Indication For Cesarean Delivery Research Articles

Primary Cesarean delivery and future risk of maternal autoimmune disease: A population-based cohort study.

To determine the association between primary Cesarean delivery and incident autoimmune disease in women. We conducted a population-based cohort study of 253,901 females in Ontario, Canada with a first childbirth between 2012 and 2017 and with no pre-existing autoimmune disease. Royston-Parmar models were used to estimate the time-varying association between Cesarean delivery (28.2% of females) versus vaginal delivery (71.8% of females; referent) and celiac disease, multiple sclerosis (MS), rheumatoid arthritis (RA), and systemic autoimmune rheumatic disease (SARD), separately, from date of delivery to date of diagnosis or censoring at death, loss of health insurance, or March 31, 2021. To account for potential confounding by indication for Cesarean delivery, models were generated using (i) overlap weighting based on propensity scores for mode of delivery and (ii) with restriction to low-risk pregnancies free of pre-labour Cesarean indications (n=146,887). At up to 9 years following childbirth (median=6.5 years of follow-up), Cesarean delivery was associated with an increased risk of MS, but not celiac disease, RA, or SARD. Overall, cumulative incidence of MS was 0.28% following Cesarean delivery and 0.21% following vaginal delivery. After overlap weighting, the adjusted hazard ratio (AHR) curve formed a slight L-shape with the largest magnitude between birth and 3 years (1-year AHR 1.37, 95% CI 1.04-1.69) and diminishing thereafter (5-year 1.23, 95% CI 0.91-1.55; 7-year 1.21, 95% CI 0.84-1.57). Results were similar when restricted to births following low-risk pregnancies. Findings suggest a possible link between Cesarean delivery and MS development among females that warrants future replication and explanatory studies.

High Cesarean Section Rates during Labor Induction in Low Risk, Late-Term Cephalic Pregnancies in a Tertiary Centre

Background: The cesarean section rate is high in countries such as Türkiye, Egypt, and Brazil. The aims of this study were to determine whether the cesarean section rate during labor induction is high in late-term cephalic pregnancies and to evaluate the related factors. Methods: This retrospective descriptive study was conducted with 254 patients with a cephalic fetal presentation who were admitted in the labor unit of a tertiary center for induction of labor (IOL) at ≥41 0/7 weeks of gestation. The patients were evaluated in terms of demographic characteristics, Bishop score, labor induction method (dinoprostone or oxytocin administration), IOL duration, vaginal delivery rate, cesarean section rate, indication for cesarean delivery, 5-min Apgar score, fetal requirement for neonatal resuscitation, oxygen treatment, and neonatal intensive care unit admission. Results: The study population comprised 254 patients, of whom 181 (71.3%) had a vaginal delivery and 73 (28.7%) had a cesarean delivery. To evaluate the factors that affect labor induction failure and cesarean indication, the patients were divided into two groups: the nulliparous (n: 122) and multiparous (n: 132). The cesarean section rates in the nulliparous and multiparous groups were 44.3% (n: 54/122) and 14.4% (n: 19/132), respectively. According to the multivariate logistic regression, being nulliparous, having a male fetus were found to be the associated risk factors for cesarean delivery (p < 0.05). Conclusions: The study results suggest that the cesarean section rate during labor induction is higher in low-risk, late-term cephalic pregnancies. Nulliparity, male fetal sex were risk factors for cesarean delivery.

Tugging the Foley catheter balloon every three hours in induction of labor after one previous cesarean: a randomized controlled trial.

