Low-risk Deliveries Research Articles

Ambivalence towards childbirth in a medicalized context: a qualitative inquiry among Iranian mothers.

Background:Today, pregnant women are treated as individuals requiring medical care. Every day, more and more technologies, surgical procedures and medications are used even for low-risk childbirths. These interventions can save mothers’ lives in threatening situations, although they might be risky for mothers and neonates in low-risk deliveries. Despite the increasing interest in medical care for childbirth, our knowledge about underlying factors for development of medicalized childbirth is limited in Iran.Objectives:The purpose of this study was to provide a broad description of medicalized childbirth in Iran.Materials and Methods:In this study, a qualitative approach was applied and data was gathered via in-depth interviews. The subjects were selected via purposive sampling. Overall, 27 pregnant and postpartum women were enrolled in this study. Participants were selected from public health centers, hospitals and offices. Data analysis was performed using conventional qualitative content analysis.Results:As the results indicated, mothers preferred medicalized childbirth under the supervision of obstetricians. The subjects mostly opted for elective cesarean section; this choice led to an increase in physicians’ authority and restricted midwives’ role in childbirth. Consequently, mothers’ preference for cesarean section led to the expansion of medicalization and challenged the realization of natural childbirth. Mothers also had a strong tendency toward natural childbirth.Conclusions:Generally, many Iranian mothers choose the medicalized approach, despite their inclination to comply with the natural mode of delivery. It seems that mothers have an ambivalent attitude toward childbirth. Health authorities can prevent the adverse effects of medicalized birth and encourage natural childbirth among women using the obtained findings.

Potential of geographical variation analysis for realigning providers to value-based care. ECHO case study on lower-value indications of C-section in five European countries.

Although C-section is a highly effective procedure, literature abounds with evidence of overuse and particularly misuse, in lower-value indications such as low-risk deliveries. This study aims to quantify utilization of C-section in low-risk cases, mapping out areas showing excess-usage in each country and to estimate excess-expenditure as a proxy of the opportunity cost borne by healthcare systems. Observational, ecologic study on deliveries in 913 sub-national administrative areas of five European countries (Denmark, England, Portugal, Slovenia and Spain) from 2002 to 2009. The study includes a cross-section analysis with 2009 data and a time-trend analysis for the whole period. Main endpoints: age-standardized utilization rates of C-section in low-risk pregnancies and deliveries per 100 deliveries. Secondary endpoints: Estimated excess-cases per geographical unit of analysis in two scenarios of minimized utilization. C-section is widely used in all examined countries (ranging from 19% of Slovenian deliveries to 33% of deliveries in Portugal). With the exception of Portugal, there are no systematic variations in intensity of use across areas in the same country. Cross-country comparison of lower-value C-section leaves Denmark with 10% and Portugal with 2%, the highest and lowest. Such behaviour was stable over the period of analysis. Within each country, the scattered geographical patterns of use intensity speak for local drivers playing a major role within the national trend. The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women's access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool.

Maternal and Neonatal Outcomes in Electively Induced Low-Risk Term Pregnancies

Objective Elective induction of labor has been discouraged over concerns regarding increased complications. We evaluated the mode of delivery and maternal and neonatal morbidities in low-risk patients whose labor was electively induced or expectantly managed at term. Study Design This was a retrospective cross-sectional study from 12 US institutions (19 hospitals), 2002 through 2008 (Safe Labor Consortium). Healthy women with viable, vertex singleton pregnancies at 37-41 weeks of gestation were included. Women electively induced in each week were compared with women managed expectantly. The primary outcome was mode of delivery. Results Of 131,243 low-risk deliveries, 13,242 (10.1%) were electively induced. The risk of cesarean delivery was lower at each week of gestation with elective induction vs expectant management regardless of parity and modified Bishop score (for unfavorable nulliparous patients at: 37 weeks = 18.6% vs 34.2%, adjusted odds ratio, 0.40; [95% confidence interval, 0.18–0.88]; 38 weeks = 28.4% vs 35.4%, 0.65 [0.49–0.85]; 39 weeks = 23.6% vs 38.5%, 0.47 [0.38–0.57]; 40 weeks = 32.3% vs 42.3%, 0.70 [0.59–0.81]). Maternal infections were significantly lower with elective inductions. Major, minor, and respiratory neonatal morbidity composites were lower with elective inductions at ≥38 weeks (for nulliparous patients at: 38 weeks = adjusted odds ratio, 0.43; [95% confidence interval, 0.26–0.72]; 39 weeks = 0.75 [0.61–0.92]; 40 weeks = 0.65 [0.54–0.80]). Conclusion Elective induction of labor at term is associated with decreased risks of cesarean delivery and other maternal and neonatal morbidities compared with expectant management regardless of parity or cervical status on admission.

