Non-elective Cesarean Delivery Research Articles

Cesarean Delivery on Maternal Request

To examine obstetrician-gynecologists' knowledge, opinions, and practice patterns related to cesarean delivery on maternal request. Questionnaires were mailed to 1,031 American College of Obstetricians and Gynecologists Fellows in February 2006, with a response rate of 68%. The questionnaire queried respondents' demographic characteristics, practices and attitudes surrounding vaginal and cesarean deliveries, knowledge and beliefs regarding the risks and benefits of elective and nonelective cesarean delivery, and counseling practices and department policies for cesarean delivery on maternal request. About half of respondents believe women have the right to cesarean delivery on maternal request, and a similar percentage acknowledge having performed at least one cesarean delivery on maternal request. Fifty-eight percent of respondents note an increase in patient inquiries regarding cesarean delivery over the past year, yet most of their practices do not have a policy regarding this procedure. Respondents attribute the increase in inquiries to the increase of information from the media and to convenience. Respondents cited more risks than benefits of cesarean delivery on maternal request, and nearly all discuss these risks with patients who are considering one. Females were more negative toward cesarean delivery on maternal request than males and endorsed more risks and fewer benefits. There were no relationships between assessment of risks and benefits or practice with clinician age or patient characteristics. Most obstetrician-gynecologists in this study recognized an increased demand for cesarean delivery on maternal request within their practices, while believing that the risks of this procedure outweigh the benefits. Clinicians would benefit from strong evidence regarding risks and benefits, evidence that is crucial to guiding policy making with regard to cesarean delivery on maternal request. III.

Analysis of Free Hemoglobin Level and Hemoglobin Peptides from Human Puerperal Uterine Secretions

Hemocidins are a novel class of antibacterial peptides generated proteolytically from hemoglobin. These peptides play a particularly important role in maintaining vaginal homeostasis during menstrual bleeding. To investigate the hemoglobin fragmentation process during the last stages of pregnancy, we examined uterine secretion (lochia) samples from a group of 22 healthy women who underwent cesarean delivery at term. Patients were divided into three groups: (1) the elective cesarean deliveries without symptoms of spontaneous labor, (2) the nonelective cesarean deliveries with spontaneous beginning of labor, and (3) the nonelective cesarean deliveries during advanced labor. The samples were subjected to chromatographic estimation of free hemoglobin and peptides. In three representative patients the identification of all lochial peptides was performed. All samples contained a significant amount of free hemoglobin and its level increased with labor progression. The presence of peptide fractions was also detected in most lochia samples. They were confirmed to be human hemoglobin fragments, almost identical to the recently described bactericidal hemocidins from menstrual discharge. The level of peptides also increased during labor. The subgroup with advanced labor demonstrated the highest amount of hemocidins. The presented results prove that proteolysis of free hemoglobin in the female upper reproductive tract begins together with the clinical symptoms of normal labor. We speculate that cesarean delivery affects molecular mechanisms involved in antibacterial hemocidins generation and, in effect, might be responsible for the increased risk of gynecologic infections in cesarean deliveries.

Umbilical Arterial pH <7.00 in Newborns Delivered by Nonelective Cesarean Delivery: Risk Factors and Peripartum Outcomes

Umbilical Arterial pH <7.00 in Newborns Delivered by Nonelective Cesarean Delivery: Risk Factors and Peripartum Outcomes

Postpartum Hemorrhage After Cesarean Delivery: An Analysis of Risk Factors

To determine the incidence and risk factors for postpartum hemorrhage (PPH) associated with cesarean delivery. Blood loss at cesarean delivery was measured and defined as 1,000 to 1,499 mL or greater than 1,500 mL and/or the need for a blood transfusion. Variables were identified and evaluated to determine the factors associated with PPH. There were 1,844 elective and 2,993 nonelective cesarean deliveries over 4 years. The PPH rate in nonelective cesarean (6.75%) was greater than after elective cesarean (4.84%, P = 0.007). Risk factors for PPH after an elective operation included leiomyomata, blood disorders, placenta previa, antepartum bleeding, preterm birth, and general anesthesia. Nonelective cesarean PPH risk factors included blood disorders, retained placenta, antepartum transfusion, antepartum/intrapartum hemorrhage, placenta previa, general anesthesia, and macrosomia (odds ratio > 1.5, confidence interval > 1.5). Nonelective cesarean deliveries have a higher risk of PPH than women delivered electively. Risk factor identification and prevention should be a priority.

Umbilical arterial pH < 7.00 in newborns delivered by nonelective cesarean delivery: risk factors and peripartum outcomes.