Induction of labor after 1 previous cesarean delivery with an unripe cervix have an especially high risk for unplanned cesarean delivery and uterine rupture. Mechanical balloon ripening is often preferred over prostaglandin-based ripening during induction of labor after 1 previous cesarean delivery, because uterine rupture has been associated with prostaglandin use. The transcervical Foley balloon can be dislodged past the ripened cervix and be retained comfortably in the vagina during passive placement. Tugging of the Foley catheter can be a noninvasive and tolerated method for timelier retrieval of the retained balloon; expediting discovery of a ripened cervix would permit an earlier follow-on amniotomy and oxytocin infusion, thereby hastening birth. This study aimed to evaluate the effect of tugging of the Foley balloon for 30 seconds every 3 hours during 12 hours of scheduled placement in comparison with standard care (no tugging) on the induction to birth interval and patient satisfaction. This randomized controlled trial, conducted at a university hospital in Malaysia, recruited participants from April 2023 to March 2024. Eligible participants admitted for Foley balloon induction of labor who had 1 previous cesarean were recruited. After balloon insertion, participants were randomized to tugging or standard care. Following balloon displacement, a vaginal examination was performed to check the cervix. The examination findings then dictated the follow-on management of induction of labor after 1 previous cesarean according to standard practice. The primary outcomes were the induction (Foley insertion) to delivery interval and participants' satisfaction with the birthing process. Secondary outcomes were largely derived from the core outcome set for trials on induction of labor. Based on a superiority hypothesis, it was calculated that a sample size of 126 would be required to detect a 4-hour reduction in the induction-to-delivery interval and a 1.5 point increase in the satisfaction score based on a 0 to 10 numerical rating scale with the level of significance set at 0.05, power at 80%, and a 10% drop out rate. Comparative analyses using an intention-to-treat approach were conducted using t tests, Mann-Whitney U tests, chi square tests, and Fisher exact tests as appropriate. A total of 126 participants were randomized with 63 in each trial arm. The induction to birth interval was (mean ± standard deviation) 29.7±9.6 hours for those in the 3-hourly tugging group and 29.8±9.1 hours for those under standard care (P=.950), and maternal satisfaction with the induction of labor after 1 previous cesarean delivery birth process, assessed using a 0 to 10 numerical rating scale, was (median [interquartile range]) 8 [7-9] and 8 [7-9] (P=.936), respectively. The cesarean delivery rate was 37 of 63 (59%) vs 41 of 63 (65%) (P=.238) for those in the tugging group vs standard care, and the main indication for unplanned cesarean delivery was failure to progress with an incidence of 24 of 37 (65%) and 24 of 41 (59%) (P=.914) for tugging vs standard care arms, respectively. Three-hourly tugging also did not shorten the interval from induction to balloon displacement, amniotomy, the start of oxytocin infusion, or the second stage of labor. Tugging the catheter every 3 hours during scheduled 12-hour Foley balloon placement for induction of labor after 1 previous cesarean delivery did not hasten birth or improve patient satisfaction when compared with standard care.

Predicting vaginal delivery after labor induction using machine learning: Development of a multivariable prediction model.

Induction of labor, often used for pregnancy termination, has globally rising rates, especially in high-income countries where pregnant women present with more comorbidities. Consequently, concerns on a potential rise in cesarean section (CS) rates after induction of labor (IOL) demand for improved counseling on delivery mode within this context. We aim to develop a prognostic model for predicting vaginal delivery after labor induction using computational learning. Secondary aims include elaborating a prognostic model for CS due to abnormal fetal heart rate and labor dystocia, and evaluation of these models' feature importance, using maternal clinical predictors at IOL admission. The best performing model was assessed in an independent validation data using the area under the receiver operating curve (AUROC). Internal model validation was performed using 10-fold cross-validation. Feature importance was calculated using SHAP (SHapley Additive exPlanation) values to interpret the importance of influential features. Our main outcome measures were mode of delivery after induction of labor, dichotomized as vaginal or cesarean delivery and CS indications, dichotomized as abnormal fetal heart rate and labor dystocia. Our sample comprised singleton term pregnant women (n = 2434) referred for IOL to a tertiary Obstetrics center between January 2018 and December 2021. Prediction of vaginal delivery obtained good discrimination in the independent validation data (AUROC = 0.794, 95% CI 0.783-0.805), showing high positive and negative predictive values (PPV and NPV) of 0.752 and 0.793, respectively, high specificity (0.910) and sensitivity (0.766). The CS model showed an AUROC of 0.590 (95% CI 0.565-0.615) and high specificity (0.893). Sensitivity, PPV and NVP values were 0.665, 0.617, and 0.7, respectively. Labor features associated with vaginal delivery were by order of importance: Bishop score, number of previous term deliveries, maternal height, interpregnancy time interval, and previous eutocic delivery. This prognostic model produced a 0.794 AUROC for predicting vaginal delivery. This, coupled with knowing the features influencing this outcome, may aid providers in assessing an individual's risk of CS after IOL and provide personalized counseling.

