Higher Rates Of Cesarean Delivery Research Articles

Maternal metabolic response to dietary treatment for impaired glucose tolerance and gestational diabetes mellitus.

Dietary advice is a standard component of treatment for pregnant women with impaired glucose tolerance (IGT) and gestational diabetes (GDM), yet few studies report glycemic profiles in response to dietary therapies and the optimal dietary approach remains uncertain. To assess changes in maternal glycemic profile and pregnancy outcomes among women with diet-controlled IGT and GDM. Pregnant women who had one or more elevated values on a 3-h oral glucose tolerance test were enrolled. All participants received dietary advice and glucose monitoring as part of routine clinical care. Fasting and 1-h post-prandial blood samples, collected prior to initiation of clinical treatment and repeated 4-6weeks later, were analyzed for glucose, insulin, and C-peptide. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. Women who required pharmacological therapy for glucose control were excluded from analyses. Participants (N = 93) were of moderately older age (mean 33years), with a high rate of overweight/obesity (mean body mass index (BMI) = 28.65kg/m2), and were diagnosed late in gestation (mean 29weeks). Fasting (mean ± SD 4.82 ± 0.53 to 4.60 ± 0.42mmol/l; p < 0.001) and post-prandial glucose (7.01 ± 1.19 to 6.47 ± 1.10; p = 0.004) decreased significantly following the intervention. Baseline HOMA-IR was elevated (3.12 ± 1.03) but did not significantly decrease (2.78 ± 1.52; p = 0.066). There were high rates of macrosomia (24.7%) and cesarean delivery (32.3%). Although improvements in blood glucose levels were observed among women with diet-controlled IGT and GDM, this was insufficient to significantly affect insulin resistance or perinatal outcome. Late diagnosis and treatment of IGT/GDM may have contributed to such outcomes.

Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy.

To identify both the trends in placenta accreta spectrum (PAS) disorders in the context of the universal two-child policy in China and risk factors for hysterectomy. The present retrospective analysis included confirmed PAS disorders during cesarean delivery at a tertiary hospital in Changsha, Hunan, China, from January 1, 2007, to December 31, 2016. Multivariable logistic regression was used to estimate the risk of hysterectomy. During the 10-year study period, the overall incidence of cesarean delivery was 51.6% (13530/26214) and that of PAS disorders was 1.2% (302/26214). The PAS rate increased from 0.1% (5/4617) in 2007-2008 to 2.1% (133/6351) in 2015-2016, alongside a rise in elective repeat cesarean delivery from 5.0% (106/2124) to 38.4% (1385/3603). Previous cesarean delivery greatly increased the likelihood of PAS disorders (odds ratio [OR] 97.4; P<0.001). Invasive depth (OR 92.0; P<0.001), inter-cesarean interval less than 36months (OR 7.0; P=0.002), rural residence (OR 5.3; P=0.018), and advanced maternal age (OR 3.0; P=0.045) were independent risk factors for hysterectomy among women with PAS disorders. The increasing incidence of elective repeat cesarean delivery combined with a high overall rate of cesarean delivery implies a high prevalence of PAS disorders within the context of the universal two-child policy in China. The main predictor of hysterectomy was invasive depth.

352: Laboring beyond the obstetric care consensus (OCC) labor dystocia guidelines: Proceed with caution

To evaluate whether or not allowing women to labor beyond the OCC labor dystocia guidelines is associated with increased maternal and neonatal complications. This is a retrospective chart review performed on 640 nulliparous, term, singleton, vertex (NTSV) patients delivering between January 2013 and May 2017 at an academic community hospital managed by the residents’ service. Forty-eight were identified with protracted active labor: ≥ 6cm and protracted at least 6 hours without change in dilation (beyond the OCC guidelines). We then compared the prospect of vaginal delivery and maternal and neonatal complications in this group with two others: those who had protracted labor within the OCC guidelines (4-6 hours in the active phase without cervical change) (N=47) as well as those that did not experience protracted labor (N=371). Women that labored beyond the OCC guidelines had a 42.5% vaginal delivery rate (mean duration of total protraction 9.1 +/- 2.1 hours). However, they also had a statistically significant higher rate of cesarean delivery (P<.001), quantified blood loss (QBL) (P=.01), and NICU admission rates (P<.001) compared to those laboring within the OCC guidelines. We also noted an increase in suspected intrauterine infection or inflammation (triple I) (P=.008), need for maternal blood transfusion (P=.01) and maternal length of stay (LOS) (P<.001) between those with protracted labor >6h and non-protracted labor. Rates of neonatal sepsis and 5-minute Apgar <7 were not statistically significant between the groups. There were no maternal ICU admissions, cesarean hysterectomies, or maternal/neonatal deaths. Women who labored beyond the OCC labor dystocia guidelines can still achieve vaginal delivery, but with increased select maternal and newborn risks. Still, there were no serious complications in either group. Proceeding with labor beyond the OCC guideline may be considered, but with caution.

