History Of Previous Cesarean Delivery Research Articles

Preference and Associated Factors for Cesarean Delivery Among Pregnant Women: A Cross-Sectional Study.

A cesarean delivery is regarded as a comparatively favourable and secure approach to childbirth when contrasted with vaginal delivery. Over the past decade, its frequency has risen in both industrialized and developing nations. Maternal request for cesarean delivery has been explained for the escalating rate along with other factors like anxiety, fear of childbirth, previous cesarean delivery, previous negative vaginal birth experience, maternal age, maternal education, and socioeconomic factors. Hence, this study was undertaken to assess pregnant women's tendency to have a cesarean birth and to investigate the factors associated with the inclination for cesarean delivery. A hospital-based cross-sectional study was carried out in the Department of Obstetrics and Gynaecology of a tertiary care hospital, a systematic sampling procedure was utilized, and 368 antenatal mothers after 36 weeks of gestation, who do not have any specific medical reasons against vaginal delivery were included in the study. Data collection was done by questionnaire. The information regarding socio-demographic factors, preexisting comorbidities, current obstetric risk factors, emotional factors, previous delivery experience, and their information preference toward the mode of delivery were collected. Univariate and multivariate analysis were performed to identify the independent variables associated with preference for cesarean delivery. The preference for cesarean delivery and non-preference for cesarean delivery was 114 (30.9%) and 201 (54.6%), respectively whereas 53 (14.4%) participants remained neutral. The Chi-square analysis revealed a notable connection between the inclination towards a preference for cesarean delivery and factors such as obstetric score, parity, comorbidities, and among obstetric risk factors such as pregnancy after in-vitro fertilization (IVF), with a history of abortion, and having a prior history of cesarean delivery. Nevertheless, no meaningful association was observed between the preference for cesarean delivery and the remaining variables. On multivariate logistic analysis, independent variables like preexisting anxiety or depression, pregnancy through IVF, and having a history of previous cesarean delivery have increased the odds of preferring cesarean delivery. The independent variables like increasing gestational age, graduates, and unemployed have decreased the odds of preferring a cesarean delivery. In conclusion, the prevalence of cesarean delivery is influenced by a complex interplay of medical, cultural, socioeconomic, and healthcare system factors. While cesarean delivery is essential in cases of medical necessity, efforts should be made to avoid unnecessary cesarean delivery that does not provide clear benefits over vaginal delivery. Balancing the risks and benefits of cesarean delivery and promoting evidence-based obstetric practices are crucial for ensuring optimal maternal and infant outcomes.

Analysis of caesarean delivery rates using Robson ten group classification system in North West Amhara referral hospitals, Ethiopia, 2022: A cross-sectional study

IntroductionThe cesarean delivery rate has been consistently rising over time and differs among different hospitals. In order to understand the specific factors contributing to this rapid increase beyond the recommended levels, it is necessary to continuously monitor and evaluate cesarean deliveries using the Robson ten-group classification system. Consequently, the objective of this study was to evaluate the rate of cesarean deliveries within each group by employing the Robson ten-group classification system. MethodA cross-sectional study design was conducted in referral hospitals in the North West Amhara region, involving 721 mothers who gave birth between January and February 2022. Participants were selected using systematic random sampling. Data collection involved an interviewer-administered, pretested, semi-structured questionnaire, as well as a review of medical charts. The women were allocated into one of the ten Robson groups. The proportion of each group, the contribution of each group to the total caesarean delivery rate, and the caesarean delivery rate within each group were all calculated. ResultThe overall caesarean delivery rate was 277 (38.3 %). The primary factors contributing to the overall cesarean delivery rate were found to be group 1 (23.9 %), group 5 (21 %), group 3 (11.6 %), and group 10 (11%). The most common indication for caesarean delivery included an abnormal fetal heart rate pattern, the presence of meconium in the amniotic fluid, a history of previous cesarean delivery, fetal-pelvic disproportion, and breech presentation. ConclusionGroup 1, 5, 3, and 10 emerged as the major contributor to the overall cesarean delivery rate. Interestingly, this study also unveiled a significant prevalence of cesarean delivery among low-risk groups. These specific groups warrant further investigation to identify potential factors that can be modified and implement targeted interventions to decrease the cesarean delivery rate. It is crucial to evaluate existing management protocols in the study area.

