High Caesarean Section Rate Research Articles

FETOMATERNAL OUTCOME IN SPONTANEOUS VERSUS INDUCED LABOR

Background and Objectives: The medical induction of labour at term gestation has always been controversial and is based on conicting evidences.The present study is an attempt to assess the feto-maternal outcome of induced labour compared to spontaneous onset labour. Type of study:It was a prospective comparative study conducted at a tertiary care hospital, Lalla Ded Hospital Srinagar. Materials and methods:Atotal of 200 patients participated in this study. 100 women who had indicated induction of labour (study group) were compared with 100 women with spontaneous onset labour in active phase with cervix atleast 4 cm dilated (control group). Results: Vaginal delivery was 66% in the study group compared to 88% in the control group. Induced labour was associated with a signicantly higher caesarean section rates (P< 0.001 ). Maternal complications include primary postpartum haemorrhage, perineal lacerations and puerperal pyrexia. The study group had longer duration of hospital stay compared to the control (P <0.001).The neonatal Apgar scores at 1 and 5 min were comparable between both groups and showed no statistically signicant difference. Conclusion:Induction of labour is associated with increased risk of caesarean delivery

Exclusive breastfeeding at 6 months after assisted and spontaneous conceiving: a prospective study in Northern Italy

Conceiving by assisted infertility treatments may influence breastfeeding duration. In one-year time, to evaluate the goal of 6 months breastfeeding, we recruited 55 consecutive mothers who conceived using assisted treatment compared to 45 mothers conceiving naturally, all giving birth to healthy, full-term, singleton infants, sharing the double-occupancy room. At birth, maternal/neonatal characteristics were obtained by medical records and interviews. Six months after, a telephonic interview was done about the exclusivity of breastfeeding, mood instability, and breastfeeding complications. All the women were supported by the same neonatal-pediatrician team, during the study period. The number of mothers who were exclusively breastfeeding at six months was not statistically different between the two groups, as well as, breastfeeding initiation, BMI, smoking habit, mood instability, co-morbidities. In the assisted group, the women were older, had fewer previous children, upper degree of education, higher rate of cesarean sections, their neonate’s birthweight was lower; they reported more breastfeeding complications, but the distribution was not different between groups. The control women had higher number of previously breastfed siblings. Our experience highlights that the mode of conception may not be the defining factor influencing the goal of 6 months lactation. The support of healthcare professional team has a crucial role in maintaining breastfeeding.

Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment.

This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..

British Society for Haematology guideline for anticoagulantmanagement of pregnant individuals with mechanical heart valves.

British Society for Haematology guideline for anticoagulantmanagement of pregnant individuals with mechanical heart valves.

Clinicians' views regarding caesarean section rates in Switzerland: A cross-sectional web-based survey.

The caesarean section (CS) rate in Switzerland is currently 32 %, well above the WHO recommended rate of 15 %. The study aims were three-fold: to explore the perception of this high rate among Swiss obstetrics-gynecology (Ob-Gyn) professionals; to assess the factors associated with a perception of a too high national CS rate; and to describe professionals' opinions on measures to reduce this rate. A cross-sectional study was conducted between 1 May and 30 June 2021 using an online questionnaire sent to Ob/Gyn physicians and midwives at a university hospital and members of the Swiss Conference of Heads of Ob/Gyn Divisions. Survey participation was voluntary. The main outcome was the belief that CS was high. Associations were explored between different factors and the main outcome with logistic regression. Results were presented as odds ratios (OR) with 95 % confidence intervals (CIs). Multivariate logistic regression included adjustments for age, gender, place of work and profession. Of 226 health professionals invited, 188 completed the questionnaire (83.2 % participation rate). Among respondents, 50.3 % (n=94) were Ob/Gyn physicians and 49.7 % were midwives (n=93); 77.1 % were women (n=145). Most participants (74.7 % [n=139]) considered the Swiss CS rate as too high and that it should be reduced (79 % [n=147]) but, notably, they considered their own CS rate as correct (71.9 % [n=123]). Improving patient education (57.5 % [n=108]) and professional training (54.8 % [n=103]) were considered as strategies to reduce this rate. In multivariate analysis, only length of professional experience was significantly associated with a higher likelihood of considering the CS rate as too high (OR 3.07, 95 % CI 1.01-9.30; p=0.047). When specialty was added in the model, the length of professional experience disappeared and the perception of having a too high CS rate was associated with being a midwife and obstetrician rather than a gynecologist (OR 3.62, 95 % CI 1.72-7.63; p=0.001). Clinicians, particularly obstetricians, believed that the current rate of CS in Switzerland was too high and that actions were needed to reduce this rate. Improving patient education and professional training were considered as the main strategies to be explored.

