Overall Rate Of Cesarean Delivery Research Articles

Misoprostol with balloon vs oxytocin with balloon in high-risk pregnancy induction: a randomized controlled trial

Pregnancies at high risk for maternal, fetal, or placental complications often necessitate induction of labor in the late preterm or early term period for delivery. Limited data exist on the safest method of induction to use in this specific patient population. This study aimed to compare the combination of oxytocin plus a Cook balloon vs misoprostol plus a Cook balloon for induction of labor in high-risk pregnancies. We conducted an open-label, randomized controlled trial at a single institution from July 2020 to May 2022. The study was approved by the institutional review board and registered with ClinicalTrials.gov (NCT04492072). Individuals with a high-risk pregnancy, at least ≥22 weeks' gestation, with a singleton in cephalic presentation, Bishop score ≤6, and intact membranes were offered enrollment. A high-risk pregnancy was defined as a pregnancy with any of the following complications: hypertensive disease of pregnancy, fetal growth restriction, oligohydramnios, suspected placental abruption requiring delivery, uncontrolled pregestational diabetes, or abnormal biophysical profile or nonstress test requiring delivery. The primary outcome was the rate of cesarean delivery. Secondary maternal outcomes included induction to delivery interval, number of vaginal deliveries within 24 hours, rates of uterine tachysystole, intraamniotic infection, operative vaginal delivery, and postpartum hemorrhage. Secondary fetal outcomes included fetal heart rate abnormalities, stillbirth, Apgar scores <7 at 5 minutes, admission to the neonatal intensive care unit, arterial umbilical blood pH <7.1, sepsis, and neonatal death. A subgroup analysis was planned for the primary outcome to assess the different indications for cesarean delivery. An intent-to-treat analysis was performed. During the 22 months of the trial, a total of 150 patients were randomized, and 73 (49%) of those were induced with oxytocin and a Cook balloon and 77 (51%) were induced with misoprostol and a Cook balloon. There was no significant difference in the overall rate of cesarean delivery between the study groups, (21.9% vs 31.1%; relative risk, 0.70; 95% confidence interval, 0.41-1.21), nor among those for which the cesarean delivery was performed for a specific indication. There were no differences in the secondary maternal and fetal or neonatal adverse outcomes. In high-risk pregnancies, the rate of cesarean delivery and adverse maternal and fetal outcomes were similar for induction of labor with oxytocin and a Cook balloon and for induction with misoprostol and a Cook balloon.

Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study

BackgroundTrial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section.MethodsWe collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions.ResultsOf the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman’ rho = 0.50 and 0.42, p value < 0.001).ConclusionsOrganizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000–2019

