Elective Cesarean Section Delivery Research Articles

Vaginal birth after one previous caesarean section in a tertiary institution in Nigeria

Vaginal birth after one previous lower segment caesarean section represents one of the most significant and challenging issues in obstetric practice. A 5-year retrospective study was carried out at the University of Benin Teaching Hospital between January 1999 and December 2003, to determine the incidence, the maternal and fetal outcome following vaginal delivery after one previous caesarean section with a view to evaluating its safety and efficacy. There were 5234 deliveries, with 395 cases of one previous caesarean section, giving an incidence of 7.5%. The incidences of emergency caesarean section, elective caesarean section and spontaneous vaginal delivery following trial of vaginal delivery were 34.7%, 9.4% and 48.1%, respectively. During the study period there were 1317 cases of caesarean section, giving an incidence of 25.2% caesarean section rate. The incidence of one previous section among all caesarean section births was 30%. The major morbidity following vaginal delivery was uterine rupture with an incidence of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures occurred before admission because the patients laboured at home. One maternal death occurred as a result of uterine rupture and postpartum haemorrhage, giving a maternal mortality ratio of 19/100 000 and a case fatality rate of 0.3%. The corrected perinatal mortality rate was 15.2/1000, mainly from obstructed labour, abruptio placenta and fetal distress. Both maternal and fetal mortalities from vaginal birth after one previous section were significantly less than the respective overall maternal and fetal mortality from the institution. The 1-minute apgar score of babies delivered by elective section was significantly (P < 0.001) higher than the apgar score of babies delivered by emergency section and vaginally. There was only one patient with wound dehiscence at elective section without associated perinatal death. Vaginal delivery following caesarean section is relatively safe. However, women in developing countries will continue to require counselling to counter the myths of aversion to operative delivery even at the expense of losing their lives. Our hospitals should have adequate monitoring equipment for high-risk pregnancies so that patients and their babies can be assured of survival.

Are girls more at risk of intrauterine-acquired HIV infection than boys?

To investigate whether previously described sex differences in virological and immunological markers in vertically infected children are preceded by sex differences in the overall risk or timing of mother-to-child transmission (MTCT) we analysed 3231 mother-child pairs enrolled in the European Collaborative Study. Girls were at a 1.5 times increased risk of MTCT overall, but the sex effect was limited to elective caesarean section deliveries, suggesting that girls may have an increased risk of intrauterine transmission compared with boys.

Reducing childhood mortality in poor countries: Antenatal and perinatal strategies to prevent mother-to-child transmission of HIV infection

Mother-to-child transmission (MTCT) is the dominant mode of acquisition of HIV infection for children. Each day an estimated 1600 children born to HIV-infected mothers become infected, 1500 of whom are in sub-Saharan Africa. Mother-to-child transmission can occur before, during and after delivery; overall rates of MTCT range from 15 to 35%. Risk factors for MTCT include maternal viral load levels, vaginal delivery, prematurity and breastfeeding. Approaches to reduce the risk of MTCT include reduction of maternal viral load through antiretroviral prophylaxis, avoidance of exposure through birth canal cleansing or elective caesarean section delivery and refraining from breastfeeding, and boosting the host immune system through nutritional supplementation or immunization. Substantial reductions in the risk of MTCT can be achieved with antiretroviral prophylaxis during pregnancy, delivery and in the neonatal period, both in settings with and without breastfeeding. Elective caesarean section independently decreases the risk, but is not a safe and feasible option in most high prevalence areas. Birth canal cleansing with chlorhexidine does not reduce the rate overall, but may be beneficial in a subgroup of women with prolonged duration of ruptured membranes. Micronutrient supplementation, including vitamin A, does not reduce MTCT of HIV, but may improve pregnancy outcome generally.

Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience

Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience

HIV and pregnancy

The number of HIV‐positive heterosexuals in the UK is rising and there are increasing numbers of HIV‐positive individuls wishing to start families. Without intervention, the risk of mother‐to‐child transmission (MTCT) of HIV is between 15‐25%, yet with anti‐retroviral therapy, elective caesarean section delivery and avoidance of breastfeeding this can be reduced to under 2%. It is, therefore, important that patients are aware of their HIV status and that obstetricians are aware of the advances in anti‐retroviral therapy and other measures that can minimise the risk of HIV infection in the neonate.

