Unscheduled Cesarean Delivery Research Articles

943 Risk factors for surgical morbidity following unscheduled cesarean delivery

943 Risk factors for surgical morbidity following unscheduled cesarean delivery

680 Impact of obesity class on unscheduled cesarean delivery outcomes

680 Impact of obesity class on unscheduled cesarean delivery outcomes

164 Adjunctive azithromycin for unscheduled cesarean delivery complicated by intraamniotic infection

164 Adjunctive azithromycin for unscheduled cesarean delivery complicated by intraamniotic infection

Obstetric operating room staffing and operating efficiency using queueing theory

IntroductionStrategies to achieve efficiency in non-operating room locations have been described, but emergencies and competing priorities in a birth unit can make setting optimal staffing and operation benchmarks challenging. This study used Queuing Theory Analysis (QTA) to identify optimal birth center operating room (OR) and staffing resources using real-world data.MethodsData from a Level 4 Maternity Center (9,626 births/year, cesarean delivery (CD) rate 32%) were abstracted for all labor and delivery operating room activity from July 2019—June 2020. QTA has two variables: Mean Arrival Rate, λ and Mean Service Rate µ. QTA formulas computed probabilities: P0 = 1-(λ/ µ) and Pn = P0 (λ/µ)n where n = number of patients. P0…n is the probability there are zero patients in the queue at a given time. Multiphase multichannel analysis was used to gain insights on optimal staff and space utilization assuming a priori safety parameters (i.e., 30 min decision to incision in unscheduled CD; ≤ 5 min for emergent CD; no greater than 8 h for nil per os time). To achieve these safety targets, a < 0.5% probability that a patient would need to wait was assumed.ResultsThere were 4,017 total activities in the operating room and 3,092 CD in the study period. Arrival rate λ was 0.45 (patients per hour) at peak hours 07:00–19:00 while λ was 0.34 over all 24 h. The service rate per OR team (µ) was 0.87 (patients per hour) regardless of peak or overall hours. The number of server teams (s) dedicated to OR activity was varied between two and five. Over 24 h, the probability of no patients in the system was P0 = 0.61, while the probability of 1 patient in the system was P1 = 0.23, and the probability of 2 or more patients in the system was P≥2 = 0.05 (P3 = 0.006). However, between peak hours 07:00–19:00, λ was 0.45, µ was 0.87, s was 3, P0 was 0.48; P1 was 0.25; and P≥2 was 0.07 (P3 = 0.01, P4 = 0.002, P5 = 0.0003).ConclusionQTA is a useful tool to inform birth center OR efficiency while upholding assumed safety standards and factoring peaks and troughs of daily activity. Our findings suggest QTA is feasible to guide staffing for maternity centers of all volumes through varying model parameters. QTA can inform individual hospital-level decisions in setting staffing and space requirements to achieve safe and efficient maternity perioperative care.