302: Placental histopathological lesions in correlation with neonatal outcome in preeclampsia with and without severe features

We aimed to compare pregnancy outcome and placental histopathology in women with preeclampsia with and without severe features. Labor, maternal characteristics, neonatal outcome, and placental histopathology reports of pregnancies complicated by preeclampsia from 2008-2016 in a single university hospital were reviewed. Results were compared between those with and without severe features according to the current ACOG guidelines. Placental lesions were classified to maternal vascular malperfusion lesions, fetal vascular lesions consistent with fetal thrombo-occlusive disease, and maternal/fetal inflammatory responses. Small for gestational age (SGA) was defined as neonatal birth-weight ≤ 10th %. Composite adverse neonatal outcome was defined as one or more of the following early complications: sepsis, blood transfusion, phototherapy, respiratory morbidity, cerebral morbidity, NEC, or death. Regression analysis was used to identify independent associations with adverse neonatal outcome. The preeclampsia with severe features group (n=284) was characterized by a lower gestational age at delivery (35.1±3.7 vs. 36.7±2.3 wks, p<0.001), and a higher rate of cesarean deliveries (p<0.001) as compared to the preeclampsia without severe features group (n=151). Placental weight <10th percentile and lesions associated with maternal malperfusion were significantly more common in the preeclampsia with severe features group as compared to the preeclampsia without severe features (p<0.001 for both). The rate of fetal vascular supply lesions or inflammatory lesions did not differ between the groups. Additionally, the preeclampsia with severe features group had higher rates of SGA (p=0.016), NICU admission (p=0.014), and composite adverse neonatal outcome (p=0.002). Using regression analysis adverse neonatal outcome was independently associated with gestational age (aOR= 0.54, 95% CI 0.49-0.68), SGA (aOR=1.75, 95% CI=1.15-3.59), severe preeclampsia (aOR=1.8, 95%CI = 1.13-3.54) and placental maternal malperfusion lesions (aOR=2.13, 95% CI=1.05-4.39). Preeclampsia with severe features is associated with a higher rate of placental lesions and adverse neonatal outcome. The adverse neonatal outcome is associated with placental malperfusion independent of background confounders.

906: Obstetricians in solo practice: do their patients have worse outcomes?

As labor management becomes more group-based with obstetricians covering discrete shifts, it is unknown if obstetricians who remain in solo practice (solo OBs) are still able to provide similar quality and safe care to women in labor as their colleagues in group practice models (group OBs). We sought to determine if women under the care of solo OBs have different delivery outcomes from women under the care of group OBs. Retrospective cohort of all live, term, singleton, vertex deliveries at one large tertiary care center from 2011-2015. In this hospital, patients are either on the resident service or under the care of a private OB. For this study, we only included patients under the care of a private OB and we compared outcomes between women whose OB was in solo practice to women whose OB was in a group practice model. Regression analysis was performed to control for any baseline differences in patient characteristics. Over the course of the study period, there were 18,214 live, term, singleton, vertex deliveries by private OBs, 2,016 (11.1%) of whom were by solo OBs and 16,198 (88.9%) of whom were by group OBs. Solo OBs were more likely to deliver at night (40.0% vs. 37.5%, p=0.002) and were less likely to induce labor (22.6% vs. 30.6%, p<0.001). After controlling for maternal age, race, body mass index, and parity, solo OBs had a significantly higher rate of cesarean delivery, but also had a significantly lower rate of shoulder dystocia, 3rd or 4th degree lacerations, and 1-minute Apgar scores <7 (Table). 5-minute Apgar scores <7 did not differ between the groups. In a large, tertiary-care hospital, Solo OBs have similar neonatal outcomes as group OBs. Their higher cesarean delivery rate is balanced by fewer shoulder dystocias, 3rd/4th degree lacerations, and 1-minute Apgar scores <7, indicating a more conservative approach to labor management. Patient safety should not be a reason to discourage a solo OB practice model.