High glucose induced HIF-1α/TREK1 expression and myometrium relaxation during pregnancy.

The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. GDM patients have a significantly higher rate of cesarean section and postpartum hemorrhage, suggesting changes in uterine contractility. TWIK-1-related potassium channel (TREK1) expressed in the pregnant uterus and its role in uterine contraction. In this study, we examined the expression of HIF-1α and TREK1 proteins in GDM uterine and investigated whether high glucose levels are involved in the regulation of human uterine smooth muscle cells (HUSMCs) contraction through TREK1, and verified the role of HIF-1α in this process. Compared the uterine contractility between GDM and normal patients undergoing elective lower segment cesarean section. The HUSMCs were divided into normal glucose group, high glucose group, normal glucose with CoCl2 group, CoCl2 with echinomycin/L-Methionine group, and high glucose with echinomycin/L-Methionine group; Compare the cell contractility of each group. Compared the expression of hypoxia-inducible factor-1α (HIF-1α) and TREK1 protein in each group. The contractility of human uterine strips induced by both KCl and oxytocin was significantly lower in patients with GDM compared with that in normal individuals, with increased TREK1 and HIF-1α protein expression. The contractility of cultured HUSMCs was significantly decreased under high glucose levels, which was consistent with increased expression of HIF-1α and TREK1 proteins. The contractility of HUSMCs was decreased when hypoxia was induced by CoCl2 and increased when hypoxia was inhibited by echinomycin. The TREK1 inhibitor L-methionine also recovered the decreased contractility of HUSMCs under high glucose levels or hypoxia. The high glucose levels decreased the contractility of the myometrium, and increased expression of HIF-1a and TREK1 proteins play a role in changes in uterus contractility.

Maternal Prepregnancy Obesity Affects Foetal Growth, Birth Outcome, Mode of Delivery, and Miscarriage Rate in Austrian Women

The increasing obesity rates among women of reproductive age create a major obstetrical problem as obesity during pregnancy is associated with many complications, such as a higher rate of caesarean sections. This medical record-based study investigates the effects of maternal prepregnancy obesity on newborn parameters, birth mode, and miscarriage rate. The data of 15,404 singleton births that had taken place between 2009 and 2019 at the public Danube Hospital in Vienna were enrolled in the study. Newborn parameters are birth weight, birth length, head circumference, APGAR scores, as well as pH values of the arterial and venous umbilical cord blood. In addition, maternal age, height, body weight at the beginning and the end of pregnancy, and prepregnancy body mass index (BMI) (kg/m2) have been documented. The gestational week of birth, the mode of delivery, as well as the number of previous pregnancies and births, are included in the analyses. Birth length, birth weight, and head circumference of the newborn increase with increasing maternal BMI. Furthermore, with increasing maternal weight class, there tends to be a decrease in the pH value of the umbilical cord blood. Additionally, obese women have a history of more miscarriages, a higher rate of preterm birth, and a higher rate of emergency caesarean section than their normal-weight counterparts. Consequently, maternal obesity before and during pregnancy has far-reaching consequences for the mother, the child, and thus for the health care system.

Narrative Review on the Trend of Childbirth in South Korea and Feasible Intervention to Reduce Cesarean Section Rate

In this study, we explored the current childbirth trend in South Korea to provide recent evidence on determinants of the cesarean section rate (CSR) and related policy interventions. We utilized national health insurance claim data to analyze the CSR. We also conducted a narrative review on factors associated with the CSR and examined evidence about interventions to reduce it. The CSR is rising in Korea; simultaneously, the overall number of births is declining. In 2012, 469,000 women gave birth, and 26.9% underwent a cesarean section. In 2021, 249,000 women gave birth, and 58.7% experienced a cesarean section. The CSR among women under age 25 was 26.7% in 2012, but by the first quarter of 2022, it was 51.6%. In 2012, the CSR in women aged 25–34 years was 34.9%; by the first quarter of 2022, it was 58.3%. We synthesized evidence on the determinants of CSR in three dimensions: users, providers, and systems. We also explored recent evidence on policy interventions to reduce the CSR, focusing on women and families, providers, and hospitals. Despite the rapid increase in the CSR in the last decade, efforts to investigate childbirth choice and women’s experiences have been insufficient. We could not locate systematic initiatives in the research community or government to lower the rate. More patient-centered efforts to reduce the high CSR rate are needed.

