Likelihood Of Caesarean Section Research Articles

Longitudinal change in cerebro-placental ratio (CPR) between 37 and 40 weeks of pregnancy is associated with non-reassuring fetal status and increased risk of cesarean section

Objective To evaluate in low-risk pregnancies if longitudinal change in cerebro-placental ratio (CPR) between 37 and 40 weeks of pregnancy is associated with cesarean section (CS) for non-reassuring fetal status (NRFS) during labor. Methods This is a prospective observational study of women with singleton low-risk pregnancies who underwent an ultrasound scan at 36 + 0 to 37 + 6 and 39 + 0 to 41 + 6 weeks of pregnancy, when the CPR was calculated from the middle cerebral artery (MCA) and umbilical artery (UA) pulsatility indices. Managing professionals were kept blinded to the Doppler results. The association of the longitudinal change between both CPR (z-velocity) to CS for NRFS was evaluated by logistic regression. Results A total of 401 pregnancies were included. The mean time interval between both CPR evaluations was 21 days (SD 7). A CS for fetal distress was performed in 7% of pregnancies. Independent of the CPR at 37 weeks, the likelihood of CS for fetal distress was significantly decreased by the longitudinal changes from 37 to 40 weeks (OR 0.61, 95%CI 0.4–0.92; p=.018). This association remained significant after further adjustment for potential confounders (nulliparity, maternal weight at booking and estimated fetal weight at 37): (OR 0.64, 95%CI 0.41–0.98; p=.044). Conclusions The longitudinal change of CPR between 37 and 40 weeks is associated with the need for CS for NRFS during labor.

The Rate of and Factors Associated with Delivery by Caesarean Section among Women with Epilepsy: Time Trend in a Single-Centre Cohort in Mazovia, Poland.

Data from literature suggest that the rate of caesarean section (CS) in women with epilepsy (WWE) is higher than in the general population. In Poland, there is neither a national registry nor another data set to access the outcome of pregnancy in WWE. Therefore, we address this gap by prospectively studying CS rates among 1021 WWE pregnancies at a single centre, their trends over time, and factors increasing the likelihood of the CS. To determine whether the diagnosis of epilepsy itself increased this likelihood, mixed models were used to analyse the contributions of specific variables, including the presence of seizures at different pregnancy-related timepoints. Over 20 years, the mean rate of CS in WWE was progressively growing and was higher than in the general population in Mazovia (47% vs. 32%). Generalized seizures in the third trimester increased the likelihood of CS with the highest odds (OR 4.4). The most frequent indication for a CS was obstetric (58.1%), followed by epilepsy-related (25.2%). Almost half of women who indicated epilepsy as the sole reason for CS had no seizure during pregnancy, and nearly 70% did not have generalized seizures. This suggests the overuse of epilepsy as an indication of CS and encourages defining more strict criteria.

Multilevel analysis to identify the factors associated with caesarean section in Bangladesh: evidence from a nationally representative survey.

Caesarean delivery has a significant role in reducing maternal and child death. However, unnecessary utilization has adverse health effects. This study aimed to assess the prevalence and associated factors of caesarean delivery in Bangladesh. Data from the latest Bangladesh Multiple Indicator Cluster Survey (MICS, 2019) was used in this study. Since MICS data are hierarchical in nature, multilevel modelling was used. The prevalence of caesarean section (CS) was 67.4% among Bangladeshi women. Multilevel analysis suggests the age of the women, household wealth status, utilization of antenatal care (ANC) , delivery at a health facility and division were significantly associated with CS. Women who delivered in a private health facility had the highest odds for CS (odds ratio [OR] 10.35 [95% confidence interval {CI} 8.55 to 12.54]). Women 30-34y of age had a 36% higher likelihood of CS compared with women 15-19y of age (OR 1.36 [95% CI 1.03 to 1.79]). The odds of CS positively increased with household wealth status. Women who had at least one ANC visit had a 1.7 times higher possibility of CS (OR 1.70 [95% CI 1.26 to 2.30]). Policy guidelines on caesarean deliveries are urgently needed in Bangladesh to avoid unnecessary caesarean deliveries and protect mothers from the consequences.

