Prelabor Cesarean Research Articles

Predictors of Vaginal Delivery among Patients Admitted with Severe Preeclampsia.

This study aimed to assess the rates of vaginal delivery (VD) and the predictors of VD in a cohort of patients with early (<34 weeks) preeclampsia with severe features (Early Severe PreEClampsia [ESPEC]). We conducted a retrospective cohort study of patients with ESPEC admitted to a single center from 2013 to 2019. Exclusion criteria included patients with contraindications to labor, multifetal gestation, or presenting in spontaneous labor. Patient characteristics were abstracted. The primary outcome was rate of VD. Secondary outcome was factors associated with VD. Secondary analysis performed including only primiparous patients. Bivariate statistics and logistic regression were used to analyze data. Of 229 patients with ESPEC, 184 (80%) were candidates for labor. Of those, 74 (40%) underwent prelabor cesarean delivery (CD). Among the 110 remaining patients who attempted VD, 47 (43%) were successful. No significant differences in characteristics between VD and CD patients were found on bivariate analysis. In regression models, BMI ≥ 40 was associated with increased odds of CD (adjusted odds ratio [aOR]: 2.83, 95% confidence interval [CI]: 1.01, 7.95), whereas private insurance was associated with reduced odds of CD (aOR: 0.37, 95% CI: 0.16, 0.86). In planned secondary analysis of primiparous patients, 101/123 (82%) were candidates for labor. Of those, 29 underwent prelabor CD. The VD rate among primiparous patients attempting labor was 40% (29/72). In this subgroup, private insurance was associated with VD (71 vs. 46%, p = 0.03). In regression models, only private insurance remained associated with CD (aOR: 0.30, 95% CI: 0.10, 0.92). Patients with ESPEC who attempted VD were successful less than half of the time, with similar rates among the subset of primiparous patients. BMI ≥ 40 was associated with increased odds of CD, whereas private insurance was associated with reduced odds of CD. These data may aid providers in counseling patients with ESPEC on the likelihood of successful VD. · Only 43% of ESPEC patients who attempted VD were successful.. · Subset of primiparous patients w/ESPEC had similar VD rate.. · BMI ≥40 kg/m2 in ESPEC patients was associated with increased odds of CD..

Microbial Etiology, Antimicrobial Resistance, and Risk Factors of Surgical Site Infections in Gestational Diabetes Mellitus Patients Undergoing Elective Pre-Labor Cesarean Deliveries.

Gestational Diabetes Mellitus (GDM) significantly increases the risk of adverse pregnancy outcomes, including elective pre-labor cesarean deliveries. Postoperative surgical site infections (SSIs) pose a significant concern, underscoring the need for a detailed investigation into their causes and preventative measures. The aim of this study is to systematically identify and analyze the microbial etiology and antimicrobial resistance profiles of pathogens responsible for SSIs in GDM patients undergoing elective pre-labor cesarean deliveries. Additionally, this research aims to elucidate the risk factors contributing to SSIs, with a specific focus on operation duration, amniotic fluid contamination, and genital tract inflammation, and their correlation with the incidence of SSIs. A retrospective analysis was conducted at our Hospital between September 2018 and July 2023, involving 150 GDM patients who underwent elective pre-labor cesarean deliveries. Patients were categorized into infected and uninfected groups based on postoperative SSIs. Clinical data were meticulously collected and analyzed using SPSS software (version 27.0). Independent sample t-tests and chi-square tests were employed for statistical analysis. Microbial profiling revealed that Gram-negative bacteria, primarily E. coli, constituted approximately 59.46% of the isolated strains, exhibiting significant resistance to commonly used antibiotics such as ampicillin and cefotaxime. Elevated levels of biomarkers, including Procalcitonin (PCT) and Hemoglobin A1c (HbA1c), were significantly associated with SSIs. Multivariate logistic regression analysis identified operation time ≥1-hour, amniotic fluid contamination, and genital tract inflammation as significant risk factors. This study highlights the microbial etiology, resistance patterns, and risk factors for SSIs in GDM cesarean patients, emphasizing the need for tailored preoperative evaluations.

