High Caesarean Section Rate Research Articles

Gestational diabetes in a multiethnic population of Spain: Clinical characteristics and perinatal outcomes

AimsTo compare clinical characteristics and perinatal outcomes between immigrant and Spanish women with gestational diabetes mellitus (GDM) in a multiethnic population of Barcelona and to identify factors independently associated with the development of large-for-gestational-age (LGA) infants. MethodsProspective study of women with GDM from five ethnic groups (Caucasian, South-Central Asian, Latin American, East Asian and Moroccan) at a single institution in Barcelona between 2004 and 2011. Maternal, gestational and newborn characteristics were recorded. ResultsThe cohort included 456 patients. In univariate analyses, Moroccan women had more frequently a pre-gestational body mass index (BMI)>25kg/m2 (76.4%, P=0.012), while East Asian women had lower BMI (23.41±2.79kg/m2, P<0.001), less need for insulin therapy (14.3%, P=0.013) and the highest rate of spontaneous labor (69.8%, P=0.014) and eutocic delivery (63.8%, P=0.032). Also, Latin American women had a higher rate of Cesarean section (52.9%, P<0.001) and LGA infants (28.6%, P=0.004), and their newborns had lower umbilical cord pH (7.23±0.06, P=0.005) and Apgar scores (9 [4–10], P<0.01) and a higher incidence of neonatal hypoglycemia (51.4%, P=0.045). Logistic regression analysis identified pre-gestational BMI (OR: 1.18; 95% CI: 1.09–1.27), pregnancy weight gain (OR: 1.19; 95% CI: 1.1–1.28) and insulin use during gestation (OR: 2.29; 95% CI: 1.09–4.82) as predictors of LGA infants. ConclusionsSignificant ethnic differences were found in clinical characteristics and perinatal outcomes of women with GDM. Latin American women had a higher frequency of adverse perinatal outcomes. Pregestational BMI, pregnancy weight gain and insulin use during pregnancy were independent predictors of LGA.

Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section

Placenta accreta is a rare and potentially life-threatening complication of pregnancy characterized by abnormal adherence of the placenta to the uterine wall. A previously scarred uterus or an abnormal site of placentation in the lower segment is a major risk factor. The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

SPRING: an RCT study of probiotics in the prevention of gestational diabetes mellitus in overweight and obese women

BackgroundObesity is increasing in the child-bearing population as are the rates of gestational diabetes. Gestational diabetes is associated with higher rates of Cesarean Section for the mother and increased risks of macrosomia, higher body fat mass, respiratory distress and hypoglycemia for the infant. Prevention of gestational diabetes through life style intervention has proven to be difficult. A Finnish study showed that ingestion of specific probiotics altered the composition of the gut microbiome and thereby metabolism from early gestation and decreased rates of gestational diabetes in normal weight women. In SPRING (the Study of Probiotics IN the prevention of Gestational diabetes), the effectiveness of probiotics ingestion for the prevention of gestational diabetes will be assessed in overweight and obese women.Methods/designSPRING is a multi-center, prospective, double-blind randomized controlled trial run at two tertiary maternity hospitals in Brisbane, Australia. Five hundred and forty (540) women with a BMI > 25.0 kg/m2 will be recruited over 2 years and receive either probiotics or placebo capsules from 16 weeks gestation until delivery. The probiotics capsules contain > 1x109 cfu each of Lactobacillus rhamnosus GG and Bifidobacterium lactis BB-12 per capsule. The primary outcome is diagnosis of gestational diabetes at 28 weeks gestation. Secondary outcomes include rates of other pregnancy complications, gestational weight gain, mode of delivery, change in gut microbiome, preterm birth, macrosomia, and infant body composition. The trial has 80% power at a 5% 2-sided significance level to detect a >50% change in the rates of gestational diabetes in this high-risk group of pregnant women.DiscussionSPRING will show if probiotics can be used as an easily implementable method of preventing gestational diabetes in the high-risk group of overweight and obese pregnant women.

