Proportion Of Cesarean Deliveries Research Articles

Jenis Persalinan dengan Waktu Pengeluaran Kolostrum Pada Ibu Bersalin Kala IV di Kota Yogyakarta

Spending colostrum was influenced by several factors, one of them was kind of maternal childbirth. Normal childbirth and SectioCaesarea (SC) has affected maternal psychological changes and pain, and it was associated with the provision of drugs in themother and it has affected spending colostrum soon after birth. The percentage of caesarean deliveries as many as 28.6% inYogyakarta City, the figure was the highest proportion of cesarean delivery in the province. Coverage of exclusive breastfeeding inthe city of Yogyakarta was the lowest in the province that was equal to 54.9%. The purpose of this research was knowing the type oflabor relations at the time peneluaran colostrum at birth mothers when IV in the city of Yogyakarta in 2016. analytic observationalstudy with a prospective cohort design. The study sample consisted of 35 respondents in the group without risk factors and 35respondents with risk factors in 1 November to December 21, 2016. Data was collected by interview and observation. Data analysiswas using Chi-Square. Characteristics of mothers in this study were age, parity, nutritional status, and maternal education. Theresults of the bivariate analysis showed that the type of delivery SC has increased the incidence of spending within the colostrum>120 minutes total of 1.75 (p = 0.031; 95% CI; 1.028 to 2.981). Conclusions that SC has extended colostrum spending time morethan 120 min.

A cross-sectional study exploring the incidence of and indications for second-stage cesarean delivery over three decades.

To observe the incidence of, indications for, and complications associated with second-stage cesarean delivery in 10-year intervals over 30years. The present analysis of prospectively collected data compared cesarean deliveries during 1976, 1986, 1996, and 2006 at John Radcliffe Hospital in Oxford, UK (n=3222). Pregnancy, delivery, and neonatal details were reviewed. The proportion of deliveries by cesarean in the second stage of labor increased from 0.5% (22/4464) in 1976 to 2.1% (124/5998) in 2006 (P<0.001). The proportion of cesarean deliveries during the second stage because of failed instrumental delivery also increased over the study period from 59.1% (13/22) in 1976 to 71.0% (88/124) in 2006. Compared with cesareans at other stages, uterine trauma (P<0.001), blood loss greater than 1000mL (P=0.002), and blood transfusion (P=0.001) were more frequent in second-stage cesarean delivery. Neonates delivered by second-stage cesarean had lower Apgar scores (P<0.001 for 1-min and 5-min scores) and cord arterial pH values (P<0.001) than did those delivered by cesarean earlier in labor. A trend towards an increase in neonatal trauma with second-stage cesarean compared with cesarean delivery before labor or during the first stage did not reach statistical significance. The proportion of deliveries by cesarean in the second stage of labor increased; these deliveries were associated with greater maternal and neonatal morbidity, but were not influenced by the indication for cesarean.

Indicações de partos cesáreos em hospitais de atendimento ao Sistema Único de Saúde: baixo e alto riscos

Objetivo: Analisar indicações de partos cesáreos em pacientes de baixo e de alto risco provenientes, respectivamente, do Hospital Santa Lucinda (HSL) e do Conjunto Hospitalar de Sorocaba (CHS), do Sistema Único de Saúde (SUS), em Sorocaba, São Paulo. Métodos: Estudo retrospectivo dos prontuários das pacientes internadas nesses hospitais, submetidas a cesáreas no período de 01 de março de 2014 a 01 de março de 2015. A pesquisa avaliou parâmetros maternos socioepidemiológicos, reprodutivos, clínicos, indicações das cesáreas e dados neonatais dos recém-nascidos. Resultados: No total de partos ocorridos, indicaram-se cesáreas em 56,3% (CHS) e 32,4% (HSL), havendo significância estatística (p&lt;0,001). Pacientes com cesárea anterior prevaleceram no HSL (77,0%) em comparação com o CHS (56,4%), com proporções estatísticas significativas (p=0,0009). As indicações prevalentes de cesáreas no HSL foram: sofrimento fetal (24,0%), falha na indução ao parto (22,0%) e desproporção céfalo-pélvica (18,7%). No CHS, as maiores proporções foram: sofrimento fetal (35,3%) e iteratividade (25,3%), revelando significância estatística (p&lt;0,0001). Conclusões: O estudo revelou que as proporções de partos cesáreos em ambas as maternidades são superiores àquelas preconizadas pela Organização Mundial de Saúde (OMS). A provável redução de proporções de partos cesáreos na maternidade de baixo risco poderia vir com indicações precisas de indução à parturição, utilização de analgesia ao parto e, ainda, com a devida prática da extração baixa transvaginal do feto pelo fórcipe de alívio às parturientes. Em relação às pacientes de alto risco, tal queda de cesáreas estará subordinada às melhores atenções das políticas públicas de atenção à saúde da mulher brasileira.