Analysis of Birth Statistics, Examination of Caesarean Rates and Caesarean Indications; Retrospective Study

Aim: This study investigated cesarean delivery rates and indications for cesarean delivery among patients who gave birth in our clinic between 2019 and 2022. Material and Method: For the study, the data of 16,559 patients who gave birth between 2019 and 2022 in the Obstetrics and Gynecology clinic of a Training and Research Hospital were retrospectively analyzed. The mode of delivery, gender information, fetal birth weight, vaginal delivery, and cesarean section rates and indications for cesarean section were analyzed. Results: Among the patients who gave birth in our clinic between January 01, 2019, and December 31, 2022, 58.1% delivered vaginally, and 41.9% delivered by cesarean section. According to the four-year average, 48.5% of the babies born were girls, and 51.5% were boys. The most common indication for cesarean section was previous uterine surgery. The rate of primary cesarean section among cesarean deliveries was 47%. The most common indications for primary cesarean section were fetal distress, breech presentation, and non-progressive labor. Conclusion: In our clinic, the four-year average cesarean delivery rate was 41.9%. Although this rate is below the national average of 53%, it is above the Ministry of Health's target rate of 35% in Turkey. When evaluated specifically for our province, we think this is mainly due to the lack of obstetrician-gynecologists in the districts and the high number of referrals to our hospital. Nevertheless, considering these results, it is clear that more comprehensive studies are needed to reduce cesarean section rates.

The impact of indication for cesarean on blood loss

BackgroundPostpartum hemorrhage is the leading cause of maternal mortality worldwide. Quantitative blood loss assessment at the time of cesarean delivery is a more accurate measure of blood loss than is simple estimation. Risk factors for postpartum hemorrhage are well described; however, contemporary, systematic investigations into the impact of the indication for cesarean delivery on quantitative blood loss are lacking. ObjectiveTo investigate whether there are clinically significant differences in quantitative blood loss and postpartum hemorrhage risk based on the indication for cesarean delivery. Study DesignA cohort of 4,881 cesarean deliveries performed at a large academic hospital between 2020 and 2022 was identified. Primary and repeat cesarean deliveries were analyzed separately and further subdivided into seven indications: elective, labor arrest, fetal heart rate abnormalities, placenta previa, placenta accreta, malpresentation, and other. Quantitative blood loss and rates of postpartum hemorrhage ( > 1000 cc and >1500cc) were compared among the different indications. ResultsMean quantitative blood loss for primary, repeat and total cesarean deliveries was 886 cc, 697 cc and 792 cc, respectively. Excluding cases of placenta accreta, the greatest blood loss in both primary and repeat groups was seen in cesareans performed for labor arrest, with blood loss exceeding 1500 cc in 18% and 13% of all cases. Blood loss exceeding 1500cc was seen in 1% and 2% of elective cesarean deliveries. The mean blood loss for planned repeat cesarean/hysterectomies for placenta accreta was < 400cc greater than primary cesareans performed for labor arrest (1442 cc vs. 1065 cc), despite the addition of an often-complex hysterectomy to the procedure. ConclusionsClinically and statistically significant differences in blood loss exist based on the indication for cesarean delivery. Large differences in rates of serious postpartum hemorrhage (>1500cc) with negligible differences in mean quantitative blood loss suggests the presence of frequent, large clinical outliers not reflected in a statistical mean. The indication for cesarean and the possibility of such outliers, rather than the predicted “average blood loss for cesarean delivery” should be considered in determining risk and the degree of necessary pre-operative blood preparation. These data raise questions about whether current, traditional techniques of non-accreta related cesarean delivery can be justified in non-emergent cases when such procedures could be performed with significantly less blood loss using accreta-specific techniques.

Videolaryngoscopy during Urgent Cesarean Delivery: Association with Neonatal Intensive Care Unit Admission.

