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A narrow pelvic outlet increases the risk for emergency cesarean section.

BACKGROUND: The rate of cesarean section (CS) is increasing in Sweden as well as in most of the industrialized world. One of the most common indications for emergency CS is protracted labor. To what extent fetal pelvic disproportion is a cause of protracted labor is unclear. The value of pelvimetry has been questioned. The purpose of this study was to investigate whether women delivered with emergency CS because of protracted labor had a narrower pelvis than women delivered vaginally did. METHODS: Thirty women delivered with CS because of protracted labor comprised the study group. Thirty women vaginally delivered served as controls. The two groups were matched for gestational age, birth weight, and parity. The study group and the control group underwent an X-ray pelvimetry within 1 month of delivery. RESULTS: The study group and the control group did not differ in maternal age or body mass index. The mean birth weight was 3914 g in the study group and 3884 g in the control group. The mean pelvic outlet was 328 mm in the study group and 346 mm in the control group (P=0.0024). The mean pelvic inlet was 245 mm in the study group and 255 mm in the control group (P=0.0038). CONCLUSION: A narrow pelvic outlet is associated with an increased risk of emergency CS because of protracted labor. A postpartum pelvimetry is recommended and should be used when to decide on route of delivery in forthcoming pregnancies.

Adult↗

[The effects of a dose of epidural clonidine combined with intrathecal morphine for postoperative analgesia].

OBJECTIVE: To evaluate the effectiveness of a single bolus of epidural (ED) clonidine (C) associated with intrathecal morphine (M) on postoperative analgesia after cesarean section (CS). DESIGN: Prospective double-blind randomized study. SETTING: Obstetric department. PATIENTS: Fourty patients ASA 1-2 submitted to combined spinal-epidural block (CSE) for CS. INTERVENTIONS: A needle through needle set for CSE was used. The intrathecal block was induced with 2.7-3 ml of isobaric 0.5% bupivacaine (B) and 250 micrograms of M. After ED test with 0.5% B, a single bolus of C 150 micrograms in NS 10 ml (group C, n 20) or NS 10 ml as placebo (group P, n 20) was given through the ED catheter. METHODS: The observation for 36 hours evaluated analgesia (VAS until the first dose of additional analgesic, total amount of analgesic and time of first analgesic request) and side effects (variations of arterial pressure and heart rate, motor block, sedation, nausea, vomiting, itching, respiratory depression). Groups were statistically compared. RESULTS: In group C lower analgesic request (significantly between 12th and 18th hour) and significant delay of first request (22.5 +/- 4.1 h) were registered. VAS showed significant trend to opposite sign variations (downwards in group C, upwards in group P) at 1, 2 and 12 hours. In group C lower sistolic arterial pressure at 1 and 4 hours, denser motor block at 2 and 4 hours and mild sedation were observed. CONCLUSIONS: A single ED bolus of C 150 micrograms after CS significantly enhances and prolongs the analgesic effect of M 250 micrograms without important side effects.

Adrenergic alpha-Agonists↗

A two-dose epidural morphine regimen for cesarean section patients: therapeutic efficacy.

A single dose of epidural morphine (EM) usually produces 24 h of post-cesarean section (CS) analgesia and patients require supplemental analgesics beyond this period. This study assesses if a second dose of EM administered 24 h after the first one offers superior therapeutic efficacy compared to conventional analgesics. Patients (n = 100) were randomized to receive one or two doses of epidural morphine. In all patients, EM 5 mg was administered after delivery. After 24 h patients received epidurally either normal saline (n = 50, Group 1) or morphine 5 mg (n = 50, Group 2). An independent observer used a visual analogue scale to assess nausea, itching, and analgesia 24 h after each injection. Results were expressed as mean +/- 1 s.e. mean and analyzed using nonparametric methods. The second dose of EM produced a significantly lower incidence and severity of nausea and itching than did the first dose (P < 0.01) in Group 2 with no difference in analgesia. The second day postoperative pain score in Group 1 was significantly greater than the first day score in the same group, and significantly greater than the severity score in Group 2. Only 36% of patients receiving two doses of EM required supplemental analgesics beyond 48 h compared to 76% of those receiving one dose (P < 0.01). No serious complications were noted. In summary, the use of a second dose of EM for post-CS analgesia produces better analgesia and reduces the need for oral analgesics. The second dose produced fewer side-effects, probably due to acute tolerance to morphine.

