Risk Of Emergency Caesarean Section Research Articles

The risk of emergency cesarean section after failure of vaginal delivery according to prepregnancy body mass index or gestational weight gain by the 2009 Institute of Medicine guidelines.

ObjectiveTo evaluate the risk of emergency cesarean section according to the prepregnancy body mass index (BMI) and gestational weight gain per the 2009 Institute of Medicine guidelines.MethodsA retrospective analysis of data from 2,765 women with singleton full-term births (2009 to 2012) who attempted a vaginal delivery was conducted. Pregnancies with preeclampsia, chronic hypertension, diabetes, planned cesarean section, placenta previa, or cesarean section due to fetal anomalies or intrauterine growth restriction were excluded. Odds ratios (ORs) and confidence intervals (CIs) for emergency cesarean section were calculated after adjusting for prepregnancy BMI or gestational weight gain.ResultsThree-hundred and fifty nine (13.0%) women underwent emergency cesarean section. The adjusted OR for overweight, obese, and extremely obese women indicated a significantly increased risk of cesarean delivery. Gestational weight gain by Institute of Medicine guidelines was not associated with an increased risk of cesarean delivery. However, inadequate and excessive weight gain in obese women was highly associated with an increased risk of emergency cesarean section, compared to these in normal BMI (OR, 5.56; 95% CI, 1.36 to 22.72; OR, 3.63; 95% CI, 1.05 to 12.54; respectively), while there was no significant difference between normal BMI and obese women with adequate weight gain.ConclusionObese women should be provided special advice before and during pregnancy for controlling weight and careful consideration should be needed at the time of vaginal delivery to avoid emergency cesarean section.

Outcome of attempted vaginal delivery after a previous vacuum extraction: a population-based study.

Few studies have investigated long-term effects of a first vaginal instrumental delivery on subsequent mode of delivery. We investigated risks of repeat vacuum extraction and risk factors associated with a repeat vacuum extraction delivery. This is a population-based register study including 391 160 women with two consecutive singleton term (≥37 weeks) live births in cephalic presentation between/within the time period of 1992-2010 in Sweden. Rates and risk ratios of mode of delivery in second pregnancy in relation to primary mode of delivery were calculated using descriptive analyses and generalized linear models. Risk of repeat vacuum extraction was adjusted for maternal age and height, interpregnancy interval, gestational length, birthweight, induction, sex and occiput posterior position. Compared with women with a primary spontaneous vaginal delivery, women with a primary vacuum extraction had an almost five-fold risk of vacuum extraction delivery and nearly a three-fold risk of emergency cesarean section at second delivery. For women with a primary emergency cesarean section, corresponding risks were substantially higher. Risk factors for a repeat vacuum extraction were increasing maternal age and an interpregnancy interval >4 years, decreasing maternal stature, increasing gestation length and birthweight, induction, giving birth to a male infant and occiput posterior position. Nine of ten women who attempted a vaginal birth after a primary vacuum extraction succeeded in having a spontaneous vaginal delivery at second delivery. Compared with women with a primary spontaneous vaginal delivery, women with a primary vacuum extraction were at increased risk of repeat vacuum extraction and emergency cesarean section in subsequent delivery although their risk was not as high as that of women with a primary emergency cesarean section.

Association of Maternal Vitamin D Status with Glucose Tolerance and Caesarean Section in a Multi-Ethnic Asian Cohort: The Growing Up in Singapore Towards Healthy Outcomes Study.