Ultrasonography Findings in Post-Methotrexate Treatment of Cesarean Scar Pregnancy

Background: Cesarean scar pregnancy (CSP) can cause life-threatening complications for pregnant women, so early diagnosis and treatment are crucial for the prevention of maternal mortality. Transvaginal color Doppler ultrasonography, along with serum beta-human chorionic gonadotropin (β-hCG) level follow-up, can be a noninvasive and proper method for the post-treatment follow-up of a CSP. The present study investigated the Doppler resistance index (RI) changes in CSPs after medical management with methotrexate (MTX), evaluated by sac diameter and serum β-hCG level measurement. Methods: Overall, 28 patients with CSP and a history of previous cesarean delivery, a gestational age of less than 9 completed weeks at ultrasonography, the decision to medical management by the gynecologist, and having a β-hCG level before treatment were enrolled and initially examined by ultrasound and Doppler studies. The RI of the closest myometrial artery to the CSP mass and its diameter underwent measurement. After 72 hours, 1 week, and 2 weeks of medical therapy with MTX, the mentioned variables were measured again and compared with the values of the pretreatment time point. Results: RI values were significantly higher at all the follow-up time points compared with the pre-treatment time points, while serum β-hCG levels were significantly lower. Moreover, sac diameter values increased 72 hours post-treatment and then represented a decline. Conclusion: Serial Doppler ultrasound examination can be a useful method to evaluate the success or failure of the medical management of CSPs, as the increase in RI values occurs rapidly after medical treatment and correlates well with serum β-hCG levels.

Incidence, risk factors and maternal outcomes of unsuspected placenta accreta spectrum disorders: a retrospective cohort study

BackgroundTo identify incidence and underlying risk factors for unsuspected placenta accreta spectrum (PAS) and compare the maternal outcomes between suspected and unsuspected cases in three large academic referral centers.MethodsA retrospective cohort study was conducted in three university-based tertiary referral centers from Jan 1st, 2013, to Dec 31st, 2022. All cases of PAS confirmed by pathology were included in the study. Unsuspected PAS cases were diagnosed at the time of delivery, while suspected cases served as the control group. Potential risk factors were compared between the two groups. Multivariable regression model was also performed to identify risk factors. Maternal outcomes were also evaluated.ResultsA total of 339 pathology-confirmed PAS cases were included in the study out of 415,470 deliveries, of which 35.4% (n = 120) were unsuspected cases. Unsuspected PAS cases were 7.9 times more likely to have a history of intrauterine adhesions (adjusted odds ratio [aOR] 7.93; 95% confidence interval [CI] 2.35–26.81), 7.0 times more likely to have a history of clinically confirmed PAS (aOR, 6.99; 95% CI 2.85–17.18), 6.3 times more likely to have a posterior placenta (aOR, 6.30; 95% CI 3.48–11.40), and 3.4 times more likely to have a history of placenta previa (aOR, 3.41; 95% CI 1.18–9.82). On the other hand, cases with gravidity > 3, placenta previa, and/or a history of previous cesarean delivery were more likely to be diagnosed antenatally (aOR 0.40, 0.19, 0.36; 95% CI 0.22–0.74, 0.09–0.40, 0.19–0.70). Although the suspected PAS group had a higher proportion of invasive cases and abdominal and pelvic organ injuries (74.4% vs. 25.8%, p < 0.001; 6.8% vs. 1.7%, p = 0.037), the maternal outcomes were more favorable in the sPAS group, with a lower median volume of 24-hour blood loss and blood product transfusion (estimated blood loss in 24 h, 1000 [800–2000] vs. 2000 [1400–2400], p < 0.001; RBC unit transfusion, 0 [0-800] vs. 800 [600–1000], p < 0.001; fresh-frozen plasma transfusion, 0 [0-450] vs. 600 [400–800], p < 0.001).ConclusionsOur findings indicate that 35% of patients with PAS were unsuspected prior to delivery. Factors associated with PAS being unsuspected prior to delivery include a history of intrauterine adhesions, a history of clinically confirmed PAS, a posterior placenta, and a history of placenta previa. Additionally, gravidity > 3, a history of previous cesarean delivery, and placenta previa increase the likelihood of antenatal diagnosis.