A mixed-method study of factors associated with differences in caesarean section rates at community level: The case of rural China

Objectiveto assess population-based caesarean section (CS) rates in rural China and explore determinants and reasons for choosing a CS. Designcross-sectional study, quantitative and qualitative methods, statistical modelling. Settingtwo rural counties in Anhui province, China. Participants(a) household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006; (b) qualitative study participants: health providers at township and village level and maternal health-care providers (N=58). Measurements and findingsthe household survey were conducted among 2326 women, collecting data on socio-economic and health status and utilisation of maternal health services. Eleven Focus Group Discussions with health-care providers and users to explore perceptions surrounding CS.the CS rate in the two areas were 46.0% and 64.7%. There were complex and different interactions among social-economic and clinical determinants associated with differences in CS rates. The main determinants that emerged were maternal age, maternal education, yearly income, primiparity, uptake of antenatal care and recorded obstetric complications with complex and differing interactions for each county. Maternal fear of pain, worry about mothers' and infants' safety, not satisfied with doctors' competences and physicians' low confidence in vaginal delivery, and absence of a strong midwifery cadre together contributed to final determination of CS. Key conclusionsthe CS rates were extremely high in the two counties in rural China. Maternal socio-economic, clinic characteristics and health providers' preference contributed together to the high rates of CS. Implications for practiceevidence-based knowledge and methods to reduce unnecessary CS should be communicated to medical professionals and women. Greater comprehensive attention needs to be paid to a complex pattern of medical, socio-cultural, political and economic contexts of maternity care.

Mastering your profession

British Journal of Midwifery • February 2013 • Vol 21, No 2 As you are all more than aware, the UK is undergoing another baby boom. In a report issued to Parliament last month, the Royal College of Midwives (RCM) highlighted that although there has been a 7% rise in the number of full-time midwives in the UK, there are still too few (about 5000) in relation to the number of births (RCM, 2012). In 2011, there were 688 120 babies born to women in England, the highest number for 40 years (RCM, 2012), and in the UK, of the 808 000 births, 196 000 were to non-UK born women (Office for National Statistics, 2012). Each culture has its own beliefs and challenges and as Britain’s population diversifies, it is more important than ever to understand these differences to help provide high quality, individualised care to women and to promote the normality of birth. One of our remits in BJM, is to encourage the expansion of knowledge and we have always placed emphasis on the importance of continual professional development. Our portfolio of study days throughout the UK provide you with the opportunity to deepen your knowledge of female genital mutilation, stillbirths and complex needs while our study tours to China, run by our partner company Master Travel, give you a unique insight into midwifery practices in a challenging and rapidly expanding nation. The exploration of midwifery in different cultures provides the opportunity to discover a different philosophy of clinical practice, and allows you to broaden your professional and personal horizons. In countries such as China, where almost 50 000 babies are born each day, the rate of caesarean sections performed are well above the World Health Organization’s recommended 10–15% (Feng et al, 2012). Sufang et al (2007) found that the huge demand for the procedure across urban and rural areas of China was linked to the ‘one-child norm’ and women’s demand for the procedure. Furthermore, the cost of a caesarean section is higher than a vaginal birth, so many hospitals encourage the surgery to make more money. However, the Beijing Health Bureau has been promoting normal vaginal birth in order to lower the high caesarean section rate. Stricter supervision will be exerted and hospitals will be punished if they are found to perform unnecessary caesareans. The recent anouncement that 100 hospitals in the UK will share a £25 million fund to improve and upgrade their maternity units is indeed a welcome one and will go far to help promote normal birth in this country. However, would this money be better spent on employing more midwives to cope with the increasing population? I am afraid I am yet another statistic who has added to this baby boom. Set to go off on maternity leave at the end the week, I believe my antenatal care in the last 8 months has given me a great insight into the fantastic work midwives do from the perspective of a service user. My care has been second to none despite the stretched nature of maternity services and I fully intend to make the most of my midwife-led birth unit. BJM

Preferences for mode of delivery in nulliparous Argentinean women: a qualitative study

