Intrapartum Caesarean Section Research Articles

Delivery outcome after trial of labor in nulliparous women 40 years or older-A nationwide population-based study.

The number of women postponing childbirth until an advanced age is increasing. Our aim was to study the outcome of labor in nulliparous women ≥40years, compared with women 25-29years, after both spontaneous onset and induction of labor. The nationwide population-based Swedish Medical Birth Register was used to study the perinatal outcome in nulliparous women with a singleton, term (gestational weeks 37-44), live fetus in cephalic presentation and a planned vaginal delivery from 1992 to 2011. We included 7796 nulliparous women ≥40years and 264262 nulliparous women 25-29years. Prevalence and risk of intrapartum cesarean section, operative vaginal delivery, obstetric anal sphincter injury and a 5-minute Apgar score <7 were calculated for women ≥40years stratified for spontaneous onset and induction of labor, using women 25-29years as the reference in both strata. Crude and adjusted odds ratios (aOR) were calculated by unconditional logistic regression and presented with 95% confidence intervals (CI). Overall, 79% of women ≥40years with a trial of labor reached a vaginal delivery. After spontaneous onset, intrapartum cesarean section was performed in 15.4% of women ≥40years compared with 5.4% of women 25-29years (aOR 3.07, 95% CI 2.81-3.35). Operative vaginal delivery was performed in 22.3% of women ≥40years compared with 14.2% of women 25-29years (aOR 1.71, 95% CI 1.59-1.85). After induction of labor, an intrapartum cesarean section was performed in 37.2% women ≥40years compared with 20.2% women 25-29years (aOR 2.51, 95% CI 2.24-2.81). Operative vaginal delivery was performed in 22.6% of women ≥40years compared with 18.4% women 25-29years (aOR 1.45, 95% CI 1.28-1.65). The risk of obstetric anal sphincter injury or a 5-minute Apgar score <7 was not increased in women ≥40years, regardless of onset of labor. Trial of labor ended in vaginal delivery in 79% of nulliparous women ≥40years. The risks of intrapartum cesarean section and operative vaginal delivery were higher in women ≥40years compared with women 25-29years, after both spontaneous onset and induction of labor. The risk of obstetric anal sphincter injury or a 5-minute Apgar score <7 was not increased.

Factors associated with intrapartum cesarean section in women aged 40 years or older: a single-center experience in Japan

Objective: To elucidate the efficacy and safety of attempting a vaginal birth and to understand the factors that contribute to the increased risk of operative delivery in women aged 40 years or older. Methods: A database of the Japanese Red Cross Nagoya Daiichi Hospital was reviewed to identify women aged 40 years or older with singleton, vertex, and vital pregnancies who attempted vaginal delivery at and after 37 + 0 gestational weeks between January 2011 and December 2016. Results: A total of 415 women met the criteria for inclusion in this study, including 372 and 43 women who gave birth by vaginal delivery and by intrapartum cesarean section (CS), respectively. Vaginal delivery was observed in 84.1% (201/239) and 97.2% (171/176) of nulliparous and multiparous women, respectively. In a logistic regression model, nulliparity [odds ratio (OR), 5.18; 95% confidence interval (CI), 1.91–14.00], assisted reproductive technology (OR, 2.83; 95% CI, 1.42–5.62), and admission for induction of childbirth (OR, 2.68; 95% CI, 1.08–6.67) were associated with a higher likelihood of intrapartum CS. Of 372 women who delivered vaginally, 62 women needed operative delivery. Operative delivery was necessary for 25.4% (51/201) and 6.4% (11/171) of nulliparous and multiparous women, respectively. A logistic regression model identified nulliparity (OR, 3.91; 95% CI, 1.89–8.08) and administration of ecbolic (OR, 2.49; 95% CI, 1.21–5.10) as being independent factors associated with vacuum extraction. Conclusions: Maternal age 40 years or older should not be a barrier for attempting a vaginal delivery, and those women should be encouraged to attempt a vaginal delivery.