Towards reducing Mother-to-Child Transmission of HIV.

Women of child bearing age in Africa are particularly vulnerable to HIV infection, and this has led to an increase in the number of paediatric HIV infections reported due to mother-to-child transmission (MTCT) of HIV during pregnancy, delivery and breastfeeding. Various approaches to prevent or reduce MTCT have been established. These include elective Caesarean section delivery, avoidance of breastfeeding and antiretroviral therapy. For these strategies to be put in place, effective voluntary and confidential HIV counseling and testing for pregnant women should be implemented in African countries. Prevention of MTCT should also be considered as part of the wider management of maternal and infant health during prenatal, delivery and postnatal care. This review attempts to bring into focus the various strategies for a reduction in MTCT with special emphasis on the problems encountered in Africa. Key Words: HIV, Reducing perinatal transmission Nigerian Journal of Paediatrics 2002; 29: 55-60.

Mother-to-child transmission of hepatitis C virus infection.

The prevalence of hepatitis C virus (HCV) infection among pregnant women in Europe is generally below 2%. Although women with a history of parenteral exposures or injecting drug use are at an increased risk of infection, a substantial proportion of infected women do not report any risk factors. Targeted screening is thus not recommended. The risk of mother-to-child, or vertical, transmission of HCV is about 5% overall but can be as high as 15%, depending on maternal HIV infection status and HCV RNA viral load. Larger studies are needed to confirm or refute the potential protective effect of elective cesarean section delivery. However, for HCV-positive women who are co-infected with HIV, elective cesarean section delivery is associated with a reduced risk of vertical transmission of HIV as well as HCV. The risk of postnatal transmission through breastfeeding cannot be excluded but is likely to be low for most HCV-infected women. The long-term natural history of vertically acquired HCV needs further elucidation and the efficacy of potential therapies for infected children need to be evaluated in randomized controlled trials.

HIV and pregnancy

The number of HIV-positive heterosexuals in the UK is rising and there are increasing numbers of HIV-positive individuls wishing to start families. Without intervention, the risk of mother-to-child transmission (MTCT) of HIV is between 15-25%, yet with anti-retroviral therapy, elective caesarean section delivery and avoidance of breastfeeding this can be reduced to under 2%. It is, therefore, important that patients are aware of their HIV status and that obstetricians are aware of the advances in anti-retroviral therapy and other measures that can minimise the risk of HIV infection in the neonate.

HIV-infected pregnant women and vertical transmission in Europe since 1986

Objective To describe changes over a 15-year period in characteristics and management of HIV-infected pregnant women in Europe. Design Prospective study. Methods Analysis of prospective data on 2876 pregnant HIV-infected women and their 3076 infants. Factors examined included maternal socio-demographic, immunological and virological characteristics, antiretroviral therapy and pregnancy outcome. Results Among women enrolled, the proportion with heterosexual acquisition of infection has increased significantly from 59% (201/342) in 1985–1987 to 69% (327/471) after 1997 while the proportion acquiring HIV through injecting drug use has declined. Overall median CD4 cell count was 440 × 106/l and 41% of women had undetectable viral load at delivery. In 1995 28% (72/256) of mother–child pairs received the full 076 regimen to reduce risk of vertical transmission, rising significantly to 89% (116/130) by 1999. Use of triple therapy started in pregnancy has increased significantly from < 1% (1/153) in 1997 to 44% (47/107) in 1999. Exposure to antiretroviral therapy was not associated with prevalence or pattern of congenital abnormalities (P = 0.88) but was associated with reversible anaemia in the infant (P < 0.002). The elective cesarean section rate has increased from 10% in 1992 to 71% in 1999/2000. The vertical transmission rate declined from 15.5% by 1994 to 2.6% after 1998. In multivariate analysis, adjusting for maternal CD4 cell count, risk of vertical transmission was reduced by 66% (95% confidence interval, 37–82%) with the full 076 regimen and by 60% (95% confidence interval, 33–73%) with elective cesarean section delivery. Conclusions Changes in treatment of adult HIV disease have affected the management of infected pregnant women. Despite therapeutic and surgical interventions, vertical transmission still occurs.

Duration of ruptured membranes and vertical transmission of HIV-1: a meta-analysis from 15 prospective cohort studies.

