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PubMed1993

Rupture of the uterus.

Fifty cases of uterine rupture were managed in 4 years giving a frequency of 1 per 89.9 deliveries. There was an obvious difference between those with a previously scarred uterus (34) vs those without a scar (16) cephalopelvic disproportion, grand multiparity and mismanagement of cases by traditional birth attendant (TBAs) were the common etiologic factors in the unscarred uterus, cephalopelvic disproportion, forceps delivery, grand multiparity and prolonged first stage of labour were the common etiologic factors in patients with previously scarred uterus. In the unscarred group both maternal and foetal (81.6%) mortality was high (JPMA 43: 174, 1993).

Adult↗

PubMed1985

Failed induction of labour.

Over a 15-month period 1,057 consecutive inductions of labour were performed representing a 10% induction rate; 174 (16.5%) of these patients were delivered by Caesarean section of which 74 (7.0%) were for failed induction of labour, 58 (5.5%) for fetal distress, 19 (1.8%) for cephalopelvic disproportion, 6 for malposition and 17 for other reasons. The mean cervical score at induction of labour was 5.7 and 5.5 for cephalopelvic disproportion (CPD) and malposition respectively but was 4.0 for failed induction. The mean cervical dilatation at the time of Caesarean section was 5.7 cm and 6.6 cm for CPD and malposition respectively whereas it was 3.5 cm for failed induction. Mean maximum dose of oxytocin was 19.2 milliunits per minute (mu/min) and 22.5 mu/min for CPD and malposition respectively whereas it was 24.7 mu/min for cases of failed induction. Nulliparas with a cervical score of 3 or less had a 65.4% Caesarean section rate of which more than two-thirds were for failed induction of labour. Analysis of indications for induction of labour revealed that a fair number of inductions had debatable obstetric indications. Tailoring induction of labour to the cervical score and indication might reduce the Caesarean section rate for failed induction of labour. Rational management to ensure an adequate dose of oxytocin and sufficient time in the first stage of labour is important. Failed induction of labour may be differentiated from failure of labour progress due to CPD or malposition.

Adult↗

PubMed2004

Symphysiotomy at the Mater Misericordiae Hospital Afikpo, Ebonyi State of Nigeria (1982-1999): a review of 1013 cases.

One thousand and thirteen (1013) symphysiotomies were performed and 27,477 deliveries were conducted during the period. The symphysiotomy rate in the study period was 3.7%. Fifty-six percent (56%) of the patients who had symphysiotomy were aged 39 years and below, and the mean age was 27.94 +/- 7.16 years. Mothers with maternal age greater than 40 years were at a higher risk for symphysiotomy. Thirty-eight percent (38%) of those who had symphysiotomy were nulliparae, 35% were multiparae, while grandmultiparae accounted for 27%. Cephalopelvic disproportion was the leading indication for symphysiotomy (88%), while arrest of the after-coming head of the breech and previous caesarean section with mild cephalopelvic disproportion were other indications for symphysiotomy. Transient post-operative pelvic and leg pain was the leading maternal complication in the study, while stress incontinence, para urethra/vagina lacerations and vesico-vagina fistula were the other complications highlighted. In the study, 69% of the symphysiotomies performed were for babies with birth weight between 3.0 and 3.9 kg. The record of one maternal death was available and was from massive pulmonary embolism on the third day postpartum. There were 104 perinatal deaths with a perinatal mortality rate of 108.7 per 1000 total births.

Adult↗

PubMed1991

Uterine activity in dysfunctional labour and target uterine activity to be aimed with oxytocin titration.

Uterine activity was quantified using a transducer tipped intrauterine catheter in 75 nulliparous women with dysfunctional labour. The active contraction area profiles in these women were below the median levels reported for those who had normal progress of labour from our institution. When uterine activity was augmented with oxytocin, 90.7% progressed in labour and delivered vaginally. Six patients (8%) showed poor progress despite good uterine activity and had to be delivered by caesarean section (CS) for failure to progress and signs of cephalopelvic disproportion. The pre- and post-augmentation uterine activity were similar in those who delivered vaginally or by CS and was not helpful in identifying those who had cephalopelvic disproportion. Of the 75 women who had slow progress of labour, 50 had a contraction frequency of less than 1 in 3 min whilst 25 had a minimum frequency of 1 in 3 min or more. All except one in the latter group delivered vaginally when oxytocin was titrated to achieve a contraction frequency of 1 in 2 to 2 1/2 min which were clinically judged to be adequate based on a duration greater than 40 sec. Oxytocin should be titrated to achieve a target contraction frequency of 1 in 2 to 2 1/2 min lasting greater than 40 sec to achieve good obstetric outcome in those with dysfunctional labour.