Maternal and fetal characteristics for predicting risk of Cesarean section following induction of labor: pooled analysis of PROBAAT trials

Induction of labor (IOL) is one of the most widely used obstetric interventions. However, one-fifth of IOLs result in Cesarean section (CS). We aimed to assess maternal and fetal characteristics that influence the likelihood of CS following IOL, according to the indication for CS. This was a secondary analysis of pooled data from four randomized controlled trials, including women undergoing IOL at term who had a singleton pregnancy and an unfavorable cervix, intact membranes and the fetus in cephalic presentation. The main outcomes of this analysis were CS for failure to progress (FTP) and CS for suspected fetal compromise (SFC). Restricted cubic splines were used to determine whether continuous maternal and fetal characteristics had a non-linear relationship with outcome. Optimal cut-offs for those characteristics with a non-linear pattern were determined based on the maximum area under the receiver-operating-characteristics curve. Adjusted odds ratios (aOR) were computed, using multivariable logistic regression analysis, for the associations between optimally categorized characteristics and outcome. Of a total of 2990 women undergoing IOL, 313 (10.5%) had CS for FTP and 227 (7.6%) had CS for SFC. The risk of CS for FTP was increased in women aged 31-35 years compared with younger women (aOR, 1.51 (95% CI, 1.15-1.99)), in nulliparous compared with parous women (aOR, 8.07 (95% CI, 5.34-12.18)) and in Sub-Saharan African compared with Caucasian women (aOR, 2.09 (95% CI, 1.33-3.28)). Higher body mass index (BMI) increased incrementally the risk of CS for FTP (aOR, 1.06 (95% CI, 1.04-1.08)). High birth-weight percentile was also associated with an increased risk of CS due to FTP (aOR, 2.66 (95% CI, 1.74-4.07) for birth weight between the 80.0th and 89.9th percentiles and aOR, 4.08 (95% CI, 2.75-6.05) for birth weight ≥ 90th percentile, as compared with birth weight between the 20.0th and 49.9th percentiles). For CS due to SFC, higher maternal age (aOR, 1.09 (95% CI, 1.05-1.12)) and BMI (aOR, 1.05 (95% CI, 1.03-1.08)) were associated with an incremental increase in risk. The risk of CS for SFC was increased in nulliparous compared with parous women (aOR, 5.91 (95% CI, 3.76-9.28)) and in South Asian compared with Caucasian women (aOR, 2.50 (95% CI, 1.23-5.10)). Birth weight < 10.0th percentile increased significantly the risk of CS due to SFC (aOR, 1.93 (95% CI, 1.22-3.05)), as compared with birth weight between the 20.0th and 49.9th percentiles. Bishop score did not demonstrate a significant association with the risk of CS for FTP or for SFC. In women undergoing IOL, maternal age, BMI, parity, ethnicity and birth-weight percentile are predictors of CS due to FTP and of CS due to SFC, but the direction and magnitude of the associations differ according to the indication for CS. These characteristics should be considered in combination with the Bishop score to stratify the risk of CS for different indications in women undergoing IOL. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

