Higher Rates Of Cesarean Delivery Research Articles

Can Obstetric Complications Explain the High Levels of Obstetric Interventions and Maternity Service Use Among Older Women? A Retrospective Analysis of Routinely Collected Data

Recent findings indicate that high rates of cesarean delivery in older women are largely independent of pregnancy and labor complications and raise important questions about just what leads to some of these operative deliveries. Age-related issues assume ever greater importance as more women defer childbearing. The authors report a retrospective study of 28,484 singleton deliveries taking place in Aberdeen during the years 1988-1997 (12,510 primiparous and 15,974 multiparous births). The goal was to learn whether cesarean delivery and other interventions can be explained by obstetrical complications. Odds ratios for interventions (induction or augmentation of labor, epidural use, assisted delivery, cesarean section) were compared with those in women 20 to 29 years of age. The same was done for the use of maternity services; criteria for increased use included more than two prenatal scans, amniocentesis, antenatal hospital admission, admission for longer than 5 days at delivery, infant resuscitation, and admission to the neonatal unit. All obstetrical interventions increased with advancing age, particularly cesarean delivery (before and during labor), assisted delivery, labor induction, and augmentation (in primiparas only). All health services were used more by older women. On reanalysis taking relevant obstetrical complications into account, the associations between age and most interventions were somewhat altered but not eliminated. Complications did not help explain the relation between older maternal age and either the likelihood of having more than two scans or a prolonged stay at delivery. Only for antenatal admission and admission to the neonatal unit was the age relationship abolished (older multiparous women may even be at lower risk of antenatal admission). For normally presenting infants, instrumental vaginal delivery, prelabor cesarean, and intrapartum cesarean all were more frequent in older women. The relation between age and cesarean delivery was greatly weakened in multiparous women with a past history of cesarean delivery. Women with hypertensive disorders of pregnancy or antepartum bleeding showed little age-related increase in the frequency of induction. The obstetrical complications considered in this study fail to explain higher levels of intervention and health service use in older parturients, whether primiparas or multiparas.

Unwanted Caesarean Sections Among Public and Private Patients in Brazil: Prospective Study

Reports of differing cesarean delivery rates in public and private patients suggest that nonmedical factors might influence physicians in their decision-making. Economic gain and the pressures of private practice are possibilities. On the other hand, patient preferences may be part of the answer. In Brazil, the cesarean rate for private patients is extremely high, more than double that for the public sector. Roughly one fourth of all deliveries are private, and more than 70% of these are operative deliveries. In an effort to better understand women's preferences, the authors conducted structured face-to-face interviews with 1093 public and 519 patients in four Brazilian cities; subjects ranged in age from 18 to 40 years. Participants were seen early in pregnancy, about 1 month before the due date, and about 1 month postpartum. A total of 1136 women completed all three interviews. Rates of cesarean delivery were 31% in the public sector and 72% for private patients. Corresponding rates of spontaneous vaginal delivery were 66% and 25%. In both groups about 3% were forceps deliveries. Differences in preferences between the two groups were not statistically significant. From 70% to 80% of women in each sector stated a preference in the two antenatal interviews to deliver vaginally. Nearly half the cesarean deliveries were decided on before hospital admission. This was the case for 23% of public-sector women and 64% of private patients. Preference for vaginal delivery included faster recovery and the natural way to deliver an infant. Those who preferred cesarean delivery mentioned avoiding pain and the possibility of concurrent tubal ligation. Furthermore, private patients often reported feeling positively about a past cesarean delivery. Only 16% of private patients having an unwanted cesarean delivery reported that their physician had recommended it. Only 37% of public patients having unwanted cesarean had discussed type of delivery with their physician. An advance decision for cesarean delivery was made much more often in the private sector. More unwanted cesarean deliveries in private patients seem to account for much of the private-public difference in cesarean delivery rates. An increasing or high cesarean delivery rate does not necessarily reflect a demand for operative delivery. If women's preferences are directly solicited, the demand for cesarean delivery may be less pronounced than expected.