BackgroundOver the last three decades, cesarean section (CS) rates have been rising around the world despite no associated improvement in maternal and perinatal mortality and morbidity. The role of women’s preferences for mode of delivery in contributing to the high CS rate remains controversial; however these preferences are difficult to assess, as they are influenced by culture, knowledge of risk and benefits, and personal and social factors. In this qualitative study, our objective was to understand women’s preferences and motivational factors for mode of delivery. This information will inform the development and design of an assessment aimed at understanding the role of the women’s preferences for mode of delivery.MethodsWe conducted 4 focus group discussions (FGDs) and 12 in-depth interviews with pregnant women in Buenos Aires, Argentina in 4 large non-public and public hospitals. Our sample included 29 nulliparous pregnant women aged 18–35 years old, with single pregnancies over 32 weeks of gestational age, without pregnancies resulting from assisted fertility, without known pre-existing medical illness or diseases diagnosed during pregnancy, without an indication of elective cesarean section, and who are not health professionals. FGDs and interviews followed a pre-designed guide based on the health belief model and social cognitive theory of health decisions and behaviors.ResultsMost of the women preferred vaginal delivery (VD) due to cultural, personal, and social factors. VD was viewed as normal, healthy, and a natural rite of passage from womanhood to motherhood. Pain associated with vaginal delivery was viewed positively. In contrast, women viewed CS as a medical decision and often deferred decisions to medical staff in the presence of medical indication.ConclusionsThese findings converge with quantitative and qualitative studies showing that women prefer towards VD for various cultural, personal and social reasons. Actual CS rates appear to diverge from women’s preferences and reasons are discussed.

Reporting of perinatal health indicators for international comparisons—enhancing the appearance of geographical plots

Tabulating annual national health indicators sorted by outcome may be misleading for two reasons. The implied rank order is largely a result of heterogeneous population sizes. Distinctions between geographically adjacent regions are not visible. Regional data are plotted in a geographical map shaded in terms of percentiles of the indicator value. Degree of departure is determined relative to control limits of a corresponding funnel plot. Five methods for displaying outcome and degree of departure from a reference level are proposed for four indicators selected from the 2004 European Perinatal Health Report. Spread of indicator values was generally largest for small population sizes, with results for large populations lying mostly close to respective European medians. The high neonatal mortality rate for Poland (4.9 per 1000); high low-birthweight rates for England and Wales (7.8%), Germany (7.3%) and Estonia (4.5%); and high caesarean section rates for Italy (37.8%), Poland (26.3%), Portugal (33.1%) and Germany (27.3%) were statistically significant exceptions to this pattern. Estonia also showed an extreme result for maternal mortality (29.6 per 100 000). Extreme deviations from EU reference levels are either correlated with small population sizes or may be interpreted in terms of differing medical practices, as in the case of caesarean section rate. EURO-PERISTAT has now decided to use 5-year averages for maternal mortality to reduce the variance in outcome. Use of two colours in three intensities and solid fill versus crosshatching is best suited to display rate and significance of difference.

A critical review of vaginal birth rates after a primary Caesarean in Queensland hospitals

For women with a lower uterine incision without indication for repeat Caesarean section (CS), vaginal birth for their next pregnancy is a safe option. Although these women should be encouraged to consider vaginal birth after a Caesarean section (VBAC) it is not consistently supported in practice. There is relatively little information on the extent to which maternal preference, birthing decisions and outcomes match best available evidence. To describe current VBAC rates for women in Queensland, Australia and compare this to safe, achievable VBAC rates reported in national and international studies. Perinatal data from 2004 to 2011 were reviewed to determine current VBAC rates following a primary CS for women birthing in Queensland. These were compared with VBAC rates reported in the literature. Queensland has a high overall CS rate and high repeat CS rate compared with the national average. In 2010, Queensland VBAC rates for next birth following primary CS were 14% (range 13-21% public sector, 7-11% private hospitals). This is substantially lower than achievable Australian rates of 24% and international rates. Low VBAC rates reflect low numbers of women commencing labour in a pregnancy subsequent to a primary CS. There is unexplained variation in VBAC rates between maternity facilities. Clinical reviews to support evidence-based practice are warranted.

Effects of gestational weight gain on the outcome of labor at the Yaounde central hospital maternity, Cameroon