ObjectiveEpidemiological studies relating maternal 25-hydroxyvitamin D (25OHD) with gestational diabetes mellitus (GDM) and mode of delivery have shown controversial results. We examined if maternal 25OHD status was associated with plasma glucose concentrations, risks of GDM and caesarean section in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study.MethodsPlasma 25OHD concentrations, fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations were measured in 940 women from a Singapore mother-offspring cohort study at 26–28 weeks’ gestation. 25OHD inadequacy and adequacy were defined based on concentrations of 25OHD ≤75nmol/l and >75nmol/l respectively. Mode of delivery was obtained from hospital records. Multiple linear regression was performed to examine the association between 25OHD status and glucose concentrations, while multiple logistic regression was performed to examine the association of 25OHD status with risks of GDM and caesarean section.ResultsIn total, 388 (41.3%) women had 25OHD inadequacy. Of these, 131 (33.8%), 155 (39.9%) and 102 (26.3%) were Chinese, Malay and Indian respectively. After adjustment for confounders, maternal 25OHD inadequacy was associated with higher FG concentrations (β = 0.08mmol/l, 95% Confidence Interval (CI) = 0.01, 0.14), but not 2HPPG concentrations and risk of GDM. A trend between 25OHD inadequacy and higher likelihood of emergency caesarean section (Odds Ratio (OR) = 1.39, 95% CI = 0.95, 2.05) was observed. On stratification by ethnicity, the association with higher FG concentrations was significant in Malay women (β = 0.19mmol/l, 95% CI = 0.04, 0.33), while risk of emergency caesarean section was greater in Chinese (OR = 1.90, 95% CI = 1.06, 3.43) and Indian women (OR = 2.41, 95% CI = 1.01, 5.73).Conclusions25OHD inadequacy is prevalent in pregnant Singaporean women, particularly among the Malay and Indian women. This is associated with higher FG concentrations in Malay women, and increased risk of emergency caesarean section in Chinese and Indian women.

EP08.01: Does cervical cerclage affect the rate of Caesarean section?

To determine the relationship between cervical cerclage and delivery by Caesarean section secondary due to cervical dystocia. This is a retrospective cohort study of patients who were high risk for preterm birth and some of them underwent cervical cerclage and others did not. Our study included 144 women who underwent cerclage (cerclage group) and 152 who had no cerclage insertion (no cerclage group). There was significant difference in the overall emergency Caesarean section rate between the groups (RR 2.02.95%CI 1.33–3.07). Cervical dystocia as an indication for emergency Caesarean section was more prevalent in cerclage group (RR 3.08.95%CI 0.81–11.61). BMI has no significant impact on the rate of emergency Caesarean section for cervical dystocia in cerclage group. Primigravida women with cerclage had a significantly higher rate of emergency Caesarean section and these decrease rate as the number of pregnancies increase (p < 0.05). In our study we found that women who underwent cervical cerclage had higher risk of emergency Caesarean section in general. We did not find positive correlation between cervical dystocia and cerclage. Low parity may play important factor in higher rate of Caesarean section after cerclage. As the parity increases, the risk for surgical delivery decreases. BMI has no influence on Caesarean section rate in pregnancies with cerclage. Whether cerclage indeed influence the rate of cervical dystocia should be further evaluated by larger studies. Cerclage (N-144) No Cerclage (N-152)

Second-trimester cervical length as risk indicator for Cesarean delivery in women with twin pregnancy.

To determine whether second-trimester cervical length (CL) in women with a twin pregnancy is associated with the risk of emergency Cesarean section. This was a secondary analysis of two randomized trials conducted in 57 hospitals in The Netherlands. We assessed the univariable association between risk indicators, including second-trimester CL in quartiles, and emergency Cesarean delivery using a logistic regression model. For multivariable analysis, we assessed whether adjustment for other risk indicators altered the associations found in univariable (unadjusted) analysis. Separate analyses were performed for suspected fetal distress and failure to progress in labor as indications for Cesarean section. In total, 311 women with a twin pregnancy attempted vaginal delivery after 34 weeks' gestation. Emergency Cesarean delivery was performed in 111 (36%) women, of which 67 (60%) were performed owing to arrest of labor. There was no relationship between second-trimester CL and Cesarean delivery (adjusted odds ratio (aOR): 0.97 for CL 26(th) -50(th) percentiles; 0.71 for CL 51(st) - 75(th) percentiles; and 0.92 for CL > 75(th) percentile, using CL ≤ 25(th) percentile as reference). In multivariable analysis, the only variables associated with emergency Cesarean delivery were maternal age (aOR, 1.07 (95% CI, 1.00-1.13)), body mass index (BMI) (aOR, 3.99 (95% CI, 1.07-14.9) for BMI 20-23 kg/m(2) ; 5.04 (95% CI, 1.34-19.03) for BMI 24-28 kg/m(2) ; and 3.1 (95% CI, 0.65-14.78) for BMI > 28 kg/m(2) ) and induction of labor (aOR, 1.92 (95% CI, 1.05-3.5)). In nulliparous women with a twin pregnancy, second-trimester CL is not associated with risk of emergency Cesarean delivery.