Should delayed cord clamping be the standard of care in term low risk deliveries? A randomized controlled trial from a medical college hospital in south India

Objective: The objective was to compare the effects of early versus delayed cord clamping (ECC vs. DCC) on immediate neonatal adverse outcomes and delayed benefits. Methodology: Prospective randomized controlled trial in mother-infant pairs who were term, singleton with uneventful pregnancies and normal vaginal deliveries. Intervention: ECC done at 10 s after birth. DCC done at 180 s after complete delivery of the fetus. Results: A sample size of 86 mothers were included, but 10 infant blood samples were discarded because they were hemolyzed. Hence final analysis was done on 76 mother-infant pairs (ECC = 39; DCC = 37). Mean serum ferritin level was 299.7 ng/ml in the ECC group versus 399.9 ng/ml in the DCC group with no significant complications in either group. Multiple regression analysis confirmed a clear relationship between DCC and serum ferritin levels after accounting for the effect of secondary variables. Conclusion: DCC should become the standard of care in all low risk singleton pregnancies.

Introduction of Routine Obstetric Ultrasound in an Urban Health Center: Results and Benefits

Background Maternal mortality ratio (MMR) in India is 200/100,000 live births, many of which are preventable. To reduce MMR, the Government of India has set up basic obstetric ultrasonography facilities in primary health centers. This service was introduced in a nurse-run, low-risk antenatal and delivery service in an urban health center. This report documents the benefit of prenatal ultrasound in an urban health center. Methods This is a retrospective observational study carried out in an urban health center of a tertiary medical college and hospital, which provides health services to the economically disadvantaged urban population. The urban health center runs a nurse-led low-risk antenatal and delivery service. All consecutive antenatal ultrasounds from March 2012 to February 2013 were analyzed. Routine obstetric ultrasound was done for all women at their booking visit. Crown-rump length was measured if the first visit was prior to 13 weeks of gestation. If they presented after 13 weeks of gestation, biparietal diameter and femur length were measured to confirm gestational age. Results A total of 715 obstetric ultrasounds were performed during the period from 2012 to 2013. Among the 715 ultrasounds, 71.6% were for estimation of gestational age and 15.7% were for amniotic fluid index estimation for fetal surveillance. Among the dating ultrasounds performed, 48.6% were for primigravida women and 51.4% were for multigravida women. Discrepancies were identified in the expected date of confinement by the last menstrual period in 26% of the dating ultrasounds and 4.2% of women were identified to have a missed abortion at booking visit. Conclusion Maternal morbidity and mortality can be reduced by early detection of missed abortion, placenta previa, twin pregnancy, and molar pregnancy by routine obstetric ultrasound at booking visit. Routine obstetric ultrasound at the first and second trimesters had obvious benefits in confirming the expected date of delivery in a community where remembering the last menstrual period was not a priority. Introduction of this procedure helped in appropriate management of post-term pregnancies.