Maternal and neonatal outcome of reverse breech extraction of an impacted fetal head during caesarean section in advanced stage of labour: a retrospective cohort study

BackgroundCaesarean section with extraction of a deeply impacted fetal head is technically challenging and is associated with serious maternal and neonatal complications. The purpose of the study was to identify risks and evaluate selected outcome parameters associated with difficult fetal head extraction during caesarean section in advanced labour comparing two different extraction techniques (head pushing vs. reverse breech).MethodsThis retrospective cohort study was conducted at the Division of Obstetrics in a tertiary care hospital in Zurich, Switzerland. 629 women at term with a singleton pregnancy in cephalic presentation during advanced intrapartum caesarean section from December 2012 until December 2016 were evaluated. Primary outcome was the incidence of uterine incision extensions. Secondary outcomes were other selected maternal and neonatal outcome parameters. Data analysis was performed using SPSS with Mann-Whitney U independent sampling test and two-tailed Fisher’s exact test (p < 0.01).ResultsDifficult fetal head extractions are associated with significantly elevated maternal and neonatal risks. When performed by reverse breech technique, significant lower rates of extensions of the uterine incision, shorter operation times and less operative blood loss were identified compared to the head pushing method. No statistically significant differences for the neonatal outcomes were described so far. However, among the group of difficult fetal delivery with the head pushing method two neonates had perinatal skull fractures, with one of those resulting in neonatal death.ConclusionsThe head pushing method is associated with higher maternal morbidity than the reverse breech method for extraction of a deeply engaged fetus during intrapartum caesarean section in advanced stage of labour.

952: Risk factors of hysterotomy extension in cesareans during the 2nd stage

Cesarean section (CS) during the 2nd stage is a common situation. Risk of hysterotomy extension is more frequent during 2nd stage CS and can be associated with maternal complications. Some 2nd stage characteristics, such as fetal station or position or 2nd stage duration could be risk factors of hysterotomy extension. Our aim was to assess factors associated with hysterotomy extension among women having a 2nd stage CS, especially the 2nd stage labor characteristics. We conducted a 5-year retrospective cohort in a tertiary center between the January 1st 2013 and December, 31st 2017. All women having a 2nd stage CS with a live term (≥37 weeks) cephalic fetus were included. Hysterotomy extension was recorded from the cesarean surgical report. Operative duration, PPH and other maternal complications were also recorded. The maternal, obstetric, and neonatal characteristics associated with hysterotomy extension were assessed through univariate and multivariable analysis. Among 3350 intra-partum CS during the study period, 747 (28.3%) were performed during the 2nd stage with a live term cephalic fetus. Eighty three (11.1%) women had hysterotomy extension. For these women, the operative duration was longer (median: 49min, interquartile (40;60) vs 32 (28;40), p<0.001), the rate of PPH and transfusion were higher in comparison with the women with no hysterotomy extension (30.1% vs 15.1%, p<0.001 and 7.2% vs 2.4%, p=0.027). Factors significantly associated with uterine extension in the multivariable analysis, were history of CS, hypertensive disorders, experience of the surgeon and use of forceps during CS (Table). The 2nd stage labor characteristics, i.e. duration of the passive and active 2nd stage, station of the fetal head and fetal position, were not associated with a higher risk of uterine extension. Hysterotomy extension occurs in one among ten 2nd stage CS, and leads to operative and maternal complications. The risk of hysterotomy extension does not seem to depend on the 2nd stage labor characteristics.

The frequency of intrapartum caesarean section use with the WHO partograph versus Zhang's guideline in the Labour Progression Study (LaPS): a multicentre, cluster-randomised controlled trial

