Pre-labour Caesarean Section Research Articles

Trends in planned early birth: a population-based study

The purpose of this study was to describe trends and outcomes of planned births. Data from linked birth and hospital records for 779,521 singleton births at ≥33 weeks' gestation from 2001-2009 were used to determine trends in planned births (prelabor cesarean section and labor inductions). Adverse outcomes were composite indicators of maternal and neonatal morbidity/death. From 2001-2009, there were increases in labor inductions and prelabor cesarean deliveries at <40 weeks' gestation, but no decrease in the stillbirth rate (trend P = .34). By 2009, 14.9% of live births at ≥33 weeks' gestation were prelabor cesarean deliveries before the due date; 11.4% were inductions. As planned births increased, maternal risks shifted, which included a decline in inductions with maternal hypertension from 31.9-23.9%. Earlier birth was contemporaneous with increases (trend P < .001) in neonatal and maternal morbidity rates from 3.0-3.2% and 1.1-1.5%, respectively. Planned birth before the due date is increasing without a contemporaneous reduction of stillbirths.

The effect of pregnancy on hiatal dimensions and urethral mobility: an observational study

Childbirth is an established risk factor of pelvic floor dysfunction. The role of pregnancy is, however, not fully understood. This study was designed to evaluate the potential effect of pregnancy on pelvic floor function. The hypothesis was: Pregnancy has no effect on urethral mobility and levator hiatal dimensions. This was a reanalysis of the translabial 3D/4D ultrasound volume data of 688 nulliparous pregnant women seen in the late 3rd trimester and again 4 months postpartum and that of 74 nulliparous, nonpregnant volunteers in previously reported studies. Hiatal dimensions and urethral mobility were determined as the outcome parameters. Multivariate regression analysis was performed after adjusting for age and BMI between the pregnant and nonpregnant cohorts. Comparison of 3rd trimester data of the pregnant cohort with that of the nonpregnant nulliparae revealed a 27 % and 41 % increase in hiatal area at rest and on Valsalva and an increase in segmental urethral mobility by 64 % to 91 % in late pregnancy. About 70 % of this difference in hiatal dimensions, but virtually identical differences in urethral mobility, were observed when comparing nonpregnant controls with women 4 months after prelabour or 1st stage caesarean section. Both hiatal dimensions and urethral mobility were markedly higher in women in late pregnancy and at 4 months after prelabour/1st stage caesarean section compared to nulliparous controls. The hormonal and mechanical changes of pregnancy may have an irreversible effect on the pelvic floor.

The harmful consequences of prelabour caesarean section on the baby

Interest in rising caesarean section (CS) rates, especially ‘non-medical’ planned prelabour CS (PLCS), has not usually focused on the potential detrimental effects on babies, especially as long-term health is harder to study. Shortening pregnancy and avoiding labour may affect fetal maturity. Babies who do not experience labour have significantly increased respiratory and other morbidities which may have profound effects on development, determining immediate and potentially life-long disease. As labour is usually beneficial, this must be factored into individual decisions. Consideration should be given to awaiting or inducing labour even in women with a high chance of CS or who are requesting this operation. Mothers must be fully informed of all the evidence before they can give valid consent and make decisions on their baby’s behalf. Although all modes of delivery carry potential risk of neonatal morbidity or mortality, avoiding labour may cause more long-term harm than good for children overall.

Multifetal pregnancies: preterm admissions and outcomes

To describe the rates of antenatal hospital admission during twin or higher order multifetal pregnancies, and the admission outcomes as discharge undelivered, transfer to higher care, or spontaneous or elective delivery. Cohort study using linked birth and hospital data. The cohort comprised women who gave birth to twins or higher order multiple infants of≥24 weeks gestation in 2001-2008 and who were admitted to hospital in weeks 20-36 of the pregnancy. In 63.4% of 10 779 twin pregnancies and 99.5% of 197 triplet and quadruplet pregnancies, the woman was admitted to hospital at least once in weeks 20-36 of the pregnancy, for a total 10 985 admissions. Almost half the admissions (46.3%) ended in discharge without delivery, 10.7% in transfer to higher care, 21.1% in spontaneous labour and birth, and 21.8% in elective delivery (induction or prelabour Caesarean section). The reason for admission was preterm labour in 34.2% of admissions. Hospital admission during pregnancy is common for women with multifetal pregnancies, with many of these admissions resulting in preterm birth. This is the first study to report the rate of pregnancy admissions for women with multifetal pregnancies, and provides a baseline for future studies of hospital use in this population.