Effectiveness of an educational intervention on the suitability of indications for cesarean delivery in a Brazilian teaching hospital

ObjectiveTo evaluate the effectiveness of an intervention to adjust the indications for caesarean delivery in a Brazilian teaching hospital in accordance with a specific protocol. MethodsThe present before-and-after study was carried out in three stages. In stages 1 and 3, data were obtained for 160 cesarean deliveries that occurred between May 20 and July 10 in 2011 and 2012, respectively. For stage 2, the protocol was implemented for 12months. The deliveries in stages 1 and 3 were classified as high or low risk, and as consistent or inconsistent clinical cases on the basis of the protocol. ResultsA total of 160 (61.1%; 95% confidence interval [CI] 55.2–67.0) of 262 deliveries in stage 1 were by cesarean, compared with 160 (71.4%; 95% CI 65.5–77.3) of 224 in stage 3 (P=0.67). In stage 1, 125 (78.1%; 95% CI 71.7–84.5) showed indications consistent with the protocol, compared with 136 (85.0%; 95% CI 79.5–90.5) in stage 3 (P=0.11). Among the low-risk cesarean deliveries, 27 (51.9%; 95% CI 38.3–65.5) of 52 were consistent with the protocol in stage 1, compared with 49 (72.1%; 95% CI 61.4–86.1) of 68 in stage 3 (P=0.02). ConclusionThe proposed intervention improved the suitability of indications for cesarean delivery among low-risk pregnancies only.

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

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

The effect of gestational age on neonatal outcome in low-risk singleton term deliveries

Objective: To assess the association between gestational age at delivery and adverse neonatal outcome among term low-risk singleton neonates.Methods: A retrospective cohort study design was used. The study group included all low-risk singleton term (37 + 0 to 41 + 6 weeks) newborns delivered in a single tertiary university-affiliated medical center over a 5-year period. Outcome of neonates delivered at 37 + 0 to 37 + 6 weeks of gestation (early term) and 41 + 0 to 41 + 6 weeks of gestation (late term) was compared to that of neonates delivered at 39 + 0–39 + 6 weeks of gestation (control).Results: Overall, the outcome of 30 229 neonates was analyzed. The incidence of neonatal mortality was 1.0 per 1000 live-born neonates, with no significant difference between the various gestational age groups. Early term newborns were at higher risk for respiratory morbidity, hypoglycemia, hypocalcemia, thrombocytopenia and unexplained jaundice, and had higher rates of prolonged hospital stay, NICU admission, sepsis workup and antibiotic treatment. On multivariate analysis, early term delivery was an independent predictor for composite respiratory morbidity (OR=2.4, 95% CI 1.6–3.8, p < 0.001), unexplained jaundice (OR=2.1, 95% CI 1.7–2.5, p < 0.001), hypoglycemia (OR=2.5, 95% CI 1.5–4.3, p < 0.001) and NICU admission (OR=1.9, 95% CI 1.5–2.5, p < 0.001). Late term neonates had a significantly higher rate of large for gestational date, but did not differ from controls with respect to the rate of composite neurologic or respiratory complications, NICU admission, birth trauma or infectious morbidity.Conclusion: Even in low-risk singleton deliveries, early term is associated with an increased risk of neonatal morbidity.