Adult↗

PubMed2005

Uterine ruptures in Yemen.

OBJECTIVE: To study the incidence, risk factors, clinical presentation, maternal morbidity and mortality, and perinatal mortality in cases with ruptured gravid uterus. METHODS: All cases with diagnosis of uterine rupture at Saudi Hospital at Hajjah, Yemen during 5-years period from April 1999 to March 2004 were studied. Detailed informations were obtained by reviewing hospital records. RESULTS: Out of the total number of deliveries during the period (N=5547), 60 cases had uterine rupture giving a hospital incidence of one in 92 deliveries (1.1%). Forty-three cases (71.7%) with unscarred uterus and 17(28.3%) had a previous cesarean scar. Poor antenatal and intra-natal care were the main contributing factor (93.3% had no prenatal visit, 95% presented to the hospital late after long period of obstructed labor at home). Grand-multiparty was encountered in 69.8% of cases with unscarred uterus and 41.2% of cases with a previous scar (p<0.05). Associated factors in unscarred uterus cases included: cephalopelvic disproportion (39.5%), shoulder presentation (25.6%), oxytocin (14%), breech delivery (7%), hydrocephalus (7%), brow (2.3%), misoprostol induction of labor (2.3%), and previous surgical evacuation (2.3%). In previous cesarean scar cases, cephalopelvic disproportion affected 58.8%, and shoulder presentation 5.9%. The complete rupture was reported in 48 cases (80%), hysterectomy was carried out for 33 cases (55%), repair for 23 cases (38%), and repair plus bilateral tubal ligation for 4 cases (7%). Five cases (8.3%) needed additional surgical intervention in the form of repair of ruptured bladder (3 cases), and repair of bladder injury (2 cases). Vesico-vaginal fistula developed in 2 cases (3.3%). Fifty-three cases required blood transfusion (88%). Hospital stay ranged between 1-17 days (mean 6.2, SD 3.6). There was one maternal death (1.7%) and 49 (81.7%) perinatal deaths. CONCLUSION: This study confirms high incidence of such serious preventable obstetrical problem. Poor antenatal and intranatal care, poor provision of health service and low socio-economic standard are the main factors contributing to uterine rupture.

Adolescent↗

PubMed1978

Changing indications for cesarean section. A 38-year experience at a community hospital.

A review of a 38-year experience with cesarean section at a community hospital shows considerable change in both the rate and indication of cesarean sections. A marked increase in the cesarean section rate was noted after 1972. This increase was due primarily to an increase in the primary cesarean section rate for cephalopelvic disproportion and labor abnormalities, fetal distress, and the breech presentation. As a result of this study, we anticipate a primary cesarean section rate of approximately 10%: 3-5% for cephalopelvic disproportion and labor abnormalities, 1-1 1/2% for fetal distress, 3% for breech presentation, and 1-2% for all other indications.

Breech Presentation↗

PubMedDate not supplied

Effect of modern obstetrics on mothers from Third-World countries.

Mothers born and raised in third-world countries compared to women born in the United States are on average of shorter size, have less weight, have narrower pelvic dimensions, and give birth to smaller infants without much difficulty. This may be due to a low-protein diet and inadequate prenatal care. Those mothers who were born and raised outside the United States (therefore with narrow pelvic dimensions), but who eat a high-protein diet and receive adequate prenatal care after migrating as adults to the United States, give birth to relatively large infants. This results in a marked cephalopelvic disproportion and severe dystocia, which frequently leads to cesarean birth. It appears that nutritional factors during pregnancy and infancy play a role as important as genetic factors in the etiology of cephalopelvic disproportion.

Adult↗

PubMed1989

The relation of the true conjugate to maternal height and obstetric performance in Ghanaians.