The health implications of birth by Caesarean section

Since the first mention of fetal programming of adult health and disease, a plethora of programming events in early life has been suggested. These have included intrauterine and postnatal events, but limited attention has been given to the potential contribution of the birth process to normal physiology and long-term health. Over the last 30 years a growing number of studies have demonstrated that babies born at term by vaginal delivery (VD) have significantly different physiology at birth to those born by Caesarean section (CS), particularly when there has been no exposure to labour, i.e. pre-labour CS (PLCS). This literature is reviewed here and the processes involved in VD that might programme post-natal development are discussed. Some of the effects of CS are short term, but longer term problems are also apparent. We suggest that VD initiates important physiological trajectories and the absence of this stimulus in CS has implications for adult health. There are a number of factors that might plausibly contribute to this programming, one of which is the hormonal surge or "stress response" of VD. Given the increasing incidence of elective PLCS, an understanding of the effects of VD on normal development is crucial.

Intrapartum caesarean rates differ significantly between ethnic groups—Relationship to induction

Objective Given international variation in obstetric practices and outcomes, comparison of labour outcomes in different ethnic groups could provide important information regarding the underlying reasons for rising caesarean delivery rates. Increasing numbers of women from Eastern European countries are now delivering in Irish maternity hospitals. We compared labour outcomes between Irish and Eastern European (EE) women in a large tertiary referral center. Study design This was a prospective consecutive cohort study encompassing a single calendar year. The cohort comprised 5550 Irish and 867 EE women delivered in a single institution in 2009. Women who had multiple pregnancies, breech presentation, and elective or pre-labour caesarean sections (CS) were excluded. Data obtained from birth registers included maternal age, nationality, parity, gestation, onset of labour, mode of delivery and birth weight. Results The overall intrapartum CS rate was 11.4% and was significantly higher in Irish compared to EE women (11.8% vs. 8.8%; p = 0.008). The proportion of primiparas was lower in Irish compared to EE women (44.8% vs. 63.6%; p < 0.0001). The intrapartum CS rate was almost doubled in Irish compared to EE primiparas (20.7% vs. 11.0%; p < 0.0001). Analysis of primiparas according to labour onset revealed a higher intrapartum CS rate in Irish primiparas in both spontaneous (13.5% vs. 7.2%; p < 0.0001) and induced labour (29.5% vs. 19.3%; p = 0.005). Irish women were older with 19.7% of primiparas aged more than 35, compared to 1.6% of EE women ( p < 0.0001). The primigravid CS rate in Irish women was significantly higher in women aged 35 years or older compared women aged less than 35 (30.6% vs. 18.3%; p < 0.0001) consistent in both spontaneous and induced labour. The primiparous induction rate was 45.4% in Irish women compared to 32% in EE women, and more Irish women were induced before 41 weeks gestation. Conclusion The results highlight that primigravid intrapartum CS rates were significantly lower in EE compared to Irish women. This could potentially be explained by the younger age and lower induction rates in EE primiparas. Further studies are required to determine the factors for this significant difference in labour outcomes for these two Caucasian groups.

Management of gestational diabetes mellitus: how well are we doing?

Gestational diabetes mellitus (GDM) affects up to 14% of women annually. Abnormal glucose tolerance leads to fetal hyperinsulinaemia and macrosomia, thus increasing perinatal morbidity. Randomized controlled trials have shown that...

Mothers’ Level of Education and Childbirth Interventions: A Population-based Study in Flanders, Northern Belgium

Interventions to influence the time and way to be born have been a global concern for decades. Yet, limited information is available on what drives these interventions and their variation in frequency among countries, institutions, and practitioners. The objective of this study was to examine to what extent first-time mothers' educational achievement contributes to the frequency of childbirth interventions. Childbirth interventions, including induction of labor, cesarean section, instrumental delivery, and epidural analgesia, registered by the Flemish Study Center for Perinatal Epidemiology for Belgian-born nulliparous women from 1999 to 2006, were linked to the level of maternal education, recorded by the Belgian civil birth registration. Education was divided into four levels based on the highest diploma attained and adjusted for marital and occupational status. Frequencies of all interventions were inversely related to the level of maternal education. The effect remained after adjustment for birth year, maternal age, marital status, occupation, infant birthweight, gestational age, assisted conception, and type of hospital. Effect sizes between highest and lowest levels of education were relatively small for operative (31% vs 36%) and instrumental vaginal birth (20.7% vs 22.3%) compared with "initiated delivery" (defined as labor induction and prelabor cesarean section; 30.2% vs 40.3%) and epidural analgesia (66.8% vs 78.0%). The educational gradient in initiated delivery occurred at all gestational ages, contributing to lower gestational age and lower birthweight of term infants with decreasing levels of education. In an affluent society with universal and equitable access to maternity care, the more educated women are, the more likely they are to have a spontaneous labor and spontaneous birth without intervention. (BIRTH 38:3 September 2011).