Parturients are at increased risk for difficult airway management with subsequent fetal complications. Videolaryngoscopy was opined to be the new standard of airway care to facilitate orotracheal intubation under urgent care conditions. We examined in parturients requiring general anesthesia for urgent cesarean delivery the association of the type of laryngoscopy technique and time required to facilitate orotracheal intubation with the incidence of subsequent neonatal intensive care unit (NICU) admission. Following institutional review board approval, 431 parturients aged 18 years and older who underwent urgent cesarean section requiring general anesthesia were entered into this study. Patient characteristics, maternal comorbidities, and indications for urgent cesarean delivery were collected from the electronic medical records from January 2013 to November 2018. Orotracheal intubation times by type of laryngoscopy (video or direct) and NICU admission rates also were collected. A measure of effect size, risk differences with 95% confidence intervals (CIs), were calculated for the likelihood of NICU admission by difficult orotracheal intubation and by type of laryngoscopy used to secure the airway. Videolaryngoscopy as the primary type of laryngoscopy was used in 24.1% (95% CI 20.3%-28.3%) of general anesthetics. The incidence of difficult orotracheal intubation was 4.4% (95% CI 2.8%-6.7%), with a higher incidence observed with videolaryngoscopy (8.7%) than with direct laryngoscopy (3.1%) and a risk difference of 5.6% (95% CI 0.001%-11.3%). The incidence of NICU admission was 38.4% (95% CI 34.0%-43.1%). Times for successful orotracheal intubation were longer with videolaryngoscopy. Videolaryngoscopy had a higher association for NICU admission (47%) than for direct laryngoscopy (36%), with a risk difference of 11.4% (95% CI 0.01%-22.3%). Videolaryngoscopy did not decrease the incidence of difficult orotracheal intubation, and it did not decrease the time associated with orotracheal intubation. Videolaryngoscopy was associated with a higher association of NICU admission. These results suggest that videolaryngoscopy does not supplant direct laryngoscopy as the standard of care for orotracheal intubation under urgent care conditions of general anesthesia for cesarean section.

Understanding Obstetrical Surgical Planning for the Pediatrician.

Cesarean deliveries are common in the United States, occurring in approximately one-third of deliveries in 2021. Given this high rate of cesarean deliveries, it is important for all clinicians caring for the pregnant person-infant dyad to be educated about cesarean deliveries. In this review, we describe the indications for cesarean delivery, the evidence-based practices of preoperative planning to ensure safe deliveries, and the clinical decision-making behind various cesarean incisions. In addition, we discuss the most common complications of cesarean deliveries for the pregnant person-infant dyad.

YouTube as a Source of Patient Information on External Cephalic Version: Cross-Sectional Study.

With the global increase of cesarean deliveries, breech presentation is the third indication for elective cesarean delivery. Implementation of external cephalic version (ECV), in which the position of the baby is manipulated externally to prevent breech presentation at term, remains suboptimal. Increasing knowledge for caretakers and patients is beneficial in the uptake of ECV implementation. In recent decades, the internet has become the most important source of information for both patients and health care professionals. However, the use and availability of the internet also bring about concerns since the information is often not regulated or reviewed. Information needs to be understandable, correct, and easily obtainable for the patient. Owing to its global reach, YouTube has great potential to both hinder and support spreading medical information and can therefore be used as a tool for shared decision-making. The objective of this study was to investigate the available information on YouTube about ECV and assess the quality and usefulness of the information in the videos. A YouTube search was performed with five search terms and the first 35 results were selected for analysis. A quality assessment scale was developed to quantify the accuracy of medical information of each video. The main outcome measure was the usefulness score, dividing the videos into useful, slightly useful, and not useful categories. The source of upload was divided into five subcategories and two broad categories of medical or nonmedical. Secondary outcomes included audience engagement, misinformation, and encouraging or discouraging ECV. Among the 70 videos, only 14% (n=10) were defined as useful. Every useful video was uploaded by educational channels or health care professionals and 80% (8/10) were derived from a medical source. Over half of the not useful videos were uploaded by birth attendants and vloggers. Videos uploaded by birth attendants scored the highest on audience engagement. The presence of misinformation was low across all groups. Two-thirds of the vloggers encouraged ECV to their viewers. A minor percentage of videos about ECV on YouTube are considered useful. Vloggers often encourage their audience to opt for ECV. Videos with higher audience engagement had a lower usefulness score compared to videos with lower audience engagement. Sources from medically accurate videos should cooperate with sources with high audience engagement to contribute to the uptake of ECV by creating more awareness and a positive attitude of the procedure, thereby lowering the chance for a cesarean delivery due to breech presentation at term.