Recent trends in term trial of labor after cesarean by number of prior cesarean deliveries

Cesarean delivery is a major source of maternal morbidity, and repeat cesarean delivery accounts for 40% of cesarean delivery, but recent data on the trial of labor after cesarean and vaginal birth after cesarean are limited. This study aimed to report the national rates of trial of labor after cesarean and vaginal birth after cesarean by number of previous cesarean deliveries and examine the effect of demographic and clinical characteristics on these rates. This was a population-based cohort study using the US natality data files. The study sample was restricted to 4,135,247 nonanomalous singleton, cephalic deliveries between 37 and 42 weeks of gestation, with a history of previous cesarean delivery and delivered in a hospital between 2010 and 2019. Deliveries were grouped by number of previous cesarean deliveries (1, 2, or ≥3). The trial of labor after cesarean (deliveries with labor among deliveries with previous cesarean delivery) and vaginal birth after cesarean (vaginal deliveries among trial of labor after cesarean) rates were computed for each year. The rates were further subgrouped by history of previous vaginal delivery. Year of delivery, number of previous cesarean deliveries, history of previous cesarean delivery, age, race and ethnicity, maternal education, obesity, diabetes mellitus, hypertension, inadequate prenatal care, Medicaid payer, and gestational age were examined concerning the trial of labor after cesarean and vaginal birth after cesarean using multiple logistic regression. SAS software (version 9.4) was used for all analyses. The trial of labor after cesarean rates increased from 14.4% in 2010 to 19.6% in 2019 (P<.001). This trend was seen in all categories of number of previous cesarean deliveries. Moreover, vaginal birth after cesarean rates increased from 68.5% in 2010 to 74.3% in 2019. The trial of labor after cesarean and vaginal birth after cesarean rates were the highest for deliveries with a history of both 1 previous cesarean delivery and a vaginal delivery (28.9% and 79.7%, respectively) and the lowest for those with a history of ≥3 previous cesarean deliveries and no history of vaginal delivery (4.5% and 46.9%, respectively). Factors associated with the trial of labor after cesarean and vaginal birth after cesarean rates are similar, but several factors have different directions of effect, such as non-White race and ethnicity, which is associated with a higher likelihood of trial of labor after cesarean but a lower likelihood of successful vaginal birth after cesarean. More than 80% of patients with a history of previous cesarean delivery deliver by repeat scheduled cesarean delivery. With vaginal birth after cesarean rates increasing among those who attempt a trial of labor after cesarean, emphasis should be put on safely increasing the trial of labor after cesarean rates.

The role of transvaginal ultrasound in the third-trimester evaluation of patients at high risk of placenta accreta spectrum at birth

Transvaginal ultrasound imaging has become an essential tool in the prenatal evaluation of the lower uterine segment and anatomy of the cervix, but there are only limited data on the role of transvaginal ultrasound in the management of patients at high risk of placenta accreta spectrum at birth. This study aimed to evaluate the role of transvaginal sonography in the third trimester of pregnancy in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth. This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy and a history of at least 1 previous cesarean delivery and patients diagnosed prenatally with an anterior low-lying placenta or placenta previa delivered electively after 32 weeks of gestation. All patients had a least 1 detailed ultrasound examination, including transabdominal and transvaginal scans, within 2 weeks before delivery. Of note, 2 experienced operators, blinded to the clinical data, were asked to make a judgment on the likelihood of placenta accreta spectrum as a binary, low or high-probability of placenta accreta spectrum, and to predict the main surgical outcome (conservative vs peripartum hysterectomy). The diagnosis of accreta placentation was confirmed when one or more placental cotyledons could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens. A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 patients (68.5%) at birth, and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Of note, 72 patients (64.9%) had a peripartum hysterectomy, including 13 cases with no evidence of placenta accreta spectrum at birth because of failure to reconstruct the lower uterine segment and/or excessive bleeding. There was a significant difference in the distribution of placental location (X2=12.66; P=.002) between transabdominal and transvaginal ultrasound examinations, but both ultrasound techniques had similar likelihood scores in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (P=.02) with an increased chance of hysterectomy, whereas on transvaginal scan, significant associations were found between the need for hysterectomy and the thickness of the distal part of the lower uterine segment (P=.003), changes in the cervix structure (P=.01), cervix increased vascularity (P=.001), and the presence of placental lacunae (P=.005). The odds ratio for peripartum hysterectomy were 5.01 (95% confidence interval, 1.25-20.1) for a very thin (<1-mm) distal lower uterine segment and 5.62 (95% confidence interval, 1.41-22.5) for a lacuna score of 3+. Transvaginal ultrasound examination contributes to both prenatal management and the prediction of surgical outcomes in patients with a history of previous cesarean delivery with and without ultrasound signs suggestive of placenta accreta spectrum. Transvaginal ultrasound examination of the lower uterine segment and cervix should be included in clinical protocols for the preoperative evaluation of patients at risk of complex cesarean delivery.