239: Perinatal outcome of pregnancies with uterine leiomyomas

Uterine leiomyomas develop in up to 50% of women older than 35 years. As maternal age rises, leiomyomas become more prevalent during pregnancy. This study was aimed to assess perinatal outcome in mothers with and without uterine leiomyoma during pregnancy. A population-based cohort analysis including all singleton deliveries which occurred between the years 1991-2014 at a single regional tertiary medical center was conducted. Fetuses with congenital malformations and multiple pregnancies were excluded. Multivariable generalized estimating equation (GEE) analysis adjusted for recurrent maternal occurrence in the dataset and possible confounders was performed. During the study period 242,232 singleton deliveries met the inclusion criteria; 0.5% of which were in mothers diagnosed with uterine leiomyoma (exposed group, n=1,226). As compared to the non-leiomyoma (comparison) group, the exposed group was characterized by more advanced mean maternal age (34.22±5.5 vs. 28.13±5.8 years, p=0.003), higher rates of fertility treatments (7.1% vs. 1.0% by in vitro fertilization; 3.9% vs. 0.7% by ovulation induction, p<0.001), and a history of recurrent pregnancy loss (9.0% vs. 5.0%, p<0.001). Significantly higher rates of hypertensive disorders, diabetes mellitus (gestational and pre-gestational), fetal growth restriction, and preterm labor (both < 37 and <34 weeks) was observed in the leiomyoma group (Table 1). In addition, the exposed group demonstrated higher rates of cesarean delivery, placental abruption, and small for gestational age newborns (defined as <5th percentile adjusted for gestational age). Nonetheless, perinatal mortality rates were comparable between the groups (0.9% vs. 0.5%, p=0.106). In the GEE multivariable analyses, controlling for maternal age, mode of delivery, hypertensive disorder and diabetes mellitus, fetal growth restriction, low birthweight (<2500gr), and small for gestational age newborns, were all found to be independently associated with uterine leiomyoma during pregnancy (Table 2). Maternal uterine leiomyoma appears to be independently associated with adverse pregnancy outcome, mainly related to fetal growth, thus emphasizing the importance of appropriate perinatal and intrapartum surveillance in these high-risk pregnancies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

340: Intrapartum hypertension, diagnosis of preeclampsia and adverse neonatal outcomes

The intrapartum diagnosis of hypertension is challenging given blood pressure (BP) measurements in labor may be affected by pain and hemodynamic changes. Our objective was to determine the prevalence of intrapartum hypertension and its clinical relevance. Secondary analysis of an intrapartum fetal heart rate monitoring trial that enrolled women with singleton gestation at >36 weeks gestation, who were attempting vaginal delivery, had ruptured membranes and a cervix 2-7 cm dilated. Women diagnosed with gestational hypertension (GHTN) or preeclampsia (PE) at the time of enrollment, or receiving magnesium sulfate, were excluded from the analysis, as well as those with chronic hypertension, lupus, or BP measured less frequently than every 30 minutes. BP was measured using an automated machine and digitally stored. The prevalence of various degrees of systolic and diastolic BP elevations after enrollment, and their associations with maternal outcomes and a composite neonatal outcome (intrapartum fetal death, neonatal death, Apgar score ≤ 3 at 5’, neonatal seizure, umbilical-artery blood pH ≤ 7.05 with a base deficit ≥ 12 mmol/L, intubation for ventilation at delivery, or neonatal encephalopathy) were determined. The prevalence of the various BP elevations is summarized in Table 1. One or more systolic BP >140 mmHg or diastolic BP >90 mmHg occurred in 64.5% of laboring women, and was not associated with the composite neonatal outcome or cesarean delivery (CD), but was associated with use of magnesium sulfate (MgSO4), and longer maternal length of stay. In addition to the association with the latter maternal outcomes, 2 or more BPs above these cutoffs at least 4 hours apart was also associated with higher CD rates. Multivariate logistic regression showed that when compared to normotensive women, increased BP with or without the diagnosis of GHTN or PE was associated with CD, but not adverse outcomes (Table 2). Two women had seizures after enrollment: one had normal BP but was diagnosed with GHTN /PE and the other had a single BP elevation BP elevations above the cutoffs used to diagnose hypertension are very common in labor and are not associated with adverse neonatal outcomes. They are, however, associated with higher cesarean rates and maternal length of stay, even if they do not lead to diagnosis of GHTN or PE

104: Is more than one dose of misoprostol needed to expedite vaginal delivery in a patient with an unripe cervix? - a randomized controlled study

