Elective Caesarean Section Rates Research Articles

Shoulder dystocia in babies born to Aboriginal mothers with diabetes: a population-based cohort study, 1998–2015

BackgroundAustralian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP.MethodsStratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg.ResultsRates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg.ConclusionsAboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

Caesarean sections before and during the COVID-19 pandemic in western Sydney, Australia

Background To determine the changes in emergency and elective caesarean section (CS) rates since the COVID-19 pandemic, identify the groups most affected, and examine changes in the factors associated with CS rates, and reasons for CS. Methods We conducted a retrospective cohort study using routinely collected data of 22,346 births from before the pandemic (January 2018–February 2020) and 18,597 births during the pandemic (March 2020–December 2021). Data were analysed using multinominal logistic regression. Results The CS rate increased by 4.1% (from 30.1% to 34.2%), reflecting increases of 2.3% in emergency CS (from 11.5% to 13.8%) and 1.7% in elective CS (from 18.7% to 20.4%). Large groups with notable increases were women who were nulliparous (7.2% increase), from South Asia (6.0%), obese (5.2%) and giving birth at a small hospital (6.1%). Compared to pre-pandemic, the relative risk of an emergency CS versus a vaginal delivery increased 1.36 times (adjusted relative risk ratio (aRRR) = 1.36; 95% CI = 1.27, 1.45) and the risk of having an elective CS increased 1.11 times (aRRR = 1.11; 95% CI = 1.04, 1.20). Factors associated with both emergency and elective CS were age, region of birth, reproductive history, body mass index, hypertension, diabetes, mode of antenatal care and hospital. Socio-Economic Indexes for Areas and antenatal care were only associated with elective CS. Baby gender was only associated with emergency CS. Preterm gestation at delivery was associated with reduced emergency but increased elective CS. Foetal compromise was the most common indication for emergency CS (43.2%) and increased the most (8.0%). Previous CS was the most common indication for elective CS (61.5%) and reduced the most (1.9%). Conclusions Both emergency and elective CS rates increased significantly during the pandemic, with the former increasing at a higher rate. The persistent upward trend of CS rates, exacerbated by increasing proportions of nulliparous women undergoing CSs, is concerning.

Twin birth rates and obstetric interventions in Iceland: A nationwide study from 1997 to 2018.

Twin pregnancies are associated with increased antepartum and intrapartum risks. Limited multiple embryo transfers are associated with decreased twin birth rates. We aimed to study the effect of 2009 Icelandic regulations on twin birth rates and examine obstetric intervention rates for twin births during the study period. The study included all births (N = 94 028) in Iceland during 1997-2018. Twin birth rates and obstetric intervention rates were compared over birth year periods using modified Poisson regression adjusted for confounders. An observed decrease in the twin birth rate trend was most notable from 2006 until 2009. Twin birth decreased in 2009-2013 (prevalence ratio [PR] 0.74, 95% confidence interval [CI] 0.64-0.86) and in 2014-2018 (PR 0.74, 95% CI 0.64-0.86) compared with 1997-2002. This decrease was only evident for women aged 30+ years in stratified analysis. Induction of labor rates increased from 26% in 1997-2002 to 44% in 2014-2018 (adjusted rate ratio [ARR] 2.10, 95% CI 1.72-2.57) whereas elective cesarean section (ARR 0.80, 95% CI 0.59-1.07) and urgent cesarean section (ARR 0.79, 95% CI 0.63-1.00) rates appeared to decline. Twin births decreased during the study period. International guidelines published before the Icelandic regulations may have affected twin birth rates in Iceland. Induction of labor rates for twins increased while cesarean section rates decreased.

Trends in the epidemiology of fear of childbirth and association with intended mode of delivery: A nationwide register-based cohort study in Finland.