PREGNANCIES IN KIDNEY TRANSPLANT RECIPIENTS, AN ANALYSIS OF 9 CASES

(Objective) Pregnancy in kidney transplant recipient continues to remain challenging due to a high rate of cesarean section along with preterm delivery, and concern for worsening renal function. This study examined the prognosis and perinatal management of post-transplant pregnancies. (Patients and methods) A total of nine post-transplant recipients at Niigata University Medical and Dental Hospital between 2007 and 2021 were retrospectively examined. (Results) All pregnancies were planned. Calcineurin inhibitors and steroids were continued, and antimetabolites were changed to azathioprine. The mean age at delivery was 33±3.8 years, and the mean time from renal transplantation to delivery was 6.5±3.5 years. Five patients (55.5%) had cesarean sections, while four (44.5%) patients had normal vaginal deliveries. The mean gestational age was 35±3.0 weeks, and the mean birth weight was 2,336±565.4 g. No congenital malformation was observed. The most common reason for early delivery was worsening renal function, seen in six (66.7%) patients. The mean serum creatinine level before pregnancy was 1.11±0.23 mg/dL and then worsened to 1.59±0.37 mg/dL during pregnancy. However, it recovered to 1.14±0.40 mg/dL after delivery. One patient had antibody-mediated rejection with donor specific antibody (DSA) prior to pregnancy, and her renal graft function worsened slightly after delivery. Another patient had a de novo DSA after delivery, which was not detected before pregnancy. (Conclusions) In our hospital, pregnancy in kidney transplant recipients were safe and renal graft function after delivery was relatively stable. Patients may require adjustment of calcineurin inhibitors during pregnancy, and the appearance of DSA after delivery should be noted.

Process of adhesion of the Adequate Childbirth Program to improve obstetric care in private hospitals in Brazil

BackgroundIn 2015, a quality improvement project called “Projeto Parto Adequado-PPA” was implemented in Brazilian private hospitals to reduce unnecessary high rates of cesarean sections. This study aimed to analyze the decision-making process of managers and care leaders to adhere to the PPA.MethodsThe Healthy Birth study is evaluative research that used mixed methods to evaluate the implementation and effects of the Adequate Childbirth Program in 12 hospitals that participated in the program. Eight out of 12 hospitals were selected for a qualitative approach. We interviewed ten managers and 24 care leaders from July to October 2017. The interviews were transcripted, and data was systematized using the MaxQda software, with Thematic Content Analysis, to identify the facilitators and barriers for adherence to the Adequate Childbirth Program. We used the conceptions of the Diffusion of Innovation as an analytical reference.ResultsThe main reasons to adhere to the Adequate Childbirth Program were the absence of other quality improvements programs in Brazilian private services using multifaceted interventions, social and market status for participating; commitment to quality of care; and the possibility of structural reforms related to the Adequate Childbirth Program implementation. In addition, inviting hospital influencers to learn about the objectives and intentions of the project before joining was considered an important strategy to motivate hospitals.ConclusionSocial, cultural, and economic constructs motivated adherence. The invitation strategy used by the Adequate Childbirth Program coordination, through socially respected members in Brazil, such as doctors, was highly valued by the leaders of the hospital team and encouraged adherence to the Program.