ABSTRACT Cesarean delivery is a method of improving outcomes for both mothers and neonates when there are medical complications to vaginal delivery. When used unnecessarily, however, it causes increased risks for adverse outcomes as a major surgery. Limited data and investigations have prevented some previous analyses of trends in cesarean deliveries, especially when classifying them as necessary or unnecessary. This study was designed to determine temporal trends in cesarean deliveries among low-risk patients over a 20-year period and to analyze trends in specific cesarean delivery indications. This study was designed as a repeated cross-sectional analysis among patients at low risk for cesarean delivery. The authors utilized the National Inpatient Sample data set, and then patients with conditions previously associated with an increased risk of cesarean delivery (eg, obesity) were excluded. Primary outcomes included temporal trends in the number of cesarean deliveries, as well as trends related to diagnoses of nonreassuring fetal status, labor arrest, or obstructed labor (including disproportion). Between 2000 and 2019, 40,517,867 eligible low-risk deliveries were identified. Of these, 4,885,716 were cesarean deliveries. The overall rate of cesarean delivery increased between 2000 and 2009 (from 9.7% to 13.9%) and then decreased between 2012 and 2019 (from 13% to 11.1%). The average annual percentage change (AAPC) from 2000 to 2005 was 6.4% (95% confidence interval [CI], 5.2%–7.6%), with a plateau from 2005 to 2009 (AAPC, 1.2%; 95% CI, −1.2% to 3.7%) and then a decrease from 2009 to 2019 (AAPC, −2.2%; 95% CI, −2.7% to −1.8%). Deliveries associated with the diagnosis of nonreassuring fetal status increased between 2000 and 2019 (AAPC, 2.1%; 95% CI, 1.7%–2.5%); those associated with labor arrest peaked in 2009 at 4.8% and then decreased to 2.7% in 2019 (AAPC 2009–2019, −5.6%; 95% CI, −6.6% to −4.6%). In contrast, cesarean deliveries due to obstructed labor continuously decreased from 2000 to 2019 (AAPC, −8.6%; 95% CI, −10.0% to −7.1%). After accounting for demographic and hospital characteristics, analysis showed that patients were at increased risk of cesarean delivery if they were between 35 and 39 years of age compared with the younger group of 25 to 29 years (adjusted odds ratio [aOR], 1.27; 95% CI, 1.25–1.28), if they delivered at a hospital in the South versus the Northeast (aOR, 1.11; 95% CI, 1.07–1.15), and if they were non-Hispanic Black versus non-Hispanic White (aOR, 1.23; 95% CI, 1.20–1.25). Overall trends showed increasing rates of cesarean delivery in the first 10 years of the study, but then decreasing rates for the final 10 years. Rates associated with diagnoses of nonreassuring fetal status increased over the study period, and those associated with labor arrest or obstruction decreased. The increase of cesarean delivery due to nonreassuring fetal status when compared with the overall trend of decreasing cesarean deliveries indicates a possible clinical oversight as the interpretation of nonreassuring fetal status can differ based on provider and facility. Some guidelines are in place for determining nonreassuring fetal status, but interpretation of the guidelines and sometimes the guidelines themselves have changed over the time period of this study. This increase is potentially attributable to the changes in requirements or the interpretation of them and should be more fully investigated. Future research should focus on more accurately identifying diagnoses of nonreassuring fetal status to reduce the number of unnecessary cesarean deliveries while improving the outcomes of those that truly need cesarean deliveries.

Use of Induction of Labour and Emergency Cesarean Section and Perinatal Outcomes in English Maternity Services: A National Hospital-Level Study

ABSTRACT Care provided by maternity services requires a fine balance between support for the physiological process of birth and clinical intervention when needed. Yet, clinical guidelines for maternity care vary widely within and between countries. For singleton babies born at term in 149 hospitals of the National Health Service (NHS) in the United Kingdom alone, the rate of induction of labor varied from 16% to 44%, and the overall rate of cesarean delivery (CD) varied from 17% to 35% between April 2016 and March 2017. This suggests a lack of consensus around the indications for interventions, such as induction of labor and emergency CD. The debate often focuses on either the safety of childbirth or the women's experience to deliver good maternity care. The aim of this study was to examine the association between the rates of induction of labor and emergency CD with the risks of stillbirth, neonatal intensive care unit (NICU) admission, and need for mechanical ventilation in neonates born at term. This was a national study using data collected from electronic maternity records between 2015 and 2017. Included were singleton pregnancies delivered in NHS hospitals providing maternity care. The primary outcomes were stillbirth, NICU admission, and mechanical ventilation. The entire cohort included 1,131,719 term, singleton births in 131 hospitals. The risks of stillbirth, NICU admission, and need for mechanical ventilation in the baby were 0.15%, 5.4%, and 0.54%, respectively. Between hospitals, the rate of induction of labor ranged from 17.5% to 40.7% (interquartile range, 24.6%–32.1%), and the rate of emergency CD ranged from 5.6% to 17.1% (interquartile range, 9.4%–11.8%). In hospitals with higher induction rates, the risk of adverse perinatal outcomes was lower, but the association was statistically significant only between the rate of induction and rates of stillbirth (P = 0.002) and mechanical ventilation (P = 0.001). For each 5%-point increase in the rate of induction at a hospital, there was a 9% decrease in the risk of stillbirth (odds ratio [OR], 0.91; 95% confidence interval [CI], 3%–15%) and a 14% decrease in the risk of mechanical ventilation (OR, 0.86; 95% CI, 6%–21%). There was no association between the rate of emergency CD and the primary outcomes (all P &gt; 0.05). In the United Kingdom, the rates of induction of labor and emergency CD varied considerably between hospitals. Those hospitals with higher rates of induction had lower risks of adverse perinatal outcomes, but not for emergency CD.