A CASE OF POSTPARTUM HEMORRHAGE DUE TO PLACENTA ACCRETA DIAGNOSED BY ANATOMOPATHOLOGY EXAM

Placenta accreta is a rare but potentially life-threatening condition in which the placenta invades the myometrium of the uterus. It is more common in women with a history of previous cesarean delivery, placenta previa, or uterine surgery. The diagnosis of placenta accreta can be challenging and is often madeintraoperatively or postoperatively. A 36-year-old gravida 4 para 3 woman presented with postpartum hemorrhage due to placenta accreta that was diagnosed by an anatomopathology exam. The management of postpartum hemorrhage typically involves several steps to stabilize the patient and control bleeding. In this case, the patient was resuscitated with intravenous fluids and blood transfusions, given uterotonic medications, and underwent emergency laparotomy to remove her uterus. An anatomopathology exam confirmed the diagnosis of placenta accreta, which had not been suspected during the initial assessment. The patients postoperative course was uneventful, and she was discharged on the seventh postoperative day. The management of PPH due to placenta accreta requires a multidisciplinary approach involving obstetricians, anesthesiologists, hematologists, and interventional radiologists. The initial management of PPH involves resuscitation and stabilization of the patient. The next step is to control bleeding by uterine massage and administration of uterotonic agents. If bleeding persists despite uterine massage and administration of uterotonic agents, surgical intervention should be considered, which includes uterine artery embolization, hysterectomy, and conservative management. The choice of surgical management depends on the severity of bleeding, hemodynamic stability, and the extent of placental invasion. Early diagnosis and management of placenta accreta are essential for the prevention of adverse outcomes, and a multidisciplinary approach is crucial for the successful management of this condition.

A Risk-Prediction Model for Placenta Accreta Spectrum Severity From Standardized Ultrasound Markers.

We aimed to generate a model to predict the risk of a woman having normal, abnormally adherent (AAP) or abnormally invasive placentation (AIP) based on the presence of recently codified ultrasound (US) markers and disease definitions of placenta accreta spectrum (PAS). We recruited women with anterior low-lying placenta or placenta previa and a history of previous caesarean delivery to a prospective cohort study. US markers of abnormal placentation were recorded on a standardized pro forma. The presence and International Federation of Gynecology and Obstetrics grade of PAS was evaluated clinically and histologically at delivery. Markers demonstrating a predictive relationship to PAS were incorporated into a logistic regression model. A total of 106 women were included, of whom 42 (40%) were normal, 24 (23%) had AAP and 40 (38%) had AIP. A model including just four key variables (loss of clear zone, abnormal placental lacunae, placental bulge and bladder wall interruption) was shown to reliably predict presence and severity of PAS, with an optimism-corrected C-index of 0.901. A simple model incorporating four US markers can predict likelihood and severity of PAS with high accuracy. This is the first time this has been demonstrated using the recently codified definitions of the US signs and disease definitions. Further work will see our model applied prospectively to a large patient cohort, ideally through a smartphone-based application, for external validation.