There is an ongoing debate concerning which guidelines and monitoring tools are most beneficial for assessing labour progression, to help prevent use of intrapartum caesarean section (ICS). The WHO partograph has been used for decades with the assumption of a linear labour progression; however, in 2010, Zhang introduced a new guideline suggesting a more dynamic labour progression. We aimed to investigate whether the frequency of ICS use differed when adhering to the WHO partograph versus Zhang's guideline for labour progression. We did a multicentre, cluster-randomised controlled trial at obstetric units in Norway, and each site was required to deliver more than 500 fetuses per year to be eligible for inclusion. The participants were nulliparous women who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labour. The obstetric units were treated as clusters, and women treated within these clusters were all given the same treatment. We stratified these clusters by size and number of previous caesarean sections. The clusters containing the obstetric units were then randomly assigned (1:1) to the control group, which adhered to the WHO partograph, or to the intervention group, which adhered to Zhang's guideline. The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, and investigators in this unit had no further involvement in the trial. Our study design did not enable masking of participants or health-care providers, but the investigators who were analysing the data were masked to group allocation. The primary outcome was use of ICS during active labour (cervical dilatation of 4-10 cm) in all participating women. The Labour Progression Study (LaPS) is registered with ClinicalTrials.gov, number NCT02221427. Between Aug 1, 2014, and Sept 1, 2014, 14 clusters were enrolled in the LaPS trial, and on Sept 11, 2014, seven obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and seven obstetric units were randomly assigned to the intervention group (adhering to Zhang's guideline). Between Dec 1, 2014, and Jan 31, 2017, 11 615 women were judged to be eligible for recruitment in the trial, which comprised 5421 (46·7%) women in the control group units and 6194 (53·3%) women in the intervention group units. In the control group, 2100 (38·7%) of 5421 women did not give signed consent to participate and 16 (0·3%) women abstained from participation. In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation. 7277 (62·7%) of 11 615 eligible women were therefore included in the analysis of the primary endpoint. Of these women, 3305 (45·4%) participants were in an obstetric unit that was randomly assigned to the control group (adhering to the WHO partograph) and 3972 (54·6%) participants were in an obstetric unit that was randomly assigned to the intervention group (adhering to Zhang's guideline). No women dropped out during the trial. Before the start of the trial, ICS was used in 9·5% of deliveries in the control group obstetric units and in 9·3% of intervention group obstetric units. During our trial, there were 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline), and the frequency of ICS use did not differ between the groups (adjusted relative risk 1·17, 95% CI 0·98-1·40; p=0·08; adjusted risk difference 1·00%, 95% CI -0·1 to 2·1). We identified no maternal or neonatal deaths during our study. We did not find any significant difference in the frequency of ICS use between the obstetric units assigned to adhere to the WHO partograph and those assigned to adhere to Zhang's guideline. The overall decrease in ICS use that we observed relative to the previous frequency of ICS use noted in these obstetric units might be explained by the close focus on assessing labour progression more than use of the guidelines. Our results represent an important contribution to the discussion on implementation of the new guideline. Østfold Hospital Trust.

Customised growth charts in large-for-gestational-age infants and the association with emergency caesarean section rate.

Large-for-gestational-age (LGA) infants are at increased risk of intrapartum complications. However, some infants classified as LGA may be appropriate-for-gestational-age (AGA) if adjusted for maternal stature. We determined whether customisation of birthweight centiles by maternal height, or height and weight, improves the detection of LGA infants at risk of complications. We conducted a retrospective analysis of 38246 term, singleton nulliparous women. We compared population birthweight centiles to those customised by height, or height and weight for complications including intrapartum caesarean section, instrumental delivery, postpartum haemorrhage, anal sphincter injury and neonatal outcomes. Those considered LGA when customised for height but AGA by population centiles (LGA-ht-only) were at increased risk of intrapartum emergency caesarean section compared with infants AGA on all charts (AGA-all); odds ratio (OR) 4.64, 95% CI 3.22-6.76. In contrast, infants considered LGA on population charts, but AGA when customised by height (LGA-pop-only) were not at increased risk compared to the AGA-all group (OR 1.43, 95% CI 0.70-1.88). Infants classified as LGA-ht-only compared to LGA-pop-only remained at significantly higher risk after adjustment for potential confounders (aOR 3.27; 95% CI 2.02-5.31). No difference was seen for any other outcomes. No benefit was seen with customisation by both maternal height and weight. Women with an infant classified as AGA on population centiles but LGA when customised for height are at increased risk of intrapartum caesarean section. This is a population unrecognised in current practice. Fetal growth should be customised for maternal height when making assessments regarding the LGA infant.

Intervention thresholds and cesarean section rates: A time-trends analysis.