The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon.

To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P= 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P= 0.02 and 0.01, respectively). The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.

Obstetric and perinatal outcomes in parturients with active SARS-CoV-2 infection during labor and delivery: a retrospective cohort study

BackgroundThe COVID-19 pandemic is an ongoing global healthcare crisis that negatively affects pregnant women. Although patients with an acute infection during pregnancy have been widely studied, information regarding labor and delivery while infected is sparse. The aim of the study was to ascertain maternal, obstetrical, and perinatal outcomes of women who gave birth while infected with SARS-CoV-2.MethodsPatients diagnosed with COVID-19 during pregnancy at a tertiary medical center in 4/20–2/21 were identified by a retrospective database search. Those with an active intrapartum SARS-CoV-2 infection were compared with those who recovered at least 10 days before labor and delivery.ResultsOf the 176 women included in the study, 84 had a SARS-CoV-2 infection at the time of delivery and 92 had recovered from the infection. There was no statistically significant between-group difference in mean gestational age at delivery (39 weeks for both, p = 0.71) and overall rate of cesarean delivery (26.2% vs 17.4%, respectively, p = 0.35) or non-elective cesarean delivery (10.71% vs 4.34%, respectively, p = 0.48). In the active-infection group, the rate of severe disease was 2.4%, and of critical disease (with intensive care unit admission, mechanical ventilation, and ECMO), 3.6%, compared to zero for both in the recovered group. No differences were found between the groups in adverse perinatal outcomes.ConclusionDelivery is safe and feasible in women with active SARS-CoV-2 infection. Nevertheless, we found a non-significant trend for more severe disease and for cesarean delivery and urgent cesarean delivery (for COVID-19-related indications) in women with an intrapartum SARS-CoV-2 infection.

Maternal Race/Ethnicity and Mode of Delivery in Twin Gestations [A273

INTRODUCTION: Women of color in the United States have an increased risk of maternal morbidity and a higher risk of cesarean delivery (CD) compared to White women. This study aims to determine whether maternal race/ethnicity influenced mode of delivery (MOD) of twin gestations. METHODS: This was an IRB-approved, retrospective cohort study of all twin deliveries at a single institution between 1/1/2001 and 12/31/2018. Pregnancies delivered&lt;24 weeks or with intrauterine fetal demise were excluded. The primary exposure, self-reported race/ethnicity, was categorized into five groups: White, Hispanic, non-Hispanic Black, Asian/Pacific Islander (PI)/Alaska Native (AN), and Other/Mixed. The primary outcome was CD. Statistical analyses included univariate analysis via Chi-square and ANOVA and logistic regression analysis. RESULTS: A total of 796 pregnancies were included; 377 (47.8%) of participants identified as White, 236 (29.9%) as Hispanic, 83 (10.5%) as Asian/PI/AN, 44 (5.6%) as Black, and 50 (6.3%) as Other/Mixed. BMI, maternal age at delivery, chorionicity, and parity were different by race/ethnicity groups, but gestational age at delivery was not. The overall rate of CD was 71.1% and did not vary by race/ethnicity (P=.51). There were no differences by race/ethnicity when analysis was limited to those delivering&gt;34 weeks and birthweights&gt;2,500 g (P=.07) or among only nulliparous women (P=.77). In multivariable analysis, only nulliparity was associated with increased risk of CD (P&lt;.01). CONCLUSION: Rate of CD for twin gestations is high but was not related to maternal race/ethnicity in this cohort. Further study is needed to evaluate the indications for cesarean deliveries across racial/ethnic groups in twin gestations as this was not examined in this cohort.

Benchmarking cesarean delivery rates using machine learning-derived optimal classification trees.

