birth options held by midwives and obstetric medical staff from 8 Sydney hospitals and assess how the health care providers' beliefs were associated with discipline or years of experience. This is a survey study of midwives and obstetric staff that was distributed between November 2018 and July 2019. Modified from the previously validated birth attitudes survey for the Australian context, survey domains include (1) maternal choice and woman's role in birth, (2) safety by mode or place of birth, (3) attitudes toward cesarean birth for preventing urinary incontinence, (4) approaches to decrease cesarean birth rates, and (5) fears of birth mode. Responses were compared between professions and within professions by years of experience using Mann-Whitney U testing. A total of 217 midwives and 58 medical staff completed the survey (response rate, 30.5%). Midwifery staff responses generally favored a physiologic approach to birth, versus beliefs more in favor of intervention (particularly cesarean birth) among medical staff. There was interprofessional discrepancy on most items, particularly regarding safety of mode or place of birth and approaches to decrease cesarean birth rates. Within disciplines, there was more variation in medical staff attitudes than within the midwifery staff. No clinically important differences in beliefs by years of experience were noted. Clinicians need to be aware of their own beliefs and preferences about birth as a potential source of bias when counselling women, particularly when there are a range of treatment options and the evidence may not strongly favor one option over another. As both groups had similar perceptions about the importance of women's autonomy, shared decision-making training could help bridge belief gaps and improve care around birth decisions.

Unexpected Gastrointestinal Stromal Tumor as Acute Abdomen in First Trimester of Pregnancy

A gastrointestinal stromal tumour (GIST) is a tumor of the gastrointestinal tract. We present a 36-year-old, gravida 2 para 1 lady presented with acute lower abdominal pain at 9 weeks period of amenorrhea (POA) associated with vomiting. She had a previous uncomplicated cesarean section 2 years ago. Abdominal examination revealed a tender and mobile 26-week-sized mass. A transabdominal scan revealed a right adnexal mass with a cystic component measuring 10 cm x 10 cm in size, as well as a viable singleton intrauterine fetus corresponding to her dates. She underwent emergency laparotomy in suspicion of a right twisted ovarian cyst. The inoperative finding revealed a large pedunculated and twisted gangrenous mass from the greater curvature of the stomach with normal uterus and ovaries. The histopathological examination of the mass reported as malignant Sarcomatoid epithelioid GIST (category 3b). The patient was managed by a multidisciplinary team approach involving the obstetrician &amp; gynaecologist, surgeon and oncologist throughout her pregnancy course. The pregnancy progressed well, and she delivered via elective repeat cesarean section. Post partumly, oesophago-gastric-duodeno-scopy and computed tomography assessment revealed no evidence of local disease or distant metastasis. She was advised for yearly follow-up with the surgical department.

INACTIVE HEPATITIS B CARRIER AND PREGNANCY OUTCOMES

Objective: To assess the impact of hepatitis B carrier status on pregnancy and perinatal outcome.&#x0D; Study Design: Cross sectional study.&#x0D; Place and Duration of Study: Department of Gynaecology and Obstetrics, Pakistan Naval Ship Shifa Hospital,Karachi, from Feb 2017 to Jan 2018.&#x0D; Methodology: A total of 9526 women delivered during study period. 9305 women fulfilling the inclusion criteriawere included in study. Two hundred and twenty one (221) women were excluded because of not fulfilling theinclusion criteria. Out of study group, 9104 women were HBsAg negative while 201 had positive hepatitis Bcarrier status. Antenatal complications (such as gestational diabetes, gestational hypertension, pre eclampsia),mode of delivery (vaginal delivery, elective cesarean, emergency cesarean) and perinatal outcomes (pretermdelivery, low birth weight at delivery, live birth rate, APGAR score at 1 and 5 min) were observed amonghepatitis B carrier and noncarrier.&#x0D; Results: There was no significant difference in point prevalence of major antenatal complications, mode ofdelivery and perinatal outcomes in HBsAg carriers and noncarriers. A slightly higher rate of preterm birth wasobserved in hepatitis B carriers (4.9%) as compared to noncarriers (2.6%).&#x0D; Conclusion: Hepatitis B carriers have slightly increased risk of preterm delivery.

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English

Caesarean birth and risk of subsequent preterm birth: a retrospective cohort study.

To determine the risk of spontaneous and medically indicated preterm birth associated with mode of birth in previous term-born pregnancy. Retrospective cohort study. Two UK maternity units. A total of 16340 women with first two consecutive singleton births and the first birth at term. Retrospective cohort study using routinely collected clinical data. Incidence of spontaneous preterm birth and medically indicated preterm birth at less than 37weeks of gestation after term birth, in relation to mode of birth in first pregnancy. Subgroup analysis on cervical dilatation at the time of first caesarean birth. Compared with vaginal birth, emergency caesarean birth at full dilatation was associated with an increase in spontaneous preterm birth (2.3% vaginal birth versus 4.5% full dilatation caesarean; adjusted odds ratio [aOR] 3.29, 95% CI 2.02-5.13, P<0.001). Elective caesarean, emergency caesarean at <4cm dilatation, and emergency caesarean at 4-9cm dilatation were associated with increased medically indicated preterm birth (0.8% vaginal births versus 1.9% elective caesarean, 3.3% <4cm caesarean, 1.3% 4-9cm caesarean; aOR 2.30, 95% CI 1.19-4.15, P=0.009; aOR 4.68, 95% CI 2.98-7.24, P<0.001; and aOR 2.43, 95% CI 1.43-4.00, P=0.001, respectively). Term caesarean in the first stage of labour or performed prelabour is associated with medically indicated preterm birth. Term caesarean in the second stage of labour is associated with spontaneous preterm birth. Caesarean in the second stage of labour is associated with spontaneous preterm birth.

Establishment of an antepartum predictive scoring model to identify candidates for vaginal birth after cesarean

BackgroundEvidence-based medicine has shown that successful vaginal birth after cesarean (VBAC) is associated with fewer complications than an elective repeat cesarean. Although spontaneous vaginal births and reductions in cesarean delivery (CD) rates have been advocated, the risk factors for VBAC complications remain unclear and failed trials of labor (TOL) can lead to adverse pregnancy outcomes.MethodsTo construct an antepartum predictive scoring model for VBAC. Retrospective analysis of charts from 1062 women who underwent TOL at no less than 28 gestational weeks with vertex singletons and no more than one prior CD.ResultsWe constructed our scoring model based on the following variables: maternal age, previous vaginal delivery, interdelivery interval (time between prior cesarean and the following delivery), presence of prior cesarean TOL, dystocia as prior CD indication, intertuberous diameter, maternal predelivery body mass index, gestational age at delivery, estimated fetal weight, and hypertensive disorders. Previous vaginal delivery was the most influential variable. The nomogram showed an area under the curve of 77.7% (95% confidence interval, 73.8–81.5%; sensitivity, 78%; specificity, 70%; cut-off, 13 points). The Kappa value to judge the consistency of the results between the predictive model and the actual results was 0.71(95% confidence interval 0.65–0.77) indicating strong consistency. We used the cut-off to divide the VBAC women into two groups according to the success of the TOL. The maternal and neonatal outcomes such as labor time, number of deliveries by midwives, postpartum hemorrhage, uterine rupture, neonatal asphyxia, puerperal infection were significantly different between the two groups.ConclusionsOur predictive scoring model incorporates easily ascertainable variables and can be used to personalize antepartum counselling for successful TOLs after cesareans.