411 Predicting caesarean section risk following induction of labour: a pooled analysis of PROBAAT trials

Up to 45% of Induction of labour (IOL) end with caesarean section (CS). Currently, the Bishop Score is a widely used prognostic tool for vaginal delivery but conversely, little is known about risk factors for CS following IOL. We aimed to assess maternal and fetal characteristics that influence likelihood of CS following IOL. A secondary analysis of pooled data from PROBAAT I, M, P and II trials. Co-primary outcomes were CS for failure to progress (FTP) or CS for suspected fetal compromise (SFC). Restricted cubic spline was used to explore non-linear relationships. Optimal cut-offs for non-linear patterns were determined with maximised Area Under the Curve. Adjusted odds ratios were computed with logistic regression using multiple imputed (m=30) dataset. Among a total of 2990 women, 540 had a CS, 313 for FTP and 227 for SFC. Regarding the risk of CS for FTP, women aged 30-35 were at elevated risk (aOR 2.32, 95% CI 1.15-1.99) compared with younger women. Nulliparous women had higher risk than multiparous women (aOR 8.07, CI 5.34-12.18). Incremental BMI increased the risk (aOR 1.06, CI 1.04-1.08). Higher birthweight percentile, using 20-49.9% as reference, was also a risk factor for CS due to FTP (for 80-89.9%, aOR 2.66, CI 2.71-4.07; for ≥90% aOR 4.08, CI 2.75-6.05). For CS due to SFC, incremental maternal age (aOR 1.09, CI 1.05-1.12) and BMI (aOR 1.05, CI 1.03-1.08) are associated with increased risk. Compared with multiparous women, nulliparous women had increased risk (aOR 5.91, CI 3.76-9.28). Low birthweight percentile (<10%) carried significantly higher risk for CS due to SFC (aOR 1.93, CI 1.22-3.05) compared to those in the 20-49.9% . Maternal age, BMI, parity, and birthweight percentile are strong predictors of CS following IOL both for FTP and SFC. These characteristics should be considered in combination with Bishop score to stratify risk of failure for women who are undergoing IOL.

Pregnancy outcomes amongst adolescents/young adults at tertiary-care hospital in a low-middle-income country: Ten-year retrospective record review.

Adolescent pregnancies are known to be associated with adverse outcomes. Our objective was to compare pregnancy outcomes amongst adolescents (young adolescents YA: 15-17 years; older adolescents OA: 18- 19 years) and young adults (20 to 25 years). Study was conducted at the Aga Khan University Hospital, Karachi. Ten-year retrospective record review was done through convenience sampling. Data was collected on predesigned proforma. Participants were 396 primiparous adolescents (15-19 years) with singleton low-risk pregnancy. Reference-group included 410 primiparous, low-risk, young adults. Pregnancies complicated with preexisting diabetes mellitus, chronic hypertension, renal disorders or cardiac diseases were excluded. Maternal /neonatal outcomes were compared amongst groups. Out of 806 charts reviewed, 75 (9.3%) were YA, 321 (39.8%) were OA and 410 (50.9%) were 20-25 years old young adults. Most of the un-booked cases were in young adolescents; 17 (22.7% YA), 41 (12.8% OA) and 33 (8.0% reference -group) (p-value 0.001). This group also booked at a later gestational age; YA (19.6±10.4 weeks), OA (17.2±9.3 weeks) and controls (15.5n±8.8 weeks) (p-value 0.002). Gestational age at delivery was not significantly different among the groups. Adolescents had a decreased likelihood of Caesarian section with youngest group having 29% less chance of Caesarian delivery (OR 95% CI 0.41, 0.2) compared to women of 20-25 years of age. Difference in maternal/neonatal outcomes remained insignificant between groups at univariate and multivariate analysis. Maternal/neonatal outcomes in adolescents were comparable to young adults. Good antenatal care, evidence-based protocols and strong family backing may reduce risks to mothers/babies in adolescent pregnancies.

Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours

BackgroundNumerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PurposeWe examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. MethodsThis retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DiscussionWhile a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our ‘optimal staffing’ model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Does the Day of the Week Predict a Cesarean Section? A Statewide Analysis