Soluble fms-like tyrosine kinase-1/placental growth factor ratio at 36 weeks’ gestation: association with spontaneous onset of labor and intrapartum fetal compromise in low-risk pregnancies

Previous evidence showed that placental dysfunction triggers spontaneous preterm or term births and intrapartum fetal compromise and often requires urgent delivery, thereby exposing both the fetus and the mother to significant risks. Predicting spontaneous labor onset and intrapartum fetal compromise could improve obstetrical management and outcomes, but this is currently difficult, particularly in low-risk populations. The objective of this study was to examine whether placental dysfunction, as assessed at 36 weeks' gestation by the soluble fms-like tyrosine kinase-1 to placental growth factor ratio, is associated with the interval to spontaneous onset of labor and intrapartum fetal compromise that requires cesarean delivery in a routinely examined population. This was a retrospective analysis of prospectively collected data of women with singleton pregnancies who underwent routine assessment at 35+0 to 36+6 weeks' gestation at the King's College Hospital (London, England). Using a general linear model, the study examined the outcomes related to the soluble fms-like tyrosine kinase-1/placental growth factor ratio, including the time interval from testing to spontaneous onset of labor and the subsequent rate of fetal compromise that required a cesarean delivery. Patients who underwent induction of labor or prelabor cesarean deliveries were excluded from the study. Competing risks regression and Cox regression models were used to estimate the cumulative incidence and the risk of the outcomes of interest. In the screened population of 45,375 patients, 23,831 (52.5%) had spontaneous onset of labor and were included in the analysis. Cases with an soluble fms-like tyrosine kinase-1/placental growth factor ratio >50 delivered about 1 week earlier than those with a ratio of ≤50 (39.2 vs 40.0 weeks' gestation; P<.001). The general linear model showed that a larger soluble fms-like tyrosine kinase-1/placental growth factor ratio was associated with earlier spontaneous onset of labor (P<.001), particularly among multiparous women. The soluble fms-like tyrosine kinase-1/placental growth factor ratio was significantly associated, as expected, with cases of preeclampsia and advanced maternal age. The cumulative incidence of spontaneous onset of labor was significantly higher in cases with an soluble fms-like tyrosine kinase-1/placental growth factor ratio >50 than in those with a ratio 50 (P<.001). Cox regression showed that the risk for spontaneous onset of labor increased with an soluble fms-like tyrosine kinase-1/placental growth factor ratio >50 (hazard ratio, 1.424; 95% confidence interval, 1.253-1.618; P<.001) and, as expected, the risk was mitigated over time from when the soluble fms-like tyrosine kinase-1/placental growth factor ratio was measured to spontaneous labor onset (P<.001). Cases with intrapartum fetal compromise had a higher mean soluble fms-like tyrosine kinase-1/placental growth factor ratio than those without intrapartum fetal compromise (21.79 vs 17.67; P<.001). Qualitative addition of fetal compromise to the general linear model showed a higher soluble fms-like tyrosine kinase-1/placental growth factor ratio in cases with fetal compromise than in those without fetal compromise (P=.014). Competing risks regression showed a positive dose-response effect for fetal compromise with increasing soluble fms-like tyrosine kinase-1/placental growth factor ratios (P<.001). Above and below the optimal cutoff of 50, the quoted cumulative incidences were 6.7% and 4.7%, respectively (P<.001). The effect of the soluble fms-like tyrosine kinase-1/placental growth factor ratio remained significant even after adjusting for preeclampsia, which is a well-known major risk factor for fetal compromise. Finally, the proportion of cases with intrapartum fetal compromise who had an soluble fms-like tyrosine kinase-1/placental growth factor ratio >50 decreased from 35% to 0% with advancing gestation. This study showed that an increased soluble fms-like tyrosine kinase-1/placental growth factor ratio at 36 weeks' gestation is associated with an earlier gestational age at spontaneous onset of labor and higher rates of intrapartum fetal compromise. There are 2 major implications, namely an soluble fms-like tyrosine kinase-1/placental growth factor ratio >50 indicates imminent labor onset with about a 40% mean risk increase and immediate clinical translation for term pregnancy monitoring. In addition, an increased soluble fms-like tyrosine kinase-1/placental growth factor ratio increases the risk for intrapartum fetal compromise, although outcome variability indicates reassessment within multimarker models.

Examining Cesarean Among Individuals of Advanced Maternal Age in Nurse-Midwifery Care.