Misoprostol is a common agent used to induce labor, yet there is no clear evidence of the optimal number of doses needed to achieve a higher rate of vaginal delivery. Our objective was to compare the rate of vaginal delivery within 24 hours between a one-dose and a multiple-dose regimen of misoprostol for induction of labor. A randomized controlled trial was conducted from March 2016 to March 2017 comparing a single dose to up to four doses of misoprostol. Randomization was stratified by parity. Women with a singleton pregnancy ≥ 37 weeks gestation with intact membranes admitted for labor induction with a Bishop score ≤ 6 were included. Our primary outcome was vaginal delivery (VD) rate within 24 hours. Secondary outcomes included time to VD and cesarean delivery (CD) rate. Student t-test, Mann-Whitney test, chi-square and Fisher's exact test were performed as appropriate with an intent-to-treat principle. Based on a power of 80% and an alpha of 0.05, a sample size of 220 patients was needed to detect a 20% increase in VD rate within 24 hours in the one-misoprostol group. 250 women were randomized. Demographics and clinical characteristics were similar between groups. In the univariate analysis, there was no difference in the VD rate within 24 hours between the one-misoprostol group and the multiple-dose group (65.5% vs. 57.9%, respectively p=NS) or time to VD (1263 min vs. 1385 min, respectively, p=NS). The one-misoprostol group had a greater CD rate (35% vs. 22.2%, p=0.035). In a multivariate analysis controlling for Bishop score prior to starting oxytocin, parity, gestational age, body mass index and birth weight, treatment group was no longer associated with CD rate. Instead, Bishop score of < 4 prior to initiation of oxytocin and nulliparity were significantly associated with higher CD rate (p<0.001, p=0.001 respectively). In this first randomized controlled trial comparing one to multiple doses of misoprostol, we found that the one-dose regimen is an acceptable alternative for induction of labor, especially for multiparous women and for patients with a Bishop score > 4 after the first dose of misoprostol.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

346: Disparate rates of cesarean delivery in term nulliparous women with hypertensive disorders of pregnancy

Despite the evidence supporting the safety of vaginal delivery in the setting of hypertensive disorders of pregnancy, women with this diagnosis continue to have high cesarean delivery (CD) rates. The aim of this study was to evaluate whether the increased CD rate in women with hypertensive disorders of pregnancy could be explained by maternal, sociodemographic, or obstetric comorbidities, or whether other external factors may be driving this phenomenon. This is a retrospective cohort study of nulliparous, term, singleton, vertex (NTSV) women delivering at 37 to 42 weeks using the US National Vital Statistics Report dataset for the year 2013. We compared prevalence of maternal, sociodemographic, and potential comorbid obstetric conditions that increase risk for CD between women diagnosed with hypertensive disorders of pregnancy and those without the diagnosis. We then used multivariate logistic regression to control for these risk factors and calculated adjusted probabilities of CD for women with and without a diagnosis of hypertensive disorders of pregnancy. We analyzed 1,439,977 NTSV women, 5% of whom were diagnosed with hypertensive disorders of pregnancy. The subgroup with hypertensive disorders of pregnancy had more risk factors for CD, most notably morbid obesity (9.0% versus 3.1%, p<0.01), diabetes (9.9% versus 4.4%, p<0.01), and induction of labor (59.2 versus 26.9%, p<0.01). The unadjusted probability of CD in women with hypertensive disorders of pregnancy was 39.5% versus 26.8% in those without the diagnosis (p<0.01; Table). After controlling for these risk factors, women with hypertensive disorders of pregnancy were significantly more likely to undergo CD than those without hypertensive disorders of pregnancy (35.1% versus 26.4%; aOR 1.53 [1.50-1.56], p<0.01). After controlling for other risk factors, the diagnosis of hypertensive disorders of pregnancy remained a significant risk factor for primary CD in NTSV women, suggesting a widespread and concerning management practice that is not supported by the most recent clinical evidence. Women with hypertensive disorders of pregnancy may therefore represent an important target population in ongoing efforts aimed at reduction of primary CD rates.

Management and Outcome of Reduced Fetal Movements-is Ultrasound Necessary?