Adult↗

The incidence of acute neonatal respiratory disorders in relation to mode of delivery.

Over a 3-year period all infants (n = 7401) born at the Department of Obstetrics and Gynecology, Central Hospital, Borås Sweden, were studied for signs of respiratory disease. For all infants who developed signs of respiratory disorders the mode of delivery and the type of anesthesia used in cesarean section (CS) were analysed. The incidence of respiratory disorders in the whole material was 3.0% (n = 220) and the mortality rate for these disorders was 0.24%. There was a significantly higher incidence (p less than 0.001) of respiratory disorders in infants weighing greater than or equal to 2500 g born by CS vis-à-vis infants born by the vaginal route. The group born by elective CS under maternal general anesthesia had a higher (p less than 0.05) rate of respiratory disorders than those born by elective CS under maternal epidural anesthesia. It is concluded that the risk of respiratory disorders in infants delivered by CS is related to the mode of delivery per se. Consequently, a reduction in the proportion of such interventions ought to reduce the overall number of infants developing respiratory disease, as indicated in the present study.

Anesthesia, Obstetrical↗

Comparison of the incidence of postpartum low back pain in natural childbirth and cesarean section with spinal anesthesia.

BACKGROUND: Many parturients and their obstetricians believe that spinal anesthesia will cause low back pain (LBP). MATERIALS & METHODS: We studied prospectively a total of 160 parturients; 80 of them had cesarean section (CS) with spinal anesthesia and another 80 who had natural childbirth. Incidence of LBP was investigated and compared in these patients before pregnancy, during pregnancy and postpartum. RESULTS: Our result showed that before pregnancy, about one third (33.1%) of the parturients already had LBP and the incidence of LBP seemed to increase during pregnancy. The incidence of LBP decreased gradually postpartum. There was no difference in the incidence of postpartum LBP between the CS with spinal anesthesia group and the natural childbirth group. CONCLUSIONS: We concluded that postpartum LBP could be related to changes during pregnancy and not related to spinal anesthesia.

Adult↗

Impact of antibiotic prophylaxis on wound infection after cesarean section in a situation of expected higher risk.

BACKGROUND: To measure rates of incisional surgical site infection (ISSI) after cesarean section (CS) and to assess risks for infection. METHODS: Prospective surveillance for ISSI at a 540-bed hospital in Saudi Arabia by using Centers for Disease Control and Prevention definitions for infection and the National Nosocomial Infections Surveillance (NNIS) system risk index. RESULTS: Seven hundred thirty-five CSs were studied from September 1998 to July 1999; 72% were emergency procedures, despite a 95% rate of antenatal care. The overall ISSI rate was 2.8% (95% confidence interval [CI], 1.7%-4.3%). The rate for NNIS risk category 0 was 2.4% (95% CI, 1.3%-4.2%; n = 536) and for category 1 was 4.1% (95% CI, 1.8%-8.6%; n = 170). In the multivariate analysis, the only independent risks for ISSI were duration of surgery (OR = 1.01; 95% CI, 1.00-1.03; P =.02) and no antibiotic prophylaxis (OR = 3.09; 95% CI, 1.10-9.11; P =.04). Antibiotic prophylaxis was inconsistently administered among both emergency and elective CS. Infection control procedures were inadequate in the obstetric suite operating room. CONCLUSIONS: Despite deficient infection control practices in the setting described, ISSI rates after CS were judged "acceptable" compared with NNIS benchmark rates. This was attributed to prescribing antibiotic prophylaxis for patients at low risk as well as high risk of infection.

Adult↗

The Dutch obstetric intervention study--variations in practice patterns.