To improve understanding of rising cesarean section (CS) rates in the UK, this study assessed the relation between clinician thresholds for performing CS for delayed labor progress or suspected fetal distress and corresponding CS rates in Aberdeen, UK. Time-trends analysis of term births from 1988 to 2012 in a population of nulliparous women (N = 53745) in Aberdeen, UK, using Chi-square test for trend, and binary logistic regression. Data were obtained from the Aberdeen Maternity and Neonatal Databank. Unplanned CS rates per quintile increased from 11.0% (1391/12686) to 21.1% (2383/11273) between 1988 and 2012, while planned CS rates increased from 2.7% (338/12686) to 5.2% (591/11273). The median duration of labor before CS for delayed progress per quintile decreased from 17.2 (IQR 12.5-22.3) to 13.1 hours (9.6-16.9) before first stage CS and from 17.1 (12.6-22.3) to 15.3 (11.5-19.1) hours before second stage CS (P<.001). The proportion of CS for suspected fetal distress performed with evidence of fetal acidosis declined from 23.4% (98/418) to 17.4% (106/608) per quintile (P<.01). Neonatal unit admission (adjusted OR 1.99, 95% CI 1.85-2.14) was more likely following unplanned CS than vaginal births. Birth trauma was less likely following both unplanned (adjusted OR 0.48, 95% CI 0.39-0.60) and planned (adjusted OR 0.33, 95% CI 0.18-0.63) CS. Increased CS rates can be partly attributed to lowered clinical thresholds for intrapartum CS. Higher CS rates are associated with less birth trauma for the offspring.

Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study

BackgroundAlthough interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics.MethodsChildbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010–2013. All single childbirths from 37 weeks’ gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman’s rank correlation coefficients.ResultsMost variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13–15% and 5–6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage.ConclusionsMost variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

Is sonographically measured cervical length at 37 weeks of gestation associated with intrapartum cesarean section? A prospective cohort study.

Cesarean section rates continue to increase globally. Prediction of intrapartum cesarean section could lead to preventive measures. Our aim was to assess the association between sonographically measured cervical length at 37 weeks of gestation and cesarean section among women planning a vaginal birth. The population was women with a low-risk pregnancy or with gestational diabetes. This was a prospective cohort study conducted in a tertiary referral hospital in Sydney, Australia. In all, 212 women with a low-risk pregnancy or with gestational diabetes were recruited including 158 nulliparous and 54 parous women. Maternal demographic, clinical and ultrasound characteristics were collected at 37 weeks of gestation. Semi-Bayesian logistic regression and Markov chain Monte Carlo simulation were used to assess the relation between cervical length and cesarean section in labor. Rates of cesarean section were 5% (2/55) for cervical length ≤20 mm, 17% (17/101) for cervical length 20-32 mm, and 27% (13/56) for cervical length >32 mm. These rates were 4, 22 and 33%, respectively, in nulliparous women. In the semi-Bayesian analysis, the odds ratio for cesarean section was 6.2 (95% confidence interval 2.2-43) for cervical length 20-32 mm and 10 (95% confidence interval 4.8-74) for cervical length >32 mm compared with the lowest quartile of cervical length, after adjusting for maternal age, parity, height, prepregnancy body mass index, gestational diabetes, induction of labor, neonatal sex and birthweight centile. Cervical length at 37 weeks of gestation is associated with intrapartum cesarean section.

Is ultrasound measured fetal biometry predictive of intrapartum caesarean section for failure to progress?

There are global concerns regarding excessive caesarean rates, which could be reduced by identification of risk factors leading to preventative measures such as induction of labour. This study aims to describe the association between antenatal ultrasound and emergency caesarean section for: (i) failure to progress; (ii) other indications; and (iii) any indication. Women who had an ultrasound in pregnancy between 36(+0/7) to 38(+6/7) weeks at Royal Prince Alfred Hospital from January 2005 to June 2009 were included. Ultrasound parameters were linked to clinical parameters from the maternity database. Missing clinical data were imputed and multiple logistic regression performed. Fetal biometry data were available for 2006 pregnancies. After adjusting for maternal age, height, body mass index, parity, previous caesarean section and diabetes, caesarean section for failure to progress was associated with estimated fetal weight (odds ratio (OR) 2.24 (95% CI: 1.76-2.84) per 500g increase); or biparietal diameter (OR 1.51 (1.16-1.97) per 5mm increase) and abdominal circumference (OR for the 4th quartile (>75th centile) compared with the 10-25th centile group was 2.09 (1.13-3.85)).* There were also non-linear associations between components of fetal biometry and caesarean section for fetal distress and for any indication. Components of fetal biometry in the third trimester are associated with intrapartum caesarean section for failure to progress. These parameters could be incorporated into models to predict emergency caesarean section which could lead to implementation of preventative strategies. *[Corrections added on 29 January 2018, after first online publication, '(OR for the 4th quartile (>7th centile)' has been changed to '(OR for the 4th quartile (>75th centile)'.].