To review the management and outcome of pregnancies of women presenting to obstetrical triage with decreased fetal movements (DFM). A retrospective review of women presenting with DFMs to two large Canadian obstetrical centres with a combined 9490 deliveries per year. The charts were reviewed for compliance with the Canadian guidelines for demographics (age, parity, GA, comorbidities, etc.), pregnancy management (admission vs. discharge, need to deliver), and pregnancy outcomes (mortality, morbidity, GA at delivery, Apgar scores, etc.). Patients who did not comply with the Canadian guidelines (requiring the patient to count six movements within two hours) were not excluded. The charts of 579 patients who self-reported DFMs between January 2012 and December 2012 were reviewed. The distribution of ages was between 18 and 47 year old. The majority of these patients had no comorbidities (454/579). A significant minority of patients had FM in the triage area (231/579). The Canadian guidelines were interpreted differently in the two centres. In one (level 3), the protocol was to have a biophysical profile (BPP) on all patients prior to discharge, whereas in the other (level 2), only patients with a non-reactive non-stress test (NST) and/or oligohydramnios or intrauterine growth restriction (IUGR) underwent a BPP. All patients had an evaluation by an RN and MD and had a NST on arrival. A combination of NST and BPP was performed on 235/579. The frequency of DFM was 6.1% (level 3 centre: 5.6%, level 2 centre: 7.8%). There were 8 stillbirths on arrival. The 187 patients who had a reactive NST and a normal BPP and were sent home did not have a single stillbirth within 2 weeks. In the level 3 centre, 19 patients were sent home without a BPP and one had a stillbirth within 2 days (5%); in the level 2 hospital, there was only one stillbirth among the NST-only group (0.35%). There were 65 admissions; 46 of them (71%) were delivered, and 50% of them had a Caesarean delivery (baseline around 30%). This is the first study looking at the performance of the Canadian guidelines of 2007. We found that the DFM rate was compatible with the literature (6.1% vs. 5%). The frequency of stillbirth on arrival was 1.4% (8/579). Patients discharged after normal NST and BPP did extremely well (no stillbirths), whereas those admitted following DFM had a relatively high Caesarean delivery rate (50%). This study was not designed to address changes in stillbirth rate, but it outlines the patients who experience DFM and their eventual outcomes.

Effect of second child intent on delivery mode after Chinese two child policy implementation: a cross sectional and prospective observational study of nulliparous women in Chongqing

ObjectivesTo assess the influence of second child intent on the delivery preferences and final delivery modes of nulliparous women, particularly caesarean delivery on maternal request (CDMR), after implementation of China’s...

Committee Opinion No. 726: Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care.

Large-scale catastrophic events and infectious disease outbreaks highlight the need for disaster planning at all community levels. Features unique to the obstetric population (including antepartum, intrapartum, postpartum and neonatal care) warrant special consideration in the event of a disaster. Pregnancy increases the risks of untoward outcomes from various infectious diseases. Trauma during pregnancy presents anatomic and physiologic considerations that often can require increased use of resources such as higher rates of cesarean delivery. Recent evidence suggests that floods and human-influenced environmental disasters increase the risks of spontaneous miscarriages, preterm births, and low-birth-weight infants among pregnant women. The potential surge in maternal and neonatal patient volume due to mass-casualty events, transfer of high-acuity patients, or redirection of patients because of geographic barriers presents unique challenges for obstetric care facilities. These circumstances require that facilities plan for additional increases in necessary resources and staffing. Although emergencies may be unexpected, hospitals and obstetric delivery units can prepare to implement plans that will best serve maternal and pediatric care needs when disasters occur. Clear designation of levels of maternal and neonatal care facilities, along with establishment of a regional network incorporating hospitals that provide maternity services and those that do not, will enable rapid transport of obstetric patients to the appropriate facilities, ensuring the right care at the right time. Using common terminology for triage and transfer and advanced knowledge of regionalization and levels of care will facilitate disaster preparedness.

Committee Opinion No. 726 Summary: Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care.

Large-scale catastrophic events and infectious disease outbreaks highlight the need for disaster planning at all community levels. Features unique to the obstetric population (including antepartum, intrapartum, postpartum and neonatal care) warrant special consideration in the event of a disaster. Pregnancy increases the risks of untoward outcomes from various infectious diseases. Trauma during pregnancy presents anatomic and physiologic considerations that often can require increased use of resources such as higher rates of cesarean delivery. Recent evidence suggests that floods and human-influenced environmental disasters increase the risks of spontaneous miscarriages, preterm births, and low-birth-weight infants among pregnant women. The potential surge in maternal and neonatal patient volume due to mass-casualty events, transfer of high-acuity patients, or redirection of patients because of geographic barriers presents unique challenges for obstetric care facilities. These circumstances require that facilities plan for additional increases in necessary resources and staffing. Although emergencies may be unexpected, hospitals and obstetric delivery units can prepare to implement plans that will best serve maternal and pediatric care needs when disasters occur. Clear designation of levels of maternal and neonatal care facilities, along with establishment of a regional network incorporating hospitals that provide maternity services and those that do not, will enable rapid transport of obstetric patients to the appropriate facilities, ensuring the right care at the right time. Using common terminology for triage and transfer and advanced knowledge of regionalization and levels of care will facilitate disaster preparedness.