The true conjugate was determined intraoperatively with a caliper in 114 Ghanaian women and was correlated with their height, obstetric performance and fetal dimensions. Those patients undergoing cesarean section for cephalopelvic disproportion (Group Ia) were found to have a significantly shorter mean true conjugate (9.54 cm +/- 0.63 S.D.) and mean body height (152.68 cm +/- 5.46 S.D.) and a smaller true conjugate - fetal biparietal diameter difference (10.93 mm) than those who had no cephalopelvic disproportion (Group Ib) and whose mean measurements were 10.61 cm +/- 0.81 S.D., 157.20 cm +/- 5.69 S.D. and 21.50 mm, respectively (P = 0.0001). Recommendations for appropriate referral of rural clinic patients and for selection of patients for repeat cesarean sections are based on the above findings.

Birth Weight↗

PubMed1985

Cesarean section deliveries among adolescent mothers enrolled in a comprehensive prenatal care program.

A comparison was made of the incidences of cesarean section deliveries between mothers 18 years of age or younger and those 19 to 21 years of age, all of whom were enrolled in a comprehensive program of prenatal care. Also compared were the indications for surgical delivery between the two groups. The rate of cesarean section deliveries was 8.7% among mothers 18 years of age or younger, compared to 14.5% among mothers 19 to 21 years of age. The general-ward cesarean section rate at the same hospital was 19.4%. Since maternal height and weight, and infant's birth weight may affect the diagnosis of cephalopelvic disproportion, these parameters were also evaluated. However, these did not differ significantly between mothers 18 years of age or younger and those 19 to 21 years of age or between vaginal and surgical births in mothers 18 years of age or younger. Thus, cephalopelvic disproportion did not contribute importantly to the cesarean section rate.

Adolescent↗

PubMed2001

Risk factors of uterine rupture.

OBJECTIVE: To determine the incidence of uterine rupture in Ministry of Health Hospitals in Bahrain and to find the risk factors associated with this obstetrical tragedy. METHODS: A case control study was conducted on all the cases of uterine rupture in Ministry of Health Hospitals in Bahrain during the period 1st of January 1990 until 31st of December 1999. The following risk factors which, were studied, included parity, gestational age, previous cesarean delivery, previous cesarean section for cephalopelvic disproportion, previous evacuation of the uterus, induction and or augmentation of labor, malpresentation, duration of the labor, type of the delivery and birth weight. RESULTS: Forty-five uterine ruptures were reported during the study period with an incidence of 1 in 2213 deliveries. Previous cesarean delivery, prior cesarean section for cephalopelvic disproportion, malpresentation, induction and augmentation of labor were found to be significant risk factors for uterine rupture. While high parity, previous evacuation of the uterus, duration of labor, type of the delivery, birth and weight were not associated with uterine rupture. CONCLUSION: An Obstetrician should be careful in monitoring the progress of labor in women with previous cesarean delivery to avoid the occurrence of a ruptured uterus. Oxytocin or prostaglandin or both should be used judiciously to prevent catastrophic uterine rupture.

Adult↗

PubMed1989

[Vaginal delivery following cesarean section].

An analysis is presented of the outcome of labour in 462 women with a previous caesarean section, who delivered in the department of obstetrics of Leiden University Hospital in the period 1977-1986. Elective repeat section was performed in 26% of these women, while 83% of those accepted for a trial of labour had a vaginal delivery. In 196 women with a history of a previous caesarean section (1984-1986) a retrospective analysis was made of the influence of the indication for the previous caesarean section with respect of the outcome of labour in the following pregnancy. A trial of labour had the highest chance of success in those who had had a previous caesarean section because of a breech presentation. Sixty-five percent of women who had had a prior caesarean section because of cephalopelvic disproportion or failure to progress delivered by the vaginal route after a trial of labour. Foetal weight estimation by ultrasound could not predict the outcome of a trial of labour. It is concluded that a trial of labour after a previous caesarean section, even when the operation was performed because of cephalopelvic disproportion or failure to progress, is safe and rational.

Birth Weight↗

PubMedDate not supplied

Obstetric challenges of massive obesity complicating pregnancy.