The impact of COVID-19 variant 501Y.V2 on maternal and perinatal mortality among pregnant South African women

Background/Aims The COVID-19 variant SARS COV 501Y.V2 was responsible for the second wave of COVID-19 in South Africa from October 2020 to March 2021. There are no studies that report on maternal mortality from this variant globally. This study's aim was to determine the impact of the variant on maternal deaths in the Ekurhuleni health district, South Africa. Methods A retrospective record review of all maternal deaths in COVID-19 positive cases in the Ekurhuleni health district from October 2020 to March 2021 was conducted. Demographic details, comorbidities and obstetric data were assessed. Results A total of 11 women who tested positive for COVID-19 died. In these cases, there were high rates of hypertension (67%), stillbirth (50%) and preterm caesarean section (67%). Laboratory abnormalities, including anaemia (64%) and high levels of lactic dehydrogenase (100%), aspartate transaminase (67%) and D-dimer (80%), were observed. Conclusions This study adds to the growing global knowledge of COVID-19 infections. Routine COVID-19 testing of all comorbid pregnant women at each antenatal visit is recommended. All pregnant women should be counselled to follow strict COVID-19 prevention protocols.

Pregnancy incidence, outcomes and associated factors in a cohort of women living with HIV/AIDS in Rio de Janeiro, Brazil, 1996-2016.

The aim of this research was to analyze pregnancy incidence and associated factors in a cohort of 753 women living with HIV/AIDS (WLWHA) in Rio de Janeiro, Brazil, from 1996 to 2016. Women aged 18-49 years who were not on menopause (surgical or natural) and did not have a tubal ligation were eligible for the study. Data were collected by medical professionals during initial and follow-up visits. Person-time pregnancy incidence rates were calculated throughout the follow-up period. Pregnancy incidence-associated factors were investigated by univariate and multiple analyzes, using an extension of the Cox survival model. Follow-up visits recorded 194 pregnancies, with an incidence rate of 4.01/100 person-years (95% CI: 3.47; 4.60). A higher pregnancy incidence was associated with CD4 nadir ≥ 350 cells/mm³, use of an antiretroviral regimen not containing Efavirenz, and prior teenage pregnancy. In turn, women with a viral load ≥ 50 copies/mL, age ≥ 35 years old, with two or more children and using a highly effective contraceptive method showed a lower incidence. Results showed a significant reduction in pregnancy incidence after 2006, a significant reduction in female sterilization from 1996 to 2016, and a high rate of cesarean sections. The association found between pregnancy incidence and the use of contraceptive methods and virological control markers suggests a good integration between HIV/AIDS and reproductive health services. The high rate of cesarean section delivery indicates the need to improve childbirth care.

Analysis of caesarean section rates according to Robson’s classification at the Municipal Clinical Hospital, Republic of Moldova

Background and aim. The worldwide rise of caesarean section (CS) is a major public health concern and a cause of significant debate due to potential maternal and perinatal risks, cost issues and inequity in access. In the Republic of Moldova, in recent years, the incidence of CS has increased by 7.7% (from 12.08% in 2007 to 20.5% in 2019); however, perinatal mortality rates haven’t changed (10.3‰ in 2007, and 9.7‰ in 2019). In order to understand the factors that determine the increasing trend of CS and to approach new strategies to reduce unnecessary caesarean sections, a standardized tool is needed to assess and compare CS rates. Methodology. A single-center, cross-section study was conducted in the period of January-December 2019. Data were collected from medical charts of women who gave birth in the Department of Obstetrics and Gynecology of the “Gheorghe Paladi” Municipal Clinical Hospital, Chişinău, and classified using the ten-group classification system according to Robson, to determine the CS rate in each group, the absolute and relative contribution made by each group to the overall caesarean section rate. Results. A total of 4279 deliveries were analyzed, and of these, 836 (19.5%) cases were delivered by caesarean section. The most representative group of our population was Group 3 (42.4%), followed by Group 1 (32.1%) and Group 5 (7.5%). The greatest contributors to the overall CS rate were Group 5 (33.8%), Group 2 (14.7%) and Group 1 (11.4%). There was also a high rate of pre-labor caesarean sections in Group 2, Group 4 and Group 10. Conclusions. The obtained results indicate that the greatest contributor to CS rate are women with previous caesarean section, followed by nulliparous women with full-term, cephalic pregnancy. An important step in reducing the total CS rate is to focus our efforts on decreasing the caesarean section rate in primary patients. We found that the Robson classification is clinically relevant and it is an effective tool for analyzing the caesarean section rate in our population.