To test the a priori hypothesis that longer duration of ruptured membranes is associated with increased risk of vertical transmission of HIV. The relationship between duration of ruptured membranes and vertical transmission of HIV was evaluated in an individual patient data meta-analysis. Eligible studies were prospective cohort studies including at least 100 mother-child pairs, from regions where HIV-infected women are counselled not to breastfeed. Analyses were restricted to vaginal deliveries and non-elective Cesarean sections; elective Cesarean section deliveries (those performed before onset of labour and before rupture of membranes) were excluded. The primary analysis included 4721 deliveries with duration of ruptured membranes < or = 24 h. After adjusting for other factors known to be associated with vertical transmission using logistic regression analysis to assess the strength of the relationship, the risk of vertical HIV transmission increased approximately 2% with an increase of 1 h in the duration of ruptured membranes [adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.04; for each 1 h increment]. There were no significant interactions of duration of ruptured membranes with study cohort or with any of the covariates, except maternal AIDS. Among women diagnosed with AIDS, the estimated probability of transmission increased from 8% to 31% with duration of ruptured membranes of 2 h and 24 h respectively (P < 0.01). These results support the importance of duration of ruptured membranes as a risk factor for vertical transmission of HIV and suggest that a diagnosis of AIDS in the mother at the time of delivery may potentiate the effect of duration of ruptured membranes.

National obstetric anaesthetic practice in the UK 1997/1998.

In the United Kingdom, the Royal College of Obstetricians and Gynaecologists requires maternity units recognised for training to complete annual statistical returns. Analysis of these data revealed that anaesthetists were directly involved in more than 251 000 procedures in the peripartum period in 1997/1998. There had been an increase in the number of women delivered by Caesarean section (18. 5% of all deliveries) compared with previous reports. The proportion of Caesarean sections performed under regional anaesthesia had increased for both elective and emergency Caesarean section deliveries (85.5% and 70.2%, respectively). For pain relief in labour, there had been neither an increase nor a decrease in the uptake of regional analgesia (23.6%). There were limited training opportunities for anaesthetists in general anaesthesia for Caesarean section and for obstetricians in vaginal breech delivery. The known admissions to intensive care units equated to over 100 women per month in the United Kingdom requiring intensive care as a result of childbirth.

The cost-effectiveness of elective Cesarean delivery for HIV-infected women with detectable HIV RNA during pregnancy.

To determine the net health consequences, costs, and cost-effectiveness of alternative delivery strategies for HIV-infected pregnant women with detectable HIV RNA in the USA. Cost-effectiveness analysis using a probabilistic decision model. The model compared two strategies: elective Cesarean section and vaginal delivery. Data for HIV transmission rate, maternal death rate, health-related quality of life and costs were obtained from the literature, national databases, and a tertiary hospital's cost accounting system. Model outcomes included total lifetime costs, quality-adjusted life expectancy, maternal death rate, HIV transmission rate, and incremental cost-effectiveness ratios. Elective Cesarean section resulted in a vertical HIV transmission rate of 34.9 per 1000 births compared with 62.3 per 1000 births for vaginal delivery. Elective Cesarean section was more effective (38.7 quality adjusted life years per mother and child pair) and less costly ($10600 per delivery) than trial of labor (38.2 combined quality adjusted life years at a cost of $14500 per delivery). However, elective Cesarean section increased maternal mortality by 2.4 deaths per 100000 deliveries. The results were consistent over a wide range of the variables, but were sensitive to the risk of HIV transmission with vaginal delivery and the relative risk of HIV transmission with elective Cesarean section. In pregnant HIV-infected women with detectable HIV RNA, elective Cesarean section would reduce total costs and increase overall quality-adjusted life expectancy for the mother-child pair, albeit at a slight loss of quality adjusted life expectancy to the mother.