Tranexamic Acid to Prevent Obstetrical Hemorrhage After Cesarean Delivery

ABSTRACT Previous research has presented convincing evidence that the administration of tranexamic acid (TXA) after cesarean delivery can reduce the incidence of postpartum hemorrhage (PPH) and the associated mortality and morbidity. Although there have been several significant studies on this topic, they are limited by small sample sizes, which make the studies difficult to generalize and limit their statistical power. This study aimed to address that gap and assess clinical outcomes related to the administration of TXA in a large sample. This was a multicenter, double-blind, randomized controlled trial including 31 hospitals participating in the Maternal-Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Eligibility criteria included scheduled or unscheduled cesarean delivery of a singleton or twin gestation. Exclusion criteria included maternal age younger than 18 years, blood transfusion before randomization, plan for transfusion after randomization, contraindications to TXA, patient decision not to use blood products, or administration of antifibrolytic agents or uterotonic agents other than oxytocin. The primary outcome was maternal death or blood transfusion before hospital discharge or 7 days after delivery, whichever came first. Secondary outcomes included intraoperative blood loss of more than 1 L and treatments or interventions in response to bleeding or related complications within 7 days of delivery, as well as infectious complications within 6 weeks of delivery. Final analyses included 11,000 patients, with 5529 in the TXA group and 5471 in the placebo group. Baseline characteristics were not significantly different between groups, and no center-dependent differences were observed. The primary outcome was observed in 3.6% of patients in the TXA group and 4.3% of patients in the placebo group (adjusted relative risk, 0.89; P = 0.19). Intraoperative blood loss of more than 1 L was recorded in 7.3% and 8.0% in the tranexamic and placebo groups, respectively (relative risk, 0.90; 95% CI, 0.79–1.05). Treatments and interventions in response to bleeding occurred in 16.1% of individuals in the TXA group and 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82–0.97). Infectious complications were reported in 3.2% and 2.5% in the TXA and placebo groups, respectively (relative risk, 1.28; 95% CI, 1.02–1.61). Sensitivity analysis showed similar results to initial analysis, and no significant differences were seen between groups in major safety outcomes. This analysis indicates that the administration of TXA during cesarean delivery did not lower the risk of maternal death or blood transfusion. These results are in direct contradiction to previous research showing that TXA is effective at reducing these outcomes. This trial was stronger than any previous studies in sample size and careful randomization ensuring equal representation of scheduled and unscheduled cesarean deliveries, which makes the contradiction to previous research especially relevant. Some limitations of this trial included limitations in time of administration of TXA as well as dosage. Outcomes related to these 2 variables are still largely unknown. This trial also excluded patients at high risk of thromboembolic phenomena, and the effect of TXA in this population is still unknown. Further research should focus on more diverse populations, as well as understanding variations in outcomes with timing and dosage, which this study did not address.

Standard-Dose Azithromycin in Class III Obese Patients Undergoing Unscheduled Cesarean Delivery.

Perioperative antibiotic prophylaxis reduces cesarean wound complications. This study investigates whether integration of standard-dose (500 mg) azithromycin prophylaxis reduced wound complications in patients with class III obesity (body mass index [BMI] ≥ 40 kg/m2) undergoing unscheduled cesarean delivery. Retrospective cohort study of patients with class III obesity undergoing unscheduled cesarean delivery in single hospital system from January 1, 2017, to January 1, 2020. A standard dose (500 mg) of azithromycin was integrated into system order sets in 2018. Medical history and postoperative wound outcomes were compared in pre- and postintegration cohorts. Wound complication was defined as composite of wound seroma, hematoma, superficial or deep infection. A total of 1,273 patients met inclusion criteria, 303 patients in the preorder set group, and 970 patients in the postorder set group. Demographics were similar between the pre- and postintegration cohorts, including BMI (median: 44.4 kg/m2, p = 0.84) and weight at delivery (mean: 121.2 ± 17.8 kg, p = 0.57). Patients in the postintegration cohort had lower rates of composite postpartum wound complication (7.9 vs. 13.9%, p = 0.002), superficial infection or deep infection/abscess (6.7 vs. 10.2%, p = 0.042), and postpartum readmission or unscheduled visits (18.7 vs. 24.4%, p < 0.029). Rates of chorioamnionitis and endometritis were similar between the pre- and postintegration groups (8.6 vs. 6.9%, p = 0.33, and 1.7 vs. 1.9%, p = 0.81, respectively). Patients in the postintegration cohort had lower risk of postoperative composite wound complication (unadjusted odds ratio [OR]: 0.54, confidence interval [CI]: 0.36-0.80, p = 0.002) and lower rates of wound infection (unadjusted OR: 0.63, 95% CI: 0.40-0.99, p = 0.044). When comparing patients who received azithromycin at delivery and patients who did not, standard-dose azithromycin reduced risk of postoperative wound complication (unadjusted OR: 0.67, 95% CI: 0.46-0.99, p = 0.043). A standard dose of azithromycin provides adequate perioperative prophylaxis in class III obese patients, decreasing rates of postcesarean wound complications and unscheduled postpartum outpatient visits. · Class III obese patients undergoing unscheduled cesarean have high rates of wound complications.. · Standard-dose azithromycin reduces risk of postcesarean wound infection in class III obese patients.. · Standard-dose azithromycin reduces readmission, unscheduled visits in class III obese patients..

