History Of C-section Research Articles

Maternal and neonatal outcomes in delivery with diagnosis of antepartum hemorrhage due to placenta previa at a tertiary hospital in Surabaya, Indonesia

HIGHLIGHTS 1. To provide effective prevention and management of placenta previa, maternal and neonatal outcomes should be identified.2. Among mothers studied, no maternal mortality was found, but most newborns had prematurity and low birthweight. ABSTRACT Objective: To identify maternal and neonatal outcomes in delivery with diagnosis of antepartum hemorrhage (APH) due to placenta previa. Materials and Methods: This was a descriptive retrospective study with cross-sectional design. Samples were taken using medical records with convenience sampling technique. Deliveries with history of APH due to placenta previa at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, on January 1 until December 31, 2019, were included. Results: In our study, 36 mothers were included. Maternal characteristics included age of 20–35 years in 72.2%, overweight in 50%, referral visits in 69.4%, from out of town (66.7%), bleeding onset at 3rd trimester (97.2%), primigravida (8.3%), nulliparity (13.9%), 69.4% with history of C-section, and 83.3% no hospital readmissions. Maternal outcomes included 100% mothers diagnosed with complete placenta previa and performed C-section. The mothers were mostly (69.4%) diagnosed with placenta accreta spectrum (PAS). There were 36.1% hysterectomy, 33.3% postpartum hemorrhage, 50% blood transfusions, and zero maternal mortality. Neonatal outcomes included prematurity in 80%, low birth weight (LBW) in 51.5%, while 77.1% and 85.7% of newborns had no asphyxia at 1 and 5 minutes, consecutively. Conclusion: All mothers experienced complete placenta previa, and underwent C-section with most of the mothers were diagnosed with PAS. Less than half of them needed hysterectomy intervention because other patients with focal type PAS were planned for conservative surgery. Moreover, they mostly did not have postpartum hemorrhage with half of them needed blood transfusion. There was zero maternal mortality, with most newborns experienced prematurity, LBW but no significant asphyxia.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation

<h3>Study Objective</h3> Discuss advantages of ethylene vinyl alcohol copolymer (EVAC) use for uterine arterio-venous malformation (AVM). Demonstrate technique for vascular control during robotic repair of isthmocele. <h3>Design</h3> Video documentation of the surgical procedure (instructive video). <h3>Setting</h3> University of California, San Francisco Hospital operating room with patient placed in dorsal lithotomy positioning. <h3>Patients or Participants</h3> A 37-year-old woman, status-post embolization of uterine AVM, presenting with a 3.5 × 2.5 cm uterine isthmocele. <h3>Interventions</h3> Discuss embolization of a uterine AVM. Then, present a case of AVM with isthmocele, review the patient's imaging, and show a stepwise approach to the procedure. Hysteroscopy is performed to identify the isthmocele location and visualize the cavity post-embolization. The robotic platform was chosen as the mode of surgery. Entry into the retroperitoneum with transient occlusion of the uterine arteries is planned due to proximity of isthmocele to left uterine artery as seen on MRI. Once the pararectal space is entered the ureter is localized on the medial leaf of the broad ligament. The uterine artery is then isolated and skeletonized. This procedure is performed bilaterally. Vascular clamps are then placed on the uterine arteries at their respective origins. The bladder is also backfilled to aid in creation of a bladder flap given the history of c-section. With firefly technology, the borders of the isthmocele are identified. This area is resected, the residual copolymer is removed from the defect, and the hysterotomy is repaired in two layers using unidirectional barbed suture. At the conclusion of the case, the vascular clamps are removed and vascular supply is restored. <h3>Measurements and Main Results</h3> Isthmocele resection and repair was achieved with an estimated blood loss of 25mL. The patient's symptoms resolved. <h3>Conclusion</h3> Evaluation of pathology on pre-operative imaging can impact surgical approach. Transient occlusion of the uterine arteries can aid in repair of isthmocele with minimal blood loss.