Obesity rates are increasing in Cameroon. Obstetric literature has recently focused on the rising incidence of complications with increases in weight gain in pregnancy. Some of these complications include gestational diabetes, hypertensive disorders, operative deliveries, genital tract lacerations and fetal birth trauma. Examining the effects of excess weight gain during the course of pregnancy could help identify weight gain limits. The Institute of Medicine (IOM) was recommended by the World Health Organization (WHO) to develop guidelines for weight gain during pregnancy and we designed this study in order to determine delivery outcomes when weight is gained above these guidelines. We also sought to know if these guidelines are applicable in our environment. In this cross-sectional analytic design, pre-pregnancy and intra-partum BMIs were calculated for all the parturients who consented. They were classified into normal weight gain and excessive weight gain based on IOM recommendations. Those in the normal weight gain group were women with BMIs that ranged between 18.5 kg/m2 and 30 kg/m2 and who gained 9 - 16 kgs. Those who gained weight above these range were considered as having gained excessive weight during pregnancy. They were all follow-up in labor using the partogram. We compared prepartum, intra-partum and post-partum outcomes in the two groups by calculating odds ratios (ORs), 95% confidence intervals and p values. One hundred and ten (110) overweight women were matched against the same number of women who had normal weight gain. There was no significant difference between social status, marital status as well as level of educational and weight gain in the two groups. Underweight (BMI p = 0.048). Women who gained weight above the recommended range suffered from preeclampsia 18.2% vs. 6.4% (OR 3.2, 95% CI 1.3 - 8.0, p = 0.014), higher cesarean section rates 27.3% vs. 10% (OR 3.3, 95% CI 1.5 - 7.1, p = 0.002), higher rates of induced labor 19.1% vs. 9.0% (OR 2.4, 95% CI 1.0 - 5.2, p = 0.05), prolonged labor 43.6% vs. 16.4% (OR 4.0, 95% CI 2.1 - 7.4, p = 0.000), postpartum hemorrhage 10% vs. 1.8% (OR 6.2, 95% CI 1.3 - 9.2, p = 0.002). There were also higher rates of fetal mal-presentation, 11.8% vs. 3.6% (OR 4.0, 95% CI 1.31 - 11.9, p = 0.004), macrosomia 30.9% vs. 6.4% (OR 7.0, 95% CI 2.7 - 15.6, p p = 0.0045) and birth trauma 10% vs. 1.8%. (OR 6.2, 95% CI 1.3 - 9.2, p = 0.023). Women who gained weight during pregnancy above the recommended range had increased risk of adverse obstetric and neonatal outcomes.

HIV Transmission to Extremely Low Birth Weight Infants

Prematurity increases the perinatal HIV transmission rate compared with term infants. There is sparse literature documenting the risk of transmission of HIV to extremely low birth weight (ELBW) infants. To determine the risk of perinatal transmission of HIV to ELBW infants in a tertiary neonatal unit in South Africa. A prospective database was maintained on all inborn ELBW infants over a 1-year period from March 2010 to February 2011. Survival and DNA HIV polymerase chain reaction results at 6 weeks were recorded. Of the 180 ELBW infants, 51 (28%) of these babies were HIV exposed. Of these 51 infants, 37 survived until 6 weeks of age. Polymerase chain reaction testing revealed 1 HIV-positive infant for a rate of 2.7% (95% confidence interval: 0.7-14.1%). Twenty-six (72%) of the 36 mothers received antiretroviral drugs, but only 16 (44%) had been treated for more than 1 month. The rate of HIV transmission in this cohort of ELBW infants is very low despite only 44% of the mothers receiving adequate antiretroviral drugs. We postulate that this is due to our high (89%) cesarean section rate, universal (100%) infant prophylactic antiretroviral drugs and the use of pasteurized breast milk.

Justified indicators for caesarean section in fetal distress

Introduction. The number of caesarean sections (CSs) carried out is rising worldwide, with one of the main fetal indicators for this method of delivery being fetal distress. In our department, the rate is reported to be particularly high compared with the literature. Our decision to perform a CS delivery during labour is based only on the cardiotocograph (CTG) recording, and so the aim of this study was to carry out an audit of CSs in fetal distress with a view to analysing this criterion, and to link the CTG findings that diagnose fetal distress to fetal outcome in order to assess the accuracy of the diagnosis. Methods. This is a retrospective and descriptive study of cases, using files, delivery book and electronic medical records which were collected over a period of 6 months. Some relevant clinical data were collected and used to measure clinical distress in the fetus. Some of the results relating to CS incidence and CTG recording have been compared with the literature. The major factors leading to emergency CSs were identified. Decision to delivery time and neonatal outcome were assessed based on Apgar score, cord pH and neonatal intensive care admission. Results. There were 1890 deliveries during the study period, i.e. 1 June 2011 to 31 December 2011. Of these, 101 women underwent CSs due to fetal distress, with 90 (17.4% of total CSs) included in the study. The remaining 11 women were excluded as they did not meet study criteria. The main indicators for CSs were CTG-recording abnormalities and meconium-stained liquor. One of the major points to emerge was that despite women having been taken for an emergency CS as a result of fetal distress, analysis of the fetal outcome showed that not one of the newborns had low Apgar score (< 7) at 5 minutes. Conclusion. The high rate of CSs for fetal distress in our department is probably due to a lack of other surveillance methods such as fetal scalp blood sampling and integrated CTG recording and fetal electrocardiography, but it is also symptomatic of the fear of medicolegal issues.