Fear of childbirth (FOC) is a common obstetrical challenge that affects the health of women. The epidemiology of FOC has not been studied in Finland for the last decade. The aim of this study was to analyze the epidemiology and risk factors for FOC and to evaluate the association between FOC and the rate of elective cesarean section (CS) as an intended mode of delivery. Data from the National Medical Birth Register were used to evaluate the epidemiology of FOC and to determine the main risk factors for FOC in Finland between 2004 and 2018. Nulliparous and multiparous women were analyzed separately. Logistic regression model was used to determine the main risk factors for FOC. Multivariable logistic regression model was used to assess the intended mode of delivery in those pregnancies with diagnosed maternal FOC. Adjusted odds ratios (aOR) with 95% confidence intervals (CIs) were calculated. A total of 1 million pregnancies were included. The annual rate of pregnancies with maternal FOC increased from 1.5% (CI: 1.4-1.6) in 2004 to 9.1% (CI: 8.7-9.3) in 2018 for all women. For nulliparous women, the rate increased from 1.1% (CI: 1.0-1.3) in 2004 to 7.1% (CI: 6.7-7.5) in 2018, and from 1.8% (CI: 1.7-2.0) in 2004 to 10.3% (10.0-10.7) in 2018 for multiparous women. The strongest risk factors for maternal FOC were higher maternal age and gestational diabetes. For multiparous women, the strongest risk factors were gestational diabetes and previous CS. The total odds for elective CS were notably higher among women with FOC (aOR 8.63, CI: 8.39-8.88). The incidence of maternal FOC rose six-fold during our study period. However, the numbers of elective CS among women with this diagnosis, which had earlier risen in parallel, leveled off in 2014.

Perinatal Outcomes Among Cases of Predicted and Unpredicted Macrosomia

OBJECTIVE: Macrosomia is strongly associated with a range of adverse maternal and neonatal outcomes. The effectiveness of screening remains controversial because expecting a macrosomic fetus affects intrapartum management, promoting elective cesarean sections. This study aims to identify differences in outcomes and management among cases with predicted and unpredicted macrosomia. STUDY DESIGN: This is a retrospective study of 779 live-born, cephalic, singleton macrosomic babies delivered at our institution from January 2017 to December 2019. Cases of macrosomia were categorized as unpredicted and predicted. Ultrasonographic weight predictions are made using the Hadlock formula. Data regarding mode of delivery, shoulder dystocia, perineal trauma, episiotomy use, and postpartum hemorrhage were retrieved. Data were stored in a secure database. The review board of the institution approved the study. Statistical analysis is performed utilizing the Mann-Whitney U test for continuous data, the chi-square test for cardinal variables, and logistic regression analysis. Significance was set as p&lt;0.05. RESULTS: Macrosomia is successfully predicted in 268 (34.4%) women. The rate of cesarean sections was significantly higher in the predicted group (46.4% vs. 35.4%, p=0.002). The higher rate of elective cesarean sections among women with predicted macrosomia (26.1% vs. 15.1%, p=0.02) contributed to this difference. Women with predicted macrosomic fetuses were more prone to perineal traumas, such as episiotomy (48.9% vs. 31.3%) or third/4th -degree lacerations (4.8% vs. 1.95%). Shoulder dystocia and other neonatal complications did not differ significantly among the groups. CONCLUSION: Acknowledging macrosomia before delivery increases elective cesarean sections and it decreases the rate of adverse neonatal outcomes such as birth asphyxia.

Pregnancy outcomes in pregnant women with diabetes treated with insulin alone and insulin with metformin