Association between external pelvimetry and vertex delivery complications in African women

To assess association between external pelvimetry and delivery complications in vertex presentation. Prospective cohort study of 2,413 pregnant women antenatally measured for height and external pelvimetry in four hospitals of the former Republic of Zaire. Complications during delivery of single fetus weighing 2,000 g or more in vertex presentation. Cut-off values at risk for delivery complications were height and pelvic distances closest to the study population 10th percentile. In univariate analysis, maternal height showed significant relative risk for predicting primary cesarean section for failure to progress: 2.0 (95% CI=1.0-4.1; p=0.050) and vacuum or forceps delivery: 15.7 (95%, CI=6.6-37.5; p<0.001). Selected external pelvic distances showed significant relative risks for predicting the following complications: primary cesarean section for failure to progress, elective repeat cesarean section, vacuum or forceps delivery and spontaneous intrapartum stillbirth. Among pelvic predictors, transverse diagonal (TD) of Michaelis sacral rhomboid area was associated with all of these complications. Intertrochanteric (IT) diameter was associated with three of them. The relative risks ranged from 2.3 (95% CI=1.1-6.3; p=0.030) to 9.6 (95% CI=4.1-22.5; p<0.001) for these strongest predictors. External pelvic distances help to predict vertex delivery complications in African women. The predicted complications are compatible with the cephalopelvic disproportion concept (CPD). After validation of current results in a separate cohort, measurements of IT and/or TD are recommended to improve antenatal screening of women at risk for CPD in limited resources settings.

Preventing perinatal transmission of HIV-1 infection.

It is now known that with the use of antiretroviral prophylaxis with zidovudine, elective caesarean section delivery and refraining from breastfeeding the rate of mother-child transmission of HIV infection can be reduced to less than 2%.

The Characterization of Human Amnion Epithelial and Mesenchymal Cells: the Cellular Expression, Activity and Glucocorticoid Regulation of Prostaglandin Output

The amnion, a single layer of epithelial cells (EC) overlying layers of mesenchymal cells (MC) has been identified as a source of intrauterine prostaglandins (PG). The objectives of the present study were: (1) to establish a technique for the isolation and culture of pure amnion EC and MC preparations, (2) to characterize the cellular expression of PGHS-II and PGHS activity within these separated amnion cells and (3) to characterize the pattern of glucocorticoid stimulation of these separated amnion cells. Term gestation human amnion was collected after elective caesarean section or vaginal delivery. A trypsin digestion was used to isolate EC and a mechanical digestion and collagenase dispersion was used to isolate MC. Following 48 or 96h in culture, cells were incubated for 24h in the presence or absence of 1μm arachidonic acid and treated with cortisol (F: 10–1000n m) or 1μm dexamethasone (DEX). Cell types were identified by immunohistochemistry (IHC). Immunoreactive PGHS-II (ir-PGHS-II) and glucocorticoid receptor (ir-GR) were localized by IHC. PGHS activity was measured as PGE2output determined by radioimmunoassay. Mean PGE2production by MC at 72h was 22-fold greater (P< 0.05) and at 120h was 32-fold greater (P< 0.03) than PGE2output by EC. Administration of arachidonic acid stimulated a 5.0-fold increase in PGE2output (P< 0.0002) by EC after 72h and a 3.6-fold increase (P< 0.05) after 120h but did not alter MC PGE2output. Despite exogenous substrate, EC PGE2output remained significantly less than PGE2output by MC. There was no difference in PG production by EC and MC with the onset of labour. Ir-GR expression was found in both EC and MC. F and/or DEX with and without arachidonic acid (AA) stimulated PGE2output by EC. Only DEX and not F increased PGE2output by MC. These data suggest that relatively pure EC and MC preparations can be established from amnion. PG output and its regulation appears to differ within these two amnion cell types, dependent upon (1) substrate availability and (2) the regulation of PGHS activity.

Antenatal screening for HIV infection.

AIDS Patient Care and STDsVol. 14, No. 3 Antenatal Screening for HIV InfectionDiana M. GibbDiana M. GibbSearch for more papers by this authorPublished Online:5 Jul 2004https://doi.org/10.1089/108729100317902AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetails Volume 14Issue 3Mar 2000 To cite this article:Diana M. Gibb.Antenatal Screening for HIV Infection.AIDS Patient Care and STDs.Mar 2000.125-131.http://doi.org/10.1089/108729100317902Published in Volume: 14 Issue 3: July 5, 2004PDF download

The influence of gestational age and mode of delivery on infants with gastroschisis