Prevention of stillbirth

Key content Most of the variability in stillbirth risk is not due to maternal risk factors, therefore modifying maternal risk factors or screening women using maternal risk factors to assess risk has limited potential impact. The primary intervention that prevents stillbirth is delivery. The overall risk of perinatal death is lowest at 39 weeks of gestation, and induction of labour at term does not increase a woman's risk of emergency caesarean section. The most promising approach to screening low risk women for stillbirth risk may be to improve identification of small‐for‐gestational‐age infants; however, there is an absence of high quality evidence around the optimal approach for achieving this goal. Learning objectives To understand the relationship between maternal risk factors, obstetric complications and fetal size in relation to stillbirth risk. To understand the approach to fetal assessment and elective delivery as methods to prevent stillbirth. Ethical issues Screening for stillbirth risk has the potential to do good by preventing deaths. However, if programmes of screening and intervention are developed, many more women may be harmed due to high false positive rates.

Maternal age effects on myometrial expression of contractile proteins, uterine gene expression, and contractile activity during labor in the rat.

Advanced maternal age of first time pregnant mothers is associated with prolonged and dysfunctional labor and significant risk of emergency cesarean section. We investigated the influence of maternal age on myometrial contractility, expression of contractile associated proteins (CAPs), and global gene expression in the parturient uterus. Female Wistar rats either 8 (YOUNG n = 10) or 24 (OLDER n = 10) weeks old were fed laboratory chow, mated, and killed during parturition. Myometrial strips were dissected to determine contractile activity, cholesterol (CHOL) and triglycerides (TAG) content, protein expression of connexin-43 (GJA1), prostaglandin-endoperoxide synthase 2 (PTGS2), and caveolin 1 (CAV-1). Maternal plasma concentrations of prostaglandins PGE2, PGF2α, and progesterone were determined by RIA. Global gene expression in uterine samples was compared using Affymetrix Genechip Gene 2.0 ST arrays and Ingenuity Pathway analysis (IPA). Spontaneous contractility in myometrium exhibited by YOUNG rats was threefold greater than OLDER animals (P < 0.027) but maternal age had no significant effect on myometrial CAP expression, lipid profiles, or pregnancy-related hormones. OLDER myometrium increased contractile activity in response to PGF2α, phenylephrine, and carbachol, a response absent in YOUNG rats (all P < 0.002). Microarray analysis identified that maternal age affected expression of genes related to immune and inflammatory responses, lipid transport and metabolism, steroid metabolism, tissue remodeling, and smooth muscle contraction. In conclusion YOUNG laboring rat myometrium seems primed to contract maximally, whereas activity is blunted in OLDER animals and requires stimulation to meet contractile potential. Further work investigating maternal age effects on myometrial function is required with focus on lipid metabolism and inflammatory pathways.

Earlier induction of labour in post term pregnancies—A historical cohort study

Objectiveto evaluate a change of guideline for earlier induction of labour in post term pregnancies and its possible impact on selected birth interventions and outcome of the newborn. Designa historical cohort study. SettingsDepartment of Obstetrics at Aarhus University Hospital in Denmark. Participants18,247 women giving birth between 1 January 2009 and 12 December 2012. Methodsto compare induction of labour in two consecutive time periods before and after implementation of a new guideline on induction of labour (42 weeks versus 41 weeks plus five days gestational age) in post term pregnancy. t-Test and χ2 were used to calculate means of gestational age and relative risk (RR) of selected birth and newborn outcomes. Stratification by Mantel–Haenszel-analysis was used to adjust for possible confounders. Robson׳s classification system ‘Ten Group Classification System’ was used to create comparable groups within the performed analysis. Findingsa difference in means of three gestational days after implementation of the new guideline on earlier induction of labour was found together with an overall unadjusted decrease in emergency caesarean section rate of 30% (RR 0.70, 95% CI; 0.54–0.91). Stratified analysis on parity showed a reduction in emergency caesarean section but only in nulliparous women (RR 0.78, 95% CI; 0.66–0.92), whereas the analysis in multiparous women showed a non-statistically significant increased risk of emergency caesarean section (RR 1.39, 95% CI; 0.89–2.18). No differences were found in assisted vaginal childbirths and outcome in newborns concerning Apgar score, pH and standard base excess in women induced in 42 weeks versus 41 weeks plus five days gestational age. Conclusionthe findings of this study suggest that earlier induction of labour due to post term pregnancy has a positive influence, but only in nulliparous women, by lowering the risk of emergency caesarean section evidently without increasing the risk on adverse outcome in newborns.