Pregnancy Outcomes in Pregnant Patients with COVID-19: A Multicenter Study

Introduction: Acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. The presence of COVID-19 in a pregnant patient can raise concerns, as other types of coronaviruses were associated with many adverse outcomes. This study aims to study the effect of COVID-19 on pregnancy outcomes. Methods: A prospective cross-sectional cohort study within Central First Health Care Cluster (multicentric), Riyadh, included all pregnant women with a singleton pregnancy diagnosed as COVID-19-positive. The primary outcome is the severity of COVID during pregnancy in terms of ICU admission and mortality. The participants were divided into three groups (preterm less than 37 weeks, the term from 37 - 40 weeks, and late-term after 40 weeks. In addition, parameters included: Gestational age at diagnosis, symptoms at presentation (cough, fever), presence of congenital anomalies, IUFD, mode of delivery, presence of PPH, newborn Apgar score, cord PH, need for NICU admission, and the newborn becoming infected with COVID-19 were also measured as secondary outcomes. Results: One hundred pregnant, COVID-19-positive women met the inclusion criteria; the average age of participants was 31.2 years (SD ± 6.4). Asymptomatic patients represented 54% of participants. Most of the deliveries occurred at 36 weeks or less as preterm delivery. Cesarean sections represented 55% of our population. Four-term mothers (12.5%), more than 37 weeks, need ICU admission compared to 13 (25%) preterm cases diagnosed with preeclampsia. No maternal death. Conclusion: COVID-19 during pregnancy can increase ICU admission. A high rate of preterm labor, miscarriage, cesarean section, and newborn testing positive for COVID-19 were observed among our population. No congenital anomalies related to COVID-19 were observed.

Analysis of cesarean section using Robson’s criteria in tertiary care center

Introduction: This study aims to analyze all the women delivering in our institute according to the Robson’s classification. Robson’s ten group classification system (TGCS) endorsed by WHO, is a global standard tool for assessing, monitoring and comparing cesarean section rates at all levels.&#x0D; Method: This cross sectional study was conducted in the department of obstetrics and gynecology, Patan hospital, Patan academy of health sciences (PAHS), Lalitpur, Nepal over 12 months’ period. All women who delivered during this period were classified according to the Robson’s classification (TGCS) into a specific group. Relative size and overall cesarean section rate of each group were calculated.&#x0D; Result: A total of 4,985 cases were analyzed. The cesarean section rate was 57.7%. Group 1+2 represented nearly half (49%) of the obstetric population served during the study period. Group 2A was found to be the highest contributor (27.4%) followed by Group 5 (22.8%) and Group 1 (13.0%). In terms of indication for cesarean section -Fetal distress and previous cesarean section were found to be the most common indications. Similarly, nulliparous women were three to four times more likely to be delivered by cesarean section when labor was induced.&#x0D; Conclusion: From this study, we can conclude that for an effective reduction in the overall high cesarean section rate in our Institution, we need to focus on a more stringent protocol for inducing labor especially among nulliparous women and to practice evidence based guidelines. Redefining failed induction needs to be considered critically as well.

Resultados perinatales tras prueba diagnóstica invasiva en el embarazo

IntroductionInvasive prenatal diagnostic techniques allow us to conduct genetic tests. The development of non-invasive techniques has reduced their use. The foetal loss rate following an invasive procedure is considered to be around 1%. The published data is heterogeneous however, although everything indicates that the risk has been overestimated, we need to conduct further studies. Material and methodsIn our single-centre retrospective study we analysed the procedures carried out using invasive prenatal diagnostic techniques between 2011 and 2019. A total of 832 invasive techniques were performed. Perinatal results are compared with a control group of pregnant women (n=1734). ResultsThe early foetal loss rate for the different techniques were 1.1% for amniocentesis, 1.6% for transvaginal chorionic biopsy and 5% for abdominal chorionic biopsy, with a total rate of 1.1%, without statistically significant differences between them (P=.57). We found differences in foetal outcome, in terms of variable early foetal loss, related to the attempts made (when three attempts were made, the risk increased). When comparing the perinatal outcomes after delivery of the group that underwent techniques with the control group, a higher rate of caesarean sections was found in the study group (28.9% vs 20.5%), in addition to lower mean gestational age at delivery (38.33 vs. 38.95 weeks). DiscussionWhen the invasive technique is performed at the right time and with no more than two attempts, we consider that the risk of foetal loss is not affected, and is equal to that of the general population.

Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data.

Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia. Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure. Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia. Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

Caesarean section or vaginal delivery for low-risk pregnancy? Helping women make an informed choice in low- and middle-income countries.