Prelabour Caesarean Section following IVF/ICSI in Older-Term Nulliparous Women: Too Precious to Push?

Objective. To compare prelabour caesarean section (CS) rates in older nulliparous women with a term singleton baby in cephalic presentation conceiving spontaneously and through IVF/ICSI. When the latter women would ask for CS, how willing are gynaecologists to comply with that request? Methods. A population-based retrospective (1995–2009) cohort study, conducted in Northern Belgium. A comparison of 1,866 nulliparous women pregnant after IVF/ICSI and 15,228 controls is made. An anonymous postal questionnaire is sent to all Belgian gynaecologists. Result. Both groups are comparable with respect to maternal age, gestational age, and birth weight. Prelabour CS is more often performed in women who conceived through IVF/ICSI compared to those who conceived spontaneously (9.2% versus 6.3%, P < 0.001). One in five gynaecologists agrees with the maternal request. Conclusion. IVF/ICSI pregnancies in older nulliparous women more often end in a prelabour CS and a substantial number of gynaecologists go along with a nonmedical reason for CS.

54 Impact of Maternal Body Mass Index on Offspring Liver Lipid Depends on Mode of Delivery

Background: Maternal overweight/obesity is associated with increased risk of Caesarean Section (CS) and offspring metabolic syndrome, though the mediating biological pathway is unknown. In an animal model pre-labour CS in comparison with vaginal delivery (VD), is associated with significantly higher offspring intrahepatocellular lipid (IHCL), a central component of the metabolic syndrome (Hyde MJ, 2010).Aim: To examine the effects of maternal Body Mass Index (BMI) and mode of delivery on neonatal IHCL.Methods: With research ethics approval and informed written parent consent we employed 1H Magnetic Resonance Spectroscopy of liver during natural sleep in healthy term neonates (Thomas EL, 2008). We used analysis of covariance to explore the effect of maternal BMI, diabetes and mode of delivery, and infant gender, birth weight and postnatal age and their interactions on IHCL (presented as the ratio of lipid CH2/water).Results: To date we have studied 57 infants (45 VD, 12 pre-labour CS). IHCL ranged from 0 to 5.5, and maternal BMI from 17 to 35 kg/m2. There was a significant interaction between maternal BMI and mode of delivery (p=0.010). In neonates born by pre-labour CS, IHCL increased by a mean of 29% [95%CI 9-54%] per unit increase in maternal BMI (p=0.004). Maternal BMI had no impact on IHCL in VD infants (p=0.81).Conclusion: VD may activate pathways that protect against liver lipid accumulation in the presence of increasing maternal BMI. Pre-labour CS may pose an added risk for the development of the metabolic syndrome in offspring of overweight/ obese mothers.

Implementing safe motherhood: a low‐cost intervention to improve the management of eclampsia in a referral hospital in Malawi

Please cite this paper as: Drost E, van Lonkhuijzen L, Meguid T, Landis Lewis D, Zeeman G. Implementing safe motherhood: a low‐cost intervention to improve the management of eclampsia in a referral hospital in Malawi. BJOG 2010;117:1553–1557.We evaluated the effect of so‐called monitoring and treatment charts on the management of eclampsia in a referral hospital in Malawi. Baseline characteristics, clinical management, as well as overall maternal and perinatal outcome were compared by reviewing the medical files of two groups, before and after introduction of the charts in 2006. The use of the charts has resulted in improved monitoring of women with eclampsia and may have contributed to the reduction in the planned prelabour caesarean section rate from 87% to 33%, as more women underwent induction of labour after stabilisation (P = 0.020). Overall maternal and perinatal outcomes were similar.