Midwife-led care should be promoted for low-risk deliveries, says NICE

Midwife-led care should be promoted for low-risk deliveries, says NICE

Maternal and neonatal outcomes in electively induced low-risk term pregnancies

Elective induction of labor has been discouraged over concerns regarding increased complications. We evaluated the mode of delivery and maternal and neonatal morbidities in low-risk patients whose labor was electively induced or expectantly managed at term. This was a retrospective cross-sectional study from 12 US institutions (19 hospitals), 2002 through 2008 (Safe Labor Consortium). Healthy women with viable, vertex singleton pregnancies at 37-41 weeks of gestation were included. Women electively induced in each week were compared with women managed expectantly. The primary outcome was mode of delivery. Of 131,243 low-risk deliveries, 13,242 (10.1%) were electively induced. The risk of cesarean delivery was lower at each week of gestation with elective induction vs expectant management regardless of parity and modified Bishop score (for unfavorable nulliparous patients at: 37 weeks= 18.6% vs 34.2%, adjusted odds ratio, 0.40; [95% confidence interval, 0.18-0.88]; 38 weeks= 28.4% vs 35.4%, 0.65 [0.49-0.85]; 39 weeks= 23.6% vs 38.5%, 0.47 [0.38-0.57]; 40 weeks= 32.3% vs 42.3%, 0.70 [0.59-0.81]). Maternal infections were significantly lower with elective inductions. Major, minor, and respiratory neonatal morbidity composites were lower with elective inductions at ≥38 weeks (for nulliparous patients at: 38 weeks= adjusted odds ratio, 0.43; [95% confidence interval, 0.26-0.72]; 39 weeks= 0.75 [0.61-0.92]; 40 weeks= 0.65 [0.54-0.80]). Elective induction of labor at term is associated with decreased risks of cesarean delivery and other maternal and neonatal morbidities compared with expectant management regardless of parity or cervical status on admission.

Adverse neonatal and maternal outcomes in Pakistani tertiary care hospitals: A prospective, observational study

Background: Neonatal and maternal death rates remain high in low-income countries, with little improvement with increasing facility births. We sought to examine risks for neonatal mortality/morbidity among low-risk hospital deliveries in a low-resource setting. Methods: Deliveries at tertiary hospitals in Karachi, Pakistan from 2005-2008 were prospectively enrolled with follow-up to 42 days postpartum. Results: Of 5,008 women enrolled, 98% were followed 28 days post-delivery. 4.3% of infants had severe illness or neonatal death. 28-day neonatal mortality rate was 19.1/1,000 births. Newborn death/severe illness was associated with being unbooked, low birth weight, newborn intensive care, and lack of cord/neonatal skin cleansing and hand-washing before handling the baby. Conclusion: Although most were low-risk and all were hospital deliveries, maternal and perinatal morbidity and mortality rates were high. Lack of cord care and maternal hand washing was significantly associated with adverse outcomes. Results suggest that in addition to improving hospital care, simple interventions such as hand-washing may reduce maternal and newborn morbidities.

Abstract 303: Frequency of Newborn Resuscitation and Stabilization in Three Normal-Risk Delivery Units in Norway

Introduction: Most newborn infants transition from intra- to extrauterine life without interventions; yet neonatal morbidity remains a significant health problem in both resource rich and resource poor health care systems. Although advanced resuscitation of newborn infants with chest compressions, intravenous drugs, and fluids is relatively rare, there are limited data on the frequency of neonatal stabilization and resuscitation measures in normal-risk delivery units. METHODS: Prospective, observational study conducted in the delivery units in three hospitals in Norway. All newborn infants assessed for stabilization and/or resuscitation during one month were included. After each incident, data on resuscitation measures and outcome were registered and reviewed by study personnel at every on-call team shift during the study period. Approval was obtained from department heads and institutional review boards. Results: 1507 babies were live born during the study period, mean weight 3.3 kg and gestational age 39.4 weeks.: 113 (7 %) needed resuscitation interventions beyond drying and stimulation. Suctioning of oropharynx was performed in 77 babies (5 %) and tracheal suctioning in 10 (1%). Positive pressure ventilation (PPV) was provided by a T-piece resuscitator and/or by a self-inflating bag to 58 (4 %) with 39 (3 %) receiving supplementary oxygen. In addition CPAP (but no PPV) was provided to 17 (1 %). One needed chest compressions. Tracheal intubation was accomplished in 4 infants of whom 3 were prematurely born and treated with tracheal surfactant. Intravenous access was established in 8 infants, two received saline infusions and one received epinephrine. After initial resuscitation, 64 (4 %) were admitted to the neonatal intensive care unit and two died. Twenty-one events were handled exclusively by midwifes, 244 by pediatric residents and 39 by attending neonatologists. CONCLUSION: Most newborns do not need advanced resuscitation procedures. However, even in low risk deliveries, more than 4 % of newborns required assisted ventilation. Correct assessment of need for ventilatory support and correct execution of positive pressure ventilation needs to be ensured.