Definitive childlessness in women with multiple sclerosis: a multicenter study.

The frequency of definitive childlessness in women with multiple sclerosis (MS) may be higher than in the general population. MS may also affect decisions on the delivery procedure and on breast-feeding issues. Aim of the study was to assess the frequency of childlessness and its possible causes, the proportion of cesarean deliveries (CD), and the frequency of breast-feeding in patients and controls who have reached the end of their reproductive period. Female MS patients (>43years) and controls (>45years) filled out a questionnaire. We enrolled 303 patients and 500 controls. MS was associated with a higher frequency of childlessness (22 vs 13%) and less patients were in a stable relationship (83 vs 89%). There was no difference in the reported rates of infertility and miscarriages, while elective abortions were more frequent in patients (20 vs 12%). MS did not significantly affect the frequency of CD or of breast-feeding. MS-related reasons for childlessness, reported by 16% of childless patients, included disability/fear of future disability, fear of genetically transmitting MS, fear of not starting/discontinuing treatments, and discouragement by physician. Definitive childlessness is more frequent in women with MS compared to controls. A portion of voluntary childlessness may be avoided through correct/tailored information to patients.

Obstetric Care in the U.S. Military

INTRODUCTION: Pregnant women with TRICARE (universal insurance coverage to members of US Armed Services and their dependents) can receive obstetric care under direct care/salary-based (DC) or purchased care/fee-for-service (PC) system. The objective of this study was to compare intra-partum obstetric care between direct and purchased care systems in TRICARE. METHODS: TRICARE (2006–2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (normal vaginal, cesarean and instrumental vaginal) and co-morbid conditions (gestational diabetes and hypertension) along with complications, including post-partum hemorrhage (PPH), lacerations, infection and thrombotic events were compared between two systems of care. RESULTS: A total of 440,138 deliveries were identified. The mean age of mothers in DC and PC was 26.7 years and 27.3 years, respectively (P<.001). A higher proportion of mothers in DC had gestational diabetes (6.9% vs 4.9%, P<.001) and gestational hypertension (5.8% vs 4.7%, P<.001). Proportion of cesarean delivery (25.8% vs 30.9%, P<.001) and instrumental vaginal delivery (5.3% vs 6.4%, P<.001) was lower in DC compared to PC. Complications such as PPH (4.9% vs 3.4%, P<.001) and perineal lacerations (8.3% vs 6.4%, P<.001) were significantly higher in DC as compared to PC. CONCLUSION: We found that the direct/military (salary-based) system had fewer interventions (such as operative deliveries) and higher complication rates. Study of the direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the US.

Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications

BackgroundThe aim of this study was to evaluate labor and delivery outcomes in parturients with inadvertent dural puncture managed by either insertion of an intrathecal catheter or a resited epidural catheter. MethodsThis was a retrospective cohort review of 235 parturients who had an inadvertent dural puncture during epidural placement over a six-year period. The primary outcome was the proportion of women with a delayed second stage of labor. Secondary outcomes were the proportion of cesarean deliveries, the proportion of cases resulting in post-dural puncture headache, and the incidence of failed labor analgesia. ResultsBaseline characteristics such as age, body mass index and parity were similar between the two groups. Among the 236 cases of inadvertent dural puncture, 173 women (73%) had an intrathecal catheter placed while 63 women (27%) had the epidural catheter resited. Comparing intrathecal with epidural catheters, there was no observed difference in the proportion of cases of prolonged second stage of labor (13% vs. 16%, P=0.57) and the overall rate of cesarean deliveries (17% vs. 16%, P=0.78). However, we observed a lower rate of post-dural puncture headache in women who had cesarean delivery compared to vaginal delivery (53% vs. 74%, P=0.007). A greater proportion of failed labor analgesia was observed in the intrathecal catheter group (14% vs. 2%, P=0.005). ConclusionThe choice of neuraxial technique following inadvertent dural puncture does not appear to alter the course of labor and delivery. Cesarean delivery decreased the incidence of post-dural puncture headache by 35%. Intrathecal catheters were associated with a higher rate of failed analgesia.

Proportion of Cesarean Deliveries According to Hospital Funding in S&amp;#227;o Paulo Metropolitan Area, Brazil

Introduction: There has been an increase in the proportion of cesarean deliveries, especially in developing countries. Methods: Cross-sectional study of all hospital live births from mothers living in Sao Paulo Metropolitan Area, Brazil. Data were obtained from the Live Birth Information System, which is linked to the National Database of Health Establishments. Hospitals were classified as public, private or mixed. Descriptive analysis and exponential regression were conducted to evaluate time trends. Poisson regression was applied to analyze each hospital type to identify risk factors and the attributable risk fraction for cesarean section. Results: There was an annual increase (1.4%) of cesarean deliveries between 2000 and2013. In2009, the percentage of cesarean deliveries was 53% overall and 83% in private hospitals. The primary risk factor for cesarean delivery was delivery in a private hospital. Other risk factors that were stronger in public hospitals included the following: advanced maternal age, high maternal education, nulliparity, high number of prenatal visits, multiple pregnancy, hospital with low annual volume of deliveries, birth outside the city of residence and white skin color. Discussion: These results may be explained by the obstetric care model of private hospitals, which is not multiprofessional. Prenatal care and delivery are conducted by the same doctor and rarely include the input of another professional, such as a midwife. In addition, the mode of delivery influences the professional’s payment.

Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes.

Diet is the cornerstone treatment of patients with gestational diabetes mellitus (GDM), but its role in maternal and newborn outcomes has been scarcely studied. The purpose of this study was to analyze the efficacy of dietary interventions on maternal or newborn outcomes in patients with GDM. A systematic review and meta-analysis of randomized clinical trials (RCTs) of dietary intervention in GDM or pregnancy with hyperglycemia was performed. MEDLINE, Embase, ClinicalTrials.gov, Cochrane, and Scopus were searched through to March 2014. The main evaluated maternal outcomes were proportion of patients using insulin and proportion of cesarean delivery; the newborn outcomes were proportion of macrosomia and hypoglycemia and newborn weight. From 1,170 studies, nine RCTs, including 884 women aged 31.5 years (28.7-33.2) with 27.4 weeks (24.1-30.3) of gestation, were eligible. We divided the RCTs according to the type of dietary intervention: low glycemic index (GI) (n = 4; 257 patients), total energy restriction (n = 2; 425 patients), low carbohydrates (n = 2; 182 patients), and others (n = 1; 20 patients). Diet with low GI reduced the proportion of patients who used insulin (relative risk 0.767 [95% CI 0.597, 0.986]; P = 0.039) and the newborn birth weight (weight mean differences -161.9 g [95% CI -246.4, -77.4]; P = 0.000) as compared with control diet. Total restriction and low carbohydrate diets did not change either maternal or newborn outcomes. A low GI diet was associated with less frequent insulin use and lower birth weight than control diets, suggesting that it is the most appropriate dietary intervention to be prescribed to patients with GDM.