Cesarean rates are rising, especially for individuals of advanced maternal age (AMA), defined as aged 35 or older. The Robson 10-Group Classification System (TGCS) facilitates assessment and comparison of cesarean rates among individuals in different settings. In midwifery-led care, in which pregnant people are typically healthier and seek a vaginal birth, it is unknown whether individuals of AMA have different antecedents leading to cesarean compared with younger counterparts. This study aimed to examine antecedents contributing to cesarean using Robson TGCS for individuals across age groups in midwifery care. This study was a secondary analysis of 2 cohort data sets from Oregon Health & Science University (OHSU) and University of Michigan Health Systems (UMHS) hospitals. The samples were individuals in midwifery-led care birthing at either OHSU from 2012 to 2019 or UMHS from 2007 to 2019. A total of 11,951 individuals were studied. Overall cesarean rates were low; however, the rate for individuals of AMA was higher than the rate of their younger counterparts (18.30% vs 15.10%). The Robson groups were similar; however, the primary contributor among AMA individuals was group 5 (multiparous with previous cesarean), followed by group 2 [nulliparous with labor induced or prelabor cesarean], and group 1 [nulliparous with spontaneous labor]. In contrast, the primary contributors for younger individuals were groups 1, 2, and 5, respectively. In addition, prelabor cesarean and induced labor partly mediated the relationship between AMA and cesarean among nulliparous individuals, whereas prelabor cesarean was the key contributor to cesarean among multiparous people. The cesarean rate in midwifery-led care was low. Using Robson TGCS provided additional insight into the antecedents to cesarean, rather than viewing cesarean as a single outcome. Future studies should continue to use Robson TGCS and investigate antecedents to cesarean, including factors influencing successful vaginal birth after cesarean in individuals of AMA.

Using Robson classification to analyze cesarean section and induction rates in relation to changes in the standards of perinatal care in one hospital in Poland.

Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten-Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions. We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time. The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period. The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct.

Potential benefits of prenatal diagnosis of TGA in Australia may be outweighed by the adverse effects of earlier delivery: likely causation and potential solutions

ObjectivePrenatal diagnosis of transposition of great arteries (TGA) is expected to improve postoperative outcomes after neonatal arterial switch operation (ASO); however, published reports give conflicting results. We aimed to determine...

Outcomes of induction vs prelabor cesarean delivery at

Hypertensive disorders of pregnancy are the leading cause of indicated preterm birth; however, the optimal delivery approach for pregnancies complicated by preterm hypertensive disorders of pregnancy remains uncertain. This study aimed to compare maternal and neonatal morbidity in patients with hypertensive disorders of pregnancy who either went induction of labor or prelabor cesarean delivery at <33 weeks' gestation. In addition, we aimed to quantify the length of induction of labor and rate of vaginal delivery in those who underwent induction of labor. This is a secondary analysis of an observational study which included 115,502 patients in 25 hospitals in the United States from 2008 to 2011. Patients were included in the secondary analysis if they were delivered for pregnancy associated hypertension (gestational hypertension or preeclampsia) between 230 and <330 weeks' gestation; and were excluded for known fetal anomalies, multiple gestation, fetal malpresentation or demise, or a contraindication to labor. Maternal and neonatal adverse composite outcomes were evaluated by intended mode of delivery. Secondary outcomes were duration of labor induction and rate of cesarean delivery in those who underwent labor induction. A total of 471 patients met inclusion criteria, of whom 271 (58%) underwent induction of labor and 200 (42%) underwent prelabor cesarean delivery. Composite maternal morbidity was 10.2% in the induction group and 21.1% in the cesarean delivery group (unadjusted odds ratio, 0.42 [0.25-0.72]; adjusted odds ratio, 0.44 [0.26-0.76]). Neonatal morbidity in the induction group vs the cesarean delivery was 51.9% and 63.8 %, respectively (unadjusted odds ratio, 0.61 [0.42-0.89]; adjusted odds ratio, 0.71 [0.48-1.06]). The frequency of vaginal delivery in the induction group was 53% (95% confidence interval, 46.8-58.7) and the median duration of labor was 13.9 hours (interquartile range, 8.7-22.2). The frequency of vaginal birth was higher in patients at or beyond 29 weeks (39.9% at 240-286 weeks, 56.3% at 290-<330 weeks; P=.01). Among patients delivered for hypertensive disorders of pregnancy <330 weeks, labor induction compared with prelabor cesarean delivery is associated with significantly lower odds of maternal but not neonatal morbidity. More than half of patients induced delivered vaginally, with a median duration of labor induction of 13.9 hours.

The Association of Fetal Acidemia With Adverse Neonatal Outcomes at Time of Scheduled Cesarean Delivery

(Am J Obstet Gynecol. 2022;227:265.e1–8) Fetal acidemia at delivery is a predictor of neonatal morbidity and mortality. Testing fetal umbilical artery (UA) blood gases at delivery can help identify neonates with acidemia who should receive additional surveillance and interventions to prevent long-term adverse outcomes. There is debate over which levels of fetal acidemia are associated with neonatal morbidity. Fetal acidemia is caused by an interruption in placental gas exchange during contractions in labor. Fetal acidemia does not occur often during scheduled, prelabor cesarean delivery (CD), and is believed to be caused by compression of the inferior vena cava or poor uterine and placental perfusion. This study examined the association between acidemia at the time of scheduled, prelabor CD, and adverse neonatal outcomes, hypothesizing that there would be no association between fetal acidemia and neonatal morbidity in this context.

