Primary Cesarean Research Articles

Impact of WHO Labor Care Guide on reducing cesarean sections at a tertiary center: an open-label randomized controlled trial

BACKGROUNDThe World Health Organization Labor Care Guide was introduced in December 2020 to implement World Health Organization (WHO) guidelines on intrapartum care for a positive childbirth experience.OBJECTIVEThis study aimed to determine the effect of the WHO Labor Care Guide on labor outcomes, especially in reducing primary cesarean deliveries, and its acceptability by healthcare providers.STUDY DESIGNThis open-label randomized control trial was conducted from September 2021 to December 2021 on 280 low-risk antenatal women admitted for delivery at a busy tertiary care institute in North India. After informed consent, women were allocated into the study and control groups. Labor monitoring was performed using the WHO Labor Care Guide in the study group and the World Health Organization–modified partograph in the control group. Women who had a cesarean delivery in the latent phase of labor were excluded from the study. The primary outcome was mode of delivery, whereas the secondary outcomes were duration of active labor, maternal complications (postpartum hemorrhage and puerperal sepsis), duration of hospital stay, Apgar score at 5 minutes, and neonatal intensive care unit admission. The labor outcomes in both groups were compared. In the study group, the acceptability, difficulty, and satisfaction levels of the users were assessed using a 5-point Likert scale. The “learning curve” for the use of the Labor Care Guide (LCG) was determined. SPSS software (version 21.0; IBM Corporation, Chicago, IL) was used for statistical analysis.RESULTSAfter excluding women who underwent cesarean delivery in the latent phase, 136 women in the study group and 135 women in the control group were observed for labor outcomes. The cesarean delivery rate was 1.5% in the study group vs 17.8% in the control group (P=.0001). The duration of the active phase of labor was significantly shorter in the study group than in the control group (P<.001). The 2 groups were similar in terms of maternal complications, duration of hospital stay, and Apgar score. The learning curve took average levels of 6.50 and 2.25 Labor Care Guide plots to shift from “very difficult” to “neutral” and “neutral” to “easy,” respectively. After an initial learning curve, acceptability and satisfaction levels were found to be high in the WHO Labor Care Guide users.CONCLUSIONThe WHO Labor Care Guide is a simple labor monitoring tool for the reducing primary cesarean delivery rate without increasing the duration of hospital stay and fetomaternal complications.

Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique: Randomized controlled study

BACKGROUNDRepeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys. The dural puncture epidural (DPE) technique provides faster and more effective analgesia for labor, but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.AIMTo determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.METHODSPatients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia (EA) groups. A 25-G spinal needle was used for dural puncture via a 19-G epidural needle. The patients in the two groups were injected with 5 mL of 2% lidocaine followed by 15 mL of a mixture of 1% lidocaine + 0.5% ropivacaine as the epidural dosage. The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.RESULTSA total of 115 women were included (EA: 57, DPE: 58). The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group (14.7 min vs 16.6 min; 95% confidence interval, 13.9 to 15.4 vs 15.8 to 17.4; P = 0.001). The cranial sensory block level was significantly higher at 5, 10, and 15 min after the initial dose in the DPE group than in the EA group (P < 0.05). The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point (P < 0.05). Adverse effects and neonatal outcomes were comparable between the two groups (P > 0.05).CONCLUSIONThe DPE technique provided higher-quality anesthesia than the EA technique, with a rapid onset of surgical anesthesia, better cranial and sacral sensory block spread and a higher motor block degree, without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.

Neonatal admission rate after vaginal breech delivery.