Commentary: Reasons for Persistently High Maternal and Perinatal Mortalities in Ethiopia: Part III–Perspective of the “Three Delays” Model

From the experience of high-income countries, the occurrence of all obstetric complications may not be preventable but almost all are treatable before resulting in serious maternal and perinatal morbidity and mortality (1, 2). The interventions may start at preconception; however, providing optimal obstetric care for all pregnant women starting from early pregnancy up to the end of puerperium has paramount significance in the reduction of maternal and perinatal deaths. Specific to low and middle-income countries, improving the intrapartum monitoring and access to a cesarean section and blood transfusion were highly recommended as key interventions to reduce maternal and perinatal deaths (3, 4). According to the Federal Ministry of Health of Ethiopia 2011/2012 Health and Health Related Indicators report, however, the proportion of at least four visits antenatal care was 19%; total births attended by skilled health personnel were 16.6%; and the proportion of cesarean delivery was about 1% (5), while the WHO cesarean delivery recommendation is 5%–15% for the general population (6). These reports indicate the big gap in utilizing reproductive health services before and after conception. In addressing issues regarding maternal and perinatal death rates, the “three delay” model is frequently used to consider factors that may be obstacles for women receiving appropriate medical care. The three delay model was initially proposed by Thaddeus and Maine in 1990 (7). The components of this model include the delays of the decision to seek health care (8), the ability to get access to a health facility (9) and receiving medical care timely and appropriately once the facility is reached (10). It is generally recognized that diminished access to facilities providing emergency obstetric care contributes to increased maternal and perinatal mortality (11, 12). The purpose of this review was to look into the high maternal and perinatal mortality from the perspective of the three delays models and to show the complexity and interlink of predisposing factors for maternal and perinatal deaths. As discussed in other articles (13, 14), the factors for high maternal and perinatal mortality in the last three decades were multidimensional (the extremely low number of health facilities and health professionals, low adult literacy rate, low utilization of contraceptive methods, high total fertility rate, high early marriage and adolescent pregnancy, low antenatal care service, low skilled person attended deliveries, and rampant harmful traditional practices). The main focus of this review is the “Delay Model”. To summarize these complex and interlinked factors for the increased risk of maternal and perinatal deaths in Ethiopia, a simplified schematic presentation from the perspective of the “three delays” model (Figure 1). As a complimentary, two more schematic presentations were developed from the perspective of “etiologic” factors (Figure 2), and to show the multidimensional nature of maternal mortality (Figure 3). Open in a separate window Figure 1 Contextual factors that contribute to high maternal and perinatal mortality in Ethiopia, using the “Delay model”

A comparison of trends in cesarean delivery in Paraguay between 1995 and 2008

ObjectiveTo identify maternal factors associated with the rise in the cesarean delivery rate in Paraguay. MethodsRetrospective analysis of the 1995 and the 2008 National Survey on Demographic and Sexual and Reproductive Health data using multivariable logistic regression. ResultsIn 2008, 1094 (37.3%) deliveries were cesarean compared with 781 (19.3%) in 1995. Home births had decreased by 72.9%, accounting for 33.3% of the change in the proportion of cesarean deliveries. Private facilities were associated with an increased odds ratio of cesarean delivery of 2.60 (95% confidence interval [CI], 2.02–3.34) and 4.89 (95% CI, 3.67–6.51) in 1995 and 2008, respectively, and accounted for 32.8% of the increase in cesarean deliveries between 1995 and 2008. Cesarean delivery was also associated with a prior cesarean, insurance status, and maternal higher educational and economic status. ConclusionBetween 1995 and 2008 the cesarean delivery rate in Paraguay almost doubled. More than one-third of deliveries were cesarean. Shifts toward facility- (particularly private) based deliveries and repeat cesarean for women with a previous cesarean influenced this increase. Practice guidelines, regulation, and oversight of facilities, along with education and information for pregnant women, are needed to curb unnecessary and potentially harmful surgical delivery interventions.