Decreasing Decision-to-Incision Times for Unscheduled, Urgent Cesarean Deliveries.

To standardize the preprocedure process for urgent, unscheduled cesarean deliveries to decrease the time from decision to skin incision to improve maternal and fetal outcomes. In our quality-improvement project, we selected indications that require urgent cesarean deliveries, created a standard algorithm, then implemented a multidisciplinary process intended to reduce decision-to-incision time. This initiative was conducted from May 2019 to May 2021, with a preimplementation period from May 2019 to November 2019 (n=199), implementation period from December 2019 to September 2020 (n=283), and postimplementation period from October 2020 to May 2021 (n=160). An interrupted time series calculation was performed, with stratification by patient race and ethnicity. The primary process measure was mean decision-to-incision time. The secondary outcomes were neonatal status as measured by 5-minute Apgar score and quantitative blood loss during the cesarean delivery. We analyzed 642 urgent cesarean deliveries; 199 were preimplementation of the standard algorithm, and 160 were postimplementation. The mean decision-to-incision time improved from 88 minutes (95% CI 75-101 min) to 50 minutes (95% CI 47-53 min) from the preimplementation period to the postimplementation period. When stratified by race and ethnicity, the mean decision-to-incision time among Black non-Hispanic patients improved from 98 minutes (95% CI 73-123 min) to 50 minutes (95% CI 45-55 min) (t=3.27, P <.01); it improved from 84 minutes (95% CI 66-103 min) to 49 minutes (95% CI 44-55 min) among Hispanic patients (t=3.51, P <.001). There was no significant improvement in decision-to-incision time among patients in other racial and ethnic groups. When the cesarean delivery was performed for fetal indications, Apgar scores were significantly higher in the postimplementation period compared with the preimplementation period (8.5 vs 8.8 beta=0.29, P <.01). Development and implementation of a standard algorithm to expedite decision-to-incision time for unscheduled, urgent cesarean deliveries led to a significant decrease in decision-to-incision time.

Advanced Maternal Age Among Nulliparous at Term and Risk of Unscheduled Cesarean Delivery

With the rise in the number of women giving birth at an advanced age, the association between advanced maternal age and adverse obstetrical outcomes is a growing concern in developed countries. Despite the well-established link between advanced maternal age and pregnancy-related complications, there has been limited research examining the specific risks related to unscheduled cesarean delivery in nulliparas at term. This study aimed to evaluate the risks associated with unscheduled cesarean delivery in nulliparas at ≥37 weeks of gestation, comparing the outcomes of younger patients with those aged ≥40 years. This retrospective cohort study was conducted in a tertiary maternity hospital in Switzerland (high-income country). The study included nulliparas who delivered a live-born infant at ≥37 weeks between January 2015 and December 2019. We excluded pregnant women who had a planned cesarean delivery, were aged <18 years, multiparous, delivered before 37 weeks of gestation, or had pregnancies that ended in stillbirth. Participants were divided into 2 age groups: (1) ≥40 years and (2) <40 years. The primary outcome was the incidence of unscheduled cesarean delivery. Its association with advanced maternal age was evaluated after adjusting for confounding factors by multivariate logistic regression, expressed as an adjusted odds ratio. Secondary outcomes included pregnancy outcomes and neonatal outcomes. A total of 5211 patients were included: 173 in the ≥40-years (advanced maternal age) group and 5038 in the <40-years (non-advanced maternal age) group; 26.01% (95% confidence interval, 19.65-33.22; n=45) of women in the advanced maternal age group had an unscheduled cesarean delivery, whereas 15.26% (95% confidence interval, 14.28-16.29; n=769) of women in the non-advanced maternal age group underwent the procedure. Advanced maternal age was associated with unscheduled cesarean delivery, with an adjusted odds ratio of 1.51 (95% confidence interval, 1.06-2.17; P=.024). Among vaginal deliveries, assisted procedures were performed on 29.7% (95% confidence interval, 21.9-38.4; n=38) of advanced maternal age patients vs 20.1% (95% confidence interval, 18.9-21.3; n=856) of non-advanced maternal age patients. Postpartum blood loss >1000 mL occurred in 5.8% (95% confidence interval, 2.8-10.4; n=10) of advanced maternal age patients and 3.1% (95% confidence interval, 2.6-3.6; n=156) of non-advanced maternal age patients. Advanced maternal age is associated with increased risk of unscheduled cesarean delivery among nulliparas. This provides healthcare professionals with confirmation that advanced age may represent an individual risk factor, suggesting that nulliparous patients aged over 40 years may benefit from improved information regarding the factors contributing to this pregnancy outcome.