The safest mode of delivery for fetuses in breech presentations is still an ongoing debate. The aim of this study was to analyze neonatal admission rates after vaginal breech delivery and compare it to other modes of delivery in order to counsel pregnant women with breech presentation adequately. We performed a retrospective monocentric analysis of all deliveries with singleton pregnancies in breech presentation > 36.0weeks of gestation between 01/2018-12/2019. Short-term neonatal morbidity data was collected for vaginal delivery and primary as well as secondary cesarean sections from breech presentations. A total of n=41/482 (8.5%) neonates had to be admitted to NICU: vaginal breech delivery n=18/153 (11.8%), primary cesarean section n=9/101 (8.9%, OR 0.73; CI 0.32-1.70; p=0.47), secondary cesarean section n=10/76 (13.2%, OR 1.14; CI 0.50-2.60, p=0.76) and vaginal vertex delivery n=4/152 (2.6%, OR 0.20; CI 0.06-0.51; p=0.005). There was no significant difference in transfer to NICU between all breech position delivery modes. Despite significantly lower pH and 5' APGAR values after vaginal delivery, neonates delivered by primary cesarean section and NICU admission had to be treated there significantly longer (mean 80.9 vs. 174.0h). No significant difference in terms of ventilation parameters and infections were found between the vaginal delivery, primary and secondary cesarean section from breech presentation. Vaginal breech delivery does not result in a higher neonatal admission rate in comparison to primary and secondary section. In contrast, there is a shorter NICU duration in case of neonatal admission after vaginal delivery.

Study of indications of primary cesarean section in multigravida patients: A retrospective study

Background: Caesarean section is one of the most widely performed surgical procedures in obstetrics worldwide. It was mainly evolved as a lifesaving procedure for mother and foetus during the difficult delivery. Multiparous means those who had delivered once or more after the age of viability. It includes multipara (para 2, 3, 4) and grand multipara (para more than 4). Primary Caesarean section in the multipara means first Caesarean section done in the patients who had delivered vaginally once or more. Aims and Objectives: The aims of this study were to study the indications for the primary cesarean section in multigravida women at tertiary care center, Medical College Jhalawar. Materials and Methods: Retrospective record-based study of all primary cesarean section in multigravida women admitted at Janana Hospital, Medical college Jhalawar during the period of 3 months. Retrospective analysis of case sheet was done in parous women who had previous vaginal deliveries. Inclusion criteria were all multigravida who went for the lower segment cesarean section (LSCS). Results: During the study period of 3 months, total 1968 deliveries occurred, out of which 806 (40.95%) underwent cesarean section and 208 (25.80%) among these cesarean sections were underwent primary cesarean section in multigravida. Maximum number of the patients were in the age group of 25–30 years 120 (57.69%). Maximum number of patients were gravida 2 (G2) 135 (63.67%) and gravida 3 (G3), 52 (24.52%). Almost all of them (96.63%) underwent emergency cesarean section. The most common indication for the primary LSCS in multigravida patients was fetal distress 46 (22.11%) followed by malpresentation 38 (18.26%) cases, meconium stained liquor with fetal distress 23 (11.05%), severe oligohydramnios 15 (7.21%), non-progress of labor 13 (6.25%), pre-eclampsia and big baby 8 (3.84%) each, elective CS with bad obstetric history, obstructed labor and placenta praevia 7 (3.36%) reach, APH and cephalopelvic disproportion 6 (2.28%) each, and PIH 5 (2.24%). Conclusion: The most common indication for the primary LSCS in multigravida patients was fetal distress 46 (22.11%) followed by malpresentation 38 (18.26%) cases in our study.

Roadshow Promotes Vaginal Births

In 2019, the national rate of primary cesareans was 25.6%. However, in Florida it was 29.6%, the 2nd highest in the United States. Birth certificate data show only 21% of hospitals in Florida meet the Healthy People 2020 national goal for nulliparous term singleton vertex (NTSV) cesareans of < 23.9%. A culture of casual acceptance of a cesareans has developed, and many women are unaware of the risks and potential complications, including risks to future pregnancies. In NTSV laboring patients, do educating nurses and changing unit culture lower NTSV cesareans rates compared with acceptance of current practice.

Promoting the Safe Reduction of Primary Cesarean Births

Evidence shows that cesareans are overused, and even though they can be life saving in many cases, nonindicated cesareans contribute to increases in maternal mortality and morbidity rates. In the state of Colorado, the average nulliparous, term, singleton, vertex (NTSV) birth rate is 22.3%, lower than the national average and the Healthy People 2030 goal of 23.6%. Despite this, hospital-specific rates vary widely, from 7% to 45%. The Colorado Perinatal Care Quality Collaborative (CPCQC) set a goal of enrolling hospitals in the SOAR project (SuppOrting VAginal Delivery for Low-Risk Women) to reduce NTSV rates.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers.

Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry. A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P &lt; .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Delivery outcome and predictors of successful vaginal birth after primary cesarean delivery: A comparative study

Objectives: This study aimed to determine the rate and predictive factors for successful vaginal birth after cesarean delivery, and measure maternal and neonatal outcomes of VBAC following one previous cesarean delivery. Methods: In this hospital-based prospective study, sixty women with one previous CD (subjects) who attempted VBAC and another sixty without previous CD (controls) carrying singleton cephalic fetuses matched for maternal age, parity, and gestational age were compared. The primary outcome measures were successful vaginal delivery and its predictors. Data were analyzed using SPSS (version 22.0), and p&lt;0.05 was significant. Results: Out of 1768 deliveries, 105 (5.9%) had one previous CD; 57.1% (60/105) attempted while 61.7% (37/60) had successful VBAC; 23 (38.3%) had failed VBAC and repeat CD, while 14 (23.3%) of the control group had CD. The significant predictors of successful VBAC were cervical dilatation ≥4cm on admission (p=0.003), maternal age &gt;35 years (p=0.019); and augmentation of labor (p=0.020); while previous vaginal delivery (p=0.108), parity (p=0.706), BMI (0.240), and inter-delivery interval (p=0.265) were not statistically significant. The maternal and neonatal outcomes were not statistically different among women who had successful VBAC after one CD compared to women without previous CD. Important morbidities following VBAC included uterine rupture (3.3%) and primary postpartum hemorrhage (6.7%). There was no peripartum hysterectomy or maternal death; the perinatal mortality rate was 16.7/1,000 live births for women who attempted VBAC while no perinatal death was recorded among the controls. Conclusion: VBAC is safe, and its outcome is comparable to women without previous CD.

Epidemiology of placenta accreta spectrum disorders in Chinese pregnant women: A multicenter hospital-based study

IntroductionPlacenta accreta spectrum disorder (PASD) is a life-threatening obstetric complication. China still lacks high-quality data on the epidemiology of PASD. We intend to examine the major risk factors for PASD, explore the association of PASD with severe adverse perinatal outcomes and describe the geographical variations in China. MethodsWe used data from the China Labor and Delivery Survey, which included a total of 75,132 births from 96 hospitals in 24 provinces in China in 2015 and 2016. Each participating hospital randomly selected 6–10 weeks within a 12-month period. In the selected weeks, all births with gestational age ≥24 weeks or birth weight ≥500 g were included. We analyzed the demographic characteristics and prevalence of PASD in pregnant women. Multivariable logistic regression was used to examine the association of previous caesarean section (CS) and repeated surgical abortion with PASD. We explored the association of PASD with severe adverse perinatal outcomes, which indicated by Weighted Adverse Outcome Score (WAOS) ≥ 20. Multivariable logistic regression was used to examine the association of PASD with WAOS. We also calculated and compared the prevalence of PASD in different regions of China. ResultsThe weighted prevalence of PASD was 2.20% (95% CI 0.76 to 4.95) in our population，and there was a substantial difference in the prevalence of PASD by geographic regions in China. Two or more previous CS (adjusted OR 2.34, 95%CI 1.41 to 3.88) and repeated surgical abortion (twice: 2.16, 1.20 to 3.92; 3 times: 4.31, 1.70 to 10.96; ≥4 times: 4.76, 3.12 to 7.26) were significant risk factors for PASD. PASD (adjusted OR 3.77, 95% CI 2.80 to 5.06) was a significant risk factor for severe adverse perinatal outcomes indicated by WAOS score. DiscussionThe prevalence of PASD in China appeared higher than that in other countries, and varied substantially by geographic regions. Two or more previous CS and repeated surgical abortion were major risk factors for PASD. Pregnant women with PASD had more severe adverse pregnancy outcomes. Reducing primary cesarean section and repeated surgical abortion are the key to decreasing PASD.

Factors Associated with the Chance of Carrying out a Primary Cesarean in a University Hospital.

The present study seeks to identify the associated factors that increased primary cesarean delivery rates. This was a cross-sectional study that evaluated the number of primary cesarean sections performed in the years 2006 and 2018 at the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym), through the collection of data from the medical records of the patients. Advanced maternal age, twin pregnancy, and higher body mass index (BMI) became more frequent in 2018 in comparison with 2006. To mitigate the impact of confounding in comparisons among groups, we made an adjustment by propensity scores and detected significant differences when comparing both age groups on twin pregnancy rates, gestational diabetes mellitus, and thyroid disease. Data from the present study can be used to prevent and improve the management of morbidities, impacting on better outcomes in obstetrical practice.