Fear of childbirth and emergency caesarean section in low-risk nulliparous women: a prospective cohort study

Objective: To assess the association between fear of childbirth (FOC) and emergency caesarean section.Design: A prospective cohort study of low-risk nulliparous women at term.Setting: Nine obstetric departments in Denmark, May 2004–July 2005.Population: A total of 2598 nulliparous women in spontaneous labor with a single fetus in cephalic presentation at term.Methods: Self-reported FOC was assessed at 37 weeks of gestation by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A and at admission to the labor ward by the Delivery Fear Scale (DFS). Mode of delivery was recorded by the attending staff. Logistic regression analyses were used to estimate unadjusted and adjusted odds ratios (OR).Main outcome measures: Risk of emergency caesarean section in women who feared childbirth.Results: FOC (W-DEQ sum score ≥85 and DFS sum score ≥70) was not associated with emergency caesarean section: adjusted OR = 0.81 (95% CI: 0.48–1.36) and OR = 0.97 (95% CI: 0.55–1.71), respectively.Conclusion: In this prospective observational study, women with FOC did not have an increased risk of emergency caesarean section compared to women with no such fear.

Sexual violence and mode of delivery: a population-based cohort study.

This study aimed to explore the association between sexual violence and mode of delivery. National cohort study. Women presenting for routine ultrasound examinations were recruited to the Norwegian Mother and Child Cohort Study between 1999 and 2008. A total of 74,059 pregnant women. Sexual violence was self-reported during pregnancy using postal questionnaires. Mode of delivery, other maternal birth outcomes and covariates were retrieved from the Medical Birth Registry of Norway. Risk estimations were performed using multivariable logistic regression analysis. Mode of delivery and selected maternal birth outcomes. Of 74,059 women, 18.4% reported a history of sexual violence. A total of 10% had an operative vaginal birth, 4.9% had elective caesarean section and 8.6% had an emergency caesarean section. Severe sexual violence (rape) was associated with elective caesarean section, adjusted odds ratio (AOR) 1.56 (95% CI 1.18-2.05) for nulliparous women and 1.37 (1.06-1.76) for multiparous women. Those exposed to moderate sexual violence had a higher risk of emergency caesarean section, AOR 1.31 (1.07-1.60) and 1.41 (1.08-1.84) for nulliparous and multiparous women, respectively. No association was found between sexual violence and operative vaginal birth, except for a lower risk among multiparous women reporting mild sexual violence, AOR 0.73 (0.60-0.89). Analysis of other maternal outcomes showed a reduced risk of episiotomy for women reporting rape and a higher frequency of induced labour. Women with a history of rape had higher odds of elective caesarean section and induction and significantly fewer episiotomies.

Elective Induction of Labor and the Risk of Cesarean Section in Low-risk Parous Women

Objective To estimate the association between elective induction of labor and cesarean section in low-risk parous women, and to assess whether the association is influenced by induction method. Design Cohort study. Setting University hospital in Sweden. Population Parous women without pregnancy complications or previous cesarean section, and with a planned vaginal term (37–41 weeks), singleton birth, in vertex position were included. Methods Information was collected from a local database containing prospectively entered antenatal and delivery data. Odds ratios for cesarean section were calculated using generalized estimating equations logistic regression and adjusted for parity, maternal age, gestational length, birthweight, use of epidural anesthesia and year of birth. Main outcome measures Emergency cesarean section. Results Among 7973 pregnancies that fulfilled the inclusion criteria, 343 (4%) had an elective induction of labor. Intravenous oxytocin was administered in 5% of these inductions, amniotomy was performed in 62%, and a cervical ripening agent was used in 33%. Electively induced labor more than doubled the risk of cesarean section compared with spontaneous labor onset (OR 2.5, 95% CI 1.4–4.2) and this risk was more than tripled when cervical ripening was used (OR 3.6, 95% CI 1.7–7.6). Conclusions In low-risk parous women, electively induced labor has an increased risk of emergency cesarean section compared with spontaneous onset labor. This risk increase is more pronounced if cervical ripening agents are required. Women need to be counseled about these risks before elective induction of delivery is decided.