Vaginal birth after cesarean in California

OBJECTIVE: To estimate rates at which women were offered and consented to trial of labor in California hospitals with high and low risk-adjusted cesarean delivery rates. METHODS: From 267 nonfederal acute-care hospitals in California that performed more than 678 deliveries in 1992–1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression model based on data from the California Patient Discharge Data System. We reviewed medical records of women with previous cesareans for evidence of counseling regarding trial of labor, other clinical variables, and method of delivery. Differences in proportions between the three groups of hospitals were compared. RESULTS: According to records of 369 women with previous cesareans, after excluding contraindications, 312 were potentially eligible for trial of labor. Hospitals with low risk-adjusted cesarean rates documented counseling women for trial of labor in over 99% of records reviewed, compared with 85% and 79%, respectively, of hospitals with intermediate and high rates ( P < .001). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospitals with intermediate and high rates ( P < .05). CONCLUSIONS: California hospitals with high cesarean rates in 1992–1993 had markedly higher rates of repeat elective cesarean delivery without evidence of counseling regarding trial of labor. Informed patient choice is a critical element of the decision for trial of labor or elective repeat cesarean, and lack of documented counseling is cause for concern.

Misoprostol induction of labor among women with a history of cesarean delivery

Objective: Several reports have appeared of uterine rupture among women with a history of cesarean delivery who received misoprostol for induction of labor. A recent review suggested a uterine rupture rate of almost 6%, but the experience at our institution did not seem to reflect this high complication rate. This study was undertaken to compare complications of labor induction with misoprostol between women with a history of cesarean delivery and women without uterine scarring. Study Design: A computerized database was used to select women with a viable fetus who underwent induction of labor with misoprostol during the period from January 1996 through December 1998. Patients were given 50 μg misoprostol every 4 hours. Women with a history of cesarean delivery were retrospectively compared with those without uterine scarring. Results: A total of 425 women were given misoprostol for induction of labor: 48 had a history of cesarean delivery and 377 did not. Women with a history of cesarean delivery were more likely to be delivered abdominally (56% vs 28%; P < .04). Among women with a history of cesarean delivery, women who had a history of vaginal birth after cesarean were more likely to be delivered vaginally (92% vs 42%; P = .003). There was no difference in the overall rate of complications (2% with scarring vs 3% without scarring). There were no uterine ruptures. However, the previous cesarean group was more likely than the unscarred group to have blood loss >500 mL (38% vs 22%; P < .03). Although the incidences of fetal distress were similar, neonates born to women in the previous cesarean group were more likely to have an Apgar score <7 at 5 minutes (13% vs 5%; P < .04). Conclusion: Misoprostol induction of labor in women with a history of cesarean resulted in a higher rate of cesarean delivery than was seen among women without uterine scarring but was not associated with a higher incidence of complications. There were no uterine ruptures in either group. (Am J Obstet Gynecol 2001;184:1115-7.)

Comparison of induced versus spontaneous labor in twins

Objective: To compare intrapartum outcomes of women with twin gestations undergoing an induction of labor versus spontaneous labor. Study design: This retrospective investigation included women with twin gestations undergoing a trial of labor between January 1995 and June 200. Only diamniotic twins with twin A presenting as a vertex at 24–40 weeks of gestation and women with an unscarred uterus were included. Statistical analysis was done using McNemar’s test, paired t test, and Wilcoxon signed rank test for paired samples. Results: A total of 121 patients underwent a trial of labor that was either induced (n = 40) or spontaneous (n = 81). No differences between groups were observed for maternal age, race, parity, and gestational age. Labor that was spontaneous eventually required augmentation in all cases. Labor that was induced, rather than spontaneous with augmentation, required a higher maximum dose (17.3 versus 7.3 mU/min , P <0.01) and a longer duration (688 versus 239 minutes, P <0.01) of oxytocin. Interruption of oxytocin infusion was uncommon when labor was either induced or later augmented (15% versus 13%). A greater need for cesarean delivery of twin A was found in the induced labor group (30.0% versus 9.8%, P <0.05). Conclusion: Labor in twin gestations that was induced, rather than spontaneous, required more time and was associated with a higher cesarean delivery rate.