Prediction of the degree of abnormal invasive placentation by obstetric history.

Diagnosis of placenta accrete spectrum (PAS) disorders is of utmost importance and mostly relies on high index of suspicion and sonographic criteria. The degree of abnormal invasive placentation is strongly associated with patients' outcomes. We aimed to determine the association between prior obstetric characteristics and the degree of PAS. A retrospective cohort study. The study cohort comprised all women who delivered by cesarean delivery with a histopathological diagnosis of PAS during 2005-2019. We divided the cohort into 2 groups: severe PAS (increta/percreta) and mild PAS (accrete). Obstetrical characteristics and last delivery and cesarean characteristics were compared. Overall, 130 cases of histopathologically proven PAS were included. Of those 104 (80.0%) were mild PAS and 26 (20.0%) severe PAS. Both groups did not differ in terms of age and obstetric history. Mean parity of both study groups was 4. Intrapartum fever as noticed in 2.9-3.8% of primary cesarean (P=1.0). Cervical dilation at time of primary cesarean delivery was similar between the groups (mean 5 vs. 6 centimeters, P=0.73). Urgent cesarean delivery rate did not differ between groups (69.2% vs. 50.%, P=0.07). Method of hysterotomy closure was comparable as well. The only different variable found between groups was the rate of cephalic presentation at previous cesarean was higher in mild PAS group 69 (66.3%) vs. 11 (42.3%), P=0.024. odds ratio 2.68, 95% confidence interval 1.11-6.45. Discrimination of PAS severity by obstetric and previous surgical history is questionable. Our findings might be limited by sample size. Future prospective studies are warranted.

Adjunctive azithromycin prophylaxis protects women from uterine cesarean scar defect: A randomized controlled trial.

Cesarean scar defect (CSD) is a long-term outcome of cesarean section (CS) and associated with numerous gynecological and obstetric problems. Previous studies indicate that infection may be a risk factor for CSD. Adjunctive azithromycin was shown to reduce the risk of postoperative infection in patients undergoing non-elective primary cesarean delivery in labor or after the rupture of membranes compared with standard antibiotic prophylaxis. This study investigated the protective effect of adjunctive azithromycin in combination with single-dose cephalosporin against CSD in women undergoing non-elective cesarean delivery. A randomized, double-blind, controlled clinical trial was conducted in a University hospital in Shanghai, China. A total of 242 women who underwent their first non-elective CS were randomly assigned to receive 1500 mg cefuroxime sodium plus 500 mg intravenous azithromycin (n=121; experimental group) or 1500 mg cefuroxime sodium plus a placebo (n=121; placebo group). The primary outcome was CSD prevalence, as determined by transvaginal ultrasound and saline infusion sonohysterography within 6months of delivery. Secondary outcomes were changes in infectious indicators (eg hypersensitive C-reactive protein and procalcitonin), postoperative morbidity, and use of postoperative antibiotics. We also examined the operative procedure, pathogenic microorganism cultures, and fetal outcomes. Outcomes were compared between groups with the chi-squared test, Fisher's exact test, or Student's t test. Between May 2018 and May 2021, 121 women were randomized to each arm. Because the sonographic follow up was disrupted by the coronavirus disease 2019 pandemic and strict management policies, we merged the follow-up time points (6 weeks and 6months) into a single time period (6 weeks to 6months); 104 and 108 women in the experimental and placebo groups, respectively, completed the first sonographic follow up. CSD was diagnosed by sonography in 34/104 (32.7%) and 50/108 (46.3%) patients in the experimental and placebo groups, respectively (relative risk 0.71, 95% confidence interval 0.50-0.99; p=0.043). Characteristics of CSD and short-term infection outcomes did not differ between groups. A single dose of intravenous 500 mg azithromycin adjunctive to single-dose cefuroxime prophylaxis significantly reduced the incidence of CSD in women undergoing non-elective CS.