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.

Neurologic Complication Rates in Obstetric Patients With Chiari Malformation Based on Mode of Delivery [ID 2683669

INTRODUCTION: Chiari malformation (CM) describes inferior displacement of hindbrain structures. Because of the theoretical effects of labor on cerebrospinal fluid dynamics, CM alone has historically been suggested as a sufficient indication for cesarean delivery because of concern for herniation. However, existing literature is limited and does not demonstrate increased adverse outcomes of vaginal delivery in this population. This novel work utilizes a national dataset to describe neurologic complication rates in CM parturients in relation to mode of delivery. METHODS: The 2016–2018 Nationwide Readmissions Datasets were queried for obstetric patients with and without documented CM. ICD-10 codes were used to identify parturients who experienced neurologic complications relevant to CM. Univariate and multivariate analyses were performed to assess associations between CM and mode of delivery. RESULTS: 11,021,188 parturients were identified, including 1,210 with preexisting CM. The primary cesarean rate was 50.7% (n=479) in CM parturients compared to 20% (n=1,823,650) in the general population and CM independently predicted cesarean delivery (OR 3.8, CI, 3.1–4.7). There was no significant difference (P=.87) in the rate of herniation based on delivery method in CM parturients. The incidence of stroke, myelopathy, and hydrocephalus was zero regardless of delivery method. CONCLUSION: There is no significant difference in neurological complication rates in CM patients based on delivery method, yet CM patients are more than twice as likely to undergo cesarean delivery. Data suggest that vaginal delivery carries minimal risk to CM patients and should be considered during clinical decision making. Future studies should stratify risk based on type and severity of CM.

Rates of Cesarean Delivery and Neurologic Complications in Parturients With Cerebrospinal Fluid Shunts [ID 2683661

INTRODUCTION: The effect of parturition on neurologic status in CSF shunt-dependent patients is poorly understood. Cesarean delivery has been proposed as a safer alternative to labor in this population based on limited case reports and retrospective data in the literature; however, the true risk of vaginal delivery has not been adequately described. To our knowledge, this is the first study to estimate national incidence of neurologic complications based on delivery mode in shunt-dependent parturients. METHODS: The Nationwide Readmissions Database (NRD) was queried for obstetric patients undergoing delivery between 2016 and 2018. ICD-10 codes were used to identify delivery mode, preexisting CSF shunt-dependence, obstetric comorbidities, and neurologic complications. Data were weighted per NRD specifications. RESULTS: Of 11,021,188 total deliveries, 1,856 were in shunt-dependent patients. The primary cesarean rate was 41.2% (n=613) versus 20.1% (n=1,823,517) for shunted and non-shunted parturients, respectively. Multivariate analysis confirmed that presence of a shunt independently predicted cesarean delivery (OR 2.4; CI, 2.0–2.9). Intrapartum shunt complication rates were low regardless of delivery mode (vaginal:0.5%, cesarean:0.5%). Additionally, there was no significant difference in rates of brain herniation (P=.82) or CNS infection (P=.15). CONCLUSION: There is no difference in neurologic complication rates between CSF shunt-dependent patients undergoing cesarean and vaginal delivery; however, cesarean delivery is performed at more than twice the rate of the general population. CSF-shunt dependence alone may not be an independent indication for cesarean delivery in the absence of other obstetric indications.

Risk of Cesarean Delivery Among People With Inflammatory Bowel Disease According to Disease Characteristics: A Population-Based Study