The objective of this study was to compare the risk factors and peripartum outcomes among patients who had nonelective cesarean delivery with umbilical arterial pH < versus > or = 7.00. A case-control study of parturients who delivered by nonelective cesarean delivery and had a neonate with a pH < 7.00 were compared with the next four patients who delivered abdominally but had a newborn with a normal pH. Among 45 newborns with pH < 7.00 the rate of cesarean delivery for nonreassuring fetal heart rate was significantly more common in the case (56%) than control group (16%). The rates of end organ failure and neonatal death were similar for both groups. Although newborns with pH < 7.00 were significantly more likely to have cesarean delivery for nonreassuring fetal heart rate patterns and be admitted to the neonatal intensive care unit, there was no means to identify these patients until the abnormalities in tracing developed.

Determinants of Caesarean Delivery Among Women Hospitalized for Childbirth in a Remote Population in China

Objective: To assess determinants of a high Caesarean delivery rate in a remote population in China.Methods: A prospective cohort study including 20 891 women who gave birth between January 1, 1997, and June 30, 1998, in one of the 18 hospitals participating in a hospital-based regional perinatal surveillance system in Qingyuan, a remote rural region in Guangdong province, China.Results: Of the 20 891 pregnant women registered by the Qingyuan Perinatal Surveillance System, 7.5% were delivered by elective Caesarean section, and 18.4% were delivered by non-elective Caesarean section. The most common indications for elective Caesarean delivery were socio-cultural, non-medical reasons, such as the woman’s fear of pain, her wish to give birth on a date or at a time believed to be particularly auspicious, or her belief that delivery by Caesarean section would protect the baby’s brain. Factors strongly related to elective Caesarean delivery included insurance status, maternal age, plurality, preeclampsia and eclampsia, gestational age, and birth weight. The most common indication for non-elective Caesarean delivery was cephalopelvic disproportion. Factors strongly related to non-elective Caesarean delivery included maternal age, preeclampsia and eclampsia, placenta previa, gestational age, and birth weight.Conclusion: Non-medical causes, including a woman’s insurance status and her personal and social demands, accounted for a large proportion of elective Caesarean deliveries in this remote population in China.

Cell-associated genital tract virus and vertical transmission of human immunodeficiency virus type 1 in antiretroviral-experienced women.

To determine the association between genital tract shedding of human immunodeficiency virus (HIV) type 1 and vertical transmission, a case-control substudy was conducted within the Women and Infants Transmission Study. Antenatal cervicovaginal lavage specimens were assessed for HIV-1 RNA in the supernatant and HIV-1 RNA and DNA in cell pellets. Multivariate analyses compared 26 women who transmitted HIV to their infants with 52 women who did not; 33% received combination antiretroviral therapy, and 65% received monotherapy. Adjusted odds ratios (ORs) for the presence (OR, 3.42; 95% confidence interval [CI], 0.76-15.4; P=.11) and titer (OR, 1.66; 95% CI, 0.93-2.99; P=.09) of HIV-1 DNA suggested that there is an independent association with vertical transmission. When analyses were restricted to vaginal and nonelective cesarean deliveries, each one-log increase in mean titer of HIV-1 DNA was associated with a significantly higher risk of transmission (OR, 2.28; 95% CI, 1.09-4.78; P=.03). The cell-associated genital tract compartment is important in the pathophysiology and prevention of vertical HIV-1 transmission.

Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery

OBJECTIVE: Our purpose was to evaluate obesity (body mass index greater than 30.0) as an independent risk factor for infectious morbidity in women having elective or nonelective cesarean deliveries. METHODS: Charts of 611 patients undergoing cesarean were reviewed. After exclusion of those with pre-existing chorioamnionitis, 574 cases were separated into two groups (elective or nonelective cesarean) and then subdivided based on the presence or not of postdelivery infectious morbidity. Estimated blood loss, operative time, number of vaginal examinations, labor length, use of internal monitors, body mass index (BMI), and obesity (BMI greater than 30.0) were then recorded. Student t test, χ 2, multivariate analysis, and receiver operating characteristics curves were used where appropriate (significance: P < .05). RESULTS: The mean gestational age at delivery was 38.3 weeks. Three hundred sixty patients had nonelective cesareans, and 214 had elective cesareans. Prophylactic antibiotics were used for 86.6% of the nonelective group and 75.2% of the elective group. In the nonelective group and after multivariate analysis, significant risk factors for postoperative infections were as follows: labor length (18.4 hours versus 10.9, P < .003), number of vaginal examinations (6.1 versus 4.5, P < .001), BMI (36.6 versus 32.3, P < .001), and obesity (81.8% versus 57.3%, P < .001). For the elective group, a higher BMI (38.9 versus 32.2, P < .003), and black race (63.2% versus 11.5%, P < .001) were found to be significant. CONCLUSION: Our data suggest that obesity is a independent risk factor for postcesarean infectious morbidity and endomyometritis, even if the cesarean is elective and prophylactic antibiotics are given.