Aim: The goal of this study was to compare maternal and neonatal results in diabetic pregnant ladies who were treated either insulin and metformin or insulin only.Methods: 220 pregnant diabetic women with type 1, 2 or gestational diabetes were randomisely assigned into two groups .each group is 110 pregnant diabetic women. One group takes insulin and metformin treatment to achieve glycemic targets and other take insulin only treatment. Pregnancy results in 110 ladies who stayed solely on insulin have been compared to pregnancy results in 110 pregnant diabetic ladies treated with insulin and metformin who were matching for age, weight, as well as ethnicity.Results: No significant variations in maternal risk factors existed at the start of the study. Group II from enrolling to term, they gained significantly more weight (5.90 vs. 4.39 kg; P &lt; 0.000). When it came to gestational hypertension, there was no significant difference between groups I and II (14.5 against 19.1%, P = 0.367), pre-eclampsia (7.27 vs. 9.09%, P = 0.622),insulin dosage was decreased in group I statistically significant (mean 39.5±16.5 vs. 55.4±17.5 units, P= 0.000), vaginal delivery (41.8 vs. 47.3%, P = 0.416) or rate of elective Caesarean section (39.1 vs. 32.7%, P = 0.325), rate of emergency caesarean section (19.1 vs. 20%, P=0.865), perinatal loss (4 cases in group II vs. 3 cases in group I;P=0.701). Group I had a lower rate of neonatal morbidity; prematurity (16.63 vs. 24.55%, P = 0.417), neonatal hypoglycemia (7.3 vs. 24.5 %, P= 0.000), respiratory distress (13.64 vs. 30 %, P= 0.003), neonatal jaundice (13.6 vs. 33.6%, P &lt; 0.000) and admittance to the newborn intensive care unit (24.55 vs. 35.45%, P = 0.077). Macrosomia occurrence (There was a significant difference in birth weight centiles &gt; 90 [group I (16.4%) vs. group II (29.1%); P = 0.024]. The incidence of polyhydramnios was significantly different [group I (13.6%) vs. group II (32.7%); P = 0.001].Shoulder dystocia [group ? (2.7%) vs. group II (4.5%); P=0.721].Conclusions: Diabetic pregnant women who were treated with insulin plus metformin who had equal baseline risk factors for unfavourable pregnancy outcomes gained less weight and needed less insulin to maintain glycemic control. Furthermore improved neonatal outcomes as macrosomia, neonatal hypoglycemia, respiratory distress and special care baby admission compared with those treated with insulin alone.

Pregnancy, delivery, and neonatal outcomes among women with spinal cord injury in Sweden 1997-2015: A population-based cohort study.

The aim of this study was to describe the rate of pregnancy in spinal cord injured women in Sweden as well as pregnancy, delivery, and neonatal outcomes. This study was based on data from the Swedish Medical Birth Register and the National Patient Register. The study population included women with spinal cord injury who gave birth in Sweden during the period 1997 to 2015. The general population was used as reference and included all non-spinal cord injured patients who gave birth during the same period of time. In the spinal cord injury group, 109 births were identified. Eighty-nine (82%) of them were among paraplegic women and 20 (18%) were among tetraplegic women. Women with spinal cord injury in our study population had urinary tract infections during pregnancy in five cases (5%) and anemia during pregnancy in nine cases (8%), compared with 0.2% and 4%, respectively, in the general population. Compared with the general population more deliveries were induced in the study population, 18 (17%) in the spinal cord injury group and 12% in the general population. Vaginal delivery was achieved in 52 (48%) of the births with 42 of them (39%) being non-instrumental and 10 (9%) being instrumental vaginal deliveries. Elective cesarean section rate was 34% (n= 37). Sixteen infants (15%) were born preterm (gestational week <37). We found an overall low rate of pregnancy and delivery complications. Our results show predominantly favorable outcomes of pregnancy and delivery in women with spinal cord injury as well as their infants. These results are in concordance with previous research.

