Frequency Of Cesarean Delivery Research Articles

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician’s shift completed

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes. The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change. This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis. Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Assessing the Factors Affecting Cesarean Section Selection in Iranian Women Using Multilevel Count Models with Excess Zeros.

Background:Iran has ranked second in the frequency of cesarean delivery (CD) and this rate in 2014 has increased by 56 percent. The CD has multiple complications for the woman and newborn, and due to the women’s readmission after surgery impose additional costs to the countries. Although CD has many complications and is not recommended by obstetrician and midwives; some factors affect the choice of this method of delivery.Methods:We used data from the Iranian Institute for Health Sciences Research (IIHSR) in 2015. We studied the effects of factors such as socioeconomic and demographic factors and supplemental insurance status in the choice of CD. We used multilevel Zero-Inflated models for the modeling of data.Results:The employed women resident in urban areas with the high-income and age greater than 34-yr old and supplemental insurance more likely chose CD. On the other hand, women with high education level, women who use at least one media (e.g. Radio, television, etc.) and women that use contraceptive methods have chosen the less CD.Conclusion:Our findings highlighted the importance of supplemental insurance and socio-economic status in choosing a CD by women. However, in some cases especially in the rich class of society, the high cost of this type of delivery does not affect the choice decrease of it, and governments should adopt rigorous policies in using this method.

Changes in the Frequency of Cesarean Delivery in Nulliparous Women in Labor in a Canadian Population, 1992-2018.

To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women. We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed. The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018. The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors.

Frequency of cesarean section in pregnant women with risk factors for preeclampsia: prospective cohort study

Background: Preeclampsia is a disorder of pregnancy associated with new-onset hypertension after the 20th week of gestation. The aim of this study is to examine frequency of cesarean delivery in pregnant women with risk for developing preeclampsia compared with pregnant women with normal pregnancy. Methods: The prospective study included 240 pregnant women. The experimental group had 120 pregnant women with preeclampsia risk factors. The control group had 120 pregnant women with no pregnancy risk factors. The method of delivery completion was analyzed. Results: In the experimental group, 88 (73.3%) pregnant women completed delivery vaginally, by cesarean section in 32 (26.7%). In the control group of vaginally deliveries were 105 (87.5%), by cesarean section 15 (12.5%). The difference in the frequency of method of delivery between the experimental and control groups is not random (p = 0.009). The chance of completing a delivery by cesarean section 2.54 times is higher in the experimental than in the control group. In the control group, it was found that the RI of uterine arteries in women who delivered by cesarean section was statistically significantly higher than in vaginal delivery (p = 0.038). Conclusion: Cesarean section is the most commonly used surgical procedure to complete delivery in pregnant womens with risk factors for preeclampsia, which confirmed our study.

Hospital-Level Variation in the Frequency of Cesarean Delivery Among Nulliparous Women Who Undergo Labor Induction

To evaluate the use of administrative data for identification of labor induction and to estimate the variation in cesarean delivery rates among low-risk women who underwent labor induction. A cross-sectional study was performed examining live births in California hospitals during 2016 and 2017 using birth certificate data linked with maternal patient discharge records. Initially, eight hospitals performed medical record reviews by using reVITALize definitions on 46,916 deliveries to assess the validity of induction identification by birth certificate or discharge diagnosis records or both. Hospital-level variation in cesarean delivery rates was then assessed among all California hospitals for women with low-obstetric-risk first births before and after further risk adjustment and after the exclusion of potential medical and obstetric indications for induction. Variation in physician-level cesarean delivery rates after induction at four large hospitals also was examined. The relationships between cesarean delivery rates among women with induced labors compared with noninduced labors and with the hospital rate of induction also were explored. Identifying induction by a combination of discharge diagnosis codes and birth certificate data had the highest accuracy (92.9%, 95% CI 92.7-93.2). Among 917,225 births at 238 birthing hospitals, there were 99,441 nulliparous women with term, singleton, vertex pregnancies who were induced. The median cesarean delivery rate after labor induction for nulliparous women with term, singleton, vertex pregnancies was 32.2%, with a range of 18.5-84.6%. This wide variation was not reduced after risk adjustment or after exclusion of all women with induction indications. A similar wide variation was noted within geographic regions, neonatal intensive care levels, and among individual physicians in the same facility. Only very weak associations were found for the cesarean delivery rate after labor induction and either the rate after noninduced labor (R<0.08) or the rate of nulliparous labor induction (R<0.12). The large variation of cesarean delivery rates after induction of labor suggests that clinical management plays an important role in achieving induction success.