Obesity as an Independent Risk Factor for Infectious Morbidity in Patients Who Undergo Cesarean Delivery

In Brief OBJECTIVE Our purpose was to evaluate obesity (body mass index greater than 30.0) as an independent risk factor for infectious morbidity in women having elective or non-elective cesarean deliveries. METHODS Charts of 611 patients undergoing cesarean were reviewed. After exclusion of those with pre-existing chorioamnionitis, 574 cases were separated into two groups (elective or nonelective cesarean) and then subdivided based on the presence or not of postdelivery infectious morbidity. Estimated blood loss, operative time, number of vaginal examinations, labor length, use of internal monitors, body mass index (BMI), and obesity (BMI greater than 30.0) were then recorded. Student t test, χ2, multivariate analysis, and receiver operating characteristics curves were used where appropriate (significance: P < .05). RESULTS The mean gestational age at delivery was 38.3 weeks. Three hundred sixty patients had nonelective cesareans, and 214 had elective cesareans. Prophylactic antibiotics were used for 86.6% of the nonelective group and 75.2% of the elective group. In the nonelective group and after multivariate analysis, significant risk factors for postoperative infections were as follows: labor length (18.4 hours versus 10.9, P < .003), number of vaginal examinations (6.1 versus 4.5, P < .001), BMI (36.6 versus 32.3, P < .001), and obesity (81.8% versus 57.3%, P < .001). For the elective group, a higher BMI (38.9 versus 32.2, P < .003), and black race (63.2% versus 11.5%, P < .001) were found to be significant. CONCLUSION Our data suggest that obesity is a independent risk factor for postcesarean infectious morbidity and endomyometritis, even if the cesarean is elective and prophylactic antibiotics are given. Obesity is an independent risk factor for post–cesarean delivery infectious morbidity.

Estorgen Receptor α and Progesterone Receptor A and B Concentration and Localization the Lower Uterine Segment in Term Parturition

To determine the localization and concentrations of estrogen receptor alpha and progesterone receptors A and B in the lower uterine segment during term parturition. Biopsies were taken from 70 patients during nonelective cesarean delivery. The patients were at different stages of cervical dilatation (<2 cm, 2-3.9 cm, 4-6 cm, >6 cm) and different duration of labor (< or =6 hours, >6-12 hours, >12 hours). The receptor concentrations were determined with solid phase immunoassays, and their localization was investigated immunohistochemically. Estrogen receptor alpha concentration decreased significantly from 2.12 fmol/mg protein at less than 2 cm dilatation to 1.08 fmol/mg (4-6 cm) but tended to increase at greater than 6 cm. Progesterone receptor A and B concentration was 84.7 fmol/mg at less than 2 cm dilatation, decreased significantly to 36.6 fmol/mg (2-3.9 cm), and increased again with further dilation. Concentrations of both receptors did not depend on duration of labor. By immunohistochemistry only progesterone receptor A and B was found to be expressed by endothelial and smooth muscle cells of the vessels, stromal fibroblasts, smooth muscle cells in the myometrium, and glandular epithelial cells. Regardless of the extent of cervical dilatation, expression of progesterone receptors A and B was marked. A decrease in estrogen receptor alpha and progesterone receptor A and B concentration in the early phase of first stage labor may play a role in cervical dilation at term.

Patient Preference the Leading Indication for Elective Caesarean Section in Public Patients—Results of a 2-Year Prospective Audit in a Teaching Hospital