Pregnant women’s awareness and acceptance of epidural anesthesia and its influence on cesarean section rate control in China: A qualitative study

Background: Epidural anesthesia, as an effective pain relief method, could be viewed as an attempt to encourage vaginal delivery and control cesarean section. Increased demand caused by psychosocial factors such as fear of childbirth and labor pain is supposed to be one predictable drive of high cesarean section rate in present China. Little qualitative information on women’s awareness and perceptions of epidural anesthesia was found, but conscious efforts should be focused on this part to help generate policy-making priority. Methods: This study was carried out under an exploratory descriptive design in Bao’an Maternity and Child Health Hospital. Those interested in participating would be invited to focus group discussion or individual interview according to a semi-structured open-ended guide after collecting the participants’ demographic characteristics. The thematic content analysis approach was used for data analysis. Results: Five major themes were identified: 1. the sources to gain information on epidural anesthesia; 2. clinical impact; 3. social impact on awareness; 4. association between epidural anesthesia and cesarean section; 5. attitudes and questions about the current service implementation. Discussions: The interplay between pregnancy knowledge, socio-economic conditions, social support, insurance policy environment, women’s judgment of health care quality influences the ways women acknowledge and utilize epidural anesthesia service. Conclusions: As maternal requested CS due to low pain tolerance emerges gradually, natural labor with epidural anesthesia is a more suitable childbirth option, which is also expected to function in reducing CS rate by service-providers and administrators in the health departments of China besides building up a pain-free labor environment.

The light is on for on line

The light is on for on line

Recent incidence of type 1 diabetes mellitus in children 0–14 years in Newfoundland and Labrador, Canada climbs to over 45/100,000: a retrospective time trend study

BackgroundTo study and update the provincial incidence of type 1 diabetes mellitus (T1DM) in Newfoundland and Labrador (NL), a province of Canada with a very high incidence previously reported in 2006, and one of the highest incidences reported worldwide. This is a retrospective time trend study of the incidence of T1DM, in children aged 0–14 years from 1987–2010 inclusive.FindingsOver the study period 931 children aged 0–14 years were diagnosed with T1DM. The incidence of T1DM in this population over the period 1987 – 2010 inclusive was 37.7 per 100,000 per year (95% CI 35. 3, 40.2)The incidence from 2007–2010 was 49.9 per 100,000 per year (95% CI 42.2, 57.6). The incidence over this 24 year period increased by a factor of 1.03 per 100,000 per year.ConclusionNL has one of the highest incidences of T1DM reported worldwide. Potential reasons for the very high incidence could be related to the unique genetic background of the population, northern latitude and vitamin D insufficiency, low breastfeeding rates, and high rates of cesarean section.

Indications for, Timing of, and Modes of Delivery in a National Cohort of Women Admitted With Antepartum Hemorrhage at 22+0 to 28+6 Weeks’ Gestation

ObjectiveAntepartum hemorrhage is associated with preterm birthand operative delivery. Since the Canadian Perinatal Networkrecords obstetric interventions for women admitted to tertiarycare hospitals with antepartum hemorrhage, our objective was todescribe the delivery characteristics of this cohort. MethodsTrained abstractors collected data by chart review fromwomen admitted with antepartum hemorrhage between 22+0 and28+6 weeks’ gestation. We included all women with completefollow-up postpartum and used descriptive statistics to report theindications for, timing of, and modes of delivery. ResultsThe study cohort included 806 women from 13 tertiaryperinatal centres in six provinces. The most common causes ofbleeding were placental abruption (n = 256) and placenta previa(n = 171). The median gestational age at delivery was 30 weeks,and 497 (61.7%) births occurred at less than 34 weeks. Over onehalf of the women began labour spontaneously, and 238 (29.5%)were delivered prior to the onset of labour. Overall, 370 (45.9%)women delivered vaginally, including 98 who had induction oflabour. Of the 436 Caesarean sections (54.1%), 345 (79.1%)were emergencies. The most common indications for Caesareansection were placenta previa, abnormal fetal presentation, andplacental abruption or vaginal bleeding. ConclusionThis inpatient cohort of women with antepartumhemorrhage had high rates of spontaneous labour, preterm birth,and emergency Caesarean section. These results can be used ascurrent Canadian benchmark rates of preterm delivery, inductionof labour, and Caesarean section in women admitted to tertiarycare centres with antepartum hemorrhage between 22+0 and 28+6weeks’ gestation, and can aid in the counselling of similar women.