The rate of elective cesarean section after pelvic or hip fracture remains high even after the long-term follow-up: A nationwide register-based study in Finland

IntroductionThere are only few studies on the effects of pelvic or hip fractures on subsequent delivery outcomes. The aim for this study is to evaluate in a nationwide sample whether the rate of elective CS and emergency CS would decrease during the time after maternal hip and pelvic fracture. Material and MethodsIn this nationwide registry-based study, data on all women aged 15–49 years with pelvic or hip fractures leading to hospitalization were retrieved from the Care Register for Health Care for the years 1998–2018. Wrist fractures were used as a control group. The data were linked with data from the National Birth Register, where each first pregnancy during the 14-year follow-up is collected. The delivery outcomes of these pregnancies were analyzed. The results were interpreted with odds ratios (OR), adjusted odds ratios (aOR), and 95 % confidence intervals (CI). ResultsA total of 2878 women with pelvic fracture, 1330 women with hip fracture, and 29 580 with wrist fracture found in the Care Register for Health Care. Of these, a total of 586 (20.4 %) women gave birth during the following 14 years after pelvic fracture, 147 (11.0 %) women after hip fracture, and 5255 (17.7 %) women after wrist fracture. Women with pelvic fracture had higher odds for CS during each time period. The aOR for CS was 1.62 (CI 1.22–2.12) during first 5 years, 1.87 (CI 1.33–2.62) during years 5–10, and 1.97 (CI 1.11–3.41) during years 10–14. Women with hip fractures had notably higher odds for CS during first 5 years after fracture (aOR 1.64, CI 1.40–2.67). ConclusionsThe results of this study advocate that vaginal delivery is generally possible rather quickly after hip or pelvic fracture. Unplanned CS after hip fractures was more common at the beginning, but the exact reason for this remains unknown and further research should be made on this topic.

Idiopathic intracranial hypertension: Evaluation of births and fertility through the Hospital Episode Statistics dataset.

Idiopathic intracranial hypertension (IIH) predominantly affects women of reproductive age with obesity, and these women have a distinct profile of hyperandrogenism and insulin resistance. Polycystic ovary syndrome (PCOS) has an established adverse fertility phenotype that typically affects obese women. As IIH may impact reproductive health, we sought to evaluate fertility, gestational complications and pregnancy outcome in IIH. Prospective cohort study from English Hospital Episode Statistics dataset. English hospitals, UK. Women aged 18-45 years seen in English hospitals between 1 April 2002 and 31 March 2019. Patients were required to have an IIH diagnosis and were compared with those with PCOS and general population female controls. Pregnancies resulting in live births, complications of gestational diabetes and pre-eclampsia, and method of delivery. Data was collected from 17 587 IIH, 199633 PCOS and 10947 012 women in the general population. The live birth rate, adjusted for age, was significantly lower among women with IIH (54.1%) than PCOS (67.9%), p< 0.0001 and the general population (57.7%), p< 0.0001. Pre-eclampsia and gestational diabetes risks were higher following a diagnosis of IIH (5.3-fold and 2.7-fold, respectively, p< 0.0001) compared with the general population controls. Following a diagnosis of IIH, elective caesarean section rates were more than twice that of general population (odds ratio [OR] 2.4) and prior to a diagnosis of IIH (OR 2.2). These data indicate there are lower age-adjusted total pregnancy rates, increased risk of pre-eclampsia and gestational diabetes, and a doubling of elective caesarean section rates in those with a diagnosis of IIH.

399 Effectiveness and safety of external cephalic version as a method of reducing cesarean sections rates

Introduction: Breech position is a common indication for caesarean section. Elective caesarean section is the mode of choice in this group of patients. RCOG recommends proposing an external cephalic version (ECV) to each patient with a pelvic presentation in a full-term pregnancy in whom no absolute contraindications for external cephalic version and vaginal delivery have been demonstrated. The procedure of external cephalic version is a minimally invasive method, safe for mother and fetus, and yet it is used only a in few centers in Poland. Lack of popularity likely results from the low awareness of patients and limitations in availability of this procedure. Aim of the study: To assess effectiveness and safety of external cephalic version in reducing cesarean sections rates. Methods: This was a retrospective analysis of electronic medical records of patients that requested and were qualified for an external cephalic version. All patients signed an informed consent to undergo the procedure. Results: In 2017-2020, 70 patients were qualified for an external cephalic version. 6 of them had caesarean section before. The success rate was 49%, which is the world average (50%) in terms of the effectiveness of this method. Success rate in the studied group after one caesarean section was 66,7 %. After successful external cephalic version, 26 patients (84%) delivered vaginally, including 3 patients (50%) after cesarean section. 4 patients had an emergency caesarean section (16%). Conclusions: Although ECV is effective in only 50% of cases, we observed a high percentage (84%) of vaginal deliveries after successful ECV. Therefore, we can demonstrate a 37% decrease in elective cesarean section rate among patients with pelvic presentation in the study group. Popularization of ECV among obstetricians and patients seems to be the optimal method of reducing elective cesarean sections rate for breech presentation.