Risk of Cesarean Delivery Varies by Race and Ethnicity Among Pregnancies Complicated by Fetal Growth Restriction [ID: 1377645

INTRODUCTION: Cesarean delivery (CD) rates differ between non-Hispanic White (NHW) and Hispanic/non-White (H/NW) patients, although the relationship varies by indication. We examined CD rates among NHW and H/NW patients in pregnancies complicated by fetal growth restriction (FGR). METHODS: This was an IRB-approved secondary analysis of a retrospective cohort of singleton live births 2003–2012 with an estimated fetal weight (EFW) less than 10th centile for gestational age on the last ultrasound prior to delivery. RESULTS: Of 563 pregnancies, 270 (46.88%) were to NHW patients and 306 (53.12%) to H/NW patients. NHW were older (27.92 versus 26.04 years), taller (160.42 versus 158.58 cm), and more likely to have private insurance (51.30% versus 20.26%) and be admitted to a private practice (70.00% versus 44.41%) (P&lt;.01 for all). There was no difference in umbilical artery Doppler findings, EFW, proportion of CD performed because of nonreassuring fetal status, maternal body mass index, gestational age at FGR diagnosis or delivery, or maternal comorbidities. Apgar scores, arterial cord pH, neonatal intensive care unit admission, hypoglycemia, need for respiratory support, and neonatal death were similar (P&gt;.05 for all). However, NHW patients were more likely to undergo CD (35.71% versus 22.90%, P&lt;.01) including prelabor cesarean (21.48% versus 13.75%, P&lt;.01). After adjusting for maternal age, height, insurance status, and delivering team, risk of CD remained higher among NHW patients (relative risk 1.56, 95% CI 1.20–2.03; adjusted relative risk 1.48, 95% CI 1.12–1.96). CONCLUSION: Despite similar neonatal outcomes, NHW are more likely than H/NW patients to deliver by CD, particularly prelabor CD, when the EFW is below the 10th centile.

Pregnancy Complications and Long-Term Mortality in a Diverse Cohort.

Pregnancy complications are associated with increased risk of development of cardiometabolic diseases and earlier mortality. However, much of the previous research has been limited to White pregnant participants. We aimed to investigate pregnancy complications in association with total and cause-specific mortality in a racially diverse cohort and evaluate whether associations differ between Black and White pregnant participants. The Collaborative Perinatal Project was a prospective cohort study of 48 197 pregnant participants at 12 US clinical centers (1959-1966). The Collaborative Perinatal Project Mortality Linkage Study ascertained participants' vital status through 2016 with linkage to the National Death Index and Social Security Death Master File. Adjusted hazard ratios (aHRs) for underlying all-cause and cause-specific mortality were estimated for preterm delivery (PTD), hypertensive disorders of pregnancy, and gestational diabetes/impaired glucose tolerance (GDM/IGT) using Cox models adjusted for age, prepregnancy body mass index, smoking, race and ethnicity, previous pregnancies, marital status, income, education, previous medical conditions, site, and year. Among 46 551 participants, 45% (21 107 of 46 551) were Black, and 46% (21 502 of 46 551) were White. The median time between the index pregnancy and death/censoring was 52 years (interquartile range, 45-54). Mortality was higher among Black (8714 of 21 107 [41%]) compared with White (8019 of 21 502 [37%]) participants. Overall, 15% (6753 of 43 969) of participants had PTD, 5% (2155 of 45 897) had hypertensive disorders of pregnancy, and 1% (540 of 45 890) had GDM/IGT. PTD incidence was higher in Black (4145 of 20 288 [20%]) compared with White (1941 of 19 963 [10%]) participants. The following were associated with all-cause mortality: preterm spontaneous labor (aHR, 1.07 [95% CI, 1.03-1.1]); preterm premature rupture of membranes (aHR, 1.23 [1.05-1.44]); preterm induced labor (aHR, 1.31 [1.03-1.66]); preterm prelabor cesarean delivery (aHR, 2.09 [1.75-2.48]) compared with full-term delivery; gestational hypertension (aHR, 1.09 [0.97-1.22]); preeclampsia or eclampsia (aHR, 1.14 [0.99-1.32]) and superimposed preeclampsia or eclampsia (aHR, 1.32 [1.20-1.46]) compared with normotensive; and GDM/IGT (aHR, 1.14 [1.00-1.30]) compared with normoglycemic. P values for effect modification between Black and White participants for PTD, hypertensive disorders of pregnancy, and GDM/IGT were 0.009, 0.05, and 0.92, respectively. Preterm induced labor was associated with greater mortality risk among Black (aHR, 1.64 [1.10-2.46]) compared with White (aHR, 1.29 [0.97-1.73]) participants, while preterm prelabor cesarean delivery was higher in White (aHR, 2.34 [1.90-2.90]) compared with Black (aHR, 1.40 [1.00-1.96]) participants. In this large, diverse US cohort, pregnancy complications were associated with higher mortality nearly 50 years later. Higher incidence of some complications in Black individuals and differential associations with mortality risk suggest that disparities in pregnancy health may have life-long implications for earlier mortality.