Four countries, four ways of discussing low-risk pregnancy and normal delivery: in France, Germany, The Netherlands, and the United Kingdom

The 2012 "4 countries meeting" of the French, Dutch, British and German Societies of Gynaecology and Obstetrics (CNGOF, NVOG, RCOG, DGGG) was dedicated to the topic "Low-risk pregnancy and normal delivery". The objective was to compare how each country organises prenatal care and normal delivery. The discussion is outlined in the article and provides new opportunities to learn from each other's strengths in order to provide the highest level of care regardless of social, demographic, educational and clinical differences.

Association Between Vaginal Birth After Cesarean Delivery and Primary Cesarean Delivery Rates

To estimate the association between vaginal birth after cesarean delivery (VBAC) rates and primary cesarean delivery rates in California hospitals. Hospital VBAC rates were calculated using birth certificate and discharge data from 2009, and hospitals were categorized by quartile of VBAC rate. Multivariable logistic regression analysis was performed to estimate the odds of cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation (nulliparous term singleton vertex) by hospital VBAC quartile while controlling for many patient-level and hospital-level confounders. There were 468,789 term singleton births in California in 2009 at 255 hospitals, 125,471 of which were low-risk nulliparous term singleton vertex. Vaginal birth after cesarean delivery rates varied between hospitals, with a range of 0-44.6%. Rates of cesarean delivery among low-risk nulliparous term singleton vertex women declined significantly with increasing VBAC rate. When adjusted for maternal and hospital characteristics, low-risk nulliparous term singleton vertex women who gave birth in hospitals in the highest VBAC quartile had an odds ratio of 0.55 (95% confidence interval 0.46-0.66) of cesarean delivery compared with women at hospitals with the lowest VBAC rates. Each percentage point increase in a hospital's VBAC rate was associated with a 0.65% decrease in the low-risk nulliparous term singleton vertex cesarean delivery rate. Hospitals with higher rates of VBAC have lower rates of primary cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation. II.

Returns to Childbirth Technologies: Evidence from Preterm Births

We investigate the impact of obstetrician supervision, as opposed to midwife supervision, on the short-term health of low-risk newborns. We exploit a unique policy rule in the Netherlands that creates a large discontinuity in the probability of a low-risk birth being attended by an obstetrician at gestational week 37. Using a fuzzy regression discontinuity design, we consistently find no health benefits from obstetrician supervision, despite increased rates of neonatal intensive care unit admissions among births supervised by obstetricians. These results indicate potential cost savings from increased use of midwifery care for low-risk deliveries.

Resultados maternos e neonatais dos partos normais de baixo risco assistidos por enfermeiras e médicos

This documental, retrospective study consisted of an evaluation of the records regarding normal and low-risk deliveries at a public maternity hospital in Rio de Janeiro. The study objectives were to describe the profiles of normal deliveries assisted by nurses and physicians, and analyze the similarities and differences in the maternal and neonatal outcomes in the service cases. Descriptive analysis of the data was performed, using Fisher’s F-test and Student’s t-test, with significance at p&lt;0.05. Both professional categories adopt the conducts of zero dieting, intravenous hydration and oxytocin during labor. A significant difference was observed (p&lt;0.01) for episiotomy performed by nurses (15%) and physicians (64.3%). Similar maternal and neonatal outcomes were observed for low-risk normal deliveries assisted by nurses and physicians. Descriptors: Obstetrical Nursing; Labor, Obstetric; Natural Childbirth.

1771 Use of Oximeter in Clinical Assessment of Infants at Birth in Low Risk Deliveries after Home Birth in the Netherlands

BackgroundObjective assessment of infant’s condition at birth by oximeter is now recommended in resuscitation guidelines. However, midwives supervising home birth in primary care still use color and count heart rate...