BackgroundAlthough guidelines for clinical indications of cesarean sections (CS) exist, nonclinical factors may affect CS practices. We hypothesize that CS rates vary by day of the week. MethodsAn analysis of the Office of Statewide Health Planning and Development database for California from 2006 to 2010 was performed. All patients admitted to a teaching or nonteaching hospital for attempted vaginal delivery were included. Patients who died within 24 h of admission were excluded. Weekend days were defined as Saturday and Sunday, and weekdays were defined as Monday to Friday. The primary outcome was CS versus vaginal delivery. Multivariable analysis was performed, adjusting for patient demographics, clinical factors, and system variables. ResultsA total of 1,855,675 women were included. The overall CS rate was 9.02%. On unadjusted analysis, CS rates were significantly lower on weekends versus weekdays (6.65% versus 9.58%, P < 0.001). On adjusted analysis, women were 27% less likely to have a CS on weekends than on weekdays (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.71-0.75, P < 0.001). In addition, Hispanic ethnicity and delivery in teaching hospitals were associated with a decreased likelihood of CS (OR 0.91, 95% CI 0.86-0.96, P = 0.01; OR 0.80, 95% CI 0.69-0.93, P < 0.001, respectively). ConclusionsCS rates are significantly decreased on weekends relative to weekdays, even when controlling for patient, hospital, and system factors.

Caesarean Section rate amongst Obstetricians at a tertiary-care hospital of Karachi.

Objective:To analyze the Caesarean Section (CS) rate among different groups of consultants dealing with Nulliparous Term Singleton pregnancy with Vertex (NTSV) presentation delivering at a tertiary care hospital of Karachi over four months.Methods:This is a secondary analysis of a retrospective data that analyzed factors affecting the CS-rate of NTSV patients. Patients with CS (n=106) were taken as cases and vaginal deliveries (n=106) as controls. This was an unmatched retrospective case-control study.Results:Mean age of patients was 26.6(SD: 4.2) years. Mean gestational-age was 38.6(SD: 1.0) weeks. Likelihood of CS was slightly less in patients who were attended by feto-maternal consultants(OR:0.81 CI:0.38-1.07) and was slightly more in patients managed by non-full-time faculty (OR:1.04 CI:0.59-1.85). Odds of CS was highest amongst consultants having average monthly volumes of 21-30 patients/month (OR:1.069 CI:0.48-2.34). However none of the above findings were statistically significant. A non-significant increase in risk of CS was observed with increase in experience of physicians (p=0.787).Conclusion:The results did not show statistically significant difference in CS rate among different groups of Obstetricians. This might indicate that managing labour according to standard guidelines can eliminate physicians’ bias. This can be further evaluated with larger multicenter prospective studies.

Medical costs, Cesarean delivery rates, and length of stay in specialty hospitals vs. non-specialty hospitals in South Korea.

BackgroundSince 2011, specialty hospitals in South Korea have been known for providing high- quality care in specific clinical areas. Much research related to specialty hospitals and their performance in many such areas has been performed, but investigations about their performance in obstetrics and gynecology are lacking. Thus, we aimed to compare specialty vs. non-specialty hospitals with respect to mode of obstetric delivery, especially the costs and length of stay related to Cesarean section (CS) procedures, and to provide evidence to policy-makers for evaluating the success of hospitals that specialize in obstetric and gynecological (OBGYN) care.MethodsWe obtained National Health Insurance claim data from 2012 to 2014, which included information from 418,141 OBGYN cases at 214 hospitals. We used a generalized estimating equation model to identify a potential association between the likelihood of CS at specialty hospitals compared with other hospitals. We also evaluated medical costs and length of stay in specialty hospitals according to type of delivery.ResultsWe found that 150,256 (35.9%) total deliveries were performed by CS. The odds ratio of CS was significantly lower in specialty hospitals (OR: 0.95, 95% CI: 0.93–0.96compared to other hospitals Medical costs (0.74%) and length of stay (1%) in CS cases increased in specialty hospitals, although length of stay following vaginal delivery was lower (0.57%) in specialty hospitals compared with other hospitals.ConclusionsWe determined that specialty hospitals are significantly associated with a lower likelihood of CS delivery and shorter length of stay after vaginal delivery. Although they are also associated with higher costs for delivery, the increased cost could be due to the high level of intensive care provided, which leads to improve quality of care. Policy-makers should consider incentive programs to maintain performance of specialty hospitals and promote efficiency that could reduce medical costs accrued by patients.

Predictors of mode of birth and duration of labour following induction using prostaglandin vaginal gel.