Associated Factors with Vaginal Delivery on a Uni- or Bi-Scar Uterus in a Low-Resource Setting

Introduction: Delivery in a scar uterus is one of the most debated topics in obstetrics. The objective was to determine the uterine test and the maternal-fetal outcome in patients with uni- and bi-scared uterus who received the uterine test at Panzi General Referral Hospital. Methodology: This is a cross-sectional study with a prospective collection of patients who delivered on a uni- or bi-scareduterus at Panzi Hospital, between January 1, 2021 and August 1, 2022. Results: The average age of the patients was 27.09 years, with an age range of 25 - 34 years, they were mostly married (88.3%), with secondary educational level (60.4%). Pauciparous women, with a history of previous caesarean delivery once, represented respectively 52.2%; 7.2% of parturients with an intergenital space equal to 18 months. 63.9% were overweight, 58.6% had undergone more than three ANC sessions. We noted statistically significant associations between modes of admission, water sac, type of membranes rupture, uterine height and success of uterine test (p 0.05). We did not find significant associations between parturient age, gestational age, intergestational interval, pregnancy term, surgical history, number of ANC performed, number of previous caesarean sections, number of newborns. We did not record any cases of maternal death but one case of perinatal death with 0.9% in this study. Conclusion: A good selection of patients with uni- or bi-scared uterus would allow the reduction of the fetomaternal morbidity during the uterine test.

The single pregnancy predicting model of 1 minute Apgar score less than 7 after preterm birth: A retrospective study.

Preterm delivery is greatly associated with perinatal mortality and morbidity, while there is no objective way to identify high-risk newborns currently. This study aimed at discovering the risk factor for Apgar score less than 7 at 1 minute of preterm neonates born with vaginal delivery. A retrospective study was performed in single pregnancy women with a vaginal delivery before 37 weeks of gestation. All the preterm infants were categorized into three types: very preterm birth (28 to 32 weeks), moderate preterm birth (32 to 34 weeks) and late preterm birth (34 to 37 weeks). Risk factors were identified through logistic regression analysis in every category of newborns mentioned above. And the receiver operating characteristic analysis was used in continuous variables to determine the best threshold of the outcome. On the basis of the selected factors, the predicting models are created and its prognosticating ability is compared by the area under the curve. A nomogram was established for the proved best model. A total of 981 cases were investigated, of whom 55 were found with 1 min Apgar scores less than 7. The nomogram was set for the predicting model with larger area under the receiver operating characteristic curve, of which is 0.742(95% confidence interval = 0.670-0.805) in very preterm birth, with the variables of first and second labor stage(> = 1.6 hours), birthweight and MgSO4(magnesium sulfate), and is 0.807(95% confidence interval = 0.776-0.837) in late preterm birth, with the variables of second labor stage(> = 1.23 hours), birthweight, a history of previous cesarean delivery, fetal distress and placental abruption. The combination of first and second labor stage, newborn weight and MgSO4 use can predict 74.2% of 1 minute Apgar score < 7 in very preterm neonates. And 80.7% high-risk infants can be identified when second labor stage, newborn weight, VBAC (vaginal birth after cesarean) and the occur of placental abruption and fetal distress were combined in the predicting model for late preterm birth. These predicting models would bring out great assistance towards obstetricians and reduce unnecessary adverse fetal outcomes.

Uterine artery Doppler indices throughout gestation in women with and without previous Cesarean deliveries: a prospective longitudinal case–control study

To determine whether a history of previous Cesarean delivery (CD) impacts uterine artery (UtA) Doppler indices throughout pregnancy. Women with and without CD (NCD) were prospectively enrolled for sequential assessments of the UtA mean/median pulsatility index (UtA-PI), resistance index (UtA-RI), and systolic/diastolic ratio (UtA-S/D) at 11–13 + 6, 14–19 + 6, 30–34 + 6, and 35–37 + 6 weeks’ gestation. Data from 269/269, 246/257, 237/254, and 219/242 CD/NCD participants from each gestational period were available for analysis. Multiples of the median (MoMs) of UtA Doppler indices showed biphasic temporal (Δ) pattern; with an initial dropping until the second trimester, then a subsequent elevation until late in pregnancy (p < 0.05). The measurements and Δs of the UtA indices between CD and NCD were not different (p > 0.05). Mixed-effects modelling ruled out effects from nulliparity (n = 0 and 167 for CD and NCD, respectively) (p > 0.05). History of CD neither influenced the measurements nor the temporal changes of the UtA Doppler indices throughout pregnancy. The biphasic Δs of UtA Doppler indices added to the longitudinal data pool, and may aid in future development of a more personalized prediction using sequential/contingent methodologies, which may reduce the false results from the current cross-sectional screening.