Rate of Primary Cesarean Delivery by Language Preference among Nulliparas.

Sociodemographic factors such as race/ethnicity and socioeconomic status affect primary cesarean delivery rates. Language is associated with disparate health care outcomes but has not been well studied in obstetrics. We examined the association between primary unscheduled cesarean delivery rate and preferred patient language. A retrospective cohort study was conducted at an urban medical center between January 2017 and January 2020. Nulliparous women with early or full-term gestation and having no obstetric or medical contraindication to vaginal delivery were included. We used multivariable linear and logistic regressions to evaluate language differences in cesarean delivery odds and indication for cesarean. Of the 1,314 eligible women, 76.8% of patients preferred English, 17.8% Spanish, and 5.4% other languages. Overall cesarean delivery rate was 27.6%. Controlling for age, race/ethnicity, body mass index, insurance, gravidity, pregnancy comorbidities, labor induction, and infant birth weight, Spanish- and other language-speaking women had significantly higher odds of undergoing cesarean compared with English-speaking women (adjusted odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.25, 2.46). Relative proportions of indications for cesarean did not differ by language group. Documented interpreter use was an effect modifier on the relationship between language preference and cesarean (OR with interpreter use: 2.89, 95% CI: 1.90, 4.39). Primary cesarean delivery rates were significantly higher among nulliparous women who prefer languages other than English. This difference may reflect lack of communication, provider bias or discrimination, or other factors, and should be further studied. Interpreter services should be routinely utilized and documented effectively. · Women who prefer languages other than English had higher odds of cesarean.. · Indication for cesarean did not differ by language.. · Interpreter use did not reduce risk for cesarean..

The gestational membrane microbiome in the presence or absence of intraamniotic infection