Adverse Perinatal Events and Subsequent Cesarean Rate

In Brief Objective To determine whether severe intrapartum complications resulting in poor neonatal outcome increased obstetricians' cesarean delivery rates. Methods From July 1996 through June 1998 we prospectively studied 3008 deliveries by 12 obstetricians. We chose adverse neonatal outcomes that would be viewed by obstetricians as anxiety-provoking experiences that are rare in obstetric practice. Index events included head entrapment of breech infants, Apgar score less than 3 at 10 minutes, shoulder dystocia resulting in persistent brachial plexus injury, and intrapartum fetal death. After an index event was identified, the obstetrician's cesarean delivery rate for the 50 deliveries before the index event was compared with the 50 deliveries after the index event. Obstetricians who had no intrapartum complication during the observational period were matched as controls. Results Six index events were identified, three cases of shoulder dystocia and three intrapartum fetal deaths. In three of these six cases, the Apgar score at 10 minutes was less than 3. Obstetricians who attended a delivery with severe intrapartum complications had an average increase in their cesarean delivery rate of 37% in the 50 deliveries after the index event (21.0% to 28.7%, P < .05). This rate was greater (P < .05) than that of matched control obstetricians observed during the same observation period (19.0% to 18.7%). Conclusion Intrapartum complications such as persistent neonatal brachial plexus injury or fetal death increased the cesarean delivery rate of the obstetrician experiencing these events. Obstetricians should be aware of the effect of these adverse events on their practice of obstetrics. Obstetrician experience with intrapartum complications and poor neonatal outcomes results in higher cesarean delivery rate.

The Toronto Tri-Hospital Gestational Diabetes Project

Sermer, Mathew; Naylor, C. David; Farine, Dan; Kenshole, Anne B.; Ritchie, J. W. K.; Gare, Douglas J.; Cohen, Howard R.; McArthur, Karen; Holzapfel, Stephen; Biringer, Anne Author Information

Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis.

Epidural labor analgesia, if selected by the patient, is associated with high cesarean delivery rates. Results of randomized trials comparing rates of cesarean delivery using epidural anesthesia vs parenteral opioids are inconsistent. To review the effects of epidural vs parenteral opioid analgesia on cesarean delivery rates. Studies were identified by searching MEDLINE from January 1966 through January 1998, the Cochrane Database of Perinatal Trials, and relevant nonindexed journals and abstracts. We included all studies that randomized patients to epidural vs parenteral opioid labor analgesia. Two authors independently extracted data from 10 trials enrolling 2369 patients. Odds ratios (ORs) for categorical data, weighted mean differences (WMDs) for continuous data, and 95% confidence intervals (CIs) were calculated using a random-effects model. The risk of cesarean delivery did not differ between patients receiving epidural (8.2%) vs parenteral opioid (5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients had longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD, 14 minutes; 95% CI, 5-23 minutes) labor stages. While epidural patients were more likely to have instrumented delivery (OR, 2.19; 95% CI, 1.32-7.78), they were no more likely to have instrumented delivery for dystocia (OR, 0.68; 95% CI, 0.31-1.49). After epidural analgesia, neonates were less likely to have low 5-minute Apgar scores (OR, 0.38; 95% CI, 0.18-0.81) or to need naloxone (OR, 0.24; 95% CI, 0.07-0.77). Women receiving epidural analgesia had lower pain scores during the first (WMD, -40 mm on a 100-mm scale; 95% CI, -42 to -38 mm) and second (WMD, -29 mm; 95% CI, -38 to -21 mm) stages of labor. The odds of dissatisfaction were lower with epidural analgesia (OR, 0.25; 95% CI, 0.20-0.32). Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.

Women's experiences of birth in St. Petersburg, Russian Federation, following a maternal and child health intervention program.

An educational program for professionals in maternal and child health care in St. Petersburg, Russian Federation, was conducted between 1994 and 1997. The program was designed to provide 12 workshops in evidence-based antenatal and intrapartum care, and appropriate preparation of parents for pregnancy, birth, and parenthood for health care professionals in the city. Observations on the quality of maternity care service provided for women at the start and after the completion of the intervention program are reported. Significant changes occurred in maternity care practices during the period in which training programs were offered in St. Petersburg. In particular, more family centered care services were introduced, and breastfeeding practices improved. Significant reductions in maternal and perinatal mortality occurred. Most maternity hospitals showed a reduction in the use of interventions in delivery over the period of study, although one or two showed tendencies to follow in their Western counterparts' footsteps, including the emergence of a high cesarean delivery rate. This is not yet a cause for concern, but is worth future monitoring by local authorities.