Frequency of Placenta Previa in Patients with Repeated C-Section

Objective: The purpose of this study is to determine the prevalence of placenta previa and adverse outcomes in patients with repeated C-sections. Study Design: Descriptive/Observational study Place and Duration: Gynaecology and Obstetrics Department, Combined Military Hospital, Peshawar for the period from February 2021 to January 2022. Methods: There were 60 pregnant women had age 20-50 years were presented. Pregnant women with the history of c-section were included in this study. After getting informed written consent demographics of included patients i.e age, body mass index, gestational age, parity and gravidity were recorded. After delivery, association of placenta previa was recorded. Maternal and fetus outcomes were also assessed in this study. SPSS 21.0 was used to analyze all data. Results: Majority of the cases 28 (46.7%) were aged between 20-30 years, 20 (33.3%) had age 31-40 years and 12 (20%) patients were aged between 41-50 years. 34 (56.7%) cases had BMI &gt;25kg/m2 and 26 (43.3%) patients had BMI &lt;25kg/m2. Mean parity of the patients was 4.7±3.21 and mean gestational age was 36.13±14.61 weeks. Frequency of placenta previa was found in 15 (25%) cases in which majority 9 (60%) were males and 6 (40%) were females. Among 15 cases of placenta previa, low apgar score, low birth weight and ICU admission were the adverse outcomes among new borns. In mothers, frequent bleeding, pre-eclampsia and gestational diabetes were the adverse events. Conclusion: The results of this research led us to the conclusion that the prevalence of placenta previa rises with an increasing number of prior caesarean sections and the associated negative fetomaternal outcome. Keywords: C-section, Placenta Previa, Adverse Events, Parity

Association between Placenta Accreta and History of Previous C-Section and position of Placenta in Pregnant Women presenting at A Public Sector Hospital of Punjab, Pakistan: a cross-sectional analysis

Background: Placenta accreta is a rare and life threatening disease during pregnancy and causes must be sorted out for its early diagnosis and treatment. Aim: To find the association between placenta accreta and history of previous C-section in pregnant women. Methods: This analytical cross-sectional survey was conducted at Radiology department of DHQ teaching hospital Gujranwala from 1st January, 2022 to 31st March, 2022. A self-administered questionnaire was filled by the pregnant women at the gynecology and obstetrics outdoor department. Data was analyzed by using SPSS-Version 26. Results: AFI and age were found to be normally distributed while all other variables were non-normally distributed. Mean ± S.D of AFI was 10.75 ± 3.99 while mean ± S.D for age were 27.05 ± 3.90. Median ± IQR for gestational age of the study participants was 33.1 ± 8.98. While median ± IQR for body weight and heart rate of the study participants were 2052 ± 1632 and 147 ± 11 respectively. The association of the placenta accreta with history of C-Section was found to be highly statistically significant in our study (P=0.012). Conclusion: It was evident from our study that plecenta accreta was associated with history of C-Section hence the multiparous with history of C-Section should undergo repeated scans for early diagnosis of placenta previa and the patients also need to have a proper follow-up as per consultant’s advice. Key words: C-section, Placenta Accreta, Pregnancy.

Sonographic Assessment of Placenta Previa with and without History of Cesarean Section or Abortion

Background: The incidence of placenta Previa has increased with increasing maternal age due to late marriages. Objective: To assess occurrence of placenta Previa in females with and without history of C- section, abortion and both. Methodology: Descriptive cross sectional study conducted in Sir Ganga Ram Hospital Lahore, radiology department. Duration of study was nine months after the approval of synopsis. Main aim was to assess occurrence of placenta Previa in females with and without history of C-section and abortion or both. The examination will start with the patient in the supine position (3.5 – 5 MHz) convex probe will be used .From the anteriorly using urinary bladder as acoustic window ultrasound will be performed in the longitudinal planes. In Transabdominal study (TAS) the bladder will be adequately distended to visualization of the cervix and lower uterine segment and to check the relationship of the placenta to the inner os. If indicated, positioning the patient in a right or left posterior oblique position may be helpful to check the posterior placenta. The diagnosis of placenta Previa will be considered if the lower placental edge covers the internal os.

Challenges in Diagnosis and Prevention of Iatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section.