Data regarding the microbiome of the gestational membranes are emerging and conflicting. Shifts in the microbial communities in the setting of labor, rupture of membranes, and intraamniotic infection are yet to be understood. This study aimed to characterize the microbiome of the gestational membranes of women in labor or with ruptured membranes, including those with and without intraamniotic infection. Women with a singleton pregnancy at ≥28 weeks' gestation undergoing unscheduled cesarean delivery in the setting of labor or rupture of membranes were included. Demographic and clinical variables were collected. We defined suspected intraamniotic infection by standard clinical criteria; placentae and gestational membranes were also reviewed for histologic evidence of infection. Sterile swabs were collected from membranes at the time of delivery. Bacteria were cultured from the swabs, and the isolates were sequenced. DNA extraction and 16S sequencing of the swabs were also performed. Bacterial taxonomy was assigned to each sequence. Alpha diversity indices and beta-diversity metrics were calculated to test for differences in microbial community diversity and composition between uninfected and infected groups. Differential abundance of bacteria between infected and uninfected groups was tested at the class, family, and genus level. Samples were collected from 34 participants. Clinical intraamniotic infection was diagnosed in 38% of participants, although 50% of placentae and membranes demonstrated histologic signs of infection. Of all samples, 68% grew bacteria on culture; this included 62% of the uninfected samples and 77% of the infected samples (P=.83). Multiple measures of alpha diversity were not significantly different between uninfected and infected groups. Similarly, analysis of beta diversity revealed that the microbial community was not significantly different between the uninfected and infected group. Several bacteria traditionally characterized as pathogenic, including Actinomyces and Streptococcus agalactiae, were identified in both infected and uninfected samples. The pathogenesis and clinical implications of intraamniotic infection remain poorly understood. Diverse bacteria are present in both infected and uninfected gestational membranes. A unique microbiologic signature may exist among the gestational membranes following labor or rupture of membranes, and further characterization of the pathogens specifically implicated in intraamniotic infection may allow for targeted therapy.

Risk factors for postpartum readmission in patients with class III obesity undergoing unscheduled cesarean delivery

Risk factors for postpartum readmission in patients with class III obesity undergoing unscheduled cesarean delivery

Vaginal cleansing before unscheduled cesarean delivery to reduce infection: a randomized clinical trial

Cesarean delivery is the most performed major surgery among women, and surgical-site infections following a cesarean delivery are a significant source of postoperative morbidity. It is unclear if vaginal cleansing before a cesarean delivery decreases post-cesarean delivery infectious morbidity. This study aimed to evaluate if preoperative vaginal cleansing with povidone-iodine among women undergoing a cesarean delivery after labor decreases postoperative infectious morbidity. This randomized clinical trial was conducted from August 3, 2015 to January 28, 2021, with 30 days of follow-up and the final follow-up completed on February 27, 2021. Patients met the inclusion criteria if they underwent a cesarean delivery after regular contractions with cervical dilation, rupture of membranes, or any cesarean delivery performed at >4 cm dilation. Participants were randomly assigned in a 1:1 ratio to either abdominal cleansing plus vaginal cleansing with 1% povidone-iodine or abdominal cleansing alone. The primary outcome was composite infectious morbidity including surgical-site infection, fever, endometritis, and wound complications within 30 days after the cesarean delivery. Secondary outcomes included individual components of the composite, length of hospital stay, postoperative hospitalization or outpatient treatment related to infectious morbidity, and empirical treatment for neonatal sepsis. A total of 608 subjects (304 vaginal cleansing group, 304 control group) were included in the intention-to-treat analysis. Patient characteristics were similar between groups. There was no significant difference in the primary composite outcome between the 2 groups (11.8% vs 11.5%; P=.90; relative risk, 1.0; 95% confidence interval, 0.7-1.6). Individual components of the composite and secondary outcomes were also not significantly different between the groups. Similar findings were observed in the as-treated analysis (11.3% vs 11.8%; P=.9; relative risk, 1.0; 95% confidence interval, 0.7-1.6). Vaginal cleansing with povidone-iodine before an unscheduled cesarean delivery occurring after labor did not reduce the postoperative infectious morbidity. These findings do not support the routine use of vaginal cleansing for women undergoing a cesarean delivery after labor.

Factors Driving the Difference in Quality of Recovery Scores Between Scheduled and Unscheduled Cesarean Delivery Patients

(Br J Anaesth. 2022;128:e219–e221. doi: 10.1016/j.bja.2021.11.026) Patients undergoing unscheduled cesarean deliveries (CDs) are shown to have worse Obstetric Quality of Recovery Scores (ObsQoR-11) than those undergoing scheduled CDs. This quality improvement study investigated the causes behind this difference in scores.

Timing of Adjunctive Azithromycin for Unscheduled Cesarean Delivery and Postdelivery Infection.