Predictors of cephalopelvic disproportion in labour a tertiary hospital in Bayelsa State, Nigeria

Background: Cephalopelvic disproportion (CPD) is a disparity between the fetal head and maternal pelvis, usually in the absence of fetal or maternal jeopardy. It is a very common complication during labour, and it is associated with a very high caesarean section rate. Delay in intervention could lead to obstructed labour. Short stature, fetal macrosomia and pelvic abnormalities are common risk factors. The aim of this study was to determine the influence of maternal height, age, clinical pelvimetry, and birth weight on cephalopelvic disproportion in the Niger Delta University Teaching Hospital, Bayelsa State. Materials and Methods: This is a retrospective case controlled analysis of 5,205 parturients who received antenatal care, and delivered at the Niger Delta University Teaching Hospital, from January 2010 to December 2015. Of these, 588 patients who had cephalopelvic disproportion were identified. Data concerning their maternal age, parity, height, pelvimetry, gestational age at delivery, and fetal demographic characteristics were collected and analyzed. This was compared to a control group of 588 parturients who were randomly selected among parturients who had spontaneous vaginal delivery (SVD) during the study period. Results: A total of 5,205 women delivered during the period of study, out of these, 588 women had cephalopelvic disproportion, giving a rate of 11.3%. Majority of the women who had CPD were nulliparous (47.6%). Women who were 150.0 cm tall or less were 3 times more likely to have cephalopelvic disproportion in labour than those who were over 150.0cm tall. P = 0.001, Odds Ratio = 3.69 [CI, 2.49 -5.47]. Women who delivered babies with birth weight ≥ 4000 grams had significantly more cephalopelvic disproportion, than those who delivered babies with birth weights of 2501 – 3999 grams. Odds Ratio = 0.22, p = 0.001 [CI, 0.14 -0.33]. There is a significant negative correlation between maternal height and parity with cephalopelvic disproportion. [r = -295, p = 0.001] and [r = -197, p = 0.001] respectively. There is also a significant positive correlation between birth weight and gestational age at deliverywith CPD [r = 0.24, p = 0.001] and [r = 0.149, p = 0.001]. Linear regression analysis of the independent variables reveal that maternal height was the biggest predictor to CPD. Coefficient of determination R2 = 0.089(8.9%), F= 112.2, p = 0.001. Conclusion: Short stature is independently associated with an increased risk of intrapartum caesarean section in Nigerian women. We advocate for an early recourse to caesarean section to avoid undue morbidity.

Study protocol: the Labor Progression Study, LAPS - does the use of a dynamic progression guideline in labor reduce the rate of intrapartum cesarean sections in nulliparous women? A multicenter, cluster randomized trial in Norway

BackgroundThe increasing rate of intrapartum cesarean sections is subject of attention and concern as it is associated with adverse outcomes. Labor dystocia is one of the most frequent indications for cesarean sections even though there is no consensus on criteria for labor dystocia. Traditionally the progression of labor follows guidelines based on Friedman’s curve from the mid 1950s. In 2010 Zhang presented a new labor curve and a dynamic guideline for labor progression based on contemporary research. The main aim of this trial is to evaluate whether adhering to Zhang’s guideline for labor progression, changes the intrapartum cesarean section rate in nulliparous women without jeopardising maternal and neonatal outcomes compared to a traditional guide line called the 4-h action line based on Friedman’s curve.Methods/designA multicenter cluster randomized trial including 14 birth care units in Norway is conducted. Seven units are randomized to use the 4-h action line guideline for labor progression and seven units are randomized to use Zhang’s new dynamic guideline for labor progression, for all nulliparous women with a singleton fetus in a cephalic presentation and spontaneous onset of labor at term. Clinical outcomes are compared between the groups. The determination of the sample size (number of clusters and individuals) is based on a power calculation of intrapartum cesarean section, which is 9.2% in the study population (p1). Further, we expect that the intrapartum cesarean section rate will be 6.7% (p2) which is a 25% reduction, when using the new guideline. With a chosen significance level of 0.05, a power of 80% and p1 = 9.2% and p2 = 6.9%, we should include at least 14 clusters and 6582 individuals.DiscussionClinical consequences when using the guideline by Zhang have, to the best of our knowledge, not been investigated earlier. The results will provide a strong basis to make a qualified decision on whether it is beneficial to introduce a dynamic labor progression curve in contemporary obstetrics both nationally and internationally.Trial registrationClinicaltrials, NCT02221427