Women's fear and uncertainty about vaginal delivery and lack of empowerment in decision-making generate decision conflict and is one of the main determinants of high caesarean section rates in low- and middle-income countries (LMICs). This study aims to develop a decision analysis tool (DAT) to help pregnant women make an informed choice about the planned mode of delivery and to evaluate its acceptability in Vietnam, Thailand, Argentina, and Burkina Faso. The DAT targets low-risk pregnant women with a healthy, singleton foetus, without any medical or obstetric disorder, no previous caesarean scarring, and eligibility for labour trials. We conducted a systematic review to determine the short- and long-term maternal and offspring risks and benefits of planned caesarean section compared to planned vaginal delivery. We carried out individual interviews and focus group discussions with key informants to capture informational needs for decision-making, and to assess the acceptability of the DAT in participating hospitals. The DAT meets 20 of the 22 Patient Decision Aid Standards for decision support. It includes low- to moderate-certainty evidence-based information on the risks and benefits of both modes of birth, and helps pregnant women clarify their personal values. It has been well accepted by women and health care providers. Adaptations have been made in each country to fit the context and to facilitate its implementation in current practice, including the development of an App. DAT is a simple method to improve communication and facilitate shared decision-making for planned modes of birth. It is expected to build trust and foster more effective, satisfactory dialogue between pregnant women and providers. It can be easily adapted and updated as new evidence emerges. We encourage further studies in LMICs to assess the impact of DAT on quality decision-making for the appropriate use of caesarean section in these settings.

Ultrasound Guided Hysteroscopy in the Complex Uterine Isthmus

<h3>Study Objective</h3> To demonstrate clinical considerations, operative setup and techniques for a reproducible method of achieving safe hysteroscopic access to the endometrial cavity using multimodal imaging techniques to navigate the complex uterine isthmus. <h3>Design</h3> Educational and stepwise instructional narrated surgical video. <h3>Setting</h3> Community Gynecologic Surgery Referral Practice <h3>Patients or Participants</h3> A 31-year-old G1P1 patient with severe cervical stenosis and high-grade isthmocele is referred for assistance with cervical dilation prior to planned embryo transfer. <h3>Interventions</h3> The patient underwent combined simultaneous hysteroscopic and ultrasonographic visualization to safely access the endometrial cavity. <h3>Measurements and Main Results</h3> A reproducible procedural setup and workflow is described in depth including positioning of patient, assistants and technology as well as detailed stepwise procedure instructions to obtain endometrial access without perforation. <h3>Conclusion</h3> As recognition of isthmocele and other anatomic pathology increases alongside high rates of cesarean section, the gynecologic surgeon must command careful perioperative planning, multimodal imaging techniques and a firm grasp of instrumentation safety parameters as part of the advanced endoscopic skill set required to navigate this complex anatomic area.

High Primary Cesarean Section Rates: Strategies for Improvement.

Approximately one in three women giving birth in the United States will undergo cesarean delivery.1 Certain high-risk pregnancy conditions, such as placenta previa, may warrant a cesarean delivery, but most low-risk pregnancies are candidates for a vaginal birth. Low risk can be defined as nulliparous, term, singleton, and vertex (NTSV). As of 2020, the Centers for Disease Control and Prevention (CDC) ranked Florida, Mississippi, and Louisiana as the three states with the highest overall cesarean delivery rate, at 35.9%, 38.2%, and 36.8%, respectively.2 (See Figure 1.) According to the Maternal Safety Foundation, Florida’s 2017 NTSV cesarean section rate was 31%, the highest in the nation.3 Rising health care costs, increasing placenta accreta spectrum cases, factors affecting breastfeeding and bonding, and the current opioid use crisis all indicate a need to address these high rates. Compared to a vaginal delivery, cesarean delivery poses greater maternal and neonatal risks. These include a higher risk of maternal mortality, hemorrhage, infection, thromboembolism, amniotic fluid embolism, neonatal respiratory distress syndrome, and other long-term sequalae such as chronic pelvic pain and abnormal placentation.4 This commentary will provide an update on evidence-based approaches to lowering cesarean rates among NTSV births. It will also discuss the influence of provider and hospital unit culture, as well as the potential application of perinatal collaborative best practices across state lines. The goal is to provide recommendations to help lower NTSV cesarean births.