A Losing Game? – Recent trends in success rates of vaginal birth after Caesarean Section

Increasing rates of elective repeat cesarean section and reducing rates of vaginal births after previous cesarean (VBAC) are contributing to the increasing trend in cesarean delivery worldwide. Success rates of VBAC vary between continents, countries and institutions. While attempting VBAC is not without risk, it can be safely achieved with tremendous patient benefit. We examined how the rate of successful trials of labor after cesarean delivery has changed in recent years, in order to give patients and medical professionals an up to date perspective on VBAC.

Elective caesarean section after 39 weeks gestation and the influence on neonatal morbidity: Does a strict policy really help?

Purpose: The aim of the current study was to determine if the decision to strictly follow clinical guidelines recommending elective caesarean section at or after 39 weeks gestation (late– term) in an effort to reduce respiratory disorders in term neonates influence the incidence of early–term elective caesarean sections and the rate of neonatal respiratory disorders.&#x0D; Methods: Hospital records pertaining to elective caesarean section after 37 weeks gestation from 1 January 2007 to 31 December 2016 were analyzed. Two subgroups were established (“before” and “after”). The rate of elective caesarean section before 39 weeks gestation, the rate of neonatal respiratory disorders, and admissions to the neonatal intensive care unit were compared between the subgroups.&#x0D; Results: A total of 1881 elective caesarean sections were performed from 37 weeks gestation (1.083 [57.6%] in the before sub–group and 798 [42.4%] in the after sub– group). In the after sub–group there was a 9.8% reduction of procedures performed before 39 weeks gestation. Of the newborns, 1.59% had various respiratory problems (2.3% and 1.00% in the before and after sub–groups, respectively; p = 0.08). Six of 30 (20.0%) newborns were transferred to the neonatal intensive unit (4/22 [18.2%] and 2/8 [25.0%] in the before and after sub–groups, respectively).&#x0D; Conclusion: The policy reduced the rate of elective caesarean sections before 39 weeks gestation and the rate of neonatal respiratory disorders, even though the incidence of these disorders was rather low, even before the new policy.

Fear of childbirth in Iran: A systematic review of psychological intervention research.

BackgroundDue to the fear of childbirth (FOC) and failure to provide painless delivery in Iran, the prevalence rate of elective cesarean section (C-section) performed on request by pregnant women is on the rise. However, no systematic review assessing the results of studies in this respect has been thus far developed.ObjectiveTo systematically review published psychological intervention research reflecting on FOC in Iran.Materials and MethodsIn this systematic review, the databases of PubMed, MEDLINE, PsycINFO, Wiley, ISI Web of Science, Scopus, Science Direct, Cochrane Library, Google Scholar, and Scientific Information Database were searched to retrieve the relevant studies. Manual searches were performed to find the relevant articles and finally 21 intervention studies were reviewed.ResultsBased on the modified Jadad Scale, a methodological quality (risk of bias) assessment tool, 14 and 7 studies had acceptable or good and low quality, respectively. The included articles covered fear, fear of childbirth, pregnancy, and psychological intervention in Iran. Cognitive behavioral therapy, relaxation techniques, psychological counseling, childbirth preparation classes (CPCs), mindfulness programs, and psychoeducation had been also practiced as the main types of psychological interventions for reducing FOC in pregnant women.ConclusionThere was no clear evidence to establish the most effective method for minimizing levels of FOC in pregnant women. Based on the assessment tool and since most of the studies had moderate or low quality, conducting standard and high-quality randomized controlled trials focusing on FOC in pregnant women is of most importance in Iranian population.