Endometriosis is a gynecological condition caused by the development of endometrial tissue outside the uterine cavity. Naturally, it commonly occurs at locations such as the ovaries and pelvic peritoneum. However, ectopic endometrial tissue may be discovered outside of the typical sites, suggesting the possibility of iatrogenic seeding after gynecological operations. Based on this hypothesis, we developed a study aiming to establish the root cause of atypical implantation of endometrial foci, as the main end point, and to determine diagnostic features and risk factors for this condition, as a secondary target. The research followed a retrospective design, including a total of 126 patients with endometriosis who met the inclusion criteria. A group of 71 patients with a history of c-section was compared with a control group of patients with endometriosis and no history of c-section. Endometriosis that developed inside or in close proximity to surgical incisions of asymptomatic patients before surgical intervention was defined as iatrogenic endometriosis. Compared with patients who did not have a c-section, the c-section group had significantly more minimally invasive pelvic procedures and multiple adhesions and endometriosis foci at intraoperative look (52.1% vs. 34.5%, respectively 52.1% vs. 29.1%). The most common location for endometriosis lesions in patients with prior c-section was the abdominal wall (42.2% vs. 5.4%), although the size of foci was significantly smaller by size and weight (32.2 mm vs. 34.8 mm, respectively 48.6 g vs. 53.1 g). The abdominal wall endometriosis was significantly associated with minimally invasive pelvic procedures (correlation coefficient = 0.469, p-value = 0.001) and c-section (correlation coefficient = 0.523, p-value = 0.001). A multivariate regression analysis identified prior c-section as an independent risk factor for abdominal wall endometriosis (OR = 1.85, p-value < 0.001). We advocate for strict protocols to be implemented and followed during c-section and minimally invasive procedures involving the pelvic region to ensure minimum spillage of endometrial cells. Further research should be developed to determine the method of abdominal and surgical site irrigation that can significantly reduce the risk of implantation of viable endometrial cells. Understanding all details of iatrogenic endometriosis will lead to the development of non-invasive disease diagnosis and minimally invasive procedures that have the potential to reduce postoperative complications.

Combined Hysteroscopic and Laparoscopic Approach to a Complicated Case of Asherman's Syndrome

<h3>Study Objective</h3> We aim to present a combined hysteroscopic and laparoscopic approach to the resection of a post-cesarean section scar causing complete obstruction of the endometrial cavity. <h3>Design</h3> Video presentation. <h3>Setting</h3> Ambulatory surgery center, academic hospital. <h3>Patients or Participants</h3> 31-year-old multiparous patient with history of c-section who presented with secondary amenorrhea and infertility due to Asherman's Syndrome. She underwent laparoscopic guided hysteroscopic adhesiolysis followed by postoperative hormone therapy and close follow up. <h3>Interventions</h3> The patient's workup included saline infusion sonohysterogram, 2D ultrasound, and 3D ultrasound. She underwent a combined hysteroscopic and laparoscopic procedure in which hysteroscopic scissors were used to remove the adhesion under laparoscopic guidance. An intrauterine balloon catheter was placed postoperatively. She took postoperative antibiotics while the balloon remained in situ as well as postoperative hormone therapy to promote growth of healthy endometrium and prevent new adhesion formation. <h3>Measurements and Main Results</h3> The use of a combined hysteroscopic and laparoscopic approach resulted in a safe and successful removal of post-cesarean uterine scar tissue and treatment of Asherman's Syndrome with subsequent resumption of menses. <h3>Conclusion</h3> Asherman's Syndrome should remain on the differential for women who present with secondary amenorrhea. The addition of 3D ultrasound to saline infusion sonohysterogram is useful for surgical planning. A combined hysteroscopic and laparoscopic approach to the resection of uterine adhesions should be considered when managing severe cases of Asherman's Syndrome and dense adhesions, especially when the location of adhesions is not clear from imaging.

OUTCOMES FOR GESTATIONAL CARRIERS VERSUS KNOWN CARRIERS, INCLUDING SAME-SEX COUPLES

To assess clinical outcomes in gestational carriers (GC) when comparing known carriers to carriers from an agency as well as those in same-sex couple relationships desiring to act as a surrogate. All GC patients from 2004-2018 having undergone single frozen embryo transfer (FET) at a large, assisted reproduction center were analyzed. Known GCs were compared to agency-recruited GCs and to those in same-sex relationships, where an embryo from one woman’s egg was transferred to her partner’s uterus (‘Co-IVF’). All blastocysts vitrified and warmed for transfer were grade BB or higher. Statistical analysis using univariate and multivariate analysis were used, with a p<0.05 considered statistically significant. We compared clinical outcomes based on the type of gestational carrier used in 1,153 cycles. An agency-recruited GC was more likely to have a full-term birth compared to known GC and Co-IVF pregnancies (89.2% vs. 86.2% vs 60.5%, p<0.001). The average age of the GC was also statistically significant. Average age of a GC at transfer was 36 y.o. for Co-IVF vs. 33 y.o. for agency recruited GCs, and 34 y.o. for known GCs. GCs in the setting of Co-IVF had higher mean BMI (p<0.001) and fewer prior term births (p<0.001). Agency-recruited GCs were most likely to have had term birth(s), with a mean of 2.7 births. When looking at medical comorbidities, there was an increased rate of comorbidities in the known and same-sex couple GCs. Using a multivariate analysis, BMI and history of C-section were not predictive of term birth. However, the use of an agency GC was predictive of a full-term birth for that pregnancy. Research remains limited on differences in GC birth outcomes, particularly when considering if the GC meets recommended ASRM criteria. Very little research exists regarding the clinical outcomes of strictly-screened gestational carriers versus known/same sex carriers. Our data suggests that a prior term delivery strongly predicts a future full-term delivery when using gestational carriers. It appears medically reasonable to allow properly-screened known and same-sex GCs to proceed with treatment, with the caveat that there may be potential medical complications for both carrier and infant. The findings should help guide our clinical decision making when counseling patients who desire a gestational carrier.