Assessing the incidence of gestational diabetes and neonatal outcomes using the IADPSG guidelines in comparison with the Carpenter and Coustan criteria in a Belgian general hospital

We have conducted a systematic universal screening for gestational diabetes mellitus (GDM) since 2008, following the criteria outlined by the International Association of Diabetes and Pregnancy Study Group (IADPSG) since 2011. However, we recently replaced the IADPSG standards with those established by the Belgian French Language Gynecologists and Obstetricians Group (GGOLFB). These new criteria indicate GDM when fasting plasma glucose (FPG) is ⩾0·92 g/l at the beginning of pregnancy or when an orally provoked hyperglycaemia test (75 g of glucose) between the twenty-fourth and twenty-eighth week results in an FPG of ⩾0·92 g/l and/or ⩾1·80 g/l after 1 hour and/or ⩾1·53 g/l after 2 hours. The goal of this retrospective study was to evaluate the incidence of GDM, neonatal outcomes, and the use of insulin therapy 21 months post-implementation of the IADPSG criteria within our centre. A total of 393 patients were diagnosed with GDM from January 2009 to December 2012. After applying the new criteria, the incidence of GDM rose significantly from 8 to 23% (P<0·0001). However, there were no significant changes in the proportion of GDM patients requiring insulin therapy (34·2% versus 34·7%) or the rate of foetal large for gestational age (11·2% versus 8·8%). In addition, the ⩾90% percentile decreased non-significantly from 96·3±0·6% to 94·3±0·70% (P = 0·057), whereas the lower quartiles and the proportion of cesarean deliveries (27·0% versus 25·6%) did not change significantly. Therefore, non-targeted screening significantly increased the incidence of GDM in our centre without significantly decreasing large for gestational age or the number of cesarean deliveries.

Cervical and Cesarean scar ectopic pregnancies: Diagnosis and management

Abstract Cervical pregnancies are rare in naturally conceived pregnancies and even after assisted reproductive technology. The ultrasonographic diagnosis rests upon the trophoblastic invasion of the cervix below the internal os. Several options have been used over the last three decades for the management of cervical pregnancy. The most successful treatments are methotrexate injection and uterine artery embolization (UAE). A step by step delineation of diagnosis and management is demonstrated in this manuscript that could aid the clinician in his management. Cesarean scar pregnancies (CSPs) are more commonly seen today, both in the East and the West, as a result of a significant increase in the proportion of Cesarean deliveries over the last three decades. The presence of a large number of management options highlights the fact that there is no standardized protocol for cervical pregnancy and CSP management. The advancement of laparoscopic management and suturing is the single most effective measure in confirmation as well as treatment of CSP. Optimal repair of uterine defect is essential for the prevention of another CSP.

Ratio of Cesarean Deliveries to Total Operations and Surgeon Nationality Are Potential Proxies for Surgical Capacity in Central Haiti

The World Health Organization has a standardized tool to assess surgical capacity in low- and middle-income countries (LMICs), but it is often resource- and time-intensive. There currently exists no simple, evidence-based measure of surgical capacity in these settings. The proportion of cesarean deliveries in regard to the total operations (C/O ratio) has been suggested as a way to assess quickly the capacity for emergency and essential surgery in LMICs. This ratio has been estimated to be between 23.3 and 41.5 % in LMICs, but the tool's utility has not been replicated. We reviewed operative logbooks for the Partners In Health/Zanmi Lasante hospital in Cange, Haiti. We recorded data on all consecutive surgical patients from July 2008 to 2010 and calculated the C/O ratio by dividing the number of cesarean deliveries by the total number of operations performed. We also analyzed surgical data by surgeon nationality to provide additional information about local surgical capacity. A total of 3,641 operations were performed between 2008 and 2010. The C/O ratio decreased significantly between 2008-2009 and 2009-2010 (13.4 vs. 10.7 %, p = 0.001) as the surgical volume and resources increased. Nationality analysis demonstrated that Haitian surgeons were able to provide a spectrum of general and specialist surgical care. In its inherent relation to essential surgical procedures and to the overall rate of cesarean deliveries in the region, the C/O ratio can provide an accessible assessment of regional surgical resources. In Haiti, the change in the C/O ratio demonstrated a relative increase in surgical capacity from 2008 to 2010. An additional analysis of surgeon nationality ensured that C/O ratio estimates more accurately reflect local practitioner activity, but deficiencies in the regional capacity to address the local burden of surgical disease may still exist.