The Association of Fetal Acidemia With Adverse Neonatal Outcomes at Time of Scheduled Cesarean Delivery

ABSTRACT Up to 30% of term labor deliveries experience fetal acidemia, a condition usually caused by hypoxia that is associated with adverse neonatal outcomes. The American College of Obstetricians and Gynecologists and American Academy of Pediatrics recommend assessing fetal umbilical artery (UA) blood gases at delivery when fetal metabolic status is in question. Although a UA pH of 7.24 to 7.28 is considered normal, the degree of acidemia associated with neonatal death is unclear. Recent data suggest that mild acidemia (UA pH of 7.0–7.2) and certain types of acidemia (metabolic, mixed, or respiratory) also indicate increased risk for adverse outcomes. Most cases of acidemia follow labor when the placental gas exchange is interrupted during contractions. But fetal acidemia is rare in cases of scheduled prelabor cesarean delivery (CD) and not well described in the literature. This study aims to determine if fetal acidemia at the time of scheduled, prelabor CD is associated with neonatal morbidity. This was a retrospective cohort study comparing patients with and without fetal acidemia, defined as a UA pH &lt;7.2. Included were singleton neonates delivered via scheduled CD at a single tertiary care center from June 2004 to December 2014. Excluded were those who delivered before 37 weeks of gestation, were diagnosed with major anomalies, or underwent CD due to labor, rupture of membranes, or nonreassuring fetal status. Also excluded were cases in which data on validated umbilical cord gases were unavailable. The primary outcome was a composite of neonatal outcomes, including neonatal death, encephalopathy, therapeutic hypothermia, seizures, intubation, and respiratory distress. A total of 2081 neonates met the inclusion criteria, with fetal acidemia present at the time of delivery in 252 cases (12.1%). Acidemia occurred more frequently in breech neonates and those born to mothers with gestational diabetes mellitus or obesity. Intraoperative maternal hypotension, use of vasopressor therapy, and increased times from anesthesia induction and skin incision to delivery were also more likely to occur in cases of acidemia. The primary composite outcome was observed in 176 (8.5%) of neonates. This outcome was significantly higher in those with acidemia than those without (7.6% vs 15.1%; adjusted risk ratio [aRR], 2.95; 95% confidence interval [CI], 2.03 to 4.12). Intubation (aRR 3.50; 95% CI, 1.27–9.13) and respiratory distress (aRR, 2.93; 95% CI, 2.00–4.13) also occurred more frequently among those with acidemia. As the rate of UA pH categories decreased, the proportion of neonates with the primary outcome increased: 13.5% morbidity if UA pH was 7.0 to 7.19 versus 42.9% morbidity if UA pH was &lt;7.0. Compared with neonates with a UA pH ≥7.2, the risk for adverse outcomes rose 3.2-fold in those with a UA pH &lt;7.1 (aRR, 3.23; 95% CI, 1.73–5.24) and 6.6-fold in those with a UA pH &lt;7.0 (aRR, 6.64; 95% CI, 3.23–8.96). The primary outcome was observed in 24.7% of neonates with respiratory acidemia, 27.5% with mixed, and 25% with other acidemia. There were no cases of metabolic acidemia. Compared with neonates without acidemia, the risk for adverse outcomes after controlling for confounders increased 2.7-fold in those with respiratory acidemia (adjusted odds ratio, 2.77; 95% CI, 1.74–4.15) and 3-fold in those with mixed acidemia (adjusted odds ratio, 3.08; 95% CI, 1.72–4.93). In conclusion, there was an increased risk of adverse neonatal outcomes in cases with mild fetal acidemia at the time of scheduled CD. Most cases in this study were attributed to respiratory acidemia.