To establish a case-adjusted hospital-specific performance evaluation tool using machine learning methodology for cesarean delivery. Secondary data were collected from patients between January 1, 2015 and February 28, 2018 using a hospital's "Electronic Data Warehouse" database from Illinois, USA. The machine learning methodology of optimal classification trees (OCTs) was used to predict cesarean delivery rate by physician group, thereby establishing the case-adjusted benchmarking standards in comparison to the overall hospital cesarean delivery rate. Outcomes of specific patient populations of each participating practice were predicted, as if each were treated in the overall hospital environment. The resulting OCTs estimate physician group expected cesarean delivery outcomes, both aggregate and in specific clinical situations. Twelve thousand eight hunderd and forty one singleton, vertex, term deliveries, cared for by practices with ≥50 births. The overall rate of cesarean delivery was 18.6% (n=2384), with a range of 13.3%-33.7% amongst 22 physician practices. An optimal decision tree was used to create a prediction model for the hospital overall, which defined 23 patient cohorts divided by 46 nodes. The model's performance for prediction of cesarean delivery is as follows: area under the curve 0.73, sensitivity 98.4%, specificity 16.1%, positive predictive value 83.7%, negative predictive value 70.6%. Comparisons with the overall hospital's specific-case adjusted benchmark groups revealed that several groups outperformed the overall hospital benchmark, and some practice groups underperformed in comparison to the overall hospital benchmark. OCT benchmarking can assess physician practice-specific case-adjusted performance, both overall and clinical situation-specific, and can serve as a valuable tool for hospital self-assessment and quality improvement.

The association between congenital uterine anomalies and perinatal outcomes – does type of defect matters?

Objective To evaluate the association between congenital uterine anomalies (CUA) and adverse perinatal outcomes stratified by type of anomaly. Methods A retrospective cohort study of all women delivered in one university-affiliated medical center between 2010 and 2017 with CUA. Multiple pregnancies and pregnancies complicated by fetal anomalies were excluded. Maternal and short-term neonatal outcomes were evaluated and compared between women with unification defects (unicornuate, bicornuate, or uterus didelphys), and canalization defects represented by septate uterus. Univariate analysis was utilized followed by multivariate analysis to adjust for confounders. p < .05 was considered significant. Results Among 167 pregnancies with CUA, 92 (55.1%) had bicornuate uterus, 32 (19.1%) septate uterus, 26 (15.6%) didelphys uterus, and 17 (10.1%) unicornuate uterus. Maternal demographics and obstetric characteristics were similar between women with unification and canalization defects. The entire cohort had high rates of preterm delivery (PTD), malpresentation, and cesarean delivery (CD) (25.7%, 42.5%, and 63.5%, respectively). In comparison to unification defects, pregnancies in women with canalization defects (septate uterus), had increased risk for PTD <32 weeks (12.5% vs. 2.9%, p = .02), and placental abruption (12.5% vs. 3%, p = .02), however, a lower overall rate of CD (46.9% vs. 67.4%, p = .03). Following adjustment to confounders (age, BMI, nulliparity, chronic hypertension, and smoking) none of the results remained statistically significant. There were no differences in neonatal outcomes between the groups. Conclusions Overall, women with CUA have a high prevalence of adverse pregnancy outcomes. However, outcome does not differ by type of anomaly.

641 Fetal growth restriction and risk of intrapartum cesarean among women with early onset preeclampsia

Early onset preeclampsia (PE) is associated with increased maternal and neonatal morbidity, including fetal growth restriction (FGR) and higher rates of cesarean delivery (CD). While the optimal route of delivery is unknown, the higher rate of CD is due to perceived failure of induction and need for expedited delivery for maternal benefit. Therefore, we aimed to compare intrapartum CD rates in women with early onset PE with and without FGR. Retrospective chart review of women with early onset PE, defined as PE with severe features that developed < 34 weeks of gestation, delivering at a single tertiary care center between 2011-2020. Women were excluded if they did not undergo trial of labor, had fetal demise or fetal anomaly. FGR was defined as estimated fetal weight or abdominal circumference less than the tenth percentile for gestational age by Hadlock calculator. Our primary outcome was intrapartum CD. Secondary outcomes included indications for CD, a composite of maternal and neonatal outcomes. Results were adjusted for tobacco use and body mass index (BMI) at delivery. Of 261 patients identified, 131 (50%) patients had viable, non-anomalous fetus and underwent a trial of labor. Patients with FGR (n=33, 25.2%) had lower body mass index at delivery (29.3 kg/m2 vs 33.6 kg/m2; P=<0.01), and were more likely to use tobacco (21.2% vs 7.1%, P=0.03), have a fetal indication for delivery (27.3 vs 10.2%, P=0.02), and lower neonatal birthweight (1162g vs 1638g, P=<0.01) compared with patients without FGR. (Table 1) The overall rate of CD was 55% in the cohort. It was higher in patients with FGR (67%) compared with those without FGR (49%), but the difference did not reach statistical significance (aOR 1.74, 95% CI 0.73-4.11). There were no differences in composite of maternal or neonatal adverse outcomes. (Table 2) Women diagnosed with early onset PE and undergo trial of labor have more than 50% rate of CD. However, FGR is not associated with higher risk for CD and should not automatically exclude women from being offered a trial of labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