Effect of counselling with men on perceived stress and social support of their pregnant wives

ABSTRACT Background Given the important role of spouses during pregnancy, this study aimed to determine the effect of counseling with men on stress and social support of their women (primary outcomes), anxiety, depression, weight gain, newborns’ anthropometric indicators, frequency of cesarean section and preterm delivery (secondary outcomes). Methods 102 pregnant women were randomly assigned to two groups of counseling and control. Four sessions of counseling were held for the spouses of intervention group. Perceived Personal Resource Questionnaire-85-Part2, Perceived Stress Scale, Edinburgh’s Postpartum Depression Scale, and Spielberger’s State and Trait Anxiety Inventory were completed before and four weeks after intervention. The participants were followed up until delivery, and newborns’ anthropometric indicators, delivery type, and preterm delivery were recorded. Results The mean score of social support increased significantly 4 weeks after intervention in the counseling group compared to the control group (MD:12.7; 95%CI: 18.5 to 6.9). There was no significant difference between groups in the mean score of stress, anxiety, depression, and weight gain during pregnancy at four weeks after intervention and also frequency of cesarean delivery, preterm delivery, and anthropometric indicators of newborns (p>0.05). Conclusions Counseling with fathers can be recommended as an effective intervention to increase social support of pregnant women. Trial registration IRCT2017042910324N38. Registered 25 June 2017, http://en.irct.ir/trial/10813

Frequency of Caesarean Delivery on maternal request in a private teaching hospital

Introduction: Caesarean section rates are increasing worldwide. There are many reasons for this increasing caesarean section rate one of them is increasing requests by women for caesarean section in the absence of medical indications. Most women think that elective caesarean section is safe both for women and babies. Some clinician also considered caesarean section safe. An increasing rate of caesarean section is alarming in developed as well as underdeveloped countries.&#x0D; Objective: To investigate the frequency of caesarean section on maternal request and factors leading to it in a private teaching hospital.&#x0D; Materials and Methods: This was a cross-sectional descriptive study carried out at Shalamar hospital from 1st May 2018 to 30th April 2019. Women of all ages who were pregnant and were going to have caesarean delivery during the study period at Shalamar hospital.&#x0D; Results: There were 3438 total births during the study period. There were 2380(69%) caesarean section and 1058(31%) were normal vaginal deliveries. Caesarean section rate was 69%. Caesarean sections performed on maternal request were 167(7%) out of 2380 caesarean. Out of these 167 Seventy-two, 43.1% of women were those who already have a previous caesarean section for different non-recurrent indications and now they don’t want the trial of labour and requested for caesarean section. Forty, 24% of women requested for a caesarean section because of fear of labour pains and eighteen, 10.8% were those who had a bad experience of the previous child-birth. Twelve, 7.2% of women had fear of failed vaginal delivery and eight women had fear of trauma to baby and three, 1.8% had fear of perineal trauma during the trial of normal vaginal delivery. Six, 3.6% of women had some social reasons for caesarean section and six, 3.6% had some bad experience of normal delivery of their relatives or friends and two, 1.2% were those who were requesting caesarean section because of their family members preferences.&#x0D; Conclusion: Most of the women requesting for caesarean section were those who had previously trial of labour. We can control the caesarean section rate by proper counselling of pregnant women.

A Review of Sleep Architecture and Sleep Changes During Pregnancy.

Poor sleep is widely recognized as a common complaint in pregnancy, and yet there are incomplete data on the exact nature of these complaints, what their implications for fetal and maternal health are, and how to best recognize and address these significant health issues. The purpose of this article is to review the current literature on the changes in objectively measured sleep parameters that occur during pregnancy, identify any possible trends, and discuss current implications for obstetric outcomes and treatments. PubMed NCBI and Google Scholars database were searched for a variety of sleep-related terms, and articles were selected based on relevance to the topic and method of sleep pattern monitoring. Poor sleep is ubiquitous during pregnancy, and the relatively few studies evaluating the issue using objective polysomnography have small sample sizes. However, data suggests sleep architecture changes begin as early as the first trimester, and there is evidence that primigravid sleep structure never returns to prepregnancy levels after birth. In addition, cesarean delivery frequency, early labor, labor length, depression, gestational hypertension, and gestational diabetes all appear to be influenced by sleep changes. Current treatments are based on nonpregnant populations and may not be appropriate for the gravid patient. Disordered sleep is a more widespread and serious issue than most women are aware, and there are numerous obstetric and general health implications to cause clinician concern. More research is needed on both electroencephalography architecture changes and treatment options.