This study examined the effects of massive maternal obesity on medical complications, mode of delivery, postpartum complications, and hospital confinement. In this retrospective case control study, women weighing > 300 pounds delivering from January 1, 1986, to November 1, 1991, were matched for age, race, parity, and height with lean parturient women (mean weight 160 +/- 21 pounds). Among massively obese women there was a greater incidence of chronic hypertension (p < 0.05) and diabetes (p < 0.05) than in the control group. Primary cesarean section was more frequent (p < 0.05), as was the postoperative complication of endometritis when obese patients were compared with lean women (p < 0.05). Cephalopelvic disproportion was the only indication for primary cesarean section, which occurred with greater frequency in the obese group. The postpartum hospital confinement was also significantly longer in the obese study group (p < 0.05). The gestation of a massively obese parturient woman is more frequently complicated by chronic hypertension and diabetes. Abdominal delivery for cephalopelvic disproportion is more likely, and this mode of birth is more often followed by endometritis, which results in longer hospital stays.

Adult↗

PubMed2004

[Comparison of indications for cesarean section in 1985-86 and 2000-01. Analysis of changes].

UNLABELLED: The aim of this research was a retrospective analysis of indications for caesarean section during last fifteen years and assessing recent trends. MATERIALS AND METHOD: 1106 pregnancies and deliveries by caesarean section at the Ist Clinic of Obstetrics and Gynaecology, Medical University of Warsaw in 1985-86 (547--I group) and 2000-01 (559--II group) were enrolled in the study. It was performed in order to estimate and evaluate such factors as age of women, mean duration of pregnancy, indications for caesarean section, complications, and general newborn condition. RESULTS: In 1985-86 and 2000-01 fetal distress was the most frequent indication for delivery via caesarean section (14.35% and 18.57% respectively, p=ns). It was followed by cephalopelvic disproportion (13.99%) and malposition (13.99%) in I group and by pregnant women diseases (14.07%) and malposition (12.45%) in II group. Analysing pathology of the placenta, we established that index of placenta praevia decreased from 2.49% to 0.57% (p < 0.01) and index of abruption of placenta from 2.25% to 0.81% (p = 0.05). Ratio of cases of cephalopelvic disproportion decreased statistically from 13.99% in the I group to 8.76% in the II group (p = 0.006). Index of prolonged labor in the I stage increased from 8.3% to 12.34% (p = 0.027). CONCLUSIONS: (1) Caesarean section is the surgical method of delivery for women with high risk pregnancy and complicated labor to protect mother and the foetus from the anticipated complications of delivery through natural passages. (2) The overall rate of caesarean section has risen because of widening of the indications. (3) Fetal distress has been the most frequent indication for caesarean section in last fifteen years. (4) Index of indications for cesarean section other than obstetric--ophthalmic, cardiological, neurological and orthopaedic, increased as a result of better health care of pregnant women. (5) Decision to perform caesarean section should be taken in consideration of present clinical situation and future consequences of abdominal delivery.

Adult↗

PubMedDate not supplied

Intrapartum hydramnios at term and perinatal outcome.

The objective of this study was to compare the intrapartum outcome among laboring patients with hydramnios (amniotic fluid index > or = 24.0 cm) versus those with adequate fluid (amniotic fluid index > 5.0 and < 24.0 cm). Prospectively, during a 2-year period, 341 patients in early labor underwent four-quadrant measurement of amniotic fluid volume. Forty-two patients had intrapartum oligohydramnios (amniotic fluid index < or = 5.0 cm) and were excluded from further analysis. The study compares the outcome between 277 subjects with adequate fluid and 22 with hydramnios. The intrapartum amniotic fluid index, birth weight, incidence of macrosomia (birth weight > or = 4000 gm), shoulder dystocia, cesarean section for fetal distress or cephalopelvic disproportion, Apgar score, and neonatal malformations were noted in each of the 299 subjects. Umbilical arterial blood gas was analyzed in 189 patients. In this study, 22 women with hydramnios had a significantly higher risk of delivering a macrosomic fetus than the 277 patients with a normal index (36.3% vs 13.7%; p = 0.01). There was no significant difference in the incidence of shoulder dystocia, cesarean section for cephalopelvic disproportion, or fetal distress, Apgar scores < 7 at 1 and 5 minutes, fetal acidosis, or neonatal anomalies. We conclude that hydramnios during the intrapartum period in patients at term is significantly associated with delivery of a macrosomic fetus, but not with delivery of a compromised neonate.