A systematic review on the effectiveness of implementation strategies to postpone elective caesarean sections to \u2265 39 + (0\u20136) weeks of gestation

BackgroundCaesarean sections often have no urgent indication and are electively planned. Research showed that elective caesarean section should not be performed until 39 + (0–6) weeks of gestation to ensure best neonatal and maternal health if there are no contraindications. This was recommended by various guidelines published in the last two decades. With this systematic review, we are looking for implementation strategies trying to implement these recommendations to reduce elective caesarean section before 39 + (0–6) weeks of gestation.MethodsWe performed a systematic literature search in MEDLINE, EMBASE, CENTRAL, and CINAHL on 3rd of March 2021. We included studies that assessed implementation strategies aiming to postpone elective caesarean section to ≥ 39 + (0–6) weeks of gestation. There were no restrictions regarding the type of implementation strategy or reasons for elective caesarean section. Our primary outcome was the rate of elective caesarean sections before 39 + (0–6) weeks of gestation. We used the ROBINS-I Tool for the assessment of risk of bias. We did a narrative analysis of the results.ResultsWe included 10 studies, of which were 2 interrupted time series and 8 before-after studies, covering 205,954 elective caesarean births. All studies included various types of implementation strategies. All implementation strategies showed success in decreasing the rate of elective caesarean sections performed < 39 + (0–6) weeks of gestation. Risk difference differed from − 7 (95% CI − 8; − 7) to − 45 (95% CI − 51; − 31). Three studies reported the rate of neonatal intensive care unit admission and showed little reduction.ConclusionThis systematic review shows that all presented implementation strategies to reduce elective caesarean section before 39 + (0–6) weeks of gestation are effective. Reduction rates differ widely and it remains unclear which strategy is most successful. Strategies used locally in one hospital seem a little more effective. Included studies are either before-after studies (8) or interrupted time series (2) and the overall quality of the evidence is rather low. However, most of the studies identified specific barriers in the implementation process. For planning an implementation strategy to reduce elective caesarean section before 39 + (0–6) weeks of gestation, it is necessary to consider specific barriers and facilitators and take all obstetric personal into account.Systematic review registrationPROSPERO CRD42017078231

Prevalence of Cesarean section delivery and associated risk factors

Background: Cesarean section (CS) is a lifesaving procedure in presence of maternal and fetal complications, but not indicated ones are associated with many adverse outcomes. Objectives: To study the prevalence and indications for caesarian section among the studied group also, studying the association between type of delivery and socio-demographic and obstetrics history of the studied group and comparing the maternal and fetal outcomes in relation to the type of delivery. Methodology: This retrospective study was conducted at Menoufia university hospitals. All records of delivered women at obstetric department during the period from 1 January 2019 to 31 December 2019 were collected. Patient affairs and statistics unit were reviewed for socio-demographic data, obstetric history, type of delivery, reasons of cesarean section, maternal and fetal outcome and complications. Data were collected, analyzed and tabulated using SPSS program. Results: Prevalence of Cesarean section was 45.9% and most of which were elective 59.8%. Associated significant risk factors were residence, educational and socioeconomic levels and working status. Post-partum hemorrhage was significantly high in CS delivery, while urinary incontinence and pelvic prolapse were more common with vaginal delivery. The main indication of CS in this study was previous CS 40.1%. Conclusion: Despite CS can be life saving for mother and baby in emergency indications, overuse of CS was associated with maternal and fetal complications. Efforts should be done to reduce the rate of elective CS through proper antenatal care counseling

Timing of term elective cesarean section and adverse neonatal outcomes: A multi-center retrospective cohort study.