Using data from a randomised controlled trial (RCT) comparing two policies of prostaglandin (PGE2) vaginal gel induction of labour (IOL) at term, this study aimed to determine: (i) demographic/clinical factors that predict IOL outcomes; and (ii) clinical characteristic(s) of women who would benefit from a policy of amniotomy once technically possible as opposed to giving more PGE2. Following an initial PGE2 dose, women were randomised to amniotomy or repeat-PGE2. Using RCT data, two multivariate models were developed, assessing the relationship between demographic/clinical characteristics and the outcomes of caesarean section (CS), and vaginal delivery within 24h (VD<24h). Regression-equations were used to predict the likelihood of CS and VD<24h, varying independent predictors from the multivariate analyses. Of 245 term women undergoing IOL, 90 had a CS, 155 delivered vaginally and 79 had a VD<24h. Controlling for confounders, nulliparity [adjusted odds ratio (aOR)=3.71 (1.55, 8.88)] and modified Bishop's score (MBS) at first review [aOR=0.78 (0.66, 0.92)] were independently associated with CS. Nulliparity [aOR=0.06 (0.02, 0.15)], MBS at first review [aOR=1.66 (1.35, 2.05)], and a policy of early amniotomy [aOR=2.28 (1.04, 5.00)] were associated with VD<24h. Modelling using regression equations, and varying both MBS at first review and parity, there was no scenario where repeat PGE2 was predicted to be superior to an earlier amniotomy. Following IOL using PGE2 vaginal gel at term, both parity and cervical favourability at first review are associated with CS and VD<24h. All combinations of parity and MBS at first review predicted fewer CS and greater likelihood of VD<24h with a policy of amniotomy once technically possible.

Characterization of potentially avoidable cases in a 1-year series of consecutive cesarean sections in the tertiary maternity unit of Guadeloupe (French West Indies).

The global increase in the rate of cesarean sections (CS) is currently an issue. We aimed to assess the rate of CS locally and to identify cases in which this procedure may have been avoidable. In this prospective consecutive series, we analyzed the 478 CS carried out in our unit in 2009. We analyzed the characteristics of each case, and classified each as potentially avoidable or unavoidable. The total rate of CS was 24.0%, including 1.7% that was scored as potentially avoidable. Parity, gestational age at birth, birthweight, cases requiring cervical ripening, cases of labor induction, and CS during labor were all significantly higher or more frequent among potentially avoidable CS. Multivariate analysis indicated that the risk of potentially avoidable CS was positively associated with gestational age and tended to be negatively associated with parity. The main indications for potentially avoidable CS were cervical dystocia and abnormal fetal heart rate, and for unavoidable CS they were abnormal fetal heart rate and history of previous CS. Labor, especially when induced, seems to be the key period for the prevention of 'avoidable' CS. This is particularly important given that potentially avoidable CS are more frequently associated with uncomplicated pregnancies than are unavoidable CS. A woman's first CS increases the likelihood of CS for subsequent deliveries, so the prevention of the first CS is a key aim for reducing the overall rate of CS.

Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database.

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project--a 20% sample of US hospitals--we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors-such as hospital policies, practices, and culture--in determining cesarean section use. Please see later in the article for the Editors' Summary.

An Analysis of the NSW Midwives Data Collection over an 11-Year Period to Determine the Risks to the Mother and the Neonate of Induced Delivery for Non-Obstetric Indication at Term.

Objective. To determine the risks of induced term delivery to the mother and neonate at different gestational ages in the absence of obstetric indications. Study Design. All deliveries in New South Wales (NSW) between 1998 and 2008 were reviewed from the MDC. Uncomplicated pregnancies which were induced for non-obstetric reasons after 37 completed weeks were reviewed. This was a retrospective, historical cohort study, and both maternal and neonatal outcomes were analysed and compared between different gestational age groups. Results. An analysis of the data shows that induction of labour after 37 completed weeks exposes the fetus and mother to different levels of risk at different gestations. Conclusion. In an uncomplicated pregnancy, induction of labour is associated with the highest rate of neonatal complication at 37 weeks as compared with rates at later gestations. With each ensuing week, the neonatal outcome improves. At 40 weeks the likelihood of neonatal intensive care admission, low Apgar scores, and perinatal death rate is at its lowest, and then there is a slight but not significant rise after 41 weeks. The likelihood of caesarean section is the lowest when inductions are carried out at 39 weeks and is the highest at 41 weeks and over.