Association Between Time of Day and the Decision for an Intrapartum Cesarean Delivery.

To examine whether the decision and indications for performing intrapartum cesarean delivery vary by time of day. We conducted a secondary analysis of a multicenter observational cohort of 115,502 deliveries (2008-2011), including nulliparous women with term, singleton, nonanomalous live gestations in vertex presentation who were attempting labor. Those who attempted home birth, or underwent cesarean delivery scheduled or decided less than 30 minutes after admission were excluded. Time of day was defined as cesarean delivery decision time among those who delivered by cesarean and delivery time among those who delivered vaginally, categorized by each hour of a 24-hour day. Primary outcomes were decision to perform cesarean delivery and the indications for cesarean delivery (labor dystocia, nonreassuring fetal status, or other indications). Secondary outcomes included whether a dystocia indication adhered to standards promoted to reduce cesarean delivery rates. Bivariate analyses were performed using χ and Kruskal-Wallis tests for categorical and continuous outcomes, respectively, and generalized additive models with smoothing splines explored nonlinear associations without adjustment for other factors. Seven thousand nine hundred fifty-six (22.1%) of 36,014 eligible women underwent cesarean delivery. Decision for cesarean delivery (P<.001) decreased from midnight (21.2%) to morning, reaching a nadir at 10:00 (17.9%) and subsequently rising to peak at 21:00 (26.2%). The frequency of cesarean delivery for dystocia also was significantly associated with time of day (P<.001) in a pattern mirroring overall cesarean delivery. Among cesarean deliveries for dystocia (n=5,274), decision for cesarean delivery at less than 5 cm dilation (P<.001), median duration from 5 cm dilation to cesarean delivery decision (P=.003), and median duration from complete dilation to cesarean delivery decision (P=.014) all significantly differed with time of day. The frequency of nonreassuring fetal status and "other" indications were not significantly associated with time of day (P>.05). Among nulliparous women who were attempting labor at term, the decision to perform cesarean delivery, particularly for dystocia, varied with time of day. Some of these differences correlate with labor management differences, given the changing frequency of latent phase cesarean delivery and median time in active phase.

Association of Oxytocin Use and Artificial Rupture of Membranes With Cesarean Delivery in France.

To evaluate whether the decrease in the frequency of oxytocin administration and artificial rupture of membranes observed between the 2010 and 2016 French Perinatal Surveys was associated with a change in the frequency of cesarean delivery or cesarean delivery indications among women who entered labor spontaneously. This cross-sectional study included women who participated in the 2010 and 2016 French National surveys who had singleton pregnancies and who gave birth at at least 37 weeks of gestation after spontaneous labor to a liveborn neonate in cephalic presentation. To test whether the observed decrease of oxytocin administration and artificial rupture of membranes between the two study years was explained by the women's individual characteristics and maternity units' organizational characteristics change, multivariable analyses were performed. The same strategy was applied for the change in intrapartum cesarean delivery rates between the 2 years. These analyses were repeated in nulliparous, low obstetric risk women, multiparous low obstetric risk women, and women with a previous cesarean delivery. The cesarean delivery indications were compared in 2010 and 2016. Oxytocin administration decreased significantly from 58.3% in 2010 to 45.2% in 2016 (adjusted odds ratio [aOR] 0.51; 95% CI 0.47-0.55), as did artificial rupture of membranes, from 52.4% to 42.6% (aOR 0.66; 95% CI 0.62-0.71). The intrapartum cesarean delivery rate remained stable-6.9% compared with 6.6% (aOR 0.93; 95% CI 0.82-1.06). The same patterns were observed in low risk groups and women with a previous cesarean delivery. The cesarean delivery indications were similar in both years. The significant decrease in oxytocin administration and artificial rupture of membranes in 2016 compared with 2010 was not accompanied by an increase in the intrapartum cesarean delivery rate for women in France who entered labor spontaneously. These results support the recent international guidelines.

Guidelines for labor assessment: failure to progress?

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits.