Association between first birth caesarean delivery and adverse maternal-perinatal outcomes in the second pregnancy: a registry-based study in Northern Tanzania

BackgroundCaesarean delivery (CD) is the commonest obstetric surgery and surgical intervention to save lives of the mother and/or the new-borns. Despite been accepted as safe procedure, caesarean delivery has an increased risk of adverse maternal and fetal outcomes. The rising rate of caesarean delivery has been a major public health concern worldwide and the consequences that come along with it urgently need to be assessed, especially in resource limited settings. We aimed to examine the relationship between first birth caesarean delivery and adverse maternal and perinatal outcomes in the second pregnancy among women who delivered at a tertiary hospital in Northern Tanzania.MethodsA retrospective cohort study was conducted using maternally-linked data from Kilimanjaro Christian Medical Centre. All women who had singleton second delivery between the years 2011 to 2015 were studied. A total of 5,984 women with singleton second delivery were analysed. Multivariable log-binomial regression was used to determine the association between first caesarean delivery and maternal-perinatal outcomes in the second pregnancy.ResultsCaesarean delivery in the first birth was associated with an increased risk of adverse maternal and perinatal outcomes in the second pregnancy. These included repeated CD (ARR 1.19; 95% CI: 1.05–1.34), pre/eclampsia (ARR 1.38; 95% CI: 1.06–1.78), gestational diabetes mellitus (ARR 2.80; 95% CI: 1.07–7.36), uterine rupture (ARR 1.56; CI: 1.05–2.32), peri-partum hysterectomy (ARR 2.28; CI: 1.04–5.02) and preterm birth (ARR 1.21; CI: 1.05–1.38).ConclusionCaesarean delivery in their first pregnancy had an increased risk of repeated caesarean delivery and other adverse maternal-perinatal outcomes in the following pregnancy. Findings from this study highlight the importance of devising regional specific measures to mitigate unnecessary primary caesarean delivery. Additionally, these findings may help both clinicians and women in deciding against or for trial of labor after previous caesarean delivery in an event of absent direct obstetric indication.

Impact of Statewide Mandatory Medicaid Managed Care (SMMC) Programs on Hospital Obstetric Outcomes.

The state of Florida implemented mandatory managed care for Medicaid enrollees via the Statewide Medicaid Managed Care (SMMC) program in April of 2014. The objective of this study was to examine the impact of the implementation of the SMMC program on the access to care and quality of maternal care for Medicaid enrollees, as measured by several hospital obstetric outcomes. The primary data source for this retrospective observational study was the Hospital Cost and Utilization Project (HCUP) all-payer State ED (SED) visit and State Inpatient Databases (SIDs) from 2010 to 2017. The primary health outcomes for obstetric care were primary cesarean, preterm birth, postpartum preventable ED visits, postpartum preventable readmissions, and vaginal delivery after cesarean (VBAC) rates. Using difference-in-differences (DID) estimation, selected health outcomes were examined for Florida residents with Medicaid beneficiaries (treatment) and the commercially insured population (comparison), before and after the implementation of SMMC. Improvement in disparities for racial/ethnic minority Medicaid enrollees was estimated relative to whites, compared to the relative change among commercially insured patients. From the DID estimation, the findings showed that SMMC is statistically significantly associated with a higher reduction in primary cesarean rates, preterm births, preventable postpartum ED visits, and readmissions among Medicaid beneficiaries relative to their commercially insured counterparts. However, this study did not find any significant reduction in racial/ethnic disparities in obstetric outcomes. In general, this study highlights the impact of SMMC implementation on obstetric outcomes in Florida and provides important insights and potential scope for improvement in obstetric care quality and associated racial/ethnic disparities.

Primary Cesarean Deliveries of Term Singletons Prior to or in Labour and Risks of Severe Maternal Morbidity: A Comparison of Canadian Tiers of Obstetric Services

To estimate the rates of severe maternal morbidity/mortality associated with primary cesarean sections (PCS) in different tiers of obstetrics services (ToS) in Canada.