379 The association between congenital uterine anomalies and perinatal outcomes – canalization vs. unification defects

To evaluate the association between congenital uterine anomalies (CUA) and adverse perinatal outcomes stratified by type of anomaly. A retrospective cohort study of all women delivered in one university affiliated medical center between 2010-2017 with CUA. Multiple pregnancies and pregnancies complicated by fetal anomalies were excluded. Arcuate and T-shaped uterus were also excluded as they represent only minimal deviation from the normal anatomy. Maternal and short-term neonatal outcomes were evaluated and compared between women with unification defects (including unicornuate, bicornuate or uterus didelphys), and canalization defects represented by septate uterus. P <0.05 was considered significant. Among 167 pregnancies with CUA, 92 (55.1%) had bicornuate uterus, 32 (19.2%) septate uterus, 26 (15.6%) didelphys uterus and 17 (10.2%) unicornuate uterus. Maternal demographics and obstetric characteristics were similar between women with unification and canalization defects. Rate of adverse pregnancy outcome was high for the entire cohort (Fig 1). There was one case of anterpartum death in the canalization defects group. In comparison to unification defects (unicornuate, bicornate and didelphys uterus), pregnancies in women with canalization defects (septate uterus), had increased risk for preterm delivery <32 weeks (12.5% vs 3%, p=0.02), and placental abruption (12.5% vs. 3%, p=0.02), however, a lower overall rate of cesarean delivery (46.9% vs. 67.4%, p=0.03). There were no differences in neonatal outcomes between the groups. Overall, women with CUA have a high prevalence of adverse pregnancy outcomes. Compared to unification defects, canalization defects represented by septate uterus have a higher rate of PTD <32 weeks and placental abruption, but overall lower rates of CD, probably due to a lower prevalence of malpresentation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

262 Risk of primary cesarean delivery among non-english speaking nulliparous women

Demographic factors such as maternal age, race, ethnicity, and socioeconomic status are known to affect rates of primary Cesarean delivery. However, effect of a patient’s primary language on rate of Cesarean is unknown. We sought to examine the association between rate of primary unscheduled Cesarean delivery and preferred patient language. A retrospective cohort study was conducted at a large urban medical center between 8/2018 and 1/2020. Inclusion criteria were nulliparity, full term gestation, and having no obstetric or medical contraindication to vaginal delivery. Multiparous women, women with medical contraindications to vaginal delivery, scheduled cesarean deliveries, preterm and multifetal gestations were excluded from the analysis. We used multivariable analyses to evaluate language differences in risk of cesarean delivery. 1316 women were eligible for this study. The overall rate of cesarean delivery was 27.9%. Of this cohort, 76.7% of patients preferred English, 18% Spanish and 5.3% other (all other languages). Spanish and other-speaking women had significantly higher odds of undergoing Cesarean compared to English-speaking women (odds ratio: 1.45; 95% CI: 1.10, 1.91), which remained significant when controlling for factors such as maternal age, race, ethnicity, BMI, insurance type, maternal co-morbidities, labor induction, and infant birthweight (adjusted odds ratio: 1.63; 95% CI: 1.15, 2.32). Interpreter use was documented in 52.1% of non-English speaking admissions. Cesarean delivery rates differ by patient’s preferred language. Specifically, primary cesarean delivery rates were found to be significantly higher among non-English speaking nulliparous women. This difference may be reflective of lack of effective communication during clinical encounters, provider bias, or other factors and should be further studied. Interpreter services should be utilized and documented effectively.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Delivery Outcomes of Pregnant Patients With Inflammatory Bowel Diseases Compared With the General Population and With Women With Other Autoimmune Diseases at a Tertiary Care Center.