Failure after cerebrospinal fluid flow and success after no cerebrospinal fluid flow during spinal anesthesia induction for intrapartum cesarean section -A report of two cases-

Failure after cerebrospinal fluid flow and success after no cerebrospinal fluid flow during spinal anesthesia induction for intrapartum cesarean section -A report of two cases-

Does ultrasound measured cervical length at 37 weeks' gestation predict intrapartum caesarean section?

Does ultrasound measured cervical length at 37 weeks' gestation predict intrapartum caesarean section?

Is Ultrasound Measured Fetal Biometry Predictive of Intrapartum Cesarean Section for Failure to Progress?

Is Ultrasound Measured Fetal Biometry Predictive of Intrapartum Cesarean Section for Failure to Progress?

A comparison of intrapartum interventions and adverse outcomes by parity in planned freestanding midwifery unit and alongside midwifery unit births: secondary analysis of \u2018low risk\u2019 births in the birthplace in England cohort

BackgroundFor low risk women, there is good evidence that planned birth in a midwifery unit is associated with a reduced risk of maternal interventions compared with planned birth in an obstetric unit. Findings from the Birthplace cohort study have been interpreted by some as suggesting a reduced risk of interventions in planned births in freestanding midwifery units (FMUs) compared with planned births in alongside midwifery units (AMUs). However, possible differences have not been robustly investigated using individual-level Birthplace data.MethodsThis was a secondary analysis of data on ‘low risk’ women with singleton, term, ‘booked’ pregnancies collected in the Birthplace national prospective cohort study. We used logistic regression to compare interventions and outcomes by parity in 11,265 planned FMU births and 16,673 planned AMU births, adjusted for potential confounders, using planned AMU birth as the reference group. Outcomes considered included adverse perinatal outcomes (Birthplace primary outcome measure), instrumental delivery, intrapartum caesarean section, ‘straightforward vaginal birth’, third or fourth degree perineal trauma, blood transfusion and maternal admission for higher-level care. We used a significance level of 1% for all secondary outcomes.ResultsThere was no significant difference in adverse perinatal outcomes between planned AMU and FMU births. The odds of instrumental delivery were reduced in planned FMU births (nulliparous: aOR 0.63, 99% CI 0.46–0.86; multiparous: aOR 0.41, 99% CI 0.25–0.68) and the odds of having a ‘straightforward vaginal birth’ were increased in planned FMU births compared with planned AMU births (nulliparous: aOR 1.47, 99% CI 1.17–1.85; multiparous: 1.86, 99% CI 1.35–2.57). The odds of intrapartum caesarean section did not differ significantly between the two settings (nulliparous: p = 0.147; multiparous: p = 0.224). The overall pattern of findings suggested a trend towards lower intervention rates and fewer adverse maternal outcomes in planned FMU births compared with planned AMU births.ConclusionsThe findings support the recommendation that ‘low risk’ women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of ‘straightforward vaginal birth’ compared with planned birth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs.

Double-balloon catheter for induction of labour in women with a previous cesarean section, could it be the best choice?