The Effect of Changes in Treatment Recommendations for Gestational Diabetes on Perinatal Morbidity [A191

INTRODUCTION: Evidence about the lack of efficacy of glyburide prompted the American College of Obstetricians and Gynecologists (ACOG) to recommend insulin as first-line treatment and metformin as an alternative for treatment of gestational diabetes (GDMA2) in February 2018. This study compared the treatments and perinatal outcomes in women before and after the ACOG recommendations. METHODS: This was a retrospective study of patients treated for GDMA2. Patients were divided into two groups (group 1: February 2016 to January 2018; group 2: February 2018 to January 2020). The primary outcome was comparison of perinatal outcomes between the groups during those two periods. The secondary outcome was comparison of the effect of glyburide, metformin, and insulin on perinatal outcomes regardless of the time frame. Outcomes were also compared between insulin glargine and insulin NPH. Maternal outcomes included rates of primary cesarean delivery, preeclampsia, and ICU admission. Neonatal outcomes included large for gestational age, shoulder dystocia, NICU admission, hypoglycemia, hyperbilirubinemia, and stillbirth. Institutional review board approval was obtained. RESULTS: A total of 160 patients received medications. Baseline characteristics were similar. Insulin was the most common medication used in both groups (58%). In group 1, 21 patients received glyburide versus seven in group 2 (P=.01). There was no difference regarding insulin or metformin use between groups (P&gt;.05). Perinatal outcomes were similar in both groups (P&gt;.05). Regardless of time frame, NICU admissions (P=.01) and shoulder dystocia (P=.04) were higher with glyburide. Preeclampsia rates were lower in women receiving insulin NPH (P=.03). CONCLUSION: Glyburide use decreased after ACOG recommendations. Decline in use of glyburide is not accompanied by significant improvements in perinatal morbidity. Regardless of time frame, glyburide is associated with higher neonatal adverse outcomes and NPH with decrease in maternal adverse outcomes.

Obstetric audit of cesarean sections according to M. Robson classification criteria – the experience of St. Petersburg in 2020-2021

An external audit of the childbirth outcomes was conducted in accordance with M. Robsons 10-group classification. The main determinants of indications and the frequency of cesarean section in obstetric medical organizations of St. Petersburg in 2020-2021 were analyzed in order to find effective mechanisms for reducing the frequency of сesarean delivery within the framework of compliance with modern principles of perinatal-oriented obstetrics and the preservation of a womans reproductive health. Possible effective reserves for reducing the frequency of CS are presented: personalized pre-gravidar preparation in high-perinatal risk women groups, personalized approach to methods of pre-induction and induction of labor in high-risk groups patients, rational management of labor in compliance with modern clinical recommendations, wider use of current classical external manual methods for antenatal correction of fetus pelvic presentation, prevention the primary cesarean deliveries, increase in the rate of vaginal deliveries among women with previous cesarean deliveries, optimization of effective antenatal psychological consultation about the delivery methods among pregnant women with breech presentation, previous cesarean deliveries and multiple pregnancy.

Risk of Adverse Pregnancy Outcomes Among Pregnant Individuals With Gestational Diabetes by Race and Ethnicity in the United States, 2014-2020

Gestational diabetes, which increases the risk of adverse pregnancy outcomes, has been increasing in frequency across all racial and ethnic subgroups in the US. To assess whether the frequency of adverse pregnancy outcomes among those in the US with gestational diabetes changed over time and whether the risk of these outcomes differed by maternal race and ethnicity. Exploratory serial, cross-sectional, descriptive study using US National Center for Health Statistics natality data for 1 560 822 individuals with gestational diabetes aged 15 to 44 years with singleton nonanomalous live births from 2014 to 2020 in the US. Year of delivery and race and ethnicity, as reported on the birth certificate, stratified as non-Hispanic American Indian, non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White (reference group). Maternal outcomes of interest included cesarean delivery, primary cesarean delivery, preeclampsia or gestational hypertension, intensive care unit (ICU) admission, and transfusion; neonatal outcomes included large for gestational age (LGA), macrosomia (>4000 g at birth), small for gestational age (SGA), preterm birth, and neonatal ICU (NICU) admission, as measured by the frequency (per 1000 live births) with estimation of mean annual percentage change (APC), disparity ratios, and adjusted risk ratios. Of 1 560 822 included pregnant individuals with gestational diabetes (mean [SD] age, 31 [5.5] years), 1% were American Indian, 13% were Asian/Pacific Islander, 12% were Black, 27% were Hispanic/Latina, and 48% were White. From 2014 to 2020, there was a statistically significant increase in the overall frequency (mean APC per year) of preeclampsia or gestational hypertension (4.2% [95% CI, 3.3% to 5.2%]), transfusion (8.0% [95% CI, 3.8% to 12.4%]), preterm birth at less than 37 weeks (0.9% [95% CI, 0.3% to 1.5%]), and NICU admission (1.0% [95% CI, 0.3% to 1.7%]). There was a significant decrease in cesarean delivery (-1.4% [95% CI, -1.7% to -1.1%]), primary cesarean delivery (-1.2% [95% CI, -1.5% to -0.9%]), LGA (-2.3% [95% CI, -2.8% to -1.8%]), and macrosomia (-4.7% [95% CI, -5.3% to -4.0%]). There was no significant change in maternal ICU admission and SGA. In comparison with White individuals, Black individuals were at significantly increased risk of all assessed outcomes, except LGA and macrosomia; American Indian individuals were at significantly increased risk of all assessed outcomes except cesarean delivery and SGA; and Hispanic/Latina and Asian/Pacific Islander individuals were at significantly increased risk of maternal ICU admission, preterm birth, NICU admission, and SGA. Differences in adverse outcomes by race and ethnicity persisted through these years. From 2014 through 2020, the frequency of multiple adverse pregnancy outcomes in the US increased among pregnant individuals with gestational diabetes. Differences in adverse outcomes by race and ethnicity persisted.