The association between episiotomy or OASIS at vacuum extraction in nulliparous women and subsequent prelabor cesarean delivery: A nationwide observational study

Severe perineal injuries at childbirth affect women's postnatal health, including future childbirths. First births with vacuum extraction carry an increased risk of obstetric anal sphincter injuries (OASIS). Lateral or mediolateral episiotomy at vacuum extraction may decrease the risk of OASIS. Our aim was to assess whether lateral or mediolateral episiotomy, or OASIS, at vacuum extraction in nulliparous women is associated with prelabor cesarean delivery in the subsequent childbirth. This is a nationwide observational study using data from the Swedish Medical Birth Register, including women having a first birth with vacuum extraction and a second birth in 2000-2014. Both births were live, single, cephalic, ≥34 gestational weeks without malformations. The association between episiotomy or OASIS in the first birth and prelabor cesarean delivery in the second birth was examined using univariate and multivariate logistic regression with inverse probability of treatment weighting, and interaction analysis. Main outcome measure was prelabor cesarean delivery in the second birth. In total, 44 656 women with vacuum extraction at their first birth were included. The rate of prelabor cesarean delivery in the second birth was 5.9% (824 of 13 950) in women with episiotomy, compared with 6.0% (1830 of 30 706) in women without episiotomy. Thus, women with episiotomy did not have an increased risk of prelabor cesarean delivery (adjusted odds ratio [aOR] 1.00, 95% confidence interval [95% CI] 0.83-1.20) compared with women without episiotomy. For comparison, the rate of prelabor cesarean delivery in the second birth was 20.6% (1275 of 6176) in women with OASIS, compared with 3.6% (1379 of 38 480) in women without OASIS (aOR 6.57, 95% CI 5.97-7.23). There was no interaction between episiotomy and OASIS. Lateral or mediolateral episiotomy at vacuum extraction in nulliparous women did not increase the risk of prelabor cesarean delivery in the subsequent childbirth. OASIS increased the odds of prelabor cesarean delivery more than sixfold.

The combined effect of pre-pregnancy body mass index and gestational weight gain on the risk of pre-labour and intrapartum caesarean section-The ICE-MCH study.

Women who are obese before pregnancy have a higher risk of caesarean section than normal weight women. We investigated the combined effect of pre-pregnancy weight and gestational weight gain on pre-labour and intrapartum caesarean section risk. We collected data on 22,763 singleton, term, live deliveries in 2003-2014 from the Icelandic Maternal and Child Health Study (ICE-MCH), based on Icelandic registries. These were the Icelandic Medical Birth Registry and the Saga Maternal and Child Health Database. Pre-pregnancy body mass index was categorised into underweight, normal weight, overweight and obese. Gestational weight gain was classified according to the Institute of Medicine´s recommendation into below, within and above the recommended range. Logistic regression models, adjusted for maternal and gestational characteristics, were used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for the risk of caesarean section. Obese women had a higher risk of pre-labour (AOR 1.56, 95% CI 1.34-1.81) and intrapartum caesarean section (AOR 1.92, 95% CI 1.70-2.17) than normal weight women in all categories of gestational weight gain. Gestational weight gain above the recommended range, compared to within the range, increased the risk of intrapartum caesarean section among normal weight (AOR 1.46, 95% CI 1.23-1.73) and overweight women (AOR 1.291, 95% CI 1.04-1.60). Gestational weight gain below the recommended range, compared to within the range, increased the risk of pre-labour caesarean section (AOR 1.64, 95% CI 1.20-2.25), but only among overweight women. Women who are obese before pregnancy have a high risk of caesarean section regardless of gestational weight gain. However, women who are normal weight or overweight before pregnancy and gain weight above the recommended range during pregnancy may also have an increased risk of caesarean section.