Quantification of risk of emergency caesarean during labour after one previous caesarean section

In its 2007 guideline, the Royal College of Obstetricians and Gynaecologists (RCOG) recommends vaginal birth after caesarean (VBAC) as safer than repeat elective caesarean sections. However, this document does not give details of risk of emergency caesarean section for women accepting VBAC. An emergency caesarean is associated with increased maternal and neonatal morbidity, and women do consider the eventuality of emergency delivery when deciding mode of delivery. We sought to quantify this risk by designing a retrospective cohort study in a consultant-led unit. While higher than average rates of successful planned VBAC were achieved, the odds of emergency caesarean delivery were increased in women undergoing VBAC (OR 3.0, 95% CI 1.2–7.6, p = 0.03). Odds of requiring a Category 1 emergency caesarean were markedly raised. Our data adds to the VBAC literature by quantifying the risk of Category 1 or 2 emergency caesarean section for women entering labour who have delivered by caesarean section once previously, giving the odds of emergency caesarean section on entering labour compared with women without a scar. This gives further information to those counselling women about birth after caesarean section.

Which women are at an increased risk of a caesarean section or an instrumental vaginal birth in the UK: an exploration within the Millennium Cohort Study

To explore the maternal demographic factors associated with operative births (instrumental vaginal births or caesarean section), after adjustment for health, interpersonal, pregnancy, labour and infant covariates. Nationally representative cohort study. Women giving birth in the UK, during the period 2000-2002. A total of 18,239 mother-infant pairs. Multinomial logistic regression models were estimated to explore the relationship between demographic characteristics and mode of birth, stratified by parity. Self-reported mode of birth, defined as unassisted vaginal birth, instrumental vaginal birth, emergency caesarean section and planned caesarean section. For primiparous women, operative births rose steeply with increasing maternal age. Women from lower occupational status households were at an increased risk of planned caesarean section. Mode of birth differed significantly by ethnicity. For multiparous women, a younger age at first birth was protective of a later caesarean section or instrumental vaginal birth at the cohort birth. Women with qualifications normally taken at the age 18 years were at an increased risk of planned caesarean section compared with women with degree-level qualifications. Mode of birth differed significantly by ethnicity, and non-UK born women were at an increased risk of emergency caesarean section. The sociodemographic characteristics of UK women independently predict mode of birth. Further research is needed to establish to what extent sociodemographic differences in mode of birth are a reflection of the attitudes and behaviours of women, or health professionals, and are therefore amenable to change.

Intrapartum monitoring of high‐risk deliveries with ST analysis of the fetal electrocardiogram: an observational study of 6010 deliveries

To evaluate the clinical use of ST analysis (STAN) for intrapartum monitoring of high-risk pregnancies. Prospective observational study. University hospital, Norway, 2004-2008. Singleton pregnancies with a gestational age above 35(+6) weeks. Analysis of maternal and neonatal outcomes for all deliveries according to the method of intrapartum monitoring. Prevalence of cord metabolic acidosis (pH < 7.05, extracellular fluid base deficit (extracellular fluid) >12 mmol/L). Of 23 203 deliveries, 6010 (25.9%) were monitored with STAN. Fetal blood sampling was performed in 146 (2.4%) of the 6010 cases. During the study period, the prevalence of cord metabolic acidosis and moderate cord acidosis (pH < 7.15) decreased in STAN-monitored deliveries from 1.4 to 0.3% (p = 0.01) and from 16.4 to 11.7% (p = 0.001), respectively. The prevalence of moderate and severe neonatal encephalopathy was 0.38%. In the birth population, the proportion of cesarean deliveries decreased from 10.1 to 8.8%. The risk of emergency cesarean section after STAN monitoring compared with those monitored with auscultation/cardiotocography was high (odds ratio 5.4, 95% confidence interval = 4.9-6.1) but remained stable during the study period. ST analysis is a useful tool for identification of fetuses at risk of intrapartum hypoxia. Despite the restricted use of fetal blood sampling, we found a low proportion of cord metabolic acidosis and newborn morbidity.