Adult↗

PubMed1990

Vaginal birth after cesarean: a meta-analysis of indicators for success.

The cesarean birth rate has continued to climb despite efforts to counteract this trend. A major reason for this rise is the practice of doing an elective repeat cesarean. Our study used a statistical model of meta-analysis to analyze the findings of 29 individual studies that looked at the association between the success of a trial of labor and various preexisting conditions. We hypothesized that various preexisting factors, including cephalopelvic disproportion, previous breech, previous vaginal delivery, more than one previous cesarean, use of oxytocin, and the length of labor and extent of dilatation in the previous cesarean, would affect the prediction of the outcome of a trial of labor. After determining odds ratios for the individual preexisting factors from the individual studies, we calculated overall odds ratios which incorporated the findings from all of the studies. For previous cephalopelvic disproportion, the odds were 0.5 for a successful trial of labor; for prior breech, 2.1; for women with a previous vaginal delivery, 2.1; for women who had had more than one cesarean, 0.7; and for women receiving oxytocin, 0.3. We were unable to analyze other preexisting factors because the data were not available, but short discussions of some of these other factors are offered. Even though the success rates do vary with the different preexisting factors, the clinician may anticipate a greater than 50% chance for success in any individual labor.

Breech Presentation↗

PubMed1982

[Choice of delivery methods for cases of breech presentation, with particular reference to premature birth (author's transl)].

Overall mortality, stillbirths and neonatal deaths up to the 28th day of age included, were tested together with selected morbidity parameters, depending on delivery methods used (vaginal route or caesarean section). The group of probands included 112 single births on terms and 136 genuine single premature births (31st to 35th weeks of pregnancy), all of them delivered from breech presentation. Caesarean section for breech presentation deliveries on full term was found to be indicated primarily for cases of cephalopelvic disproportionality and severe risk factors and secondarily on account of cardiotocographic monitoring. Caesarean section has been the method of choice from 1979 for premature births from breech presentation, delivery dates being between the 31st and 35th weeks of pregnancy.--Breech presentation delivery goes along with higher morbidity or mortality risk and, therefore, has become a priority problem in the context of prematurity and its prevention. Efforts should be made to achieve vaginal birth on full term by abandonment of oxytocics and with general cardiotocographic monitoring, despite higher risk of acidosis, however, only in the absence of cephalopelvic disproportionally and grave risk factors. Higher mortality and acidosis risks, accumulation of pulmonary complications, and the need for neonatal intensive care for newborns vaginally delivered from breech presentation were all found by more detailed analysis to be concentrated in the period just before the 35th week of pregnancy. In cases of premature births from breech presentation which could not be therapeutically prevented, caesarean section should be performed up to the 35th week of pregnancy. Vaginal delivery of newborns from breech presentation is considered acceptable beyond the 35th week of pregnancy, with due consideration to be given to the selection criteria generally valid for births on term.

Breech Presentation↗

PubMed1995

Practice variations between family physicians and obstetricians in the management of low-risk pregnancies.

BACKGROUND: Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians. METHODS: A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865. RESULTS: During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. CONCLUSIONS: Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.

Anesthesia, Epidural↗

PubMed1982

Fetal monitoring in a community hospital: analysis of health maintenance organization, fee-for-service, and clinic populations.

This paper was a review of 2,210 deliveries in a community hospital in which electronic fetal monitoring was used. Patients were evaluated from three different types of group practices-health maintenance organization, fee-for-service, and clinic populations. Electronic fetal monitoring was used in 48%, 41%, and 70% of these groups, respectively. The respective cesarean section rates were 13%, 20%, and 10%. Monitored and nonmonitored, high- and low-risk groups were identified. A higher cesarean section rate for cephalopelvic disproportion was found in the monitored groups. However, this difference was most marked in the fee-for-service group. Perinatal morbidity and mortality results did not differ significantly among the three groups despite differences in electronic fetal monitoring use and cesarean section rates. The use of electronic fetal monitoring did not correlate with the cesarean section rate. Reasonable perinatal morbidity and mortality are compatible with relatively high electronic fetal monitoring rates (70%) and low cesarean section rates (10%). Within certain groups, use of electronic fetal monitoring may increase the cesarean section rate because of an increased diagnosis of cephalopelvic disproportion.

Attitude of Health Personnel↗