Maternal complications related to the mode of delivery in pregnant women with heart disease in a specialist high risk delivery hospital in Fortaleza, CE

To determine the association between maternal complications and type of delivery in women with heart disease and to identify the possible clinical and obstetrical factors implicated in the determination of the route of delivery. This was a retrospective and descriptive study of the medical records of pregnant women with heart disease admitted to a tertiary reference hospital in the municipality of Fortaleza, Ceará, from 2006 to 2007. The study population included all pregnant women with an antepartum diagnosis of heart disease admitted for delivery, while women who received a diagnosis of heart disease after delivery were excluded, regardless of age and gestational week. A semi-structured questionnaire regarding sociodemographic, clinical and obstetrical variables was used. A descriptive analysis was first performed based on simple frequencies and proportions of the sociodemographic variables. Next, possible associations between clinical and obstetrical aspects and type of delivery were analyzed, with the verification of association between maternal complications and type of delivery. The Fisher exact test was applied for this analysis, with the level of significance set at p<0.05. The collected data were processed and analyzed using the Epi-InfoTM software version 6.04 (Atlanta, USA). Seventy-three pregnant women with heart disease were included in the study. Interatrial communication was the condition most frequently observed among congenital diseases (11.0%) and mitral calcification among the acquired ones (24.6%). The proportion of cesarean deliveries was higher than the proportion of vaginal deliveries, except for women with acquired heart disease. An association was detected between type of heart disease and type of delivery (p=0.01). There were 13 cases of maternal complications (17.8%). Among them, ten (76.9%) occurred during cesarean section and three during vaginal delivery. No association mas detected between maternal complications and type of delivery in pregnant women with heart disease (p=0.74). There was no association between the occurrence of maternal complications and route of delivery among pregnant women with heart disease.

The relative proportion of cesarean deliveries rather than their actual number is an independent predictor for intraoperative maternal morbidity in subsequent pregnancies after primary cesarean section

ACTUAL NUMBER IS AN INDEPENDENT PREDICTOR FOR INTRAOPERATIVE MATERNAL MORBIDITY IN SUBSEQUENT PREGNANCIES AFTER PRIMARY CESAREAN SECTION OFFER EREZ, LENA NOVACK, VERED KLEITMAN-MEIR, DORON DUKLER, MOSHE MAZOR, Soroka University Medical Center, BeerSheva, Israel, Ben Gurion University of the Negev Faculty of Helth sciences, Epidemiology, Beer-Sheva, Israel, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, OB/GYN, BeerSheva, Israel OBJECTIVE: To investigate the association between the number of subsequent deliveries after primary cesarean section (CS), the rate of successful vaginal deliveries and intraoperative maternal morbidity during repeated CS. STUDY DESIGN: A retrospective population based cohort study was designed. Patients with primary CS comprised the study population (n = 6233), women in the study group were followed up to maximum 4th consecutive delivery after their primary CS. A survival analysis model (Cox regression) was performed to investigate the association between the number of repeated CS, their proportion out of the number of subsequent deliveries after the primary CS and intraoperative maternal morbidity. Intraoperative morbidity was defined as primary outcome and included scar dehiscence, uterine rupture, cesarean hysterectomy, trauma to adjacent organs and transfusion of blood products. RESULTS: During the study period there were 11,338 deliveries of them 5,859 VBAC deliveries, and 5479 recurrent CS. The prevalence of repeated CS in subsequent deliveries was found to be an independent risk factor for dehiscence of cesarean scar, uterine rupture, cesarean hysterectomy, trauma to adjacent organs during the operation and blood transfusion ((Hazard Ratio (HR) 14.27, p=0.005; HR-5.12 p=0.005; HR-3.38 p!0.02; HR-7.73 p=0.004; HR2.5 p=0.02, respectively). Maternal parity before the primary CS was an independent risk factor for cesarean hysterectomy (HR-1.33 p!0.001). Elective CS had an overall protective effect against intraoperative complications (HR-0.74 p=0.027), this effect could not be attributed to a specific complication. CONCLUSION: 1) The higher intraoperative morbidity is positively related to the percentage of repeated cesarean deliveries rather than their actual number representing the protective effect of repeated successful VBAC; 2) the increased risk for cesarean hysterectomy among multiparous patients can be attributed to intraoperative medical judgment; and 3) elective repeated cesarean delivery has a protective effect against intraoperative complications.