To estimate the association between timing of administration of adjunctive azithromycin for prophylaxis at unscheduled cesarean delivery and maternal infection and neonatal morbidity. We conducted a secondary analysis of a randomized trial of adjunctive azithromycin prophylaxis in patients with singleton gestations who were undergoing unscheduled cesarean delivery. The primary exposure was the timing of initiation of the study drug (after skin incision or 0-30 minutes, more than 30-60 minutes, or more than 60 minutes before skin incision). The primary outcome was a composite of endometritis, wound infection, and other maternal infections occurring up to 6 weeks after cesarean delivery. Secondary outcomes included composite neonatal morbidity, neonatal intensive care unit admission for longer than 72 hours, and neonatal sepsis. The association of azithromycin with outcomes was compared within each antibiotic timing group and presented as risk ratios (RRs) with 95% CIs. A Breslow-Day homogeneity test was applied to assess differences in association by antibiotic timing. Of 2,013 participants, antibiotics were initiated after skin incision (median 3 minutes, range 0-229 minutes) in 269 (13.4%), 0-30 minutes before skin incision in 1,378 (68.5%), more than 30-60 minutes before skin incision in 270 (13.4%), and more than 60 minutes before skin incision (median 85 minutes, range 61-218 minutes) in 96 (4.8%). The RRs (95% CIs) of the infectious composite outcome for azithromycin compared with placebo were significantly lower for groups that initiated azithromycin after skin incision or within 1hour before skin incision (after skin incision: RR 0.31, 95% CI 0.13-0.76; 0-30 minutes before: RR 0.62, 95% CI 0.44-0.89; more than 30-60 minutes before: 0.31, 95% CI 0.13-0.66). Risks were not significantly different in patients who received azithromycin more than 60 minutes before skin incision (RR 0.59, 95% CI 0.10-3.36). Results were similar when endometritis and wound infections were analyzed separately. Neonatal outcomes were not significantly different for azithromycin compared with placebo across all timing groups. Adjunctive azithromycin administration up to 60 minutes before or at a median of 3 minutes after skin incision was associated with reduced risks of maternal composite postoperative infection in unscheduled cesarean deliveries. ClinicalTrials.gov, NCT01235546.

Postpartum depression, mode of delivery, and indication for unscheduled cesarean delivery: a retrospective cohort study.

To examine the relationship between postpartum depression (PPD), mode of delivery (MOD), and indication for unscheduled cesarean delivery (uCD). Patients with antenatal and postpartum Edinburgh Postnatal Depression Scale (EPDS) scores were compared by MOD and indication for uCD if applicable. Patients with an antenatal EPDS>12 were excluded to ascertain the incidence of new depression. The primary outcome was EPDS≥13 by MOD. The secondary outcome was EPDS≥13 by indication for uCD. Seven hundred and thirty eight patients met inclusion criteria. There were statistically significant differences in MOD by age, race, BMI, and multi-gestation pregnancy. Patients delivered via uCD had a higher rate of peripartum complications and NICU admission. There were no differences in medical comorbidities or use of psychiatric medications by MOD. There was no difference in EPDS by MOD. The rate of PPD was higher in patients with uCD for non-reassuring fetal heart tones (NRFHT) compared to other indications for uCD (p=0.02). While there was no difference in the incidence of PPD by MOD, the incidence of PPD was higher among patients delivered via uCD for NRFHT. These findings may have implications for patient counseling, post-operative mental health surveillance, and support of postpartum patients.

Post-cesarean infections before and after implementation of adjunctive azithromycin: does presence of chorioamnionitis matter?

The CSOAP trial showed azithromycin (AZI) plus standard antibiotic prophylaxis in unscheduled cesarean deliveries (CDs) decreased postoperative infections, but excluded women with chorioamnionitis (chorio). We evaluated whether the association between chorio and post-CD infectious outcomes differed before and after the implementation of AZI and secondarily assessed the effect of AZI on outcomes among women with chorio.