Pre-Pregnancy Physical Fitness, Body Mass Index and Gestational Weight Gain as Risk Factors for Cesarean Delivery: A Study of Active Duty Women.

The World Health Organization considers the optimal rate of delivery by Cesarean among healthy nulliparous women to be <15%. In 2020, the rate of primary Cesarean delivery (CD) in the US among nulliparous women with singleton, vertex pregnancies was 26%. An enhanced understanding of factors associated with women undergoing CD may assist in reducing this rate. One potential factor is the level of physical fitness in women before pregnancy. Active duty (AD) soldiers provide a cohort of women who begin pregnancy while actively pursuing physical fitness. The research team sought to assess the effects of pre-pregnancy physical fitness of AD soldiers as measured by the Army Physical Fitness Test (APFT) on the incidence of CD in AD women, in addition to examining known demographic and pregnancy risk factors in this cohort. We conducted a retrospective study of healthy AD nulliparous women who delivered their singleton pregnancy of >32 weeks at a tertiary medical center between 2011 and 2016. Soldiers undergoing non-labored CD were excluded. Demographics, pre-pregnancy APFT results, antepartum and labor and delivery data were collected from the Digital Training Management System, the outpatient, and inpatient medical records respectively. Weight gain in pregnancy was assessed using the Institute of Medicine Guidelines for pregnancy. Fisher's exact tests and chi-squared tests assessed associations between categorical outcomes, and unpaired t-tests assessed differences in APFT scores between women who underwent CD vs. vaginal delivery. Multivariable logistic regression analysis was used to assess for independent risk factors among all collected variables. The protocol was approved by the Regional Health Command-Pacific Institutional Review Board. Five-hundred-and-twenty-three women delivering singleton pregnancies between 2011 and 2016 were reviewed for this study. Three-hundred ninety women met inclusion criteria: 316 in the vaginal delivery cohort, and 74 in the CD cohort, with a CD rate of 19%. Twenty non-labored CDs were excluded. Neither total APFT performance nor performance on the individual push-up, sit-up or run events in the 15 months prior to pregnancy was associated with mode of delivery. Excessive gestational weight gain (EWG) and neonatal birth weight were the only two factors independently associated with an increased rate of cesarean delivery. Women who had excessive gestational weight gain, were twice as likely to undergo CD as those who had adequate or insufficient weight gain (24% vs. 12%, p = 0.004). Soldiers delivering a neonate ≥4,000 g were 2.8 times as likely to undergo CD as those delivering a neonate <4,000 g (47% vs. 17%, p < 0.001). Age, race, and rank, a surrogate marker for socioeconomic status, were not associated with mode of delivery. Pre-pregnancy fitness levels as measured by the APFT among healthy physically active nulliparous AD women showed no association with the incidence of labored CD. EWG is one modifiable factor which potentially increases the risk for CD in this cohort and has been documented as a risk factor in a recent metanalysis (RR-1.3). Counseling on appropriate weight gain in pregnancy may be the most effective way to reduce the rate of CD among this population of healthy and physically active women.

A Nonimmune Hydrops Case.

A Nonimmune Hydrops Case.