Variable data have suggested that pregnant women with inflammatory bowel diseases (IBD) are more likely to have cesarean deliveries and adverse pregnancy outcomes than the general population. The aim of this study was to describe the rates of cesarean delivery and adverse pregnancy outcomes among patients with IBD as compared with patients with other autoimmune diseases and with the general population. Pregnant patients with IBD, those with non-IBD autoimmune diseases, and control patients were identified. Baseline demographics, disease characteristics, medication use, and delivery outcomes were recorded in a retrospective manner. The primary outcome was overall rate of cesarean delivery; secondary outcomes included rates of planned and unplanned cesarean delivery, delivery complications, preterm delivery, and fetal complications. Ninety-three women with IBD were age-matched to 376 control patients; 38 women with other autoimmune diseases were also identified. Women with IBD had higher rates of cesarean delivery (47%) when compared with control patients (31%; P < 0.0001) but not when compared with women with other autoimmune diseases. There were high rates of planned cesarean deliveries for IBD-related factors in the IBD cohort. Women with IBD did not have increased rates of adverse delivery or fetal outcomes. Women with IBD have higher rates of cesarean delivery than the general population and rates similar to those of women with other autoimmune diseases. Planned cesarean delivery plays an important role in maintaining continuity and sphincter control in select situations, but a diagnosis of IBD does not mandate cesarean delivery.

The associated factors of cesarean section during COVID-19 pandemic: a cross-sectional study in nine cities of China

BackgroundImproving and maintaining the health of mothers and newborns is indisputably a global priority, especially during a pandemic. This study intends to examine the factors associated with cesarean section (CS) during lockdown time.MethodsA total of 678 women who just gave birth within 7 days were enrolled from maternal and children hospitals in nine cities of China from April to May 2020. The delivery modes and potential influencing factors were investigated. The subgroup analysis and sensitivity analysis were used to examine the association of CS and risk factors among populations with different characteristics and to control for possible confounding, respectively.ResultsThe overall rate of cesarean delivery was 37.3%. In multi-variant model, maternal age > 30 years (OR, 95% CI = 1.71, 1.21–2.41), higher pre-gestational BMI (OR, 95% CI = 1.16, 1.10–1.23), living in regions with confirmed COVID-19 cases > 500 (OR, 95% CI = 2.45, 1.74–3.45), and excess gestational weight gain (OR, 95% CI = 1.73, 1.17–2.55) were associated with cesarean delivery. These trends of associations were not changes in sensitivity analysis and subgroup analysis. Cesarean delivery occurred more in women who got more nutrition instruction during the pandemic period in the univariant model; however, this association showed insignificance in the multiple-variant analysis.ConclusionA high cesarean delivery rate was found in uninfected women who experienced lockdown in their third trimester. During the COVID-19 pandemic, more medical support should be provided in severely affected regions to ensure and promote health in pregnancy.

The Edmonton Obesity Staging System Predicts Mode of Delivery After Labour Induction.

This study sought to evaluate the use of the Edmonton Obesity Staging System (EOSS) in predicting cesarean delivery among term, nulliparous, singleton pregnancies in women with overweight or obesity who are undergoing an induction of labour. A prospective cohort study was performed in Edmonton, Alberta. Women undergoing an induction of labour at term were recruited to either a sample cohort, including women with a body mass index of ≥25 kg/m2 at first antenatal visit, or a control cohort with a body mass index of 18.5 to 24.9 kg/m2. Participating women provided a self-reported health history and consented to review of their medical records allowing allocation into EOSS categories. The primary outcome was the rate of cesarean delivery based on EOSS category. Secondary outcomes consisted of a summary score of adverse maternal, delivery, and neonatal events (Canadian Task Force Classification II-2). Overall, 345 women were recruited, with a participation rate of 93.7%. The sample cohort consisted of 276 women with overweight or obesity, whereas the control cohort included 69 normal-weight women. The overall rate of cesarean delivery was 30.4% for the control cohort and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS category 0, 1, 2, and 3, respectively (P < 0.001). A summary score was not indicative of overall rate of adverse maternal, delivery, and neonatal events (P = 0.22). The EOSS may help predict the chance of cesarean delivery in a high-risk group of nulliparous women with overweight or obesity who are undergoing an induction of labour at term.