Do Mothers Decide?: The Impact of Preferences in Healthcare

In this study we analyze whether immigrant mothers in Norway can influence their mode of delivery. Patient preferences were measured as the rate of Caesarean section from their home country, and by a survey question measuring the extent to which people believe they have freedom of choice and control over their lives in their home country. Preferences have a causal effect on the likelihood of Caesarean section. Medical risk factors are still the most important reasons for having a Caesarean section, but our regression estimates show that a substantial share of Caesarean sections is due to preferences as well.

‘Planned home birth reduces likelihood of caesarean section’

Last month’s ‘Hot Topic’ focused on the recent guideline on caesarean section published by the National Institute for Health and Clinical Excellence (NICE) (2011). It compared the sensational headlines generated by the guideline, e.g. ‘Women promised caesarean section on demand!’, with the reality of the actual content of the guideline which is more broad and complex than such headlines would suggest. However, members of the public do not, on the whole, access the whole guideline, and often believe the newspaper headlines. Many midwives in clinical practice have noticed and commented on the reaction of pregnant women and their partners to the newspaper coverage of the guideline. An increase in request for elective caesarean has been widely noted, with women expressing relief that they believed they could now opt for a caesarean section. These requests have not, in the main, come from women who have serious fears or a phobia about birth; rather they reflect the current crisis in women’s confidence in their ability to give birth, and the rising anxiety levels of partners and members of their families and communities. This is a major challenge to us as midwives. Rebuilding women’s confidence is absolutely key to helping them rediscover their ability to labour and to birth their babies, without surgical intervention. There are other elements of the NICE guideline which could, potentially, be equally ‘headline-grabbing’. Two of these elements (which were also contained in the 2004 NICE guideline on caesarean section) are concerned with place of birth and support in labour. So one headline could read: ‘Planned home birth reduces caesarean section rates!’ Both the 2004 and draft 2011 guidance documents advise that healthy pregnant women with ‘anticipated uncomplicated pregnancy’ should be informed that: ‘Planning a home birth reduces the likelihood of CS’ (NICE, 2011: 7).

The Risk of Cesarean Delivery in Short Saudi Women

Objectives: To evaluate the relationship between maternal height of 37 weeks), uncomplicated singleton nulliparous pregnant women were enrolled on admission to labour room. The patients were divided into two groups based on maternal height, >155 cm (247 cases) as control and < 155 cm (158 cases) as study group. The medical records of these women were reviewed. Various baseline clinical characteristics were collected. Maternal characteristics and maternal and neonatal outcomes were recorded. Results: Caesarean section rate for all indications was higher among study group than control group (26.6% and 19.4% respec-tively, p = 0.023). Significant difference was observed in the rate of caesarean delivery due to failure to progress (7.3% and 12% in control and study group respectively, p-value 0.038). The rate of caesarean delivery due to failure to progress was highest among those with height 150 - 155 cm (p-value 0.022). Mean birth weight was significantly higher among control group than study group (3137 ± 403 g and 3030 ± 408 respectively, p-value 0.010). Conclusion: Term singleton nulliparous Saudi pregnant women with maternal height 151 - 154 cm were associated with a greater likelih-ood of caesarean section for failure to progress. Women with height <150 cm did not have increased cesarean section rate. However, mean birth weight was significantly lower in this group.