Insights into the Physiology of Childbirth Using Transcriptomics

Few biological processes as central to the survival of viviparous species are so incompletely understood as childbirth (parturition) [ 1]. Premature labor and prolonged gestation due to failure of labor to commence are associated with an increased risk for perinatal death and long-term handicap. Even when labor begins at term, “failure to progress” is so frequently diagnosed that at least 20% of all births occur through cesarean delivery, the most common operation performed worldwide. The rationale for performing a cesarean delivery in women whose cervix has failed to dilate in active labor (arrest of dilatation), or in whom the fetal head does not descend after complete dilatation of the cervix (arrest of descent), is that “failure to progress” is an indicator of cephalopelvic disproportion. However, this explanation is unlikely to be true in many cases, because a proportion of mothers with a previous cesarean delivery due to “failure to progress” in labor will deliver a larger baby vaginally in a subsequent pregnancy. Thus, a central question in reproductive biology is: what is “failure to progress” in labor? A “functional disorder,” rather than cephalopelvic disproportion, may be the underlying reason for a proportion of cesarean deliveries performed after labor has begun. Such “functional disorders” could be due to inadequate preparation of the uterine muscle (myometrium) and/or the cervix for labor. Indeed, accumulating evidence suggests that the myometrium develops a contractile phenotype as pregnancy approaches term and the cervix also undergoes preparatory changes [ 2]. The cellular and biochemical phenomena underpinning preparation of the uterine muscle and the cervix [ 3] are different and have been the focus of intensive investigation [ 4, 5].

Secular Trends in Cesarean Delivery Rates among Macrosomic Deliveries in the United States, 1989 to 2002

We describe national trends in cesarean delivery rates among macrosomic infants during 1989 to 2000 and evaluate the maternal characteristics and risk factors for macrosomic infants delivered by cesarean section as compared to macrosomic infants delivered vaginally. We analyzed US 1989 to 2000 Natality files, selecting term (37 to 44 week) single live births to U.S. resident mothers. We compare macrosomic infants (4000 to 4499, 4500 to 4999 and 5000+ g infants) to a normosomic (3000 to 3999 g) control group. The proportion of cesarean deliveries among 5000+ g infants increased significantly over the time period. The adjusted odds ratio of cesarean delivery increased for all macrosomic categories over the 12-year period, as compared to normal birth weight infants. Rates of cesarean delivery among macrosomic infants continue to increase despite a lack of evidence of the benefits of cesarean delivery within this population. Further exploration of the rationale for this trend is warranted and should include the development of an optimal delivery strategy for such patients.

Racial Differences in Cesareans: An Analysis of U.S. 2001 National Inpatient Sample Data