Large reductions in cesarean delivery rates in China: a qualitative study on delivery decision-making in the era of the two-child policy

BackgroundIn 2010, China’s cesarean delivery (CD) rates increased to one of the highest in the world, a significant proportion of which were without medical indication. However, recent studies have indicated some declines, coinciding with national and local efforts to promote vaginal birth, as well as the relaxation of the one-child policy. Considering these trends, we aimed to qualitatively explore attitudes towards childbirth and experiences of delivery decision-making among women and physicians.MethodsSemi-structured interviews were conducted with 45 postpartum women and 7 healthcare providers at one county-level and one provincial-level maternity hospital in Zhejiang Province. We also collected routine data from 2007 to 2016 and observed doctor-patient interactions and hospital facilities as context for the interviews. Interviews were recorded, translated and transcribed into English, and then analyzed using a framework approach.ResultsFrom 2007 to 2016, cesarean delivery rates at the county-level and provincial-level hospital decreased from 46% to 32% and 68% to 44%, respectively. For low-risk women, vaginal birth was the primary choice of delivery method, encouraged by doctors and nurse-midwives. Elective CD was not as widely accepted, in contrast to previous years. Women were aware of and took into consideration the consequences of CD for future pregnancies. Among those who delivered vaginally, women viewed the existing pain relief methods, epidurals and transcutaneous electrical nerve stimulation, with caution or uncertainty. Even when requested, epidurals were only given under certain circumstances. For multiparas with previous CD, repeat CD remains the norm. Both women and professionals were cautious about vaginal birth after cesarean delivery (VBAC) given the associated risks.ConclusionIn China, changes in family planning policy and efforts to promote vaginal birth have greatly changed the culture of delivery decision-making, leading to decreased CD rates. This demonstrates the powerful role social factors and public policy can play, and provides a model for other countries with high CD rates. Further research should explore changes in other reproductive decisions during this new multiparous era, particularly across provinces.

Placenta response of inflammation and oxidative stress in low-risk term childbirth: the implication of delivery mode

BackgroundCaesarean delivery rate is increasing gradually in China and there is no doubt that delivery mode is closely associated with the maternal health and infant development.This study examined the independent effect of delivery mode on placenta inflammation response and oxidative stress response.MethodsA total of 3474 pregnant women recruited in Ma’anshan Birth Cohort Study were the initial study population. Data on maternal socio-demographic characteristics and pre-pregnancy BMI were collected at their 1st antenatal checkups. Pregnancy-specific anxiety was assessed during the three trimesters of pregnancy. Common pregnant complications were monitored in the whole pregnancy period. Delivery modes, as well as newborn characteristics were abstracted from medical records. Delivery modes included vaginal deliveries (VD), caesarean delivery with medical indications (CDMI), caesarean delivery on maternal request (CDMR) and urgent cesarean delivery (UCD). Placentas were collected during childbirth. The mRNA expression of IL-1β, TNF-a, IL-6, IFN-γ, IL-4, IL-10, IL-8, and HO-1 were assessed in the final sample of 1978 low-risk women with singleton term-births.ResultsThe overall rate of caesarean delivery (CD) was 50.5% (1650/3265) in singleton term childbirths in this study. Among women who reported definite CD reasons, 56.8%of them chose the surgery without any medical indications.It shows a non-linear relationship between cytokines related with placenta inflammatory response, oxidative stress response and different delivery modes. At high percentiles of IL-1β, IFN-γ and IL-8, women with CDMR had higher expression levels compared to women with VD. Women with CDMI had higher levels at median percentiles of IL-1β, IFN-γ and IL-8. Women with CDMR had higher expression compared with VD at high percentiles of IL-6 and HO-1, and women with CDMI had higher levels of these two cytokines at their low percentiles. It is worth noting that at high percentiles, compared with normal delivery, the expression of IL-1β, IFN-γ, IL-8 and HO-1 have significantly altered in women with CDMR.ConclusionA high overall CD rate was found in this study, and caesarean delivery on maternal request was the major contributor to the high prevalence. Maternal placental oxidative stress and inflammatory response were closely associated with delivery mode. The effect is much amplified at high levels of expression in women who chose CD on maternal request.Such difference needs to be noticed and may have important implications for obstetricians, midwives and other perinatal health care workers.