Elective induction of labor and the risk of cesarean section in low‐risk parous women: a cohort study

To estimate the association between elective induction of labor and cesarean section in low-risk parous women, and to assess whether the association is influenced by induction method. Cohort study. University hospital in Sweden. Parous women without pregnancy complications or previous cesarean section, and with a planned vaginal term (37-41weeks), singleton birth, in vertex position were included. Information was collected from a local database containing prospectively entered antenatal and delivery data. Odds ratios for cesarean section were calculated using generalized estimating equations logistic regression and adjusted for parity, maternal age, gestational length, birthweight, use of epidural anesthesia and year of birth. Emergency cesarean section. Among 7973 pregnancies that fulfilled the inclusion criteria, 343 (4%) had an elective induction of labor. Intravenous oxytocin was administered in 5% of these inductions, amniotomy was performed in 62%, and a cervical ripening agent was used in 33%. Electively induced labor more than doubled the risk of cesarean section compared with spontaneous labor onset (OR 2.5, 95% CI 1.4-4.2) and this risk was more than tripled when cervical ripening was used (OR 3.6, 95% CI 1.7-7.6). In low-risk parous women, electively induced labor has an increased risk of emergency cesarean section compared with spontaneous onset labor. This risk increase is more pronounced if cervical ripening agents are required. Women need to be counseled about these risks before elective induction of delivery is decided.

Indications for operative delivery between 1999-2010 and induction of labor and epidural analgesia on the risk of operative delivery – A population based Swedish register study

ObjectivesThe aim of this study was to describe the distribution of indications for vacuum extraction (VE) and emergency cesarean section (EMCS) from 1999 to 2010. Furthermore, we investigated the association of induction of labor and epidural analgesia (EA) on the risk of operative delivery. Study designPopulation based register study with data from the Swedish Medical Birth Register during 1999–2010 including all 415230 primiparous women giving birth in gestational week 37+0 to 41+6. Main outcome measuresIndication for operative delivery as well as VE and EMCS. ResultsAmong the VE deliveries the indication “signs of fetal distress” increased while “multiple indications” decreased. For EMCS, “prolonged labor” increased steadily while “multiple indications” decreased. The total rate of induction of labor increased from 8.2% in 1999 to 11.9% in 2010, and was associated with an increased risk of both EMCS (OR 3.37) and VE (OR 1.5). The total rate of EA increased from 43.7% in 1999 to 49.8% in 2010, and was associated with a double risk for VE (OR=2.23) and with an increased risk of EMCS (OR=1.64). ConclusionThere have been changes in the distribution of indications for VE and EMCS during the study period. A growing number of mothers are being induced and more mothers receive EA. These factors seem to have influenced the rate of operative deliveries. Our findings underline the importance of carefully considering the advantages, disadvantages and risks with EA and induction of labor.