IHI Views Collaboration vs Competition in Quality

THIS ISN'T a trick question: If surgery is scheduled for 9 AM, what does that mean? Should the patient simply arrive in the operating room at the appointed hour, or should the incision be made at 9 AM? "One reason surgery doesn't start on time is that no one agrees on what the start time is," said Donald M. Berwick, MD, president, chief executive officer, and cofounder of the Institute for Healthcare Improvement (IHI) in Boston, Mass. Such miscommunication that results in delays for patients and physicians is among a dozen or so topics that IHI has targeted in its 2-year-old Breakthrough Series. The series is a set of formal collaborations that IHI sponsors to bring up to 40 health care organizations together "to put knowledge into action" on a single health care improvement issue, Berwick said. Whether the series has addressed reduction in waiting times, high cesarean delivery rates

Induction of labor versus expectant management in macrosomia: A randomized study

Macrosomia at term is associated with increased maternal and neonatal morbidity, including a higher rate of cesarean delivery and shoulder dystocia. Induction of labor has been suggested as a means to prevent further weight gain and improve outcome. The aim of this study was to determine whether or not induction of labor in these cases improves maternal and neonatal outcome. Patients at term with an ultrasonic fetal weight estimation of 4000-4500 g were prospectively randomized into two groups: induction of labor (group D and expectant management (group II). Patients with diabetes, a previous cesarean delivery, or nonvertex presentation were excluded. Outcome variables included mode of delivery, arterial cord pH, presence of shoulder dystocia, brachial plexus injury, clavicular fracture, cephalohematoma, and intraventricular hemorrhage. Of 273 patients who were eligible for the study, 134 were randomized to group I and 139 to group II. Parity, gestational age, and fetal weight estimation were similar in the two groups. The neonates of group II patients were significantly heavier (4132.8 +/- 347.4 versus 4062.8 +/- 306.9 g; P = .024). The rate of cesarean delivery was 19.4% in group I and 21.6% in group II patients (not significant [NS]). Cord pH was similar in both groups. Shoulder dystocia was diagnosed in five group I and six group II patients (NS). None developed brachial plexus injury. There were two cases of mild, transient brachial plexus injury in group II patients without documented shoulder dystocia. Mild intraventricular hemorrhage was diagnosed in three of 44 group I and two of 31 group II neonates evaluated (NS). In this prospective, randomized study, induction of labor for suspected macrosomia at term did not decrease the rate of cesarean delivery or reduce neonatal morbidity. Ultrasonic estimation of fetal weight between 4000 and 4500 g should not be considered an indication for induction of labor.

Cesarean Delivery in Relation to Birth Weight and Gestational Glucose Tolerance

<h3>Objective.</h3> —To examine the relationship between birth weight and mode of delivery among women with untreated borderline gestational diabetes mellitus (GDM), treated overt GDM, and normoglycemia. <h3>Design.</h3> —Prospective cohort study <h3>Setting.</h3> —Three Toronto, Ontario, teaching hospitals. <h3>Patients.</h3> —A total of 3778 volunteers aged 24 years or older. <h3>Interventions.</h3> —Subjects underwent a 3-hour, 100-g oral glucose tolerance test at 28 weeks' gestation, regardless of screening test results. Usual care was provided to 143 women who met the National Diabetes Data Group criteria for GDM. Physicians were blinded to glucose test results for all others, including 115 untreated women with borderline GDM by the broader criteria of Carpenter and Coustan. <h3>Main Outcome Measures.</h3> —Crude and adjusted rates of cesarean delivery and neonatal macrosomia (birth weight &gt;4000 g). <h3>Results.</h3> —Compared with normoglycemic controls, the untreated borderline GDM group had increased rates of macrosomia (28.7% vs 13.7%,<i>P</i>&lt;.001) and cesarean delivery (29.6% vs 20.2%,<i>P</i>=.02). Cesarean delivery in this subgroup was associated with macrosomia (45.5% vs 23.5%,<i>P</i>=.03). Usual care of known GDM normalized birth weights, but the cesarean delivery rate was about 33% whether macrosomia was present or absent. A clearly increased risk of cesarean delivery among treated patients compared with normoglycemic controls persisted after adjustment for multiple maternal risk factors (adjusted odds ratio, 2.1; 95% confidence interval, 1.3 to 3.6). <h3>Conclusions.</h3> —Infant macrosomia was a mediating factor in high cesarean delivery rates for women with untreated borderline GDM. While detection and treatment of GDM normalized birth weights, rates of cesarean delivery remained inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment. (<i>JAMA</i>. 1996;275:1165-1170)

Cesarean delivery in relation to birth weight and gestational glucose tolerance: pathophysiology or practice style? Toronto Trihospital Gestational Diabetes Investigators