ObjectivesIt is unclear if use of cesarean delivery in people with inflammatory bowel disease (IBD) is guideline-concordant. We compared the odds of cesarean delivery among primiparous individuals with IBD versus without, overall, and by disease characteristics, as well as time to subsequent delivery. MethodsRetrospective matched population-based cohort study between 1 April 1994 and 31 March 2020. Primiparous individuals aged 15–55 years with IBD were matched to those without IBD on age, year, hospital, and number of newborns delivered. Primary outcome was cesarean delivery versus vaginal delivery. Multivariable conditional logistic regression analyses were performed to estimate the odds of cesarean delivery among individuals with and without IBD as a binary exposure, and a categorical exposure based on IBD-related indications for cesarean delivery. Time to subsequent delivery was evaluated using a Cox proportional hazard model. ResultsWe matched 7472 individuals with IBD to 37 360 individuals without (99.02% match rate). Individuals with IBD were categorised as having perianal (PA) disease (IBD-PA, n = 764, 10.2%), prior ileal pouch-anal anastomosis (n = 212, 2.8%), or IBD-Other (n = 6496, 86.9%). Cesarean delivery rates were 35.4% in the IBD group versus 30.4% in their controls (adjusted odds ratio 1.27; 95% CI 1.20–1.34). IBD-ileal pouch-anal anastomosis had a cesarean delivery rate of 66.5%, compared to 49.9% in IBD-PA and 32.7% in IBD-Other. There was no significant difference in the rate of subsequent delivery in those with and without IBD (adjusted hazard ratio 1.03; 95% CI 1–1.07). ConclusionsThe higher risk of cesarean delivery in people with IBD reflects guideline-concordant use. Individuals with and without IBD were equally likely to have a subsequent delivery with similar timing.

Cardiovascular and obstetrical outcomes among delivering patients with Marfan or Loeys-Dietz syndrome: a retrospective analysis by hospital delivery setting

BackgroundPregnancy is a high-risk time for patients with Marfan syndrome (MFS) or Loeys-Dietz (LDS) syndrome due to risk for cardiovascular complications including risk of aortic dissection. Little is known about differences in obstetric and cardiac outcomes based on delivery hospital setting (academic/academic-affiliated versus community medical centers). ObjectiveThis study aimed to evaluate obstetric and cardiac outcomes of patients with MFS or LDS based on delivery hospital setting. Study DesignThis is a secondary analysis of a retrospective, observational cohort study of singleton pregnancies among patients with a diagnosis of MFS or LDS from 1990 to 2016. Patients were identified through the Marfan Foundation, Loeys-Dietz Syndrome Foundation, or Cardiovascular Connective Tissue Clinic at Johns Hopkins Hospital. Data were obtained via self-reported obstetric history and verified by review of medical records. Nonparametric analysis was performed via Fisher's Exact Test and Wilcoxon rank-sum tests. Results273 deliveries among patients with MFS or LDS were included in this analysis. More patients who had a known diagnosis prior to delivery for either MFS or LDS delivered at an academic hospital as compared community hospital (78.6% vs. 59.9%, p=0.001). Patients with MFS or LDS who delivered at academic centers were more likely to have an operative vaginal delivery compared to those at community centers (23.7% vs 8.6%, p=0.002). When indications for cesarean delivery were assessed, connective tissue disease was the primary reason for indication for mode of delivery at community centers compared to academic centers (55.6% vs 43.5%, p=0.02). There were higher rates of cesarean for arrest of labor and/or malpresentation at community hospitals compared to academic centers (23.6% vs 5.3%, p=0.01). There were no differences between groups in regards to method of anesthesia for delivery. Among those with a known diagnosis of MFS or LDS prior to delivery, there were increased operative vaginal delivery rates at academic hospitals compared to community hospitals (27.2% vs 15.1%, p=0.03; Table 2). More patients with an aortic root measuring ≥4 cm pre-pregnancy or postpartum delivered at academic centers compared to community centers (33.0% vs. 10.2%, p=0.01), but there were no significant differences in median size of the aortic root during pregnancy or on postpartum assessment between delivery locations. Cardiovascular complications were rare: eight patients who delivered at academic centers and seven patients who delivered at community centers had an aortic dissection either in pregnancy or the postpartum period (p=0.79). ConclusionPatients with MFS/LDS and more severe aortic phenotypes were more likely to deliver at academic hospitals. Those who delivered at academic hospitals had higher rates of operative vaginal delivery. Despite lower frequencies of aortic root diameter >4.0 cm, those delivered at community hospitals had higher rates of cesarean delivery for the indication of MFS/LDS. Optimal delivery management of these patients requires further prospective research.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth

BackgroundAn increased risk of preterm birth has been observed among individuals with a previous second stage cesarean delivery compared with a previous vaginal delivery. One mechanism that may contribute to the increased risk of preterm birth following second stage cesarean delivery is the increased risk of cervical injury due to extension of the uterine incision (hysterotomy) into the cervix. Investigating the contribution of hysterotomy extension to the rate of preterm birth has not been well-studied and may shed light on the mechanisms underlying the observed relationship between mode of delivery and subsequent preterm birth. ObjectiveWe aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. Study designWe performed a retrospective cohort study using electronic perinatal data collected in two university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks; secondary outcomes included subsequent preterm birth <34, <32 and <28 weeks. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios (RRs) and 95% confidence intervals (CIs). Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labour, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. ResultsA total 4,797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labour, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses controlling for several confounders showed that a history of hysterotomy extension is not associated with a higher risk of preterm birth <37 weeks gestation (adjusted RR 1.55, 95% CI 0.98-2.47), but is associated with preterm birth <34 weeks gestation (adjusted RR 2.49, 95% CI 1.06-5.42). ConclusionPatients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks compared with patients who do not sustain this injury. This association was not observed for preterm birth <37 weeks. Future research should aim to replicate our analyses while incorporating additional data to minimize the potential for residual confounding.

New labor curves of dilation and station to improve the accuracy of predicting labor progress

BackgroundThe diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references of expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making. ObjectiveTo compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using 2 modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method. Study designThis was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex presenting fetus at ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first exam in the 20 hours before delivery; dilation, effacement and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, we calculated the differences between each model’s predicted value and its corresponding observed value. These prediction errors were summarized using mean absolute error and root mean squared error statistics. Results(1) Dilation curves based on multiple parameters were more accurate than those derived from time alone. (2) The mean absolute error with the multifactor methods were better (lower) than those from the single-factor methods [0.826 cm (95% CI, 0.820–0.832) for the multifactor machine learning and 0.893 cm (95% CI, 0.885–0.901) for the multifactor mixed-effects method and 2.122 cm (95% CI, 2.108–2.136) for the single-factor methods; P<0.0001 for both comparisons]. (3) The root mean squared errors with the multifactor methods were also better (lower) than those from the single-factor methods [1.126 cm (95% CI, 1.118–1.133) P<0.0001 for the machine learning and 1.172cm (95% CI, 1.164–1.181) for the mixed-effects method and 2.504 cm (95% CI, 2.487–2.521) for the single-factor; P<0.0001 for both comparisons]. (4) The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<0.0001). (5) The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% CI, 0.509–0.515) and a root mean squared error of 0.660 cm (95% CI, 0.655–0.666). (6) External validation using independent data produced similar findings. Conclusions(1) Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone; (2) the mean prediction errors were reduced by more than 50%; and (3) a more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.

Evaluation of cesarean delivery rates and factors associated with cesarean delivery among women enrolled in a pregnancy cohort study at two tertiary hospitals in Thailand.

Cesarean delivery rates have increased globally resulting in a public health concern. We estimate rates of cesarean deliveries among Thai women using the World Health Organization(WHO) Robson Classification system and compare rates by Robson group to the Robson guideline for acceptable rates to identify groups that might benefit most from interventions for rate reduction. In 2017 and 2018, we established cohorts of pregnant women aged ≥ 18 years seeking prenatal care at two tertiary Thai hospitals and followed them until 6-8 weeks postpartum. Three in-person interviews (enrollment, end of pregnancy, and postpartum) were conducted using structured questionnaires to obtain demographic characteristics, health history, and delivery information. Cesarean delivery indication was classified based on core obstetric variables (parity, previous cesarean delivery, number of fetuses, fetal presentation, gestational week, and onset of labor) assigned to 10 groups according to the Robson Classification. Logistic regression was used to identify factors associated with cesarean delivery among nulliparous women with singleton,cephalic, term pregnancies. Of 2,137 participants, 970 (45%) had cesarean deliveries. The median maternal age at delivery was 29 years (interquartile range, 25-35); 271 (13%) participants had existing medical conditions; and 446 (21%) had pregnancy complications. The cesarean delivery rate varied by Robson group. Multiparous women with > 1 previous uterine scar, with a single cephalic pregnancy, ≥ 37 weeks gestation (group 5) contributed the most (14%) to the overall cesarean rate, whereas those with a single pregnancy with a transverse or oblique lie, including women with previous uterine scars (group 9) contributed the least (< 1%). Factors independently associated with cesarean delivery included age ≥ 25 years, pre-pregnancy obesity, new/worsen medical condition during pregnancy, fetal distress, abnormal labor, infant size for gestational age ≥ 50th percentiles, and self-pay for delivery fees. Women with existing blood conditions were less likely to have cesarean delivery. Almost one in two pregnancies among women in our cohorts resulted in cesarean deliveries. Compared to WHO guidelines, cesarean delivery rates were elevated in selected Robson groups indicating that tailored interventions to minimize non-clinically indicated cesarean delivery for specific groups of pregnancies may be warranted.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Cesarean delivery. The rate of general anesthesia for cesarean delivery by race and ethnicity. Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Cesarean section prior to 28 weeks’ gestation: which type of uterine incision is optimal?