Does Adjunctive Azithromycin for Cesarean Prophylaxis Reduce Racial-Ethnic Disparities in Maternal Infection?

Adjunctive azithromycin (AZI) (plus usual cefazolin) antibiotic prophylaxis for unscheduled cesarean delivery (CD) reduced the risk of post-cesarean infection by ∼50% overall. Since non-Hispanic (NH) Black race-ethnicity is associated with a 2-3 fold increase in risks of maternal infection and death compared to NH Whites, we assessed whether adjunctive AZI reduces the disparity in infection.

Path analysis model of epidural/spinal anesthesia on breastfeeding among healthy nulliparous women: Secondary analysis of the United States Certificate of Live Births 2016.

The effect of epidural/spinal anesthesia during labor on breastfeeding is unclear. Few studies had assessed whether or how medically assisted delivery (operative vaginal delivery or unscheduled cesarean birth) plays a mediating role. We aimed to examine whether the relationship between using epidural/spinal anesthesia and breastfeeding is mediated by increased medically assisted delivery among healthy nulliparous women. A secondary, cross-sectional analysis was conducted using US birth certificate data from 2016 (n=381199). Logistic regression was used to examine associations between factors. Structural equation modeling (SEM) was used to analyze the model fit of the path models and to quantify the direct, indirect, and total effect of anesthesia on breastfeeding at discharge, considering medically assisted delivery as a mediator. Women who were administered epidural/spinal anesthesia were more likely to experience medically assisted delivery (adjusted odds ratio [AOR]: 95% confidence interval [CI] 3.01 (2.91-3.12)) and less likely to be breastfeeding at discharge (0.95 [0.92-0.98]). Operative vaginal and unscheduled cesarean deliveries were significantly associated with nonbreastfeeding at discharge (0.81 [0.77-0.84] and 0.81 [0.79-0.84], respectively). SEM revealed excellent model fit for our model. The indirect effect was significant (β=-0.038; 95% CI, -0.043 to -0.033), as was the total effect (β=-0.038; 95% CI, -0.043 to -0.033). Epidural/spinal anesthesia is associated with nonbreastfeeding at discharge, mediated through medically assisted delivery. Health care providers should consider these risks and provide adequate support to help all parents attain their breastfeeding goals.

Associations between cesarean delivery and child mortality: A national record linkage longitudinal study of 17.8 million births in Brazil.

There is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances. We conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available. In this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality.

A retrospective review of clinical and non-clinical factors associated with unscheduled cesarean deliveries at one urban medical center.

To investigate factors associated with unscheduled cesarean delivery at one urban tertiary medical center. A retrospective chart review was performed on 11162 deliveries between 2009 and 2019. The dependent variable was unscheduled cesarean delivery. Covariates examined included time of delivery, as well as several maternal and pregnancy-related factors. There were a total of 7037 (63.1%) vaginal, 1133 (10.1%) elective cesarean, and 2992 (26.8%) unscheduled cesarean deliveries. Independent factors associated with increased odds for unscheduled cesarean delivery included daytime delivery (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.42, P<0.001); advanced maternal age (OR 1.40, 95% CI 1.26-1.56, P<0.001); obesity (OR 1.04, 95% CI 1.03-1.05, P<0.001); history of previous cesarean delivery (OR 2.77, 95% CI 1.91-4.01, P<0.001); hypertension (OR 1.72, 95% CI 1.27-2.32, P<0.001); multiparity (OR 3.99, 95% CI 2.82-5.64, P<0.001); pre-eclampsia (OR 1.96, 95% CI 1.33-2.89, P=0.001); and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome (OR 5.45, 95% CI 1.13-26.28, P=0.035). Factors associated with unscheduled cesarean delivery in this study cohort included daytime delivery, advanced maternal age, obesity, hypertension, previous cesarean delivery, multiparity, preterm labor, pre-eclampsia, and HELLP syndrome.