To examine the relationship between birth weight and mode of delivery among women with untreated borderline gestational diabetes mellitus (GDM), treated overt GDM, and normoglycemia. Prospective cohort study. Three Toronto, Ontario teaching hospitals. A total of 3778 volunteers aged 24 years or older. Subjects underwent a 3-hour long, 100-g oral glucose tolerance test at 28 weeks' gestation, regardless of screening test results. Usual care was provided to 143 women who met the National Diabetes Data Group criteria for GDM. Physicians were blinded to glucose tolerance test results for all others, including 115 untreated women with borderline GDM by the broader criteria of Carpenter and Coustan. Crude and adjusted rates of cesarean delivery and neonatal macrosomia (birth weight >4000 g). Compared with normoglycemic controls, the untreated borderline GDM group had increased rates of macrosomia (28.7% vs 13.7%, P<.001) and cesarean delivery (29.6% vs 20.2%, P=.02). Cesarean delivery in this subgroup was associated with macrosomia (45.5% vs 23.5%, P=.03). Usual care of known GDM normalized birth weights, but the cesarean delivery rate was about 33% whether macrosomia was present or absent. A clearly increased risk of cesarean delivery among treated patients compared with normoglycemic controls persisted after adjustment for multiple maternal risk factors (adjusted odds ratio, 2.1; 95% confidence interval, 1.3 to 3.6). Infant macrosomia was a mediating factor in high cesarean delivery rates for women with untreated borderline GDM. While detection and treatment of GDM normalized birth weights, rates of cesarean delivery remained inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment.

Defensive Medicine and Obstetrics

To test the hypothesis that physicians with greater malpractice claims exposure, either through personal experience or in their practice environment, will use more prenatal resources and have a higher cesarean delivery rate than physicians with lesser claims exposure. Retrospective cohort study using county malpractice defendant rate data from the Washington State Physicians Insurance and Exchange Association and prenatal care, delivery method, and self-reported obstetric suit experience data from the Content of Obstetrical Care Study database. Washington State obstetric practices. Stratified random samples of obstetrician-gynecologists and family physicians. The rates of obstetric ultrasound use, referral and consultation, prenatal care resource use, and cesarean delivery. After controlling for patient, physician, and sociodemographic characteristics, we found no difference in prenatal resource use or cesarean delivery rate for low-risk patients between physicians with more and less exposure to malpractice claims. This study does not support an association between the malpractice experience or exposure of individual physicians and an increase in the use of prenatal resources or ceserean deliveries for the care of low-risk obstetric patients.

Advanced maternal age as a risk factor for cesarean delivery

The rate of delivery by cesarean has increased steadily in the United States since the 1970s. The reasons for this increase are not fully established. Improved diagnosis of maternal and fetal complications, medicolegal concerns, and the changing age composition of childbearing women have been cited as contributing factors. To assess whether advanced maternal age by itself is an indicator for a primary cesarean delivery, we analyzed data from the vital records of all female residents of King County, Washington 35 years and older (N = 2985) who had a live singleton birth in 1986 or 1987. These women were compared with a sample of women 20-29 years old (N = 6140) who gave birth in the same time period and geographic area. Primiparous and multiparous women 35 years and older were at a similar increased risk of cesarean (relative risk = 1.6, 95% confidence interval 1.1-2.4). Primiparous women of all ages experienced more complications of pregnancy and labor and higher cesarean delivery rates. However, among primiparous mothers with no recorded complications, older women were at significantly increased risk of cesarean birth (relative risk = 2.5, 95% confidence interval 1.8-3.5). This analysis suggests that advanced maternal age alone may influence a physician's decision regarding method of delivery, thereby placing some older women at an unnecessary risk of cesarean.

Comparisons of National Cesarean-Section Rates

Our study of cesarean rates in 19 industrialized countries of Europe, North America, and the Pacific revealed sharp differences in rates, ranging from a low of 5 (Czechoslovakia) to a high of 18 (United States) per 100 hospital deliveries in 1981. Differences in cesarean rates according to maternal age, parity, and complications of pregnancy and childbirth reflected national differences in obstetrical practice. For example, the percentage of mothers who had a vaginal birth after a previous cesarean section was only 5 in the United States as compared with 43 in Norway, where the cesarean rate was half that in the United States. Despite the wide range of cesarean rates, almost all the countries studied have had consistent increases over the past decade, and the annual rate of increase for all countries appears to be converging. The steady pace of increase in developed countries, combined with comparable or even higher rates of cesarean delivery now being reported in less developed countries, underscores the need for the medical community to consider the appropriateness of this continued rise in the number of cesarean deliveries.