Objective The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy. Methods This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery. Results There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 – 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03. Conclusion In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.

Obstetrical and perinatal consequences of childbirth in women with antenatally undiagnosed fetal growth restriction

Fetal growth restriction (FGR) is one of the most studied topics in the medicine of the mother and fetus. However, not identified antenatally FGR can have an increased risk of both perinatal morbidity and mortality, as well as adverse long-term consequences. The identification of FGR during pregnancy will contribute to the reduction of both perinatal morbidity and perinatal mortality.&#x0D; Aim. Based on a retrospective analysis, assess the obstetric and perinatal consequences of childbirth in women with antenatally undiagnosed fetal growth restriction.&#x0D; Materials and methods. An analysis of 488 cases of childbirth in women with singleton pregnancy, who gave birth to a live child, was conducted. In all cases, the gestational age was ≥22 weeks with a fetal weight less than the 10th percentile for the corresponding gestational age. Depending on the antenatally established diagnosis of FGR, two study groups were formed: group I consisted of 204 (41.8 %) cases with antenatally diagnosed FGR, group II – 284 (58.2 %) cases in which signs of FGR were identified after the birth of the child. Maternal characteristics, neonatal outcomes, and evaluation of short-term infant outcomes were analyzed.&#x0D; Results. Both groups were dominated by women with first births, the number of which was almost the same. Somatic pathology was almost 2 times more common in women of group I, 17.2 %, compared to 9.2 % of women in group II (p &lt; 0.01), this indicates that the majority of women who were not diagnosed with FGR during pregnancy belong to the low-risk group. Fetuses with impaired blood flow in the umbilical cord arteries were twice as common in group I, 49.5 % versus 23.9 % in group II (p &lt; 0.0001), and the frequency of absent/reversible end flow in the umbilical arteries in group I compared to group II, prevailed 3 times (p &lt; 0.0001), indicating more serious lesions of the placenta and, as a result, early manifestation of the fetal condition disorder. The frequency of premature abdominal delivery was 3.75 times higher in group I compared to group II. The most frequent indication for cesarean delivery in both groups was signs of fetal distress syndrome. Analysis of neonatal outcomes showed that the average birth weight was significantly lower in group I and was 2180 ± 55 g against 2420 ± 61 g in group II (p &lt; 0.0001). The need for hospitalization of newborns in the intensive care unit had no statistical difference between the groups (p &gt; 0.05). However, the complications of the early neonatal period and the total length of stay in the hospital were greater in children of the I group, compared to the II group (p &lt; 0.0001).&#x0D; Conclusions. The results of the conducted research indicate a low level of prenatal diagnosis of fetal growth restriction. Most pregnant women with antenatally undiagnosed fetal growth restriction belong to the group of low perinatal risk. The most frequent indication for cesarean section operation, regardless of the date of delivery, in both groups were signs of fetal distress, the frequency of which was 1.5 times higher in the antenatally diagnosed fetal growth retardation group. Newborns with an undetected growth anomaly before delivery have an increased risk of fetal distress, the severity of which is determined by the degree of deterioration of fetal oxygenation, and not by weight percentile, which requires more careful observation of fetuses with signs of growth restriction.