To evaluate racial differences in potentially unnecessary cesareans in the United States. The 2001 Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was used to analyze various maternal demographic and clinical parameters among women having cesarean deliveries. For the purpose of our study, if there were no diagnoses related to cesarean delivery on the discharge certificate, the cesarean was classified as potentially unnecessary Using our methodology, 11% of 540,174 primary and 65% of 371,863 repeat cesareans for the year 2001 in the United States were classified as potentially unnecessary. After controlling for age, payment source, ZIP income, admission day, region of the country, and hospital size, location, and teaching status, black women had a higher likelihood of having potentially unnecessary primary cesareans when compared with white (P < .001) or Hispanic women (P < .001). White women had a higher likelihood of having potentially unnecessary repeat cesareans than black women (P < .001), although the magnitude of the odds ratio for race was not as striking as in primary cesarean. Potentially unnecessary primary cesareans were also more likely to occur in women aged 35 years or older, Medicare patients, weekend admissions, or those residing in the South or Northeast. Potentially unnecessary repeat cesareans were more likely to occur in women younger than 35 years, in rural hospitals, and in weekday admissions. In the United States, racial differences exist in the proportion of cesarean deliveries that are potentially unnecessary. Further exploration of these differences is warranted. III.

Maternal pre-pregnancy overweight status and obesity as risk factors for cesarean delivery

Objective. To determine the extent to which, if at all, maternal pre-pregnancy adiposity and other anthropometric factors are related to risk of cesarean delivery.Methods. This hospital-based prospective cohort study included 738 nulliparous women who initiated prenatal care prior to 16 weeks gestation. Participants provided information about their pre-pregnancy weight and height and other sociodemographic and reproductive covariates. Labor and delivery characteristics were obtained from maternal and infant medical records. Risk ratios (RR) and 95% CI were estimated by fitting generalized linear models.Results. The proportion of cesarean deliveries in this population was 26%. Women who were overweight (BMI 25.00–29.99 kg/m2) were twice as likely to deliver their infants by cesarean section as lean women (BMI < 20.00 kg/m2) (RR = 2.09; 95% CI 1.27–3.42). Obese women (BMI ⩾ 30.00 kg/m2) experienced a three-fold increase in risk of cesarean delivery when compared with this referent group (RR = 3.05; 95% CI 1.80–5.18). The joint association between maternal pre-pregnancy overweight status and short stature was additive. When compared with tall (height ⩾ 1.63 m), lean women, short ( < 1.63 m), overweight (BMI ⩾ 25.00 kg/m2) women were nearly three times as likely to have a cesarean delivery (RR = 2.79; 95% CI 1.72–4.52).Conclusion. Our findings suggest that nulliparous women who are overweight or obese prior to pregnancy, and particularly those who are also short, have an increased risk of delivering their infants by cesarean section.

Neonatal mortality in weekend vs weekday births.

Increases in neonatal mortality for infants born on the weekend were last noted several decades ago. Although the current health care environment has raised concern about the adequacy of weekend care, there have been no contemporary evaluations of daily patterns of births, obstetric intervention, and case mix-adjusted neonatal mortality. To compare the neonatal mortality of infants born on weekdays and weekends. Case series of 1 615 041 live births (weight >or=500 g) in California between 1995-1997 to determine patterns of births, cesarean deliveries, and neonatal deaths. Analyses were stratified by birth weight and delivery method. To assess the role of weekend differences in case mix, observed and birth weight-adjusted odds ratios (ORs) for increased weekend mortality were estimated using logistic regression. Birth weight-adjusted neonatal mortality. There was a 17.5% decrease in births on weekends, accompanied by a decrease in the proportion of cesarean deliveries from 22% on weekdays to 16% on weekends. Weekend decreases in births were least pronounced in smaller infants, resulting in a weekend concentration of high-mortality, very low-birth-weight (<1500 g) births. Observed neonatal mortality increased from 2.80 per 1000 weekday births to 3.12 per 1000 weekend births (OR, 1.12; 95% confidence interval [CI], 1.05-1.19; P =.001) for all births, and from 4.94 to 6.85 (OR, 1.39; 95% CI, 1.25-1.55; P<.001) for cesarean deliveries. After adjusting for birth weight, the increased odds of death for infants born on the weekend were no longer significant. The provision of optimal care regardless of the day of week is an important goal for perinatal medicine. Comparing the neonatal mortality of infants born on weekdays and weekends provides a straightforward assessment of this goal. After controlling for birth weight, we found no evidence that the quality of perinatal care in California was compromised during the weekend.