Because the rate of cesarean delivery has grown markedly in recent decades and recent research indicates that patient requests may be one of the strongest indications, a prospective study was undertaken to audit indications for operative delivery. A total of 9138 deliveries at an Australian teaching hospital in a 2-year period were reviewed. The cesarean delivery rate was 17.8 percent, and of the 1624 caesarean deliveries, 39 percent were elective. More than one fourth of elective cesarean deliveries (27 percent) were done solely because of the mother’s request, and this was the leading indication for elective surgery. In 103 of 170 cases, the woman had previously had a cesarean delivery, but the current pregnancy was otherwise suitable for a trial of labor. All 56 women with breech presentation also were otherwise suitable for attempted vaginal birth. Only five women presented no particular reason for requesting elective delivery. The most common medical indication for elective cesarean delivery was more than one previous cesarean delivery. Other medical indications included a previous complicated cesarean delivery, a term breech presentation in which a trial of labor was considered inadvisable, placenta previa, severe intrauterine growth retardation with abnormal placental function, transverse and unstable fetal lie, suspected cephalopelvic disproportion, and preeclampsia. Preterm breech presentation, active herpes simplex, multiple gestation, and abruptio placenta were other indications. Nonelective cesarean deliveries were most often done because of suspected fetal distress or failure to progress in labor. The investigators believe that current maternal decision-making may well be influenced by the modern emphasis on patient advocacy and consumer choice. Attempts to lower the cesarean delivery rate should focus on promoting a trial of vaginal delivery in cases of a history of past cesarean delivery and also in cases of breech presentation. It also would help to develop better means of detecting fetal acidosis during labor. Aust NZ J Obstet Gynaecol 1999;39:207–214

Obstacles to Reducing Cesarean Rates in a Low-Cesarean Setting

In Brief Objective To examine risk factors for elective and nonelective cesarean delivery in a population with a low cesarean rate. Methods Nulliparous women delivering singleton births in Sweden during 1992–93 were included (n = 92,623). Logistic regression analyses were performed to calculate adjusted odds ratios (ORs) and rates of cesarean delivery. Results The overall cesarean rate was 11.9%. Risks for cesarean increased consistently with increasing maternal age, decreasing maternal height, and increasing prepregnancy body mass index (BMI). Compared with teenagers, the OR of cesarean was 2.6 among women 30–34 years and 4.4 among women 35 years of age or older. Compared with tall women (greater than 174 cm), the OR of cesarean for women 155–164 cm was 2.0, and 4.5 for short women (less than 155 cm). Compared with lean women (BMI less than 20.0), the ORs of cesarean for overweight (BMI 25.0–29.9) and obese women (BMI of at least 30.0) were 1.8 and 2.4, respectively. Similar risks also were obtained when the analyses were restricted to elective or nonelective cesarean deliveries. The effect of prepregnancy BMI on cesarean rate was influenced by maternal height: among tall women, rates of cesarean increased from 5% among lean women to 11% among obese women, whereas corresponding rates among short women were 19% and 36%, respectively. The influence of mother's education, type of hospital, and other factors was considerably less. Conclusion The increase in maternal age at first birth and the weight among young women present obstacles to the reduction of cesarean rates in developed countries. Maternal age, height, and body mass index are the primary influences on the risks of elective and nonelective cesarean delivery among nulliparous women in Sweden.

Obstacles to reducing cesarean rates in a low-cesarean setting: the effect of maternal age, height, and weight

Objective: To examine risk factors for elective and nonelective cesarean delivery in a population with a low cesarean rate. Methods: Nulliparous women delivering singleton births in Sweden during 1992–93 were included ( n = 92,623). Logistic regression analyses were performed to calculate adjusted odds ratios (ORs) and rates of cesarean delivery. Results: The overall cesarean rate was 11.9%. Risks for cesarean increased consistently with increasing maternal age, decreasing maternal height, and increasing prepregnancy body mass index (BMI). Compared with teenagers, the OR of cesarean was 2.6 among women 30–34 years and 4.4 among women 35 years of age or older. Compared with tall women (greater than 174 cm), the OR of cesarean for women 155–164 cm was 2.0, and 4.5 for short women (less than 155 cm). Compared with lean women (BMI less than 20.0), the ORs of cesarean for overweight (BMI 25.0–29.9) and obese women (BMI of at least 30.0) were 1.8 and 2.4, respectively. Similar risks also were obtained when the analyses were restricted to elective or nonelective cesarean deliveries. The effect of prepregnancy BMI on cesarean rate was influenced by maternal height: among tall women, rates of cesarean increased from 5% among lean women to 11% among obese women, whereas corresponding rates among short women were 19% and 36%, respectively. The influence of mother’s education, type of hospital, and other factors was considerably less. Conclusion: The increase in maternal age at first birth and the weight among young women present obstacles to the reduction of cesarean rates in developed countries.

Epidural Analgesia as a Risk Factor for Operative Delivery

Abstract Objective: To study the relationship between epidural analgesia and instrumental and non-elective cesarean delivery in the 1990s in Finland. Methods: The data was extracted from a nationwide birth register in 1991–1993. To adjust for other factors, hospital-based analyses were made separately for different types of hospitals and in individual-based analyses logistic regression was used. Results: In the hospital-based analyses there was no systematic correlation between rates of epidural analgesia and operative delivery, but on the individual level there was. Comparison of hospitals with different levels of epidural rates and different types of hospitals suggests that the contradictory findings in the hospital and individual-based analyses are partly due to selection bias, and partly to different hospital policies. Conclusions: The results in previous studies and our results suggest that epidural analgesia is a risk factor for an operative delivery, but not a sufficient one, and its impact is likely to be modified by other obstetric practices and interventions.