Prenatal diagnosis and cesarean section in a large, population-based birth defects registry

Objective. To describe the patterns of cesarean section (CS) and vaginal delivery by type of birth defect and determine whether prenatal diagnosis predicts a higher or lower likelihood of CS for selected defect categories.Methods. Data from a large population-based registry were analyzed to determine percentages of vaginal versus CS delivery for each of 49 categories of birth defects. Odds ratios and statistical significance were computed to determine if a record of prenatal diagnosis (PND) predicted delivery mode. Cases were liveborn children with any of these defects born in Texas between 1997 and 2005.Results. Forty-three percent of infants in the study were delivered by CS, with a range of 25.3% (aniridia) to 62.4% (spina bifida). A record of prenatal diagnosis of the primary assigned birth defect was found in 43.0% of all records but varied substantially by defect category. PND significantly predicted higher CS percentages for spina bifida without anencephaly, encephalocele, hydrocephaly, transposition of the great vessels, ventricular septal defect, pulmonary valve atresia/stenosis, craniosynostosis, diaphragmatic hernia, gastroschisis, and trisomy 21. Vaginal delivery was predicted by PND of anencephaly, agenesis, aplasia, or hypoplasia of the lung, renal agenesis or dysgenesis, and trisomy 18.Conclusion. Texas children with birth defects are more likely to have been delivered by CS than the population in general. For several types of defects, prenatal diagnosis is predictive of higher odds of CS; for others, especially fatal defects, PND predicts lower CS likelihood.

Urbanization and the likelihood of a cesarean section

Objective This study examines the association between the likelihood of cesarean section (CS) and the degree of urbanization in Taiwan, exploring possible explanations for the difference. Study design The database used in this study was the Taiwan 2004 National Health Insurance Research Database. A total of 200,207 singleton deliveries fulfilled our criteria and were included in our study. The urbanization level of cities/towns where parturients resided at the time of delivery was stratified into seven categories. A multilevel logistic regression model was applied to examine the relative likelihood of CS by urbanization level after adjusting for parturient, physician and hospital characteristics. Results There was an upward trend in the CS rate with advancing urbanization level; the CS rates for urbanization level 1 (most urbanized) through 7 (least urbanized) were 33.7, 32.3, 30.4, 30.2 29.7, 29.5, and 28.6%, respectively. Compared with participants living at the highest urbanization level, the adjusted odds of a CS were 0.91 (95% CI = 0.85–0.98, p = 0.014), 0.84 (95% CI = 0.78–0.91, p < 0.001), 0.83 (95% CI = 0.68–0.88, p < 0.001), 0.79 (95% CI = 0.72–0.86, p < 0.001), and 0.70 (95% CI = 0.62–0.80, p < 0.001) times, respectively, for those living in cities/towns ranked from the third highest to the lowest levels of urbanization. Conclusions We conclude that higher urbanization levels were associated with higher odds of CS. Highly urbanized communities could therefore be targeted for policy intervention aimed at reducing the unnecessary CS rate.

Epidural analgesia associated with low-dose oxytocin augmentation increases cesarean births: A critical look at the external validity of randomized trials

Randomized controlled trials suggest epidural analgesia (EA) does not increase the frequency of cesarean births compared with opioid analgesia. We analyzed trials comparing EA with opioid analgesia to determine their external validity in contemporary North American practice. Randomized controlled trials comparing EA with opioid analgesia were identified from the Cochrane database and Medline and included if they reported labor outcomes and management protocols. Labor management was then compared with current obstetric practice determined from surveys of North American teaching maternity units and clinical practice guidelines. Of 19 trials identified, 8 were included. Seven trials used Active Management of Labor protocols that used high-dose oxytocin; each demonstrated no epidural-related increase in cesarean births. One trial that used low-dose oxytocin demonstrated a marked increase in cesarean births. Most large North American obstetric units use low-dose oxytocin. Randomized trials showing no effect of EA on cesarean section (CS) rate lack external validity in much of North American practice. The limited data available suggest EA and low-dose oxytocin used together increase the CS rate. Early detection of dystocia and high-dose oxytocin augmentation should be considered for women receiving EA; those delivering in low-dose oxytocin settings should be advised of a probable increase in the likelihood of CS.