The rising trend in caesarean section rates: should we and can we reduce it?

<strong><em>Introduction: </em></strong>The rising caesarean section ( CS) rates in Sri Lanka are causing great concern. <strong><em>Objective: </em></strong>To study whether it would be justified and feasible to attempt reducing the rising caesarean section (CS) rates at the Teaching Hospital, Mahamodara, Galle (THMG). <strong><em>Method: </em></strong>Using the records available at the THMG, the trends in CS rates from 2007-2010 were studied. A prospective audit of CS was carried out in 2010, using a modified version of Robson’s Ten Group Classification of Caesarean Sections. <strong><em>Results: </em></strong>During 2007-2010 the mean CS rate in THMG has significantly increased, and fluctuated between 29.6% and 33.5 %, with no significant changes in perinatal morbidity and mortality, but with a significant increase in the proportion of mothers requiring intensive monitoring and intensive care. In 2010 the CS rates in THMG varied from 44.2% in Unit A, to 31.8% in the Academic Unit and 23.6% in Unit B. The main contributions to the high CS rates in the three units of the THMG were from the categories 5A and 5B (repeat CS), 2B (nulliparous term singleton vertex-NTSV, prior to the onset of labour), 1 (NTSV in spontaneous labour) and 2A (NTSV after induction of labour). The proportions in these categories varied significantly from one unit to another. <strong><em>Conclusions: </em></strong>A detailed analysis of the indications for CS in each group in each of the units is required. The possibility of more nulliparous women and women with only one previous CS scar and no other obstetric complication being carefully selected for a trial of vaginal birth should be explored. The possibility of pre-induction cervical ripening and careful selection of NTSV for induction of labour, and improving intrapartum management and the specificity of diagnosis of antepartum and intrapartum fetal distress needs to be explored. Reducing the high CS rates appears to be justified and feasible in THMG. DOI: <a href="http://dx.doi.org/10.4038/sljog.v34i1.4816">http://dx.doi.org/10.4038/sljog.v34i1.4816</a> <em>Sri Lanka Journal of Obstetrics and Gynaecology </em>2012; <strong>34</strong>: 11-18

Editor’s Choice

Editor’s Choice

984 Population-Based Study to Evaluate the Neonatal Morbidity and Mortality in Maternal Diabetes

AimThe aim of the study is to determine any connections between maternal diabetes and the pregnancy outcome of mothers and newborns.MethodsFrom 03/2003 to 11/2008 in local and university hospitals in...

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial

To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. Randomised controlled trial. Tertiary-care women's hospital in Melbourne, Australia. A total of 2314 low-risk pregnant women. Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care. In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.

Management of the occiput posterior presentation: A single institute experience

We have examined the risk factors and management processes of the persistent occiput posterior (pOP) position by analyzing medical records from our hospital. Medical records and delivery notes from January 2007 to December 2009 were reviewed and 103 patients were identified as having the pOP position during active labor. A total of 1054 patients who had occiput anterior (OA) deliveries were used as control. There was no significant difference in population background between the pOP and control groups. Fifty-eight (56%) cases of pOP were identified before the birth of the fetal head whereas 45 were found to be in pOP at the birth. Among these cases identified as pOP before the birth, 30 (52%) patients underwent an attempt to rotate pOP to OA manually. A total of 14 (47%) attempts were successful and delivered OA vaginally. Of 16 cases whose attempts failed, five (31%) had cesarean delivery and 11 had vaginal OP delivery. The overall cesarean rate in this group was 16.7%. Twenty-eight patients who did not have any corrective intervention had a significantly higher rate of cesarean section (60.7%, P<0.001 by χ(2) analysis). The advanced head station and the wider dilatation resulted in a successful manual rotation. Attempts to correct pOP by manual rotation have better results when the head is in the mid-pelvis. Also, posture change reduces cesarean section rate. The current data suggest attempts to correct pOP to OA reduce cesarean section rate.