1071 Uterine scars and risk of placenta accreta: is a prior myomectomy equivalent to a C-section?

To determine if history of prior myomectomy in those with prior CS increases the risk of placenta accreta spectrum (PAS) disorders. A retrospective cohort study of patients who delivered at a tertiary academic center from 2012-2019 and had a sonographic evaluation of the placenta during their pregnancy at a single ultrasound unit. Demographic, clinical history, sonographic results, and pathology information were collected. Women with a history of C-section and myomectomy were compared based on their number of prior C-sections to those without myomectomy. Analysis was done using Mann-Whitney U test and Chi-square as appropriate. All p-values were considered statistically significant if p <0.05. We identified 585 women with a history of prior C-section (CS) or prior CS with Myomectomy. Of 44 patients in the latter group, 39 (88.6%) had only one prior CS. The baseline characteristics of both groups were similar, except that women with Prior CS with Myomectomy were older (Table 1). The five patients with histologically-confirmed PAS and prior CS with Myomectomy all had one prior CS. Of 33 cases of PAS in the CS only group, 15 (45.4%) occurred in those with multiple prior CS. The rate of PAS in those with one prior CS with Myomectomy was higher compared to those with one prior CS only (12.8% vs. 4.6%; p=0.03), and comparable to those with multiple prior CS (10.3% vs. 12.8%; p=0.65). Of the 33 cases with PAS and CS only, 28 (84.8%) had placenta previa, compared to only 2 of 5 (40%) with PAS in the CS with Myomectomy group (p=.05). The rate of PAS in women with a history of 1 CS and myomectomy was higher compared to those with 1 CS alone, and more comparable to those with multiple prior CS. This suggests an incremental risk associated with myomectomy. As there were too few women with multiple CS with Myomectomy, the incremental risk associated with myomectomy in these women will require larger studies. PAS appears more likely to happen in the absence of placenta previa in those with prior myomectomy.

Effectiveness and Tolerability of a Patch Containing Onion Extract and Allantoin for Cesarean Section Scars.

BackgroundThe prevention or early treatment of pathological scars is the most appropriate therapeutic approach. Gels and patches containing onion extract and allantoin are safe and effective in patients with scars of various origins and severity. However, no controlled studies have evaluated the effects of the patch formulation in women after Cesarean delivery. This study aimed to investigate the effects of a patch containing Allium cepa and allantoin on Cesarean section (C-section) scars.MethodsThis is an observational study. Women were consecutively recruited at the University Hospital of Salerno and subdivided into two groups considering the number of C-section. Group A included subjects without and group B with a history of C-section. Scars assessment was made using digital photographs and the Patient and Observer Scar Assessment Scale (POSAS). After 4 weeks, the C-section of the women who had applied a patch containing Allium cepa and allantoin and those of women who had not used any products (controls) were re-evaluated as at baseline. The Observers independently performed the scars assessment at baseline and after 4 weeks. Data are expressed as the difference of the POSAS scores after 4 weeks minus the POSAS scores at baseline. The statistical significance was established at a p value <0.05.ResultsNinety-three subjects completed the study (47 in group A and 46 in group B). Women who had used a patch showed an improvement in total score by observer scale when compared with controls (p = 0.013). By the patient scale, no significant changes from baseline were found in group A and group B. Group B with patch showed changes in scars’ pigmentation (p = 0.015), relief (p = 0.039), and pliability (p = 0.046) in comparison of controls. Digital photographs confirmed such improvements in women who had already undergone previous C-section, while no significant changes from baseline were found in women without a history of C-section.ConclusionsIntense treatment of just 4 weeks with a patch containing Alium Cepa extract and allantoin was able to improve pigmentation, relief, and pliability of C-section scars in women with a history of C-section.Clinical trial registrationClinicalTrials.gov, identifier NCT04046783.