Effect of severity of illness on cesarean delivery rates in Washington State

Hospitals and providers are increasingly held accountable for their cesarean delivery rates. In the perinatal quality improvement arena, there is vigorous debate about whether all hospitals can be held to the same benchmark for an acceptable cesarean rate regardless of patient acuity. However, the causes of variation in hospital cesarean delivery rates are not well understood. We sought to evaluate the association and temporal trends between severity of illness at admission and the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. We hypothesized that hospitals with higher patient acuity would have higher cesarean delivery rates and that this pattern would persist over time. In this cross-sectional analysis, we analyzed aggregate hospital-level data for all nonmilitary hospitals in Washington State with ≥100 deliveries/y during federal fiscal years 2010 through 2014 (287,031 deliveries). Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System, which includes inpatient demographic, diagnosis, procedure, and discharge information derived from hospital billing systems. Age, admission diagnoses and procedure codes were converted to patient-level admission severity-of-illness scores using the All Patient Refined Diagnosis Related Groups classification system. This system is widely used throughout the United States to adjust hospital data for severity of illness. Mean admission hospital-level severity-of-illness scores were calculated for each fiscal year among the term singleton vertex population with no history of cesarean delivery. We used linear regression to evaluate the association between hospital admission severity of illness and the primary term singleton vertex cesarean delivery rate, calculated Pearson correlation coefficients, and compared regression line slopes and 95% confidence intervals for each fiscal year. Hospitals were diverse with respect to delivery volume, level of care, and geographic location within Washington. Hospital aggregate admission severity-of-illness score correlated with primary term singleton vertex cesarean delivery rate in all fiscal years (R2 0.38-0.58, P < .001). For every year in the study interval, as admission severity of illness increased so did the primary term singleton vertex cesarean rate. The slope of the regression line decreased during the study interval, suggesting that statewide decrease in primary term singleton vertex cesarean rate occurred across the range of severity of illness. Admission severity-of-illness score is strongly associated with the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. Approximately 50% of variation in hospital primary term singleton vertex cesarean delivery rates appeared to be related to admission severity of illness. This relationship persisted over time despite a statewide decrease in cesarean delivery, suggesting that patient acuity will likely continue to contribute to hospital variation in cesarean delivery rates despite perinatal quality improvement efforts. The major implication of this study is that patient acuity should be considered when determining optimal cesarean delivery rates. High-acuity hospitals are likely to have high cesarean rates because they provide a specific role in serving regional needs. To hold these centers to an arbitrary benchmark may jeopardize the funding necessary to support regional safety net institutions.

Conception by means of in vitro fertilization is not associated with maternal depressive symptoms during pregnancy or postpartum

To study whether conception by means of invitro fertilization (IVF) is associated with maternal depressive symptoms during pregnancy or postpartum. Longitudinal observational study. University hospital. A total of 3,283 women with singleton pregnancies receiving antenatal care and delivering in Uppsala from 2010 to2015. A web-based self-administered structured questionnaire including sociodemographic, clinical and pregnancy-related items, and the Edinburgh Postnatal Depression Scale (EPDS) was delivered at 17 and 32 gestational weeks and at 6weeks and 6months postpartum. Prevalence of significant depressive symptoms (EPDS ≥12) and EPDS scores. A total of 167 women (5%) had conceived via IVF and 3,116 (95%) had a spontaneous pregnancy. IVF mothers were more frequently ≥35years of age (46.1% vs. 22.6%) and primiparous (71.7% vs. 49.9%) and had a higher cesarean delivery rate (22.4% vs. 14.2%). Demographic and clinical characteristics were otherwise similar between the two groups. Significant depressive symptoms were reported by 12.8%, 12.4%, 13.8%, and 11.9% of women at 17 and 32 gestational weeks and 6weeks and 6months postpartum, respectively. The prevalence of depressive symptoms and the EPDS scores during pregnancy and postpartum were similar between women conceiving spontaneously or through IVF. The mode of conception was not associated with significant depressive symptoms at any time point, even when adjusting for several possible confounders in multivariable logistic regression analysis. Despite the psychologic distress characterizing subfertility and its treatment, conception by means of IVF is not associated with maternal depressive symptoms during pregnancy or postpartum.