BackgroundRate of cesarean section (CS), including elective CS has globally increased. Studies have found that term elective CS before 39 weeks of gestation is associated with increased risk of adverse respiratory outcomes.ObjectiveTo determine the rate of elective CS and examine the association between timing of elective term CS and adverse neonatal outcomes in a large population of Lebanese women.MethodsA Multi-Center Study was conducted using data from the National Collaborative Perinatal Neonatal Network database. Simple and multivariable logistic regression models were used to examine the association between timing of term elective CS and adverse neonatal outcomes. Some of the neonatal adverse outcomes we examined included respiratory distress syndrome, admission to the NICU, and a composite of respiratory outcomes.ResultsA total of 28,997 low risk mothers who delivered through primary and repeat elective CS were included in the study. Uncomplicated elective planned term CS constituted 25% of all CS deliveries in Lebanon. Primary and repeat CS at 37 weeks of gestation increased the odds of most of the studied adverse neonatal outcomes. There were few associations between CS and adverse neonatal outcomes at 38 weeks of gestation.ConclusionsTerm primary and repeat cesarean delivery prior to 39 weeks of gestation is associated with respiratory and other adverse neonatal outcomes. Delaying birth 1–2 weeks till 39 weeks of gestation can prevent 64–77% of adverse respiratory outcomes.

Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

BackgroundCaesarean section rates are higher among pregnancies conceived by assisted reproductive technology (ART) compared to spontaneous conceptions (SC), implying an increase in neonatal and maternal morbidity. We aimed to compare caesarean section rates in ART pregnancies versus SC, overall, by indication (elective versus emergent), and by type of ART treatment (in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), fresh embryo transfer, frozen embryo transfer) in a systematic review and meta-analysis.MethodsWe searched Medline, EMBASE and CINAHL databases using the OVID Platform from 1993 to 2019, and the search was completed in January 2020. The eligibility criteria were cohort studies with singleton conceptions after in-vitro fertilization and/or intracytoplasmic sperm injection using autologous oocytes versus spontaneous conceptions. The study quality was assessed using the Newcastle Ottawa Scale and GRADE approach. Meta-analyses were performed using odds ratios (OR) with a 95% confidence interval (CI) using random effect models in RevMan 5.3, and I-squared (I2) test > 75% was considered as high heterogeneity.ResultsOne thousand seven hundred fifty studies were identified from the search of which 34 met the inclusion criteria. Compared to spontaneous conceptions, IVF/ICSI pregnancies were associated with a 1.90-fold increase of odds of caesarean section (95% CI 1.76, 2.06). When stratified by indication, IVF/ICSI pregnancies were associated with a 1.91-fold increase of odds of elective caesarean section (95% CI 1.37, 2.67) and 1.38-fold increase of odds of emergent caesarean section (95% CI 1.09, 1.75). The heterogeneity of the studies was high and the GRADE assessment moderate to low, which can be explained by the observational design of the included studies.ConclusionsThe odds of delivering by caesarean section are greater for ART singleton pregnancies compared to spontaneous conceptions. Preconception and pregnancy care plans should focus on minimizing the risks that may lead to emergency caesarean sections and finding strategies to understand and decrease the rate of elective caesarean sections.

The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study.

Breech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation. We carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists. In this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.

Mode of birth and risk of infection-related hospitalisation in childhood: A population cohort study of 7.17 million births from 4 high-income countries.