IntroductionWe analysed the efficacy and safety of double-balloon catheter for cervical ripening in women with a previous cesarean section and which were the most important variables associated with an increased risk of repeated cesarean delivery.Materials and methodsWe designed an observational retrospective study of 418 women with unfavourable cervices (Bishop Score <5), a prior cesarean delivery, and induction of labour with a double-balloon catheter. Baseline maternal data and perinatal outcomes were recorded for a descriptive, bivariate, and multivariate analysis. A p value <0.05 was considered statistically significant.ResultsMost women improved their initial Bishop Score (89.5%) although only a 20.8% of them went into spontaneous active labour. Finally, 51.4% of the women achieved a vaginal delivery. Five cases of intrapartum uterine rupture (1.2%) occurred. After multivariate analysis, main risk factors for repeated cesarean section were dystocia in the previous pregnancy (OR 1.744; CI 95% 1.066–2.846), the absence of previous vaginal delivery (OR 2.590; CI 95% 1.066–6.290), suspected fetal macrosomia (OR 2.410; CI 95% 0.959–6.054), and duration of oxytocin induction period (OR 1.005; CI 95% 1.004–1.006). The area under the curve was 0.789 (p < 0.001).ConclusionsDouble-balloon catheter seems to be safe and effective for cervical ripening in women with a previous cesarean delivery and unfavourable cervix. In our study, most women could have a vaginal delivery in spite of their risk factors for cesarean delivery. A multivariate model based on some clinical variables has moderate predictive value for intrapartum cesarean section.

Labour in women with gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) constitutes one of the most common pregnancy complications and affects 3-5% of all pregnancies, with its incidence still growing. Due to possible maternal and fetal complications, the peripartum management of GDM patients continues to be a debatable issue. The aim of the study was to analyse the course and final way of delivery in women with gestational diabetes mellitus. The effectiveness of induction of labour (IOL) was also assessed and factors predisposing to cesarean section were identified. The study group consisted of 204 women with GDM who delivered in the Academic Centre for Woman's and Neonate's Health in Warsaw over the years 2013 and 2014. The indications and ratios of elective and intrapartum cesarean sections were analysed. Patients qualified for induction of labour were compared depending on their final way of delivery. Over a half of all deliveries in the study group (53%) were cesarean sections. Elective surgeries accounted for 70% of all cesarean sections, predominantly due to a history of previous operational deliveries. Only 12% of the study group developed spontaneous uterine contractions and delivered vaginally. A comparison of the vaginal delivery group (n = 96) with cesarean section group (n = 108) pointed to high pregestational BMI value and advanced maternal age as factors increasing the patient's risk for surgical delivery (p = 0.0000 and p = 0.048 accordingly). The comparison of women undergo-ing IOL vs. omen with spontaneous uterine contractions showed no increase in the ratio of intrapartum cesarean sections in the IOL group - in both subgroups vaginal delivery was achieved in 75% of cases. Patients with GDM are more likely to undergo cesarean section, but the implementation of induction of labour at term does not further aggravate this risk. Major risk factors for operational delivery in GDM population included: advanced maternal age, high pregestational BMI value and undergoing insulin therapy.

Comparing epidural surgical anesthesia and spinal anesthesia following epidural labor analgesia for intrapartum cesarean section: a prospective randomized controlled trial.

BackgroundThe conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often fails, resulting in intraoperative pain. Spinal anesthesia (SA) can provide a denser sensory block than ESA. The purpose of this prospective, non-blinded, parallel-arm, randomized trial was to compare the rate of pain-free surgery between ESA and SA following ELA for intrapartum CS.MethodsBoth groups received continuous epidural infusions for labor pain at a rate of 10 ml/h. In the ESA group (n = 163), ESA was performed with 17 ml of 2% lidocaine mixed with 100 µg fentanyl, 1 : 200,000 epinephrine, and 2 mEq bicarbonate. In the SA group (n = 160), SA was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 µg fentanyl. We investigated the failure rate of achieving pain-free surgery and the incidence of complications between the two groups.ResultsThe failure rate of achieving pain-free surgery was higher in the ESA group than the SA group (15.3% vs. 2.5%, P < 0.001). There was no statistical difference between the two groups in the rate of conversion to general anesthesia; however, the rate of analgesic requirement was higher in the ESA group than in the SA group (12.9% vs. 1.3%, P < 0.001). The incidence of high block, nausea, vomiting, hypotension, and shivering and Apgar scores were comparable between the two groups.ConclusionsSA after ELA can lower the failure rate of pain-free surgery during intrapartum CS compared to ESA after ELA.

Immediate impact of physiology based training and introduction of fetal ECG on intrapartum caesarean section rate

Immediate impact of physiology based training and introduction of fetal ECG on intrapartum caesarean section rate