OBJECTIVE: To compare obstetric intervention rates between Dutch hospitals. METHODS: A total of 28,934 hospital births under secondary care (specialist care for medium-/high-risk pregnancies) in 1990 were analyzed in a stratified, random sample of Dutch hospitals based on the records of the Dutch Netherlands perinatal database. Comparisons were made of the intervention rates between hospitals. RESULTS: The intervention rates of the various hospitals differed widely. The most striking difference was in the cesarean section (CS) rate for non-vertex first twins, with a range of 0-100% and a mean rate of 47.6%. On average a CS for a term breech was performed in 30.8% of cases and sedation or analgesics were administered in 16.2% of cases. The mean rate of episiotomy for a term breech was 71.5%, the lowest rate being 18.8%. CONCLUSION: Our results show relatively low intervention rates with considerable interhospital variation.

Birth Weight↗

Vaginal delivery after cesarean section.

We retrospectively analyzed 194 pregnancies in women with a history of previous cesarean section (CS) who were offered a trial of labor. We offered every woman a trial of labor as long as she did not have a known previous classical scar. One hundred fifty-one women delivered vaginally (79%), 24 women had multiple uterine scars. Multiple gestations and breech presentation were not considered a sole indication to perform CS. Fetal and maternal morbidity are presented. We conclude that women with multiple previous CS scars can safely deliver vaginally as can women with unknown uterine scars, with careful intrapartum surveillance. Although our numbers of women with breech presentation and multiple gestations are small, in the absence of significant morbidity, we continue to allow these women to labor and deliver vaginally.

Cesarean Section↗

Association between maternal age and the likelihood of a cesarean section: a population-based multivariate logistic regression analysis.

BACKGROUND: A majority of studies examining the relationship between advancing maternal age and the likelihood of cesarean section (CS) use data from regional samples or from a limited number of medical institutions. This study uses population-based data from Taiwan to explore the relationship between maternal age and the likelihood of a CS. METHODS: The National Health Insurance Research Database (NHIRD) on registries of medical facilities and board-certified physicians and monthly claim summaries for inpatients were used. In total, 502 524 singleton deliveries were included in the study. Multivariate logistic regressions were performed with the presence of CS as the dependent variable and maternal age (<20, 20-29, 30-34 and >34 years) as the independent variable. The study controlled for maternal indications, institution characteristics, maternal requests and attending physician characteristics. RESULTS: CS rates for the age groups <20, 20-29, 30-34 and >34 years were 17.7, 27.4, 37.4 and 47.5%, respectively. The regression analyses consistently showed that the likelihood of a CS significantly increased with advancing maternal age within each category of complication after adjusting for medical institution characteristics and characteristics of the attending physician. CONCLUSIONS: This study found that, after adjusting for maternal indications, and healthcare institution and physician characteristics, there was a significant relationship between advancing maternal age and an increased likelihood of a CS. This finding, together with the high CS rate of 32.1% in Taiwan, one of the highest reported in the world today, highlights an imperative need to devise interventions to reduce the frequency of CSs.

Adult↗

The association between glucose challenge test, obesity and pregnancy outcome in 6390 non-diabetic women.

OBJECTIVE: To evaluate the association between obesity, glucose challenge test (GCT) and pregnancy outcome. METHODS: A prospective cohort study of 6854 consecutive gravid patients screened for gestational diabetes (GDM) using 50-gram GCT, at 24-28 weeks' gestation was performed. A screening value 130 mg/dl was followed by 100 gr oral GTT. Patients who were diagnosed with GDM were excluded. For purpose of analysis patients were categorized by prepregnancy BMI and by different GCT thresholds. Maternal outcome was defined by rate of preeclampsia, gestational age at delivery, cesarean section (CS) rate and the need for labor induction. Neonatal outcome was defined by fetal size (macrosomia/LGA), arterial cord pH, respiratory complications and neonatal intensive care unit (NICU) admission. RESULTS: Overall, a positive GCT result (GCT > or = 130 mg/dl) was identified in 2541/6854 (37%) women. GDM was further diagnosed in 464/6854 (6.8%) of subjects. In both groups of screening results ( > 130 mg/dl and < 130 mg/dl), the obese women were significantly older, gained more weight during pregnancy and had a lower rate of nulliparity in comparison to the non obese women. The obese women had higher rates of macrosomia, LGA and induction of labor. No difference was found in mean birth weight, the total rate of cesarean section, preterm delivery, 5 minute Apgar score < or = 7, mean arterial cord pH, NICU admission and a need for respiratory support in comparison to non obese women in both groups of screening results. A gradual increase in the rate of macrosomia, LGA and cesarean section was identified in both obese and non-obese women in relation to increasing GCT severity categories. CONCLUSION: Fetal size and cesarean section rate are associated with the degree of carbohydrate intolerance (screening results). Furthermore, obesity remains the main contributor impacting fetal size.