Obstetrician perceptions of the causes of high cesarean delivery rates in Turkey

To assess obstetricians' perceptions surrounding cesarean delivery rates in Turkey. The present cross-sectional descriptive study was performed between May 1 and June 30, 2016. Practicing obstetricians with contact details known by the researchers and those attending a conference in Turkey were asked to complete a self-administered questionnaire that collected demographic data and information on participants' opinions, beliefs, knowledge, attitudes, and practices related to cesarean delivery. There were 100 obstetricians who responded to the survey. Awareness of high cesarean delivery rates was reported by 96 (96%) participants and 95 (95%) respondents said they were supportive of efforts to reduce it. There were 60 (60%), 83 (83%), and 100 (100%) participants aware of associations between high cesarean delivery rates and increased maternal and infant mortality; increased risk of uterine rupture; and increased risk of placenta previa, placenta accreta, and emergency cesarean hysterectomy, respectively. The most commonly reported reason for high cesarean delivery rates was high compensation costs during medical litigation legal proceedings, reported by all 100 (100%) participants. Participants were generally aware of the risks associated with high cesarean delivery rates. The results suggest that the greatest concern among obstetricians who perform cesarean deliveries was malpractice litigation.

Outcomes of Twin Pregnancies in Women 45 Years of Age or Older.

To investigate outcomes of twin gestations in women 45 years or older at the time of delivery. This was a retrospective cohort study of 139 women with twin gestations who were at least 45 years old when they delivered. They were cared for at two referral centers between 2005 and 2016. Analysis included baseline characteristics and pregnancy outcomes including mode of delivery, gestational age at delivery, hypertensive disease in pregnancy, gestational diabetes, and fetal growth restriction. Univariate analysis of the association between patient characteristics and outcomes was performed. The mean maternal age at delivery was 47.3±1.9 years with 99.3% undergoing in vitro fertilization and 95% using donor eggs. Patients had low baseline rates of hypertension (7.2%), obesity (9.5%), and pregestational diabetes (1.4%). The average gestational age of delivery was 35.4 weeks; 22.3% delivered before 34 weeks of gestation. There were high rates of cesarean delivery (93.5%, 95% confidence interval [CI] 87.7-96.8%), preeclampsia (44.6%, 95% CI 36.3-53.3%), and gestational diabetes (19%, 95% CI 13.0-26.8%). Preeclampsia developed in 50.5% of nulliparous women compared with 30.5% of women with a prior birth (P=.028). Preterm birth at less than 34 weeks of gestation occurred in 18.1% of women of white race compared with 30.3% of women of nonwhite race (P=.036). Twin pregnancy in a predominantly healthy cohort of women who were at least 45 years old when they delivered was associated with high rates of cesarean delivery, preeclampsia, and gestational diabetes, but overall favorable outcomes.

Parity and Foley Catheter Using Tension or No Tension: A Randomized Controlled Trial [12L

INTRODUCTION: A secondary analysis of a randomized controlled trial was performed to determine the effects of parity on the use of a Foley transcervical balloon catheter for cervical ripening and the effects of tension on each group. METHODS: 73 nulliparous and 67 multiparous women underwent cervical ripening with a Bishop score ≤ 6. Tension was created by securing the catheter to the thigh and replacing tension in 30 minute increments. Major outcomes included time from insertion to delivery, time from insertion to catheter expulsion, and mode of delivery. A p value of &lt; 0.05 denoted statistical significance. RESULTS: Nulliparous patients had a higher rate of Cesarean delivery (CD) (39.7% vs 22.4%, p = 0.027). They had a longer median time to delivery (17.5 vs 14.6 hours, p=0.054). Applied tension did not shorten times from catheter insertion to delivery or to expulsion. A significantly shorter median time from catheter insertion to expulsion was found in the tension group in multiparous women (2.88 vs 4.61 hours, p= 0.003). Multiparous women in the no tension group had a higher rate of CD than women in the tension group (31.6 % vs 10.3%, p= 0.039). CONCLUSION: Within multiparous patients, applied tension decreased the time to expulsion of the catheter, whereas no tension may increase the likelihood of CD. Further studies to evaluate these findings are needed. As expected, nulliparity increased the risk of CD and there was a trend towards longer delivery times compared to multiparous patients.