The correlation between total deceleration and acceleration surface areas on electronic fetal monitoring and neonatal cord blood pH in postdate pregnancies.

To assess the correlation between the total decelerations area in the final 120 min before delivery and neonatal cord blood pH in postdate pregnancies. This cross-sectional study included women with gestational age greater than 41 weeks, singleton pregnancy, and a category II electronic fetal monitoring (EFM) of at least 30 min during the final 120 min before delivery. We included postdate deliveries of an otherwise low-risk parturient population. Each area was calculated as duration × depth × 1/2. Correlations were tested using the Spearman correlation coefficient. A total of 100 EFMs were included in the analysis. Median pH was significantly lower in neonates above the median total deceleration area under the curve (AUC; 7.26 vs. 7.32, P=0.002). Gestational age at delivery was independently associated with total deceleration AUC above median (adjusted odds ratio 1.21, 95% confidence interval 1.09-1.37) controlling for history of previous cesarean delivery and duration of second stage of labor. A significant correlation was found between cord blood pH and total deceleration area (P < 0.001, Spearman correlation coefficient -0.37). Among women with postdate pregnancies, the total deceleration area and the mean maximum duration of decelerations were negatively correlated with cord blood pH. Further studies are needed to incorporate deceleration area as a method in predicting fetal acidemia.

Early arrivals: association of maternal obstetric factors with preterm births and their survival in India

ObjectivesPreterm birth (PTB) increases the risk of various acute and chronic morbidities and premature mortality in children under 5 years of age. The present study examines the association between different maternal obstetric factors and PTB. In addition, this study estimates the risk of neonatal mortality among children born preterm. Study designRetrospective two-stage stratified sample design. MethodsThe weighted prevalence of PTB was estimated using data on 148,746 most recent institutional births from the National Family Health Survey (NFHS)-4, 2015–16. The Poisson regression model was used to investigate the association between maternal obstetric factors and PTB. Using Cox's proportional hazard model, the risk of neonatal mortality among PTBs was estimated. ResultsMaternal obstetric factors, such as minimal antenatal care, delivery complications, history of previous caesarean delivery and delivery at private health facilities, were significantly associated with an increased risk of PTB. The survival probability of preterm babies sharply declined in the first week of life and thereafter was found to stabilise. The risk of mortality in the first 28 days of life increased 2.5-fold if the baby was born preterm. Optimising antenatal care was found to lower the likelihood of PTB and improve their chances of survival. ConclusionAntenatal care services and delivery care practices in private facilities were strongly associated with the incidence and survival of PTB. Evaluating associations of history of caesarean births on future pregnancies can help understand their deleterious effects on PTB. Affordable, accessible and available antenatal care services, in both public and private facilities, can increase the survival rates of PTBs.

Predictors of cesarean delivery in public referral hospitals in Botswana: a case control study

INTRODUCTION: Globally there is concern of rising cesarean delivery trend over the decades from a world average of 6.7% in 1990 to a high of 19.1% in 2014. Similarly, predictors of the cesarean delivery have been documented in other parts of the world, but there is paucity of evidence of those in Botswana. This study therefore aims to determine socio-demographic, obstetrics predictors as well as common indications for cesarean delivery in public referral hospitals in Botswana. METHODS: a case control study was conducted that involved retrospective review of 672 (112 cases:223 for each facility) patient´s medical records, hospital delivery registers and theater records from 01/01/2018 to 31/12/2018. Multivariate logistic regression modelling was applied using SPSS 24 to determine association between independent predictors and cesarean section. RESULTS: logistic regression analysis found out the following; women who were referred from other facilities (AOR=2.551; C.I=1.686 - 3.861), history of previous cesarean delivery (aOR=15.840; C.I 8.826 - 28.430), delivered with fetal birth weight of over 4000 grams (AOR=4.420; C.I 1.303 - 14.997), attended antenatal clinics less than four times during the index pregnancy (AOR=2.584; C.I 1.708 - 3.908), unemployed (AOR=1.619; C.I1.066 - 2.458) as well as those whose moment of delivery was at night (AOR=1.511; C.I 1.004 - 2.275). There was no statistically significant association between HIV serostatus and cesarean delivery. The most common indication for cesarean delivery was the previous cesarean delivery at 29.5%. CONCLUSION: predictors of cesarean delivery were identified as birth weight over 4000 grams, history of previous Cesarean delivery, unemployed status as well referral cases from other facilities.