Comparisons of National Cesarean Section Rates

Our study of cesarean rates in 19 industrialized countries of Europe, North America, and the Pacific revealed sharp differences in rates, ranging from a low of 5 (Czechoslovakia) to a high of 18 (United States) per 100 hospital deliveries in 1981. Differences in cesarean rates according to maternal age, parity, and complications of pregnancy and childbirth reflected national differences in obstetrical practice. For example, the percentage of mothers who had a vaginal birth after a previous cesarean section was only 5 in the United States as compared with 43 in Norway, where the cesarean rate was half that in the United States. Despite the wide range of cesarean rates, almost all the countries studied have had consistent increases over the past decade, and the annual rate of increase for all countries appears to be converging. The steady pace of increase in developed countries, combined with comparable or even higher rates of cesarean delivery now being reported in less developed countries, underscores the need for the medical community to consider the appropriateness of this continued rise in the number of cesarean deliveries.

Utilization of health services by Mexican immigrant women in San Diego.

The limited empirical data available on maternal health problems among Mexican immigrant women in the United States suggest that they underutilize health services, especially general preventive care. Research conducted among legal and undocumented women in the Mexican immigrant population in San Diego, California, support these findings. Among undocumented mothers, 11.5% of their births in the U.S. occurred with no prenatal care or care sought in the third trimester, which is much higher than Mexican women legally in the country (3.6%) and the general San Diego maternal population (3.8%). When we examine births which occurred within the last five years by immigration status, we find that women legally in the country have a much higher rate of cesarean delivery of both undocumented women and women in the general San Diego maternal population. Undocumented women in our sample were much less likely than their legal counterparts to return for postpartum examinations for themselves, to seek neonatal care for their infants, and to have had Pap examinations or carry out breast self-examinations.

Intra-uterine growth retardation and gestational age.

This is a 5-year material of all singleton SGA (small for gestational age) infants born at the University Hospital in Lund, 1977-81, with a long-term follow-up. After the introduction of routine ultrasound scanning for all pregnancies in weeks 17 and 32 (1980-81), the rate of SGA-diagnosis before birth increased from 54.6% to 74.5% and the long-term outcome improved for term SGA infants. All women were treated according to a uniform policy regarding the termination of pregnancy--even in the early preterm period, if signs of fetal jeopardy appeared. More than half of all infants born before gestational week 34 died (40.0%) or showed major neurological handicap (16.0%) in spite of all being delivered by cesarean section. The corresponding figures for infants born in weeks 34-36 were 8.3% (deaths) and 8.3% (major handicaps); the cesarean section rate in this group was 83.3%. Term SGA-infants had an excellent outcome, with a low rate both for postnatal death (0.5%) and for major handicaps (2.0%). The results suggest that despite a high rate of antenatal diagnosis of intra-uterine growth retardation, and a uniform management of the pregnancy and the newborn, the high rate of cesarean delivery, and also intensive neonatal care, preterm SGA-infants are exposed to a greater risk of death or severe handicap.

Effect of fathers at cesarean birth on postpartum infection rates

Stephen H Jackson, Frederick R Schlich ting, Russell L Hulme, MD MD MD W hile most modern maternity units encourage a family-centered birth during labor and vaginal birth, physicians, nurses, and hospital administrators have been reluctant to allow fathers to be present at cesarean births.l In view of the high rate of cesarean deliveries, this policy eliminates a large percentage of fathers from being present a t the birth of their children. There are two rational concerns when a father is present in the operating room: an increased risk of maternal postpartum infection and the management of the father’s physical and mental presence. A study at our hospital evaluated these concerns. Methods. There are approximately 3,500 births annually in the obstetric unit of our hospital. One of the four delivery rooms is used almost exclusively for cesarean deliveries. A protocol for allowing fathers at the cesarean deliveries was established by the departments of obstetrics, anesthesiology, and pediatrics. We require a request signed by both parents. The obstetrician instructs the father,as to the policy and procedure to be followed and conditions for admission to, and exclusion from, the operating room. The obstetrician, anesthesiologist, and pediatrician must agree that the father can be present during cesarean delivery. The nursing staff outfits the father with a clean full-length cover gown, cap, mask, and shoe covers and supervises his handwashing with surgical soap. After regional anesthesia is administered, the father is placed in a wheelchair and brought to a position by one of the annboards. No attempt is made to facilitate or prevent the father from seeing the operative site. After the birth, the father can either accompany the newborn to the adjacent neonatal examination-resuscitation room for the initial evaluation and examination o r can remain with the