Factors Contributing to Iranian Pregnant Women’s Tendency to Choice Cesarean Section

Background: Cesarean section (C-section) not only is associated with health risks for both mother and child, but also is costly. C-section rates are on the rise worldwide. In Iran, it is becoming a major challenge for current population policies. Objectives: The current study aimed to investigate the main factors of the tendency to C-section in Iran. Methods: In this cross-sectional study 320 pregnant women admitted to health centers in Lorestan province (west of Iran) in 2019 are included. Participants were selected using the multi-stage cluster sampling technique. Data were collected using a demographic form, the Fear of Pain Questionnaire, and the Knowledge and Attitude about Delivery Methods scale. Descriptive statistics and multivariate logistic regression model were employed to analyze the data using the Stata version 14. Results: 48.44% of participants preferred cesarean delivery. The mean scores of fear of pain in the C-section and vaginal delivery groups were 39.98 ± 8.21 and 36 ± 8.62, respectively, indicating a significant difference (P &lt; 0.001). Level of education of the husband (OR = 2.79), income (OR = 5.9), fear of labor pain (OR = 1.04), history of C-section, and improved attitude toward C-section (P &lt; 0.001) were directly associated with increased tendency to C-section (OR = 0.36); in contrast, female gender of the fetus (OR = 0.36), increased BMI (OR = 0.75), and improved attitude toward vaginal delivery were indirectly associated with women’s tendency to C-section. Conclusions: This study showed that while many pregnant women prefer vaginal delivery, the tendency to C-section in Lorestan province is high, which reveals the need to design and implement effective interventions and programs to reduce unnecessary C-section and promote vaginal delivery. Educating families, especially pregnant women, about the advantages and disadvantages of delivery modes, promoting and using new low pain techniques of vaginal delivery, and increasing women’s participation in childbirth preparation programs are effective measures that can reduce the rate of unnecessary C-section.

Determinants of maternal near miss among women in public hospital maternity wards in gambella region health facility, gambella, Southwest of Ethiopia: A facility based unmatched case: control study, 2019

Background: In Ethiopia, 20,000 women die each year from complications during pregnancy, childbirth and the post-partum period. For every woman who dies of pregnancy complications, about 20 more experience injury, infection, disease, or disability. In Ethiopia, few studies have been performed on MNM, and little is known regarding determinant factors. This study aims to identify determinants of MNM among women in Gambella Region, Ethiopia. Methods: Unmatched case-control study in hospitals in Gambella Region, southwest of Ethiopia, from July 01 - August 30, 2019. The sample included 103 cases and 205 controls recruited from women seeking obstetric care at six public hospitals. Clients having a life-threatening obstetric complication including hemorrhage, hypertensive diseases of pregnancy, dystocia, infections, and anemia or clinical signs of severe anemia in women without hemorrhage were taken as cases and those with normal obstetric outcomes were considered as controls. Cases were selected based on proportional to size allocation while systematic sampling was employed for controls. Data on socio-economic and demographic factors, reproductive history and nutrition related factors were collected using a structured questionnaire. Blood sample were collected to analyze biochemical indicators. Data was coded and entered into Epi-info version 3.5.4 and exported to SPSS version 20 for further cleaning and analysis. Multivariable logistic regression analysis was employed to assess the relative effect of various explanatory variables on the outcome variables. Variables with P-value less than 0.05 at 95 % confidence interval were considered as statistically significance. Results: The largest share of cases and controls were between the ages of 20–29 years, accounting for 39(37.9%) of cases and 65(31.7%) of controls. Ninety-two (90.2%) of cases and 185(89.3%) of controls were married. About two-thirds of controls and 47(45.6%) of cases had gestational age between 37-41 weeks. History of chronic medical conditions was reported in 57(55.3%) of cases and 68(33.2%) of controls. Women with no formal education [AOR=3.2;95%CI:1.24, 8.12], being less than 16 years old at first pregnancy [AOR=2.5; 95%CI:1.12,5.63],induced labor[AOR=3; 95%CI:1.44, 6.17],history of C-section [AOR=4.6; 95%CI: 1.98, 7.61] and chronic medical disorder[AOR=3.5;95%CI:1.78, 6.93], and women who traveled more than 60 minutes before reaching their final place of care[AOR=2.8;95% CI: 1.19,6.35] all had higher odds of experiencing MNM. Conclusions: The Government of Ethiopia should continue efforts to address lack of road and health facility access and education. Work should also be continued to educate women and providers about common predictors of MNM like history of C-section and chronic illness as well as teenage pregnancy at the facility, community, family and individual levels. Targeted follow-up to women with history of chronic disease and C-section could also be a practical way to reduce MNM.