Adult↗

Prevention of mother-to-child transmission of HIV-1 infection: alternative strategies and their cost-effectiveness.

OBJECTIVE: To estimate the cost-effectiveness of alternative interventions to reduce the risk of mother-to-child transmission of HIV. DESIGN: A model capturing the sequential nature of mother-to-child transmission in utero, at delivery and postnatally was used to determine how the effects of bottle-feeding, elective Cesarean section (CS) and zidovudine (ZDV) would combine to prevent mother-to-child HIV transmission. Parameter estimates were derived from the literature, UK health service costs applied, and incremental cost effectiveness ratios (ICER) estimated for alternative risk reduction strategies. Results can be transposed to other cost assumptions or currencies. RESULTS: In a woman who breast-feeds her baby, has a vaginal or emergency CS delivery and takes no ZDV, the estimated transmission risk is 31.6% (range, 23.7-38.1%), at a cost of 400 UK pound per woman; this falls to a risk of 3.7% (range, 1.7-6.9%) when bottle-feeding, ZDV therapy and elective CS are all implemented at a cost of 1968 UK pound per woman. From a public health perspective the ICER of ZDV and elective CS each depend on the acceptance rates of the other. In women counselled against breast-feeding, ZDV with 100% acceptance of elective CS has an ICER of 11 342 UK pound (95% confidence interval (CI), 7084-21 515 UK pound]. However, the ICER of CS ranges from 9248 UK pound (95% CI, 5072-46 913 pound sterling) at zero ZDV acceptance to 27 895 UK pound (95% CI, 10 018-154 462 pound sterling) at 100% ZDV acceptance. CONCLUSIONS: Considering the estimated cost of caring for an infected child, ZDV appears to be cost-effective under any of the circumstances examined. However, elective CS may not be cost-effective in populations where the uptake of ZDV is high, and a more precise estimate of its efficacy is required.

Anti-HIV Agents↗

[Clinical analysis of 36 repeat cesarean sections performed extraperitoneally].

Extraperitoneal repeat cesarean section (CS) performed in 36 women with previous intraperitoneal CS (group A) was compared with another 36 cases of intraperitoneal repeat CS (group B). The average blood loss was 146ml in group A and 230ml in group B (P < 0.01). Operation time in group A lasted 40 minutes including 9 cases of tubal ligation coincidentally and 66 minutes in B with 12 tubal ligation (P < 0.05). There were 2 cases of peritoneal damage and 1 transient hematuria in group A. Postoperative morbidity in group A was 16.7% and 38.9% in group B (P < 0.01). The average time for bowel function recurrence was 26.2 hours in A and 52.6 in B respectively. No evident complication occurred in either group. It indicated that extraperitoneal route might be superior to intraperitoneal one for repeat cesarean section.

Adult↗

Pregnancy outcome following recurrent spontaneous abortions.

OBJECTIVE: The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy. METHODS: A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001). CONCLUSION: A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.

Abortion, Habitual↗

Epidural anesthesia with the Trendelenburg position for cesarean section with or without a cardiac surgical procedure in patients with severe mitral stenosis: a hemodynamic study.