Congenital abnormalities and other birth outcomes in children born to women with ulcerative colitis in Denmark and Sweden

Studies of women with ulcerative colitis (UC) during pregnancy have reported increased risks of preterm delivery, growth restriction, and congenital malformation. However, the results are inconsistent due to inadequate study design and limitations in sample size. We performed a population-based prevalence study on 2637 primiparous women with a UC hospital diagnosis prior to delivery and 868,942 primiparous women with no UC diagnosis in Denmark and Sweden, 1994-2006. Logistic regression analysis was used to estimate relative risks for moderately (32-36 weeks) and very (before 32 weeks) preterm birth, 5-minute Apgar score <7, small-for-gestational-age (SGA) birth, stillbirth, neonatal death, and congenital abnormalities. Maternal UC was associated with increased risk of moderately preterm birth (prevalence odds ratio [POR] 1.77, 95% confidence interval [CI]: 1.54-2.05), very preterm birth (POR 1.41, 95% CI: 1.02-1.96), cesarean section (POR 2.01, 95% CI: 1.84-2.19), and neonatal death (POR 1.93, 95% CI: 1.04-3.60). The strongest associations were observed for prelabor cesarean section (POR = 2.78, 95% CI: 2.38-3.25) and induced preterm delivery (POR 2.55, 95% CI: 1.95-3.33). There was a slightly increased risk of SGA birth (POR 1.27, 95% CI: 1.05-1.54). We found no association between UC and overall risk of congenital abnormalities (POR 1.05, 95% CI: 0.84-1.31) or specific congenital abnormalities. Risks for adverse birth outcomes were higher in women with previous UC-related surgery and hospital admissions. Women with UC have increased risks of preterm delivery, SGA-birth, neonatal death, and cesarean section but not congenital abnormalities. Adverse birth outcomes appeared correlated with UC disease severity.

Uterine rupture after previous caesarean section

To determine the risk factors, percentage and maternal and perinatal complications of uterine rupture after previous caesarean section. Population-based registry study. Mothers with births > or =28 weeks of gestation after previous caesarean section (n = 18 794), registered in the Medical Birth Registry of Norway, from 1 January 1999 to 30 June 2005. Associations of uterine rupture with risk factors, maternal and perinatal outcome were estimated using cross-tabulations and logistic regression. Odds of uterine rupture. A total of 94 uterine ruptures were identified (5.0/1000 mothers). Compared with elective prelabour caesarean section, odds of rupture increased for emergency prelabour caesarean section (OR: 8.63; 95% CI: 2.6-28.0), spontaneous labour (OR: 6.65; 95% CI: 2.4-18.6) and induced labour (OR: 12.60; 95% CI: 4.4-36.4). The odds were increased for maternal age > or =40 years versus <30 years (OR: 2.48; 95% CI: 1.1-5.5), non-Western (mothers born outside Europe, North America or Australia) origin (OR: 2.87; 95% CI: 1.8-4.7) and gestational age > or =41 weeks versus 37-40 weeks (OR: 1.73; 95% CI: 1.1-2.7). Uterine rupture after trial of labour significantly increased severe postpartum haemorrhage (OR: 8.51; 95% CI: 4.6-15.1), general anaesthesia exposure (OR: 14.20; 95% CI: 9.1-22.2), hysterectomy (OR: 51.36; 95% CI: 13.6-193.4) and serious perinatal outcome (OR: 24.51 (95% CI: 11.9-51.9). Induction by prostaglandins significantly increased the odds for uterine rupture compared with spontaneous labour (OR: 2.72; 95% CI: 1.6-4.7). Prelabour ruptures occurred after latent uterine activity or abdominal pain in mothers with multiple or uncommon uterine scars. Trial of labour carried greater risk and graver outcome of uterine rupture than elective repeated caesarean section, although absolute risks were low. A review of labour management and induction protocol is needed.

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Crohn's Disease Is a Risk Factor for Preterm Birth