Severe maternal morbidity among women with a history of cesarean section at a tertiary referral teaching hospital in the southeast of Iran

ObjectivesAlthough the cesarean section (C-section) is known as a lifesaving procedure, it can also increase the risk of maternal mortality and morbidity. This study was conducted to achieve two objectives: (1) determination of maternal near miss (MNM) indicators and pregnancy outcomes among women with a history of C-section and (2) investigation of the women's experience of near miss events during childbirth to provide a deeper understanding of the weaknesses of care delivery process. Study designThe present study was conducted using a prospective cross-sectional study using the World Health Organization (organ system dysfunction–based) criteria. MethodsAll subjects were women at more than 22 weeks of gestation who gave birth in Ali ibn Abi Talib Hospital, Zahedan, Iran, and were referred to this hospital for childbirth or those within 42 days of pregnancy termination. Logistic regression was used to predict the risk factors for severe maternal outcomes (SMOs). ResultsNearly 58% of all MNM cases were related to women with a history of C-section. The MNM ratio was estimated at 8.04 per 1000 live births. Moreover, the frequent causes of SMOs were reported as severe hemorrhage (58.3%), severe pre-eclampsia/eclampsia (27.8%), medical condition (8.3%), and sepsis or severe systemic infection (5.6%). Abnormally invasive placenta (61%) was the most common cause of severe hemorrhage. After adjustment for potential confounder variables, the hemoglobin level of <11 g/dl (odds ratio [OR] = 0.18, 95% confidence interval [CI] = 0.09–0.36) and place of residence (OR = 0.41, 95% CI = 0.19–0.90) remained as independent risk factors for SMOs in the final model of multivariate analysis. ConclusionA risk assessment system is needed to diagnose and manage the risk factors for SMOs during prenatal care. In addition, there should be a continuous audit of the indication and number of C-sections performed across health facilities.

Determinants of maternal near miss among women in public hospital maternity wards in Northern Ethiopia: A facility based case-control study.

BackgroundIn Ethiopia, 20,000 women die each year from complications related to pregnancy, childbirth and post-partum. For every woman that dies, 20 more experience injury, infection, disease, or disability. “Maternal near miss” (MNM), defined by the World Health Organization (WHO) as a woman who nearly dies, but survives a complication during pregnancy, childbirth or within 42 days of a termination, is a proxy indicator of maternal mortality and quality of obstetric care. In Ethiopia, few studies have examined MNM. This study aims to identify determinants of MNM among a small population of women in Tigray, Ethiopia.MethodsUnmatched case-control study was conducted in hospitals in Tigray Region, Northern Ethiopia, from January 30-March 30, 2016. The sample included 103 cases and 205 controls recruited from among women seeking obstetric care at six (6) public hospitals. Clients with life-threatening obstetric complications, including hemorrhage, hypertensive diseases of pregnancy, dystocia, infection, and anemia or clinical signs of severe anemia (in women without hemorrhage) were taken as cases and those with normal obstetric outcomes were controls. Cases were selected based on proportion to size allocation while systematic sampling was employed for controls. Binary and multiple variable logistic regression (“odds ratio”) analyses were calculated at 95% CI.ResultsRoughly 90% of cases and controls were married and 25% experienced their first pregnancy before the age of 16 years. About two-thirds of controls and 45.6% of cases had gestational ages between 37–41 weeks. Among cases, severe obstetric hemorrhage (44.7%), hypertensive disorders (38.8%), dystocia (17.5%), sepsis (9.7%) and severe anemia (2.9%) were leading causes of MNM. Histories of chronic maternal medical problems like hypertension, diabetes were reported in 55.3% of cases and 33.2% of controls. Women with no formal education [AOR = 3.2;95%CI:1.24, 8.12], being less than 16 years of age at first pregnancy [AOR = 2.5;95%CI:1.12,5.63], induced labor[AOR = 3.0; 95%CI:1.44, 6.17], history of cesarean section[AOR = 4.6; 95% CI: 1.98, 7.61] or chronic medical disorder[AOR = 3.5;95%CI:1.78, 6.93], and women who traveled more than 60 minutes before reaching their final place of care[AOR = 2.8;95% CI: 1.19,6.35] had higher odds of experiencing MNM.ConclusionsMacro-developments like increasing road and health facility access as well as expanding education will all help reduce MNM. Work should be continued to educate women and providers about common predictors of MNM like history of C-section and chronic illness as well as teenage pregnancy. These efforts should be carried out at the facility, community, and individual levels. Targeted follow-up with women with history of chronic disease and C-section could also help reduce MNM.