Background/Purpose : It has been proposed that preterm and prelabor cesarean section may improve the outcome of infants with gastroschisis. The purpose of this study is to examine the impact of gestation and delivery method on infants with gastroschisis. Methods : The medical records of 60 infants with gastroschisis treated at a tertiary care center from 1985 through 1995 were reviewed retrospectively. The gestational age, the mode of delivery, the type of operative repair, and the length of hospital stay were recorded for each patient. Results : Infants born vaginally were more likely to require silo stage repair than those delivered by cesarean section (21 of 29 v 11 of 31, P < .01). Infants born vaginally also had longer hospital stay than those delivered by cesarean section (53 v 39 days, P = .19). Infants born before 33 weeks' of gestation stayed longer in the hospital than those born after 33 weeks. After 33 weeks' gestation, infants had similar hospital stay regardless of the gestational age. Conclusions : Cesarean section delivery was beneficial for infants with gastroschisis. Preterm delivery did not shorten the length of hospital stay. The role of elective cesarean section delivery at term should be considered for infants with gastroschisis diagnosed antenatally.

Prophylactic Angiotensin II Infusion During Spinal Anesthesia for Elective Cesarean Delivery

VINCENT, ROBERT D. JR.; WERHAN, CAROL F.; NORMAN, PATRICIA F.; SHIH, GRACE H.; CHESTNUT, DAVID H.; RAY, TAPATI; ROSS, ELAINE L.; BOFILL, JAMES A.; SHAW, DOUGLAS B. Author Information

CAESAREAN SECTION DELIVERY IS ACCOMPANIED WITH DEFECTIVE CAPACITY TO GENERATE IGA IN NEONATES

63 AIM Microbial antigens preferentially expand T helper 1-type cells and thereby provide optimal conditions to redirect the immunologic memory away from the T helper 2-type phenotype of atopy. Caesarean section delivery interferes with the development of normal intestinal microflora which contribute to the development of mucosal immunity in the gut. This study aimed to evaluate the effect of caesarean delivery on IgA generation. METHODS Blood samples were obtained during 12 vaginal deliveries (VD) and 16 elective caesarean sections (ECS), and 2 and 6 months later. The number of immunoglobulin secreting cells (ICS)/ 106 cord and peripheral blood mononuclear cells were determined by the enzyme-linked immunospot method, the immunophenotypes by a flow cytometer and the cytokine concentrations in plasma/serum samples by ELISA. RESULTS The number of ISC/106 IgA-secreting cells expressed in median (interquartile ranges) in cord blood samples of VD vs. ECS were 19.5 (5.0-25.7) vs. 4.9 (0.0-8.4) respectively, p=0.03. The percentage of NK cells in ECS samples tended to be lower than that in VD; 12.2 (14.6-9.7) in ECS and 18.3 (25.1-11.3) in VD. The concentration of IL6 of ECS samples was lower than that of VD. These differences at birth were no longer significant when the infants were 2 and 6 months old. CONCLUSIONS These results indicate that ECS predisposes neonates to low capacity to generate IgA concomitantly with low circulating levels of IL6 and NK cells. Caesarean section delivery can hinder the first-line nonspecific immunity to enteral antigens of microbial or dietary origin at a critical period of life when the immune memory is yet to be established. This may explain the observation that the incidence of atopic diseases increases concurrently with the frequency of elective caesarean section deliveries in the developed countries.

Distribution of Interleukin-1 Receptors in Term Human Fetal Membranes and Decidua

Interleukin-1 (IL-1) is a dimorphic cytokine that acts on target cells through high-affinity receptors, type I and type II. It has been implicated in the onset of term and preterm labour with associated intrauterine infection. To define better the potential action of this cytokine in the human fetal membranes and decidua, the objective of this study was to define the type(s) of IL-1 receptors present in the tissues at term, examine the tissue and cellular distribution of the receptor(s) and determine if there were any changes in their expression or distribution with the onset of labour. Tissues were obtained following elective caesarean section (n=12) or normal labour delivery (n=11). Paraffin embedded and frozen sections were examined by immunohistochemistry and in situ hybridization for evidence of the type I and type II receptors and their corresponding mRNAs. In all tissues studied the type I receptor was localized mainly to the decidua and the type II receptor was localized to the decidua and scattered cells in the amnion-chorion mesenchymal layer. In situ hybridization localized type I receptor mRNAs and type II receptor mRNAs to the decidua. The type I and type II receptor protein in the decidua showed a similar pattern of staining as that found for CD-68, a macrophage marker. The pattern of receptor expression and distribution was unrelated to the mode of delivery. No evidence for the presence of the type I or type II receptor or their mRNAs in the amnion epithelial cells or chorion laeve trophoblast was found.