Pregnancy after direct cerebral bypass for moyamoya disease.

Moyamoya disease (MMD) disproportionately affects young to middle-aged women. The main treatment for this challenging disease is cerebral bypass surgery. Vascular neurosurgeons often need to counsel women regarding pregnancy following bypass for MMD, but there is a paucity of data. The authors set out to examine neurological and obstetric outcomes in an extensive cohort of MMD patients who had pregnancies following cerebral revascularization at the Stanford Medical Center. The authors identified all patients at their institution who underwent cerebral bypass for MMD from 1990 through 2018 and who later became pregnant. Some of these patients also had pregnancies prior to undergoing bypass surgery, and the authors examined these pregnancies as well. They performed a chart review and brief telephone survey to identify obstetric complications, transient ischemic attacks (TIAs), and strokes. Neurological and obstetric outcomes were compared to published rates. They also compared pre- and post-bypass pregnancy complication rates using logistic regression techniques. There were 71 pregnancies among 56 women whose mean age was 30.5 years. Among 59 post-bypass pregnancies, there were 5 (8%) perinatal TIAs. There were no MRI-confirmed strokes or strokes with residual deficits. Among 12 pre-bypass pregnancies, there were 3 (25%) TIAs and 2 (17%) MRI-confirmed strokes. There were no hemorrhagic complications in either group. In the generalized estimating equations analysis, performing cerebral revascularization prior to pregnancy versus after pregnancy was associated with lower odds of perinatal stroke or TIA (OR 0.15, p = 0.0061). Nine pregnancies (13%) were complicated by preeclampsia, and there was one (1%) instance of eclampsia. The overall rate of cesarean delivery was 39%. There were 2 miscarriages, both occurring in the first trimester. There were no maternal deaths. The authors present neurological and obstetric outcomes data in a large cohort of MMD patients. These data indicate that post-bypass pregnancy is accompanied by low complication rates. There were no ischemic or hemorrhagic strokes among post-bypass pregnant MMD patients. The rate of obstetric complications was low overall. The authors recommend close collaboration between the vascular neurosurgeon and the obstetrician regarding medical management, including blood pressure goals and continuation of low-dose aspirin.

Pregnancy After Cerebral Bypass for Moyamoya Disease

Abstract INTRODUCTION Moyamoya disease (MMD) disproportionately affects young to middle age women. Vascular neurosurgeons are often needed to counsel women regarding pregnancy following bypass for MMD, but there is a paucity of data. We set out to examine neurological and obstetric outcomes in an extensive cohort of MMD patients who had pregnancies following cerebral revascularization at the Stanford Medical Center. METHODS We identified all patients who underwent cerebral bypass for MMD and later became pregnant from 1990 through 2018. Some of these patients also had pregnancies prior to bypass, and we examined these pregnancies as well. We performed a chart review and a brief telephone survey to identify obstetric complications, transient ischemic attack (TIA), and stroke. Neurological and obstetric outcomes were compared to published rates. We also compared pre- and postbypass pregnancy complication rates using logistic regression techniques. RESULTS There were 71 pregnancies among 56 women with mean age 30.5. Among 59 postbypass pregnancies, there were 5 (8%) perinatal TIAs. There were no magnetic resonance imaging (MRI) confirmed strokes or strokes with residual deficits. Among 12 prebypass pregnancies, there were 3 (25%) TIAs and 2 (17%) MRI-confirmed strokes. There were no hemorrhagic complications in either group. In the multivariable logistic regression analysis, performing cerebral revascularization prior to pregnancy versus postpregnancy was associated with lower odds of perinatal stroke or TIA (OR 0.13, P = .007). The overall rate of cesarean delivery was 39%. CONCLUSION We present neurological and obstetric outcomes in a large cohort of MMD patients. These data indicate that postbypass pregnancy is accompanied by low complication rates. There were no ischemic or hemorrhagic strokes among postbypass, pregnant MMD patients. Obstetric complications were low overall. We recommend a close collaboration between the vascular neurosurgeon and the obstetrician regarding medical management, including blood pressure goals and continuation of aspirin.

Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy.

To identify both the trends in placenta accreta spectrum (PAS) disorders in the context of the universal two-child policy in China and risk factors for hysterectomy. The present retrospective analysis included confirmed PAS disorders during cesarean delivery at a tertiary hospital in Changsha, Hunan, China, from January 1, 2007, to December 31, 2016. Multivariable logistic regression was used to estimate the risk of hysterectomy. During the 10-year study period, the overall incidence of cesarean delivery was 51.6% (13530/26214) and that of PAS disorders was 1.2% (302/26214). The PAS rate increased from 0.1% (5/4617) in 2007-2008 to 2.1% (133/6351) in 2015-2016, alongside a rise in elective repeat cesarean delivery from 5.0% (106/2124) to 38.4% (1385/3603). Previous cesarean delivery greatly increased the likelihood of PAS disorders (odds ratio [OR] 97.4; P<0.001). Invasive depth (OR 92.0; P<0.001), inter-cesarean interval less than 36months (OR 7.0; P=0.002), rural residence (OR 5.3; P=0.018), and advanced maternal age (OR 3.0; P=0.045) were independent risk factors for hysterectomy among women with PAS disorders. The increasing incidence of elective repeat cesarean delivery combined with a high overall rate of cesarean delivery implies a high prevalence of PAS disorders within the context of the universal two-child policy in China. The main predictor of hysterectomy was invasive depth.

Third trimester ultrasound accuracy and delivery outcome in obese and morbid obese pregnant women

Objective: Several studies have highlighted the negative impact of maternal obesity on ultrasound accuracy for fetal weight estimation (EFW). However, the evidence is conflicting. We aimed in our study to find if the ultrasound accuracy for EFW would differ or decrease in obese and morbid obesity classes. We also studied the mode of delivery within the same cohort.Methods: It is a retrospective study of obese patients with recorded BMI ≥30 kg/m2, class I and II (BMI: 30–39.9 kg/m2) compared with extreme obese class III (BMI ≥40 kg/m2), who gave birth after 28-week gestation of viable singleton, who had an ultrasound within 7 d of delivery with reported normal amniotic fluid and no major fetal anomaly; the EFW was consistently measured through Hadlock regression formula in the period of 2014–2015 inclusive. Differences between the EFW and actual birth weight (ABW) were assessed by percentage error, accuracy in predictions within ±10% of error and the Pearson correlation coefficient were used to correlate EFW with the ABW. The study’s secondary outcome was to study the mode of delivery and the rate of cesarean section in obese and morbid obese patients.Results: Total 106 cases fulfilled our criteria. Class I and II as the first group (n = 53). Class III as the second group (n = 53). Maternal and birth characteristics were similar. The Pearson correlation coefficient equal 1 in both groups. The overall mean absolute difference (MAD) in grams of the whole obese cohort was 242 ± 213. The MAD was 242 ± 202 and 242 ± 226 g for the first and second group, respectively (p = 1.0). The overall mean absolute percentage error (MAPE) in this obese cohort was 8%. The MAPE for the first and second group, respectively were 8 and 7% (p = 0.4). The overall rate of cesarean delivery was 60% (64/106) with no differences between the obese and morbid obese BMI classes. Sixty-six percentage (42/64) of these cesarean cases was for repeat cesarean section.Conclusion: Despite what has been previously reported about the negative impact of maternal obesity on EFW accuracy, we could not demonstrate this relationship in our obese cohort (MAPE <10%). In addition, we could not illustrate a significant difference in ultrasound accuracy across various obesity classes. However, we found a significantly increased rate of delivery by repeated cesarean section in this obese cohort.

Born Large for Gestational Age: Bigger Is Not Always Better

Born Large for Gestational Age: Bigger Is Not Always Better