Adverse perinatal outcomes of pregnancies among adolescents vs women of advanced age in the Brazilian public health system

Abstract Objectives: to compare the adverse perinatal outcomes in pregnancies of adolescents and elderly women of public health network. Methods: a cross-sectional study carried out with pregnant women at the extremes of reproductive age according to the classification of the Brazilian Ministry of Health (adolescents those aged ≤19 years and those who were older than 35 years) and their newborns. Socioeconomic data (income, schooling, occupation and marital status), as well as clinical (diseases), anthropometric (maternal BMI) and perinatal (gender, weight, length, Apgar and gestational age) data were collected, and Poisson regression in hierarchical model was performed, with the results in Ratio of Prevalence (PR) and its respective Confidence Interval at 95% (95% CI). Results: when comparing adolescent and elderly women, 38.7% vs 54.6% (PR=0.71, CI=0.54-0.94, p=0.002) were observed, respectively, cesarean deliveries; 37.8% vs 25.2% (PR=0.83, CI=0.58-1.19, p=0.332) preterm births; 16.6% vs 20.5% (RP=1.07, CI=0.78-1.46, p=0.666) births of small infants for gestational age (SGA); 18.0% vs 15.3% (RP=1.01, CI=0.69-1.47, p=0.948) births of large-for-gestational-age newborns (LGA); 32.2% vs 34.7% (RP=1.08, CI=0.82-1.42, p=0.578), low birth weight infants and 28.5% vs 42.9% (RP=1.18, CI=0.91-1.54, p=0.201) with high birth length. Conclusions: When compared with adolescent women, pregnant women of advanced age presented a higher frequency of cesarean deliveries.

Elective Induction of Labor in the 39th Week of Gestation Compared With Expectant Management of Low-Risk Multiparous Women

To compare perinatal and maternal outcomes in low-risk multiparous women who underwent elective induction of labor in the 39th week of gestation with those who were expectantly managed. We performed a single center retrospective cohort study of low-risk multiparous women delivering nonanomalous singletons between 39 and 42 completed weeks of gestation from 2014 to 2018. The primary outcome was a perinatal composite of death, neonatal respiratory support, a 5-minute Apgar score of 3 or less, and shoulder dystocia. Groups were compared using χ, Fisher exact, two sample t-test, and Wilcoxon rank sum tests, as appropriate. Multivariable logistic regression models were used to adjust for potential confounders. Of the 3,703 low-risk multiparous women meeting inclusion criteria, 453 (12%) delivered between 39 0/7 and 39 4/7 after an elective induction of labor. Women who underwent elective induction of labor were more likely to be privately insured, non-Hispanic, and weigh more at their first prenatal visit (all P<.01) compared with expectant management. An elective induction of labor was associated with decreased frequency of the perinatal composite morbidity (4.0% vs 7.1%; adjusted odds ratio [aOR] 0.57, 95% CI 0.34-0.96) compared with expectant management. Fewer cesarean deliveries occurred among women in the elective induction of labor group (5.1% vs 6.6%; aOR 0.60, 95% CI 0.37-0.97). Other maternal outcomes (hypertensive disorders, chorioamnionitis, and operative vaginal deliveries) as well as neonatal intensive care unit admissions were not different between groups. Elective induction of labor in low-risk multiparous women in the 39th week of gestation was associated with decreased perinatal morbidity and a lower frequency of cesarean delivery compared with expectant management.

Evaluation of cesarean delivery rates at three university hospital labor units using the Robson classification system.

To analyze the frequency of cesarean delivery using the Robson 10-groupclassification. A multicenter retrospective cohort study was conducted at three university hospital labor units in the Slovak Republic. The medical records of all women who gave birth at these centers from January 1 to December 31, 2017, were assessed. In all, 1437 of 3361 (42.8%), 729 of 2795 (26.1%), and 303 of 2080 (14.6%) births recorded at the three centers during the current study period were by cesarean delivery. Among the nulliparous term singleton vertex deliveries (Robson group 1 and 2), the frequency of cesarean delivery at the three centers was 613 of 1653 (37.1%), 278 of 1389 (20.0%), and 91 of 898 (10.1%). Among term multiparas with one fetus in a cephalic position and at least one previous cesarean delivery (Robson group 5), the frequency of cesarean delivery at the three centers was 405 of 418 (96.9%), 261 of 343 (76.1%), and 55 of 115 (47.8%). Analysis of the frequency of cesarean delivery by Robson classification could help to identify possibilities for safely decreasing cesarean delivery rates in the clinic. Robson groups 1, 2, and 5 were the most modifiable groups.

Trends of caesarean delivery from 2008 to 2017, Mexico.

Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health-ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487–2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068–1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936–991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1 091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.