The proportion of births via cesarean section (CS) varies worldwide and in many countries exceeds WHO-recommended rates. Long-term health outcomes for children born by CS are poorly understood, but limited data suggest that CS is associated with increased infection-related hospitalisation. We investigated the relationship between mode of birth and childhood infection-related hospitalisation in high-income countries with varying CS rates. We conducted a multicountry population-based cohort study of all recorded singleton live births from January 1, 1996 to December 31, 2015 using record-linked birth and hospitalisation data from Denmark, Scotland, England, and Australia (New South Wales and Western Australia). Birth years within the date range varied by site, but data were available from at least 2001 to 2010 for each site. Mode of birth was categorised as vaginal or CS (emergency/elective). Infection-related hospitalisations (overall and by clinical type) occurring after the birth-related discharge date were identified in children until 5 years of age by primary/secondary International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes. Analysis used Cox regression models, adjusting for maternal factors, birth parameters, and socioeconomic status, with results pooled using meta-analysis. In total, 7,174,787 live recorded births were included. Of these, 1,681,966 (23%, range by jurisdiction 17%-29%) were by CS, of which 727,755 (43%, range 38%-57%) were elective. A total of 1,502,537 offspring (21%) had at least 1 infection-related hospitalisation. Compared to vaginally born children, risk of infection was greater among CS-born children (hazard ratio (HR) from random effects model, HR 1.10, 95% confidence interval (CI) 1.09-1.12, p < 0.001). The risk was higher following both elective (HR 1.13, 95% CI 1.12-1.13, p < 0.001) and emergency CS (HR 1.09, 95% CI 1.06-1.12, p < 0.001). Increased risks persisted to 5 years and were highest for respiratory, gastrointestinal, and viral infections. Findings were comparable in prespecified subanalyses of children born to mothers at low obstetric risk and unchanged in sensitivity analyses. Limitations include site-specific and longitudinal variations in clinical practice and in the definition and availability of some data. Data on postnatal factors were not available. In this study, we observed a consistent association between birth by CS and infection-related hospitalisation in early childhood. Notwithstanding the limitations of observational data, the associations may reflect differences in early microbial exposure by mode of birth, which should be investigated by mechanistic studies. If our findings are confirmed, they could inform efforts to reduce elective CS rates that are not clinically indicated.

Pre-Gestational Diabetes and Pregnancy Outcomes

IntroductionPre-gestational, type 1 and type 2 diabetes are associated with adverse neonatal outcomes and increased rates of emergency caesarean sections.MethodsWe studied pregnancy outcomes associated with pre-gestational diabetes in 174 women who attended the National Maternity Hospital in Dublin, Ireland, between 2015 and 2017.ResultsFifty women (28.6%) had type 2 diabetes mellitus, and 124 women (71.4%) had type 1 diabetes mellitus. Women with type 2 diabetes mellitus were older (36 vs. 34 years, p 0.02) and had a higher BMI (32.6 vs. 26.2 kg/m2, p 0.00). Duration of diabetes mellitus in type 1 and type 2 was 15.7 and 5.7 years, respectively, and mean HbA1c in type 2 diabetes mellitus at booking was 44.5 mmol/mol (6.2%) and in type 1 diabetes mellitus was 56.3 mmol/mol (7.3%). Forty women (32%) with type 1 diabetes mellitus used continuous subcutaneous insulin infusion. In our cohort, 45.4% had a caesarean delivery. Offspring of patients with multiple dose injections were lighter (3.58 kg) than infants of continuous subcutaneous insulin infusion-treated patients (3.75 kg). More emergency caesarean sections were observed in the continuous subcutaneous insulin infusion group than in the group treated with multiple dose injections (37.5% vs. 28.5%), while the elective caesarean section rate was higher in the multiple dose injection group (17.8% vs. 12.5%). Women treated with continuous subcutaneous insulin infusion had a higher rate of miscarriage (25% vs. 19%) with more congenital malformations (10% vs. 2.3%).ConclusionsWomen in our study with pre-gestational diabetes were overweight, were older and had long-standing diabetes mellitus. Our patients with type 2 diabetes had a higher BMI, were older, had a shorter duration of diabetes mellitus and had better diabetes control compared to women with type 1 diabetes. Women treated with continuous subcutaneous insulin infusion had a higher rate of miscarriage with more congenital malformations. The initial inadequate diabetes control was significantly improved during pregnancy.