A Check List to Reduce Misuse of Primary Cesarean Sections in Women with a Single Fetus in Cephalic Position

Background: Avoiding primary C-section is the safest and most effective way of decreasing C-section rates. We analyzed circumstances and decisions made among pregnant women without history of C-section and cephalic single fetus (group B), who ended up having a Cesarean birth, to identify opportunities that may optimize the decisions about delivery. Methodology: We evaluated the clinical histories of pregnant women from group B who completed their pregnancies in the Hospital Universitario de Santander (Bucaramanga, Colombia) during 2013. We evaluated the decision moments from admission until birth, including the registry of the reasons for having a C-section, compliance of all the criteria to support the decision and its appropriateness, and how adequate were the procedures done during the induction or augmentation of labor. Results: We evaluated 1320 histories; 666 (55.7%) ended by C-Section. In 59.8% of the histories, we identified at least one decision that could have been addressed differently to optimize the delivery type and, potentially, avoid ending in a Cesarean birth. The most frequent opportunities arise due to a lack of clarity in the record of the reason for performing the C-section (70.1%), and inadequate use of labor induction in the patients that had to end their gestation (38.5%). Conclusion: In the Hospital Universitario de Santander during 2013, despite observing a meaningful subregistry of the indication to perform a C-section, we found that in one out of every two patients there are opportunities of improvement in the registry and attention to reduce the high incidence of C-sections in the institution. This analysis allowed us to create a checklist to fill out before making the final decision of performing a Cesarean birth.

Intérêt et faisabilité du Doppler cérébral en cours de travail pour prédire une acidose néonatale

ObjectivesTo evaluate feasibility and interest of fetal cerebral Doppler during labor and the link with fetal pH to predict perinatal fetal asphyxia. MethodsOur prospective study in a university perinatal center, included patients during labor. There were no risk factors during pregnancy and patients were included after 37 weeks of pregnancy. For each patient an ultrasound with cerebral Doppler was done concomitant to a fetal scalp blood sample. We collected maternal and fetal characteristics as well as cervix dilatation, fetal heart rate analysis and fetal presentation. ResultsAmong 49 patients included over a period of 4 months, cerebral Doppler failed in 7 cases (11%). Majority of failure occurred at 10cm of dilatation (P=0.007, OR=14.1 [1.483; 709.1275]). Others factors like: maternal age, body mass index, parity, history of C-Section were not associated with higher rate of failure. We did not found either significant correlation between cerebral fetal Doppler and pH on fetal scalp blood sample (r=0.15) nor pH at cord blood sample (r=0.13). No threshold of cerebral Doppler is significant for fetal asphyxia prediction. ConclusionFetal cerebral Doppler is feasible during labor with a low rate of failure but not a good exam to predict fetal acidosis and asphyxia.

Impact of Epidural Analgesia on Labor: Length of Labor, Operative Vaginal Delivery Rate and Occiput Posterior

Summary Introduction.Epidural analgesia (EA) is widely used as labor analgesia. It has been reported that EA can slow down the course of labor and increase the risk of operative vaginal delivery. Slower course of labor can lead to an increased risk of abnormal fetal heart rate (FHR). Some studies have also demonstrated an increase in occiput posterior position of the fetal head at delivery if EA is used. It represents a mechanism that may contribute to the lower rate of spontaneous vaginal delivery. Aim of study. To evaluate the impact of EA on the length of labor and the rate of operative vaginal delivery, and to determine whether EA increases the rate of occiput posterior of the fetal head at delivery Material and methods. We carried out a retrospective case-control study based on clinical records from parturients admitted to Riga Maternity Hospital in 2013. Parturients were divided into two groups: case group comprised parturients who had EA, while parturients of control group did not have EA. Groups were further subdivided into primiparas and multiparas and comparisons were made according to parity. We excluded parturients who had obstructed labor, pathological labor, induction of the labor, history of C-section and significant anomaly of the fetus. Results. A total of 832 parturients were included in the study, 304 in EA group (220 primiparas and 84 multiparas) and 528 in control group (257 primiparas and 271 multiparas). Primiparas of EA group had longer latent phase of the first stage of labor in comparison to primiparas of control group (p=0.001), while multiparas of EA group had longer first stage (p=0.031) of labor and longer latent phase of labor (p&lt;0.001) than their respective controls. Vacuum extraction was used in 1.27% of all deliveries with EA. Moreover, vacuum extraction was used only in primiparas an there was no statistically significant difference between EA group primiparas and control group primiparas (1.7% vs. 1.2%, p=0.593). EA did not increase the rate of occiput posterior positon of fetal head. However, primiparas with EA and occiput posterior were more likely to have an abnormal FHR tracing in comparison to primiparas with EA and without occiput posterior position of fetal head (40% vs. 9.8%, p=0.029; RR=4.09, 95% CI 1.3-12.9). There was no statistically significant link between occiput posterior position and abnormal FHR tracing in control group primiparas. Conclusion. EA does not increase the likelihood of operative vaginal delivery. However, parturients with EA have longer latent phase of the first stage of labor. Risk for occiput posterior at delivery is not increased in labor with EA. However, the risk for abnormal FHR among primiparas who receive EA is increased in case of occiput posterior position of the fetal head.

Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population.

BackgroundWorldwide there has been a dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Growing evidence suggests that maternal overweight and obesity is associated with poor maternal and perinatal outcomes. This study evaluated the impact of maternal pre-pregnancy overweight and obesity on pregnancy, labour and delivery outcomes in a cohort of women with term, singleton pregnancies cared for by family physicians in community based practices.MethodsThis study is a secondary analysis of the All Our Babies Cohort, a prospective, community-based pregnancy cohort in Calgary, Alberta. Maternal self-reported data on height and pre-pregnancy weight from term, singleton, cephalic pregnancies (n = 1996) were linked to clinical data on pregnancy and birth events retrieved from electronic health records. Descriptive and bivariate regression analysis were used to compare pregnancy and birth outcomes between women categorized as normal weight, overweight and obese based on the pre-pregnancy BMI. Multinomial regression analysis stratified by type of labour onset examined the association between pre-pregnancy BMI and mode of delivery controlling for maternal age, pre-existent health conditions, parity, fertility treatments, history of C-section and pregnancy complications.ResultsThe cohort consisted of 65.8% normal weight, 23.6% overweight and 10.6% obese women. Women with increased pre-pregnancy BMI were more likely to develop pregnancy complications such as preeclampsia (OR 3.5, CI 2.0-4.6 for overweight; OR 5.3, CI 3.3-8.5 for obese) and gestational diabetes (OR 3.0, CI 1.8-5.0 for overweight; OR 6.5, CI 3.7-11.2 for obese) than normal weight women. Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1).ConclusionsEven among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery. These findings highlight the importance of tailored maternal care in pregnancy and at delivery of pregnant women with increased BMI in order to improve the outcomes and wellbeing of these women and their children.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-014-0422-y) contains supplementary material, which is available to authorized users.

C-section rate in low-risk women: a useful indicator to compare hospitals attending deliveries with different risks

the C-section rate has been criticized as a performance indicator for not considering that different hospitals manage deliveries with diverse risks. In this work we explore the characteristics of a new indicator restricted to low C-section risk deliveries. retrospective cohort of all births (n=214,611) in all public hospitals during 2005-2010 in the Valencia Region, Spain (source: minimum basic dataset). A low-risk subpopulation consisting of women under-35, no history of c-section, between 37 and 41 gestational weeks, and with a single fetus, with cephalic presentation and normal weight (2500-3999 g) was constructed. We analyzed variability in the new indicator, its correlation with the crude indicator and, using multilevel logistic regression models, the presence of residual risks. a total of 117 589 births (58.4% of the whole deliveries) were identified as low C-section risk. The c-section rate in these women was 11.9% (24.4% for all deliveries) ranging between hospitals from 7.0% to 28.9%. The c-section rate in low-risk and total deliveries correlated strongly (r=0.88). The remaining risks in the population of low risk did not alter the hospital effect on the c-section rate. the percentage of C-section in low risk women include a high volume of deliveries, correlated with the crude indicator and residual risks are not differentially influenced by hospitals, being a useful indicator for monitoring the quality of obstetric care in the National Health System.

Frequency of Smooth Muscle Tumors and Adenomyosis in Patient with Previous History of Cesarean Section and the Fate of the Cesarean Section Scar: A Long Term Follow-Up Study

Leiomyoma and adenomyosis are two common pathologic entities encountered in hysterectomy specimens. It is often speculated, but not confirmed, that repeated injury to uterine wall may initiate smooth muscle proliferation resulting in a smooth muscletumor. Similarly injury to the wall may lead to entrapment of endometrium in muscle layer leading to adenomyosis. To evaluate the above questions and assess the long term morphologic appearance of the C-section scar, 55 consecutive hysterectomies with previous history of C-section and 45 control cases were studied to evaluate the frequency of leiomyoma and adenomyosis. Our findings show no significant statistical difference in the frequency of such lesions between study and control groups in this series. Besides the scar formation, only rare instances of cystic change, osseous metaplasia and abnormal vasculature were noted at the site of C-section incision in the uterus.