Perinatal survival among very preterm singletons born after detection of early-onset fetal growth restriction with or without maternal hypertensive disorders: A population-based study in France

ObjectiveTo investigate the management and survival of very preterm singletons born because of fetal growth restriction (FGR) with or without maternal hypertensive disorders in France. Study designFrom a population-based cohort of very preterm births between 22 and 31 weeks in France in 2011, the study population included all non-anomalous singleton pregnancies delivered because of detected FGR with or without maternal hypertensive disorders. Antenatal detection of FGR was defined as an estimated fetal weight <10th percentile with or without fetal Doppler abnormalities or growth arrest. All fetuses were alive at the time of detection of FGR. Indicators of active perinatal management (antenatal steroids, pre-labor cesarean and birth in level 3 maternity unit) and fetal/neonatal outcomes (terminations of pregnancy (TOP), stillbirths, neonatal deaths and survival to discharge) were compared by gestational age between FGR associated with maternal hypertensive disorders and isolated FGR. ResultsOverall, 398 pregnancies delivered before 32 weeks for FGR associated with hypertensive disorders and 234 for isolated FGR. Active perinatal care was rare before 26 weeks in both groups and about one in five cases associated with maternal hypertensive disorders received steroids and was born by prelabor cesarean compared to none for isolated FGR. Before 25 weeks of gestation age, more pregnancies resulted in TOP when FGR was associated with hypertensive disorders compared to isolated FGR (respectively, 76.2 % vs 28.0 % at 22–23 weeks, P = 0.002 and 57.9 % vs 21.1 % at 24 weeks, P = 0.028) whereas stillbirths were more common among isolated FGR (respectively, 23.8 % vs 72.0 % at 22–23 weeks, P = 0.002 and 36.8 % vs 73.7 % at 24 weeks, P = 0.030). Survival to discharge was higher at any gestational age when the cause of birth was FGR associated with hypertensive disorders compared to isolated FGR. ConclusionThe management and pregnancy outcomes differed when FGR was associated with maternal hypertensive disorders or isolated. The proportion of TOP was higher when FGR was associated with hypertensive disorders and the proportion of stillbirths was higher in isolated FGR.

Adjunctive Azithromycin Prophylaxis for Prelabor Cesarean Birth.

To evaluate maternal postoperative infections before and after addition of adjunctive azithromycin to standard antibiotic prophylaxis for prelabor cesarean births. We conducted a retrospective cohort study of patients with singleton gestations at more than 23 weeks of gestation who underwent prelabor cesarean birth at a single tertiary care center. Deliveries were categorized as those before implementation of 500 mg intravenous azithromycin in addition to standard preoperative cephalosporin antibiotic prophylaxis (pre-AZI group; January 2013-September 2015) and those after implementation of adjunctive azithromycin (post-AZI group; January 2016-December 2018). Cesarean births from October to December 2015 were excluded as a washout period. The primary outcome was a composite of postcesarean infections (endometritis, superficial or deep wound infections, intra-abdominal abscess, urinary tract infections). Secondary outcomes included composite components, other wound or postoperative complications, and select neonatal morbidities. Outcomes were compared between groups, and adjusted odds ratios (aORs) and 95% CIs were calculated using multivariable analysis. Propensity score matching was performed to assess the robustness our analysis. Of 2,867 delivering patients included for analysis, 1,391 (48.5%) were in the pre-AZI group and 1,476 (51.5%) were in the post-AZI group. Patients in the post-AZI group were older and were more likely to have private insurance, use aspirin, and receive predelivery antibiotics within 2 weeks. There were significantly lower odds of composite infection after azithromycin implementation (3.3% vs 4.8%, aOR 0.60, 95% CI 0.40-0.89), driven by a reduction in wound infection odds (2.4% vs 3.5%, aOR 0.61, 95% CI 0.39-0.98). There were lower odds of other postpartum complications, including wound seroma (0.5% vs 0.9%, aOR 0.34, 95% CI 0.13-0.90) and dehiscence (0.5% vs 1.2%, aOR 0.32, 95% CI 0.13-0.79). There were no differences in select neonatal morbidities between groups. Of 1,138 matching sets in the propensity analysis, the primary outcome remained significantly lower in the post-AZI group (aOR 0.64, 95% CI 0.41-0.99). Adopting adjunctive azithromycin for prelabor cesarean deliveries was associated with lower odds of postpartum infection.

Ultrasound Evaluation of Caesarean Scar of Prelabour and Labour Caesarean Sections: A Cross Sectional Analytical Study

Ultrasound Evaluation of Caesarean Scar of Prelabour and Labour Caesarean Sections: A Cross Sectional Analytical Study

Cerebral oxygenation during the period of transition to extrauterine life after natural versus cesarean birth