Mode of delivery in antepartum stillbirths

Stillbirth complicates 1 in 160 pregnancies in the United States. We sought to determine the rate of cesarean delivery in pregnancies complicated by antepartum stillbirth and to identify characteristics associated with cesarean delivery. This was a population-based retrospective cohort study of all stillbirths in the United States during the year of 2014. Frequency of cesarean delivery was stratified by week of gestation. Maternal, obstetric, and fetal characteristics were compared between women with antepartum stillbirth who underwent cesarean delivery compared with vaginal delivery. Multivariate logistic regression estimated the relative influence of maternal, obstetric, and fetal factors on the outcome of cesarean delivery. There were 16,160 nonlaboring women diagnosed with stillbirth during 2014 in the United States. Of the 16,160 stillbirths, 2449 (15.2%) underwent cesarean delivery. At 20-23, 24-27, 28-31, 32-36, and >36 weeks of gestation, the cesarean delivery rate was 4.0%, 16.2%, 23.7%, 30.8%, and 28.8%, respectively. Factors associated with cesarean delivery included gestational diabetes, preeclampsia, use of assisted reproductive technology, history of prior cesarean delivery, and increasing gestational age at delivery. Approximately 15% of women diagnosed with a stillbirth after 16 weeks of gestation underwent a cesarean delivery in 2014. The stillbirth cesarean delivery rate peaked during the third trimester, during which more than 1 in 4 women underwent a cesarean birth.

Effects of maternal obesity, excessive gestational weight gain and fetal macrosomia on the frequency of cesarean deliveries among migrant and non-migrant women - a prospective study.

Background Maternal obesity, excessive gestational weight gain and fetal macrosomia may affect the health of the mother and the newborn, and are associated with cesarean delivery. Pregnant women with a migration background have a higher risk of obesity but nevertheless a lower frequency of cesarean deliveries than women from the majority population. This study assesses which of these factors most influence the risk of a cesarean delivery and whether their prevalence can explain the lower cesarean rates in migrant women. Methods A total of 2256 migrant women and 2241 non-immigrant women subsequently delivering in three hospitals of Berlin/Germany participated. Multivariate logistic regression analysis was conducted to assess the effects of obesity, excessive gestational weight gain and macrosomia on cesarean delivery. Standardized coefficients (STB) were used to rank the predictors. Results Obesity was more frequent in immigrant than among non-immigrant women. The mean gestational weight gain was independent of migration status. The frequency of macrosomia increased with maternal weight. Obesity and excessive gestational weight gain were the most important predictors of cesarean besides older age; fetal macrosomia played a much smaller role. Despite similar distributions of the three risk factors, the frequency of cesarean deliveries was lower in migrant than in non-immigrant women. Conclusion The presence of obesity and/or excessive gestational weight gain is associated with an increased risk of a cesarean delivery; fetal macrosomia does not increase the risk when obesity and weight gain are considered. The distribution of these risk factors is similar in migrant and non-immigrant women, so they cannot explain the lower frequency of cesarean deliveries in migrant women.

The impact of different classes of lupus nephritis on maternal and fetal outcomes: a cohort study of 147 pregnancies.

To analyze the impact of different classes of lupus nephritis as risk variables for maternal and fetal adverse outcomes in a cohort of pregnant lupus patients. This is a cohort study with retrospective and prospective data collection, conducted at the University Hospital of State University of Rio de Janeiro, Brazil, from 2011 to 2016. A total of 147 pregnancies of 137 systemic lupus erythematosus patients of whom 66 had lupus nephritis were included. Demographic and clinical features, as well as maternal and fetal outcomes were observed for each nephritis histological class among systemic lupus erythematosus patients and compared with those without nephritis. Categorical variables were expressed as absolute and relative frequencies and numerical variables as means and standard deviation. The chi-square test with Fisher's correction and Student's t-test were used for statistical analysis. A pvalue < 0.05 was considered statistically significant. Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV, n = 54) presented more frequent disease flares ( p = 0.02), continuous active disease during pregnancy and puerperium ( p = 0.006), hospitalization due to systemic lupus erythematosus ( p < 0.001), hospitalization not directly associated to systemic lupus erythematosus ( p = 0.04), higher frequency of cesarean delivery ( p = 0.03) and preeclampsia ( p = 0.01) than patients without nephritis. Permanent damage measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was more frequent in classes III/IV than among the other patients. The frequency of adverse fetal outcomes such as prematurity and admission to neonatal intensive care unit were not different among systemic lupus erythematosus patients with or without nephritis. However, perinatal deaths were more frequent in patients with all classes of nephritis ( p = 0.003). Systemic lupus erythematosus patients with proliferative nephritis (classes III/IV) have a higher frequency of adverse maternal outcomes. This is probably due to the major impact of proliferative forms of nephritis on women's global heath, which is corroborated by the higher Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index findings, although we cannot exclude the negative influence of disease activity for the maternal adverse events. The findings indicate a need for further lupus nephritis classification beyond the nonspecific term nephritis in the context of lupus pregnancy as the impact on maternal and fetal outcomes varies according to histological class.