Obstetric Interventions for Low‐Risk Pregnant Women in France: Do Maternity Unit Characteristics Make a Difference?

In many countries the closure of small maternity units has raised concerns about how the concentration of low-risk pregnancies in large specialized units might affect the management of childbirth. We aimed to assess the role of maternity unit characteristics on obstetric intervention rates among low-risk women in France. Data on low-risk deliveries came from the 2010 French National Perinatal Survey of a representative sample of births (n = 9,530). The maternity unit characteristics studied were size, level of care, and private or public status; the interventions included induction of labor; cesarean section; operative vaginal delivery (forceps, spatulas or vacuum); and episiotomy. Multilevel logistic regression analyses were adjusted for maternal confounding factors, gestational age, and infant birthweight. The rates of induction, cesarean section, operative delivery, and episiotomy in this low-risk population were 23.9 percent, 10.1 percent, 15.2 percent, and 19.6 percent, respectively, and 52.0 percent of deliveries included at least one of them. Unit size was unrelated to any intervention except operative delivery (adjusted odds ratio [aOR] = 1.47 (95% CI, 1.10-1.96) for units with >3,000 deliveries per year vs units with <1,000). The rate of every intervention was higher in private units, and the aOR for any intervention was 1.82 (95% CI, 1.59-2.08). After adjustment for maternal characteristics and facility size and status, significant variations in the use of interventions remained between units, especially for episiotomies. Results for level of care were similar to those for unit size. The concentration of births in large maternity units in France is not associated with higher rates of interventions for low-risk births. The situation in private units could be explained by differences in the organization of care. Additional research should explore the differences in practices between maternity units with similar characteristics.

Maternal and Newborn Outcomes Related to Unplanned Hypothermia in Scheduled Low-Risk Cesarean Delivery Births

Neuraxial (spinal or epidural) anesthesia is the most common form of pain management during labor and birth and the method of choice for cesarean births because it allows mothers to be awake for the birth of their infant. A side effect of neuraxial anesthesia is vasodilatation, core-to-peripheral redistribution of body heat, and loss of cold perception, placing the patient at risk for developing hypothermia. Perioperative hypothermia increases the patient risk of developing morbid myocardial outcomes, coagulopathy, and increased incidence of surgical wound infection. In addition, hypothermia in the cesarean delivery patient places the newborn at risk for hypothermia. In a retrospective review of low-risk scheduled cesarean deliveries, N = 143, covering a 6-month period, 21% of mothers and 36.5% of newborns experienced hypothermia. Newborns also experienced hypoglycemia and respiratory instability.

Risk Adjustment for Inter-Hospital Comparison of Caesarean Delivery Rates in Low-Risk Deliveries

BackgroundCaesarean delivery (CD) rates have been frequently used as quality measures for maternity service comparisons. More recently, primary CD rates (CD in women without previous CD) or CD rates within selected categories such as nulliparous, term, cephalic singleton deliveries (NTCS) have been used. The objective of this study is to determine the extent to which risk adjustment for clinical and socio-demographic variables is needed for inter-hospital comparisons of CD rates in women without previous CD and in NTCS deliveries.MethodsHospital discharge records of women who delivered in Emilia-Romagna Region (Italy) from January, 2007 to June 2009 and in Tuscany Region for year 2009 were linked with birth certificates. Adjusted RRs of CD in women without a previous Caesarean and NTCS were estimated using Poisson regression. Percentage differences in RR before and after adjustment were calculated and hospital rankings, based on crude and adjusted RRs, were examined.ResultsAdjusted RR differed substantially from crude RR in women without a previous Caesarean and only marginally in NTCS group. Hospital ranking was markedly affected by adjustment in women without a previous CD, but less in NTCS.ConclusionRisk adjustment is warranted for inter-hospital comparisons of primary CD rates but not for NTCS CD rates. Crude NTCS CD rates are a reliable estimate of adjusted NTCS CD.