Women with Crohn's disease (CD) are considered to be at increased risk for adverse outcomes of pregnancy. However, the few studies assessing this risk have had small sample sizes and limitations. We examined outcomes of pregnancy among a large cohort of primiparous women with CD. Our population-based prevalence study utilized data from medical birth registries in Sweden and Denmark between 1994 and 2006. Linking birth registry data with national patient registries, we identified 2377 women with a hospital diagnosis of CD prior to delivery and 869,202 women with no diagnosis of CD. Using logistic regression analysis, we estimated relative risks with 95% confidence intervals (CI) for pre-eclampsia, preterm birth, 5-minute Apgar scores below 7, cesarean section, small for gestational age (SGA), stillbirth, and congenital malformations. Maternal CD was associated with increased risk of moderately and very preterm birth (prevalence odds ratio [POR], 1.76; 95% CI, 1.51-2.05; and POR, 1.86; 95% CI, 1.38-2.52, respectively). Maternal CD was also associated with increased risk for cesarean section (POR, 1.93; 95% CI, 1.76-2.12). The strongest associations with CD were observed for prelabor cesarean section and induced preterm delivery. Risk of small size for gestational age birth was slightly increased among women with CD, especially during the time period of 2002-2006 (POR, 1.43; 95% CI, 1.09-1.89). We found no increased risks for pre-eclampsia, low 5-minute Apgar score, stillbirth, or congenital malformations. Maternal CD is a risk factor for preterm birth, but not birth defects.

Getting evidence into obstetric practice: appropriate timing of elective caesarean section

There is considerable variation in the timing of elective pre-labour caesarean section at term where there is no immediate threat to the life of the mother or baby. Given the outcomes, elective or pre-labour caesarean section ought not be offered or performed before 39 completed weeks' gestation. Primary data sources indicated that the rate of term elective caesarean sections with no medical indication undertaken before 39 weeks' gestation at our institution was ~30% in 2005 and 2006. A project was undertaken during the 6-month period from March 2007 to August 2007 with the aim of reducing this rate to 10%. Over the 6-month period, the rate of elective caesarean section with no medical indication done before 39 weeks' gestation in the target group fell to 10%. Over the same timeframe the number of admissions to the neonatal nursery of term babies born by caesarean section at less than 39 weeks fell to zero. Although the numbers are small and not statistically significant, this work suggests implementation across larger jurisdictions or states could result in significant improvements in clinical outcomes.

202: The placenta as a significant modulator of iodine supply to the fetus

Iodide supply to the developing fetus is dependent on maternal dietary iodine intake and on functioning placental iodine transport; maternal iodine excretion falls precipitously at delivery. The aim of this study was to evaluate iodide uptake, tissue iodine content and transporter expression in placental tissue obtained from women undergoing prelabor cesarean section (CS) at term. The influences of different pregnancy-associated hormones on placental iodine uptake and its relationship to alterations in the expression levels of the iodide transporters, sodium iodide symporter (NIS) and Pendrin (PDS) were also assessed.

Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants

ObjectiveTo determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. MethodsWe conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term. ResultsThere were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery. ConclusionAn elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.

Neonatal arterial ischaemic stroke: obstetric issues

Perinatal arterial ischaemic stroke (PAIS) is increasingly recognised as an important cause of neurological morbidity in children. The aetiology remains unclear although perinatal risk factors have been identified from limited case series. Risk factors for PAIS in term infants are different from those in preterm infants. Maternal primiparity, infertility, cocaine use, prothrombotic disorders, prolonged rupture of membranes, abnormal cardiotocograph, instrumental deliveries and emergency caesarean sections are reported risk factors in term infants. Uncomplicated vaginal delivery and prelabour caesarean section are uncommon in cases of PAIS. The presence of multiple risk factors increases the odds of developing PAIS. For preterm babies, fetal heart abnormalities, twin-twin transfusion and hypoglycaemia are recognised risk factors. Larger cohort studies are required to elucidate further the multifactorial pathway to perinatal arterial stroke.

Neonatal respiratory morbidity and mode of delivery in a population‐based study of low‐risk pregnancies

The aim of this study is to evaluate the association between the mode of delivery and the risk of neonatal respiratory complications in a cohort of term newborns in the Lazio region, Italy. Data on 139,379 term singleton infants born in 2003-2005 were retrieved from birth and hospital discharge database. Odds Ratios (ORs) adjusted by age, parity, birth weight, gestational age, and gender were calculated using logistic regression models. The rate of prelabor cesarean section (CS) was 26.2%. The rates of neonatal respiratory morbidity were 29.6/1,000 in infants delivered by prelabor CS and 17.4/1,000 in infants delivered vaginally or by CS in labor. The adjusted risk of neonatal respiratory morbidity associated with prelabor cesarean birth at 37 weeks is four times higher than in intended vaginal birth after 37 weeks. Prelabor cesarean delivery should be performed after at least 38 weeks' of gestation in order to minimize neonatal respiratory morbidity.