Objective. We aim to evaluate the implications of cesarean delivery compared to natural birth by analyzing newborns’ systemic and cerebral oxygenation levels during the first 10 minutes of life. Design. This paper presents a 4-year prospective cohort study. Setting. Polizu Maternity, "Alessandrescu-Rusescu" National Institute for Mother and Child's Protection, Bucharest, Romania. Patients. Randomly selected pregnant women and their fetuses. Interventions. During the 10 min following umbilical cord clamping, regional cerebral oxygen saturation (rcSO2) was measured using the INVOS 5100 device and peripheral oxygen saturation (SpO2) was determined using the Masimo SET pulse oximeter in neonates from cesarean and natural deliveries. Main outcome measures. The cerebral fractional tissue oxygen extraction (cFTOE) in the first 10 minutes of life was calculated based on these values. Results. Newborns delivered vaginally showed higher rcSO2 levels at 1 minute of life than those born via C-section (40.5 ± 16.5% vs 33.7 ± 14.8%, AUC = 0.625; IC 95%: 0.506 - 0.743; p = 0.043). Neonatal cFTOE at 1 minute of life was significantly higher in caesarean-delivered newborns versus naturally born neonates (0.40 ± 0.25 vs 0.50 ± 0.19, p = 0.03; AUC = 0.638; IC 95%: 0.517-0.758; p = 0.023). Conclusions. Prelabor cesarean delivery seemingly plays a significant role in the process of fetal and neonatal cerebral oxygenation immediately postnatally, which is highlighted by lower rcSO2 and higher cFTOE values. Cerebral oxygen saturation monitoring in the delivery room allows the optimization of oxygen therapy in order to prevent the consequences of hypoxia or hyperoxia.

Quality of maternal and newborn care around the time of childbirth for migrant versus nonmigrant women during the COVID‐19 pandemic: Results of the IMAgiNE EURO study in 11 countries of the WHO European region

To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe. Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women. Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P= 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P= 0.001), lack of timely care (14.7% vs 13.0%; P= 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P= 0.004), inadequate number of women per room (9.4% vs 8.6%; P= 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P= 0.011), or suffering abuse (14.5% vs 12.7%; P= 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P= 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P= 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women. Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all.

Red blood cell parameters in early childhood: a prospective cohort study.

Red blood cell parameters are frequently used biomarkers when assessing clinical status in newborns and in early childhood. Cell counts, amounts, and concentrations of these parameters change through gestation and after birth. Robust age-specific reference intervals are needed to optimize clinical decision making. The Copenhagen Baby Heart Study (CBHS) and the COMPARE study are prospective cohort studies including red blood cell parameters from 7,938 umbilical cord blood samples and 295 parallel venous blood samples from newborns with follow-up at two and at 14-16months after birth. For venous blood at birth, reference intervals for hemoglobin, erythrocytes, and hematocrit were 145-224g/L, 4.1-6.4×1012/L, and 0.44-0.64, respectively. Hemoglobin, erythrocytes, and hematocrit were lower at birth in children delivered by prelabor cesarean section compared to vaginal delivery. Conversion algorithms based on term newborns were: venous hemoglobin=(umbilical cord hemoglobin-86.4)/0.39; venous erythrocytes=(umbilical cord erythrocytes-2.20)/0.44; and venous hematocrit=(umbilical cord hematocrit-0.24)/0.45. This study presents new reference intervals for red blood cell parameters in early childhood, describes the impact of delivery mode, and provide exact functions for converting umbilical cord to venous blood measurements for term newborns. These findings may improve clinical decision making within neonatology and infancy and enhance our clinical understanding of red blood cell parameters for health and diseases in early life.

Association of maternal, fetal and labor variables with a low Apgar score in the fifth minute in term pregnancy: a case-control study.

To search for maternal, labor-related and fetal variables associated with low Apgar in the fifth minute in term pregnancy. A retrospective case-control study with term births was conducted in a public teaching hospital from 2013 to 2020. Cases were term births with Apgar score less than 7 in the fifth minute, and controls, the next one or two births following a case, with Apgar of 7 or more. Non-cephalic presentations, multiples and malformations were excluded. We accessed 100 cases and 190 controls. We considered significant values of p < 0.05. Were accessed 27 variables which could be risk factors, from which 12 were associatedwith the outcome. We found a protective effect of prelabor cesarean for the outcome, odds ratio (OR) 0.38, p = 0.013. Consequently, we conducted two sets of analyses: in the whole group and in the group of laboring women. The values of OR were in general greater in the group of laboring women, compared with the whole group. We conducted multivariate analysis within the group of women in labor. The variables which fitted best in the model were nulliparity, male sex of the fetus, less than six prenatal visits and abnormal cardiotocography; all remained significant. An association of rupture of membranes more than 360min with the outcome, even after controlling fpr duration of labor, was found; adjusted OR 2.45, p = 0.023. Twelve variables were associated with the outcome. Prelabor cesarean had a protective effect. The time of ruptured membranes was associated with low Apgar.