Mode of Delivery After Epidural Analgesia in a Cohort of Low-risk Nulliparas

Abstract: Background: Although epidural analgesia is widespread and very effective for alleviating labor pain, its use is still controversial, as the literature is inconsistent about the risk of adverse birth outcome after administration of epidural analgesia. The aim of this study was to explore associations between epidural analgesia and mode of delivery. Methods: Data were obtained from a prospective cohort from nine Danish labor wards and comprised 2,721 term nulliparous women with spontaneous onset of labor and a singleton fetus in cephalic presentation. Information about epidural analgesia, mode of delivery, and birth complications was obtained by the staff attending labor. Additional information was provided from self-administered questionnaires in gestational week 37. Multiple logistic regression analyses were used to estimate the association between epidural analgesia and birth outcomes. Results are presented as crude and adjusted odds ratios (OR [95% CI]). Results: Of the total cohort, 21.6 percent required epidural analgesia, 8.7 percent had emergency cesarean section, and 14.9 percent had vacuum extraction. Women with epidural analgesia had a higher risk of emergency cesarean section (adjusted OR: 5.8; 95% CI: 4.1–8.1), and vacuum extraction (adjusted OR: 1.7; 95% CI: 1.3–2.2). In a subgroup of the cohort with a very low overall risk of cesarean section, 3.4 percent had emergency cesarean section and an increased risk of emergency cesarean section was also found in this group (adjusted OR: 3.5; 95% CI: 1.5–8.2). Conclusions: In nulliparous women of a very low-risk population, use of epidural analgesia for labor pain was associated with higher risks of emergency cesarean section and vacuum extraction. (BIRTH 38:4 December 2011)

Emergency caesarean section in low risk nulliparous women

The rising incidence of caesarean section (CS), including emergency caesarean section (ECS) in nulliparas is of concern. Previous CS may have implications for future pregnancies and deliveries. This article describes the prevalence and indications for ECS in a cohort of low risk nulliparas and identifies maternal and fetal risk factors associated with ECS. We included 2,748 low-risk women and 8.7% had ECS. Failure-to-progress (FTP) accounted for 68.3% of the ECS and 30.4% were performed due to suspected fetal distress (SFD). Multivariate logistic regression analyses were done to estimate the association between risk factors and indications for ECS. Smoking during pregnancy (OR 2.33; CI 1.18–4.61) and BMI ≥ 30 (OR 2.87, CI 1.34–6.16) were associated with increased risk of ECS due to SFD. Birth weight (BW) ≥ 4,000 (OR 2.95; CI 1.92–4.53) and smoking cessation during pregnancy (OR 2.02; CI 1.26–3.20) were associated with increased risk of ECS due to FTP.

Mode of Delivery after Epidural Analgesia in a Cohort of Low-Risk Nulliparas

Although epidural analgesia is widespread and very effective for alleviating labor pain, its use is still controversial, as the literature is inconsistent about the risk of adverse birth outcome after administration of epidural analgesia. The aim of this study was to explore associations between epidural analgesia and mode of delivery. Data were obtained from a prospective cohort from nine Danish labor wards and comprised 2,721 term nulliparous women with spontaneous onset of labor and a singleton fetus in cephalic presentation. Information about epidural analgesia, mode of delivery, and birth complications was obtained by the staff attending labor. Additional information was provided from self-administered questionnaires in gestational week 37. Multiple logistic regression analyses were used to estimate the association between epidural analgesia and birth outcomes. Results are presented as crude and adjusted odds ratios (OR [95% CI]). Of the total cohort, 21.6 percent required epidural analgesia, 8.7 percent had emergency cesarean section, and 14.9 percent had vacuum extraction. Women with epidural analgesia had a higher risk of emergency cesarean section (adjusted OR: 5.8; 95% CI: 4.1-8.1), and vacuum extraction (adjusted OR: 1.7; 95% CI: 1.3-2.2). In a subgroup of the cohort with a very low overall risk of cesarean section, 3.4 percent had emergency cesarean section and an increased risk of emergency cesarean section was also found in this group (adjusted OR: 3.5; 95% CI: 1.5-8.2). In nulliparous women of a very low-risk population, use of epidural analgesia for labor pain was associated with higher risks of emergency cesarean section and vacuum extraction.

Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women

To assess the risk for emergency cesarean section among women in whom labor was induced in gestational week ≥41 and to evaluate if parity and mode of induction affected this association. Hospital-based retrospective cohort study. Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden, during 2002-2006. Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with a Bishop score of <7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients' medical files. Results were adjusted for body mass index, age and the use of epidural analgesia. Risk for emergency cesarean section. Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women (OR 3.34, 95%CI 2.77-4.04) and an almost twofold increase in risk for multiparous women (OR 1.94, 95%CI 1.24-3.02). There was no significant difference in risk for emergency cesarean section between the two methods of induction (PGE(2) and transcervical catheter). Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced, the high risk for emergency cesarean must be kept in mind.