Conflicts Between Physicians and Patients in Nonelective Cesarean Delivery

Lescale, Keith B.; Inglis, Steven R.; Eddleman, Keith A.; Peeper, E. Quinn; Chervenak, Frank A.; McCullough, Laurence B.Author Information

Epidural analgesia as a risk factor for operative delivery

Objective: To study the relationship between epidural analgesia and instrumental and non-elective cesarean delivery in the 1990s in Finland. Methods: The data was extracted from a nationwide birth register in 1991–1993. To adjust for other factors, hospital-based analyses were made separately for different types of hospitals and in individual-based analyses logistic regression was used. Results: In the hospital-based analyses there was no systematic correlation between rates of epidural analgesia and operative delivery, but on the individual level there was. Comparison of hospitals with different levels of epidural rates and different types of hospitals suggests that the contradictory findings in the hospital and individual-based analyses are partly due to selection bias, and partly to different hospital policies. Conclusions: The results in previous studies and our results suggest that epidural analgesia is a risk factor for an operative delivery, but not a sufficient one, and its impact is likely to be modified by other obstetric practices and interventions.

Are multiple cesarean sections safe?

To assess the maternal and neonatal risk associated with high-order cesarean sections, a case-control study was carried out in two university affiliated maternity wards. The outcome of 154 pregnancies of women undergoing cesarean section for the 4th time or more was compared with 148 women sectioned for the 2nd or 3rd time and 132 women of similar age and parity after spontaneous birth. The main outcome measures were maternal operative and postoperative morbidity and neonatal prematurity and its complications, Apgar scores, and the need for intensive care. Women undergoing multiple (⩾4) cesarean sections had significantly more intra-abdominal adhesions ( P < 0.0001) than women sectioned for the 2nd or 3rd time. However, the time interval from incision to delivery and the total duration of operation were similar. The postoperative course was not adversely affected by multiple cesarean sections. A high incidence (16.2%) of preterm cesarean deliveries was noted in the study group. This was due to non-elective repeat cesarean delivery rather than to poor timing of scheduled cesarean sections. The significantly increased ( P < 0.05) need for neonatal intensive care was explained by the higher occurrence of prematurity. Low Apgar scores (≤ 7) at 1 and 5 min were significantly ( P < 0.01) related to multiple cesarean sections, even after controlling for the effect of gestational age. We conclude that multiple cesarean sections pose little risk for the mother, but may be associated with increased neonatal risk, attributed mainly to preterm non-elective cesarean sections.

Complications during spinal anesthesia for cesarean delivery: a clinical report of one year's experience.

To evaluate the incidence and causes of complications associated with spinal anesthesia for cesarean delivery. Prospective study, case series. Tampere University Hospital, 284 patients scheduled for elective or nonelective cesarean delivery with spinal anesthesia. Complications occurring during spinal anesthesia with hyperbaric 0.5% bupivacaine during a 1-year period were analyzed. Hyperbaric 0.5% bupivacaine for cesarean delivery proved to be a reliable anesthetic with a failure rate of 2.8%. The most common complications were hypotension (42%) and nausea (14%). In 81% of patients, hypotensive periods occurred before delivery. Hypotension before delivery had no correlation with low Apgar scores or with low pH in the umbilical artery of the infant. Risk factors for hypotension were elective procedures and operations without prophylactic ephedrine infusion. Nausea occurred significantly more often if a lower interspace was used for administering the subarachnoid block. Spinal anesthesia proved to be a safe, reliable, and rapid method of anesthesia for cesarean delivery, but, in view of a high incidence of minor complications, careful patient monitoring during spinal anesthesia is necessary to make the outcome optimal for mother and fetus.

Neonatal Outcome in Cesarean Section under General Anesthesia, Related to Gestational Age, Induction-Delivery and Uterus-Delivery Intervals

Neonatal outcome after cesarean section under general anesthesia may be influenced by several factors. Two of these are the interval between anesthesia induction and delivery and the interval between uterine incision and delivery. The present authors evaluated the relationship between both factors and the Apgar scores of newborn infants delivered by cesarean section at various gestational ages. The study comprised 568 cesarean deliveries that were performed and under general anesthesia without any sign of fetal distress before operation. Of the 568 women, 216 had elective operations, and 352 had nonelective cesarean deliveries.