Attributable factors for the rising cesarean delivery rate over 3 decades: an observational cohort study

Cesarean delivery rates continue to rise globally, the reasons for which are incompletely understood. We aimed to characterize the attributable factors for the increasing cesarean delivery rates over a 30-year period within our health network. This was a planned observational cohort study across 2 hospitals (a large tertiary referral hospital and a metropolitan hospital) in Sydney, Australia using data from a previously published study. The following 2 time periods were compared: 1989-99 and 2009-16, between which the cesarean delivery rate increased from 19% to 30%. The participants were all women who had a cesarean delivery after 24 weeks' gestational age. The data were analyzed using multiple imputation and robust Poisson regression to calculate the differences in the adjusted and unadjusted relative risk of cesarean delivery and estimate the changes in the cesarean delivery rate attributable to maternal and clinical factors. The primary outcome was cesarean delivery. After 576 exclusions, 102,589 births were included in the analysis. Fifty-six percent of the increase in the rate of cesarean delivery was attributed to changes in the distribution of the maternal age, body mass index, and parity and to a history of previous cesarean delivery. An additional 10% of the increase was attributed to changes in the obstetrical management of the following high-risk pregnancies: multiple gestation, malpresentation (mainly breech), and preterm singleton birth. When prelabor cesarean deliveries for maternal choice, suspected fetal compromise, previous pregnancy issues, and suspected large fetus were excluded, 78% of the increase was attributed to either maternal factors or changes in the obstetrical management of these high-risk pregnancies. Most of the steep rise in the cesarean delivery rate from 19% to 30% was attributed to changes in the maternal demographic and clinical factors. This observation is relevant to developing preventative strategies that account for nulliparity, age, body mass index, and management of high-risk pregnancies.

Placenta increta presenting with threatened miscarriage during the first trimester in rhesus-negative mother: a case report

BackgroundPlacenta accreta is known to be associated with significant maternal morbidity and mortality—primarily due to intractable bleeding during abortion or delivery at any level of gestation. The complications could be reduced if placenta accreta is suspected in a patient with a history of previous cesarean delivery and the gestational sac/placenta is located at the lower part of the uterus. Then, a proper management plan can be instituted, and complications can be reduced. The diagnosis of placenta accreta in the first trimester of pregnancy is considered uncommon.Case presentationA 34-year-old Malay, gravida 4, para 3, rhesus-negative woman was referred from a private hospital at 13 weeks owing to accreta suspicion for further management. She has a history of three previous lower-segment cesarean sections. She also had per vaginal bleeding in the early first trimester, which is considered to indicate threatened miscarriage. Transabdominal ultrasound revealed features consistent with placenta accreta spectrum. She was counseled for open laparotomy and hysterectomy because of potential major complication if she continued with the pregnancy. Histopathological examination revealed placenta increta.ConclusionA high index of suspicion of placenta previa accreta must be in practice in a patient with a history of previous cesarean deliveries and low-lying placenta upon ultrasound examination during early gestation.

Induced labour with prostaglandin E2 in different parity groups after premature rupture of membranes

The study compared the outcome of induction of labour with prostaglandin E2 vaginal tablets in patients with premature rupture of membranes (PROM) at term in different parity groups. A retrospective review was made of the hospital records of 169 women attending the maternity unit of King Faisal Military Hospital, Saudi Arabia. There were no statistically significant differences between the 3 groups (parity 0, parity 1-4 and parity 5+) in rates of labour augmentation, caesarean sections, neonatal intensive care admissions or low Apgar scores. There were no serious complications of induction of labour such as infection or uterine hyperstimulation or rupture. Prostaglandin E2 may be used with care for labour induction in women with PROM at term, even grand multiparas, unless there is history of previous caesarean delivery.