Prevalence of Cesarean Section and Analysis of Neonatal Apgar Score and the Mean Time of Second Phase of Labor in Pregnant Women.

Introduction:The labor pain is probably the most severe pain a mother experiences in her lifetime and is usually severe and prolonged in women with pregnancy,Aim:To evaluate the effects of labor epidural and spinal analgesia on the incidence of cesarean section in painless delivery.Methods:This randomized clinical trial was conducted on pregnant women aged 37-42 weeks of pregnancy. Female candidates for painless labor were divided into two groups: Epidural Analgesia (EA) and Spinal Analgesia (SA). Patients in the labor epidural group underwent analgesia using marcaine and fentanyl and after fully assuring the normal hemodynamic status of the mother and fetal hearth rate (FHR), labor spinal analgesia was used for other group.Results:The average age of mothers was 27.5 years, their mean gestational age was 39 weeks and their mean weight was determined to be 72 kg. Frequency of cesarean delivery in mothers was found as 12.9%. Significantly, the incidence of cesarean section in the labor epidural analgesia group was higher than the labor spinal analgesia group (P = 0.02). In addition, the mean second phase of delivery in the labor epidural analgesia group was significantly higher than the labor spinal analgesia group (P = 0.03). There was no significant in 1st and 5th min Apgar scores between groups in infants (8.6 and 9.6, respectively).Conclusion:Labor epidural analgesia and labor spinal analgesia result in a significant reduction in pain due to normal delivery. Due to the similarity of Apgar and arterial blood gas (ABG) in neonates, labor epidural analgesia may serve as an alternative in childbirth delivery.

808: Oxytocin regimen for induction of labor and pregnancy outcomes

Uncertainty exists regarding the optimal oxytocin dose regimen for induction of labor (IOL). We evaluated the association of oxytocin regimen for IOL with cesarean delivery and with adverse perinatal composite outcome in low-risk nulliparous women. Secondary analysis of a multi-center randomized control trial of IOL at 39 weeks compared with expectant management in low-risk nulliparous women. Women in either group who underwent IOL with a mid-to high-dose oxytocin (MHD) regimen were compared with those induced with a low-dose oxytocin (LD) regimen. The primary outcomes were cesarean delivery and a composite of perinatal death or severe neonatal complications (Table 1). M ultivariable regression was used to estimate relative risks (RR) controlling for related covariates, although site could not be adjusted for given collinearity with oxytocin regimen. Interaction between oxytocin regimen and modified Bishop score, induction indication and treatment group were also evaluated. Of 6,106 women enrolled in the primary trial, 3,034 women underwent induction with oxytocin; 889 in the MHD group and 2145 in the LD group. There was a shorter duration from start of oxytocin to delivery (median 11.7 hours vs. 13.4 hours) and higher percentage of women in the lowest quartile for time to delivery in the MHD group compared with the LD group (p<0.001 for both). The lower frequency of cesarean delivery in the MHD group (20.9% vs. 25.0%) was not significant after adjustment (Table 1). There was an increase in operative vaginal delivery in the MHD group (9.7% vs. 6.8%, P=0.007). The adverse perinatal composite outcome was significantly more frequent in the MHD group (6.6% vs. 4.3%, adjusted RR 1.59, 95% CI (1.15-2.21)) compared with LD group; this association was most notable among those with an elective induction (p=0.03 for interaction). The higher frequency of the adverse perinatal outcome in the MHD group was mostly due to a higher frequency of continuous positive airway pressure or high-flow nasal cannula (Table 2). Compared with LD regimen, MHD regimen for induction was associated with a similar chance of spontaneous vaginal delivery as well as a higher risk of an adverse perinatal composite outcome, particularly for elective induction. It remains uncertain if this finding is related to the actual regimen or other confounding variables such as site of use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)