Previous mode of delivery affects subsequent pregnancy outcomes: a Chinese birth register study.

BackgroundWith the comprehensive implementation of the second child policy in China, the proportion of multiparous women has increased dramatically in the past few years. As nearly half of them have a history of previous cesarean delivery, there is widespread concern regarding complications of their pregnancy.MethodsThe aim of this study was to evaluate the effect of the previous delivery mode on subsequent pregnancy outcomes in the real world based on data from a Chinese birth registry. Birth registry data from July 1, 2016 to June 30, 2017 among a Chinese population were collected and analyzed retrospectively. This study included 14 representative hospitals from 10 provinces of China. All delivery data were collected by an internet-based system using a birth registration platform. The study enrolled 36,355 multiparas. Information extracted for analysis included basic demographic characteristics, previous delivery mode, current delivery mode, major maternal complications, and neonatal outcomes. Pregnancy outcomes of women with previous cesarean delivery (PCS group, n=14,774) were compared with the outcomes of women with previous vaginal delivery (PVD group, n=21,581).ResultsThere were statistically significant differences in the major pregnancy outcomes between the PCS group and the PVD group. The PCS group had a higher incidence of cesarean section (CS), placenta previa, postpartum hemorrhage, uterus rupture, hysterectomy, gestational diabetes, gestational hypertension, delivery before 37 weeks of gestation, low birth weight, and Apgar Score at 5 min ≤3.ConclusionsWomen with previous cesarean delivery had poorer pregnancy outcomes than women with previous vaginal delivery. Avoiding unnecessary CS, especially in primiparas is essential to improving maternal and neonatal outcomes in later pregnancies.

Maternal and neonatal outcomes in transverse and vertical skin incision for placenta previa

BackgroundPlacenta previa, a serious obstetric issue, should be managed by experienced teams. The safe and appropriate mode of delivery for placenta previa is by cesarean delivery. However, no studies were found comparing either maternal or neonatal outcomes for different skin incision in women with placenta previa. The aim of this study was to compare maternal and neonatal outcomes by skin incision types (transverse compared with vertical) in a large cohort of women with placenta previa who were undergoing cesarean delivery.MethodsThis was a retrospective cohort study carried out between January 2014 and June 2019. All pregnant women with placenta previa had confirmed by ultrasonologist before delivery and obstetrician at delivery. The primary outcome was the estimated blood loss during the surgery and within the first 24 hours postoperatively. Mean (standard deviation), median (interquartile range) or frequency (percentage) was reported to variables. Appropriate parametric and nonparametric tests were used to analyses.ResultsThe study included 1098 complete records, 332 (30.24%) cases in the vertical skin incision group and 766 (69.76%) cases in the transverse skin incision group. Those with vertical incision showed a higher percentage of preterm delivery, anterior placenta, abnormally invasive placenta, and history of previous cesarean delivery, and a lower percentage of first pregnancy, in vitro fertilization, and emergency cesarean delivery. After controlling for confounding factors, higher incidence of post-partum hemorrhage (OR 5.47, 95% CI 3.84–7.79), maternal intensive care unit (OR 4.30, 95% CI 2.86–6.45), transfusion (OR 5.97, 95% CI 4.15–8.58), and 5-min APGAR< 7 (OR 9.03, 95% CI 1.83–44.49), a more estimated blood loss (β 601.85, 95%CI 458.78–744.91), and a longer length of hospital stay after delivery (β 0.54, 95%CI 0.23–0.86) were found in the vertical skin incision group.ConclusionsOur data demonstrated that transverse skin incision group showed the better perinatal outcomes in women with placenta previa. Future collaborative studies are needed to be done by centers for placenta previa to have a better understanding of the characteristics and the outcomes of the disease in the choosing skin incision.

Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery

Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December2016. In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.