The hemodynamic effects of epidural anesthesia (EA) with the Trendelenburg position were studied in seven patients with severe mitral stenosis undergoing emergency cesarean section (CS) because of hemodynamic deterioration. In six patients, the CS was immediately followed by an open mitral commissurotomy under general anesthesia, whereas in one patient, the CS was performed alone. A significant reduction in heart rate (120 +/- 5 to 83 +/- 7 beats/min; P less than 0.001) was observed after induction of EA. Mean arterial pressure (MAP) decreased (78 +/- 9 to 55 +/- 5 mm Hg; P less than 0.01) simultaneously with reduction of the pulmonary capillary wedge pressure (PCWP) (37 +/- 4 to 15 +/- 4 mm Hg, P less than 0.001) and cardiac index (CI) (2.4 +/- 0.3 to 1.8 +/- 0.32 L/min/m2; P less than 0.001). However, PCWP could be adjusted by selecting the appropriate angle of the Trendelenburg position. When the PCWP was approximately 25 mm Hg, MAP and Cl increased to 72 +/- 7 mm Hg and 3.1 +/- 0.4 L/min/m2, respectively, and a satisfactory hemodynamic state was achieved. Systemic vascular resistance decreased after induction of EA (2,250 +/- 250 to 1,750 +/- 450 dyne.s.cm-5; P less than 0.001), and remained unchanged during the perioperative period. It is concluded that the combination of epidural anesthesia with tilting of the table is a safe method for urgent CS in pregnant women with critical mitral stenosis in whom termination of pregnancy is indicated because of hemodynamic deterioration.

Adult↗

Cesarean section and delayed contact: effect on baby's behaviour.

Fifty two babies were assessed by the Brazelton Neonatal Behaviour Assessment Scale (BNBAS) first at 24-48 hours after birth and next at 28 days of age. Of these 26 belonged to the normal vaginal delivery (NVD) group where the babies were roomed in with their mothers immediately after birth. The other 26 were delivered by Cesarean Section (CS) and had a mean separation of 2.8 +/- 1.0 day from their mothers. Babies in the NVD group performed better for the interactive processes at both the initial and follow-up assessment. They were more active initially and on follow up. Although no differences were obtained at the initial assessment for organisational processes (physiological response to stress and state control) the follow up revealed that the NVD babies smiled more, cried less and were less irritable.

Behavior↗

Cesarean delivery of the breech very-low-birth-weight infant: does it make a difference?

We evaluated the impact of cesarean section (CS) delivery on the outcome of breech very-low-birth-weight (VLBW) (500-1,499 g) infants. This retrospective study used data from a large perinatal data base with 109,428 consecutive deliveries including 1,564 VLBW infants born between 1982 and 1987. The study infants included 982 (62.8%) vertex and 582 (37.2%) breech presentations. The CS rate was higher for the breech group than for the vertex group (72.5% breech, 34.3% vertex, OR 5.1, 95% CI 4.0, 6.4). Breech infants delivered by CS were twice as likely to survive until discharge than those delivered vaginally (breech CS 71.7%, breech vaginal 36.5%, P < .0001). The increased survival with CS for breech presentation (mainly due to fewer deaths on day 1) was not seen with vertex presentation. The CS survival advantage for breech infants was seen in all 250g birth weight subgroups. However, breech VLBW infants delivered by CS had a mean birth weight 233 g more and gestational age 2.1 weeks more than those delivered vaginally. Further, breech infants delivered by CS were more likely to be intubated at birth than vaginally delivered breech infants (OR 4.2, 95% CI 2.0, 5.9). Central nervous system morbidity as measured by the occurrence of seizures and intraventricular hemorrhage was comparable for CS and vaginal infants. Cesarean birth of breech VLBW infants is associated with improved survival. However, breech CS infants were bigger, more mature, and more likely to be intubated at birth than vaginally delivered infants, indicating the presence of a strong selection bias. A prospective randomized trial is needed to evaluate the ideal delivery route for breech VLBW infants.

Birth Weight↗

Effects of labor on serum levels of insulin and insulin-like growth factor-binding proteins at the time of delivery.

BACKGROUND: The purposes of this study were to explore whether serum levels of insulin, insulin-like growth factor-I (IGF-I), insulin-like growth factor-binding protein-1 (IGFBP-1) and IGFBP-3 in both maternal and fetal compartments were affected by the stress of labor, and to investigate the relationship between the fetal birthweight and serum levels of insulin, IGF-I and IGFBPs. METHODS: Blood samples were collected at the time of delivery from 147 parturients with vaginal delivery and 128 cases of Cesarean section (112 cases without labor and 16 cases with arrest of cervical dilatation during the active phase of labor). Serum concentrations of insulin, IGF-I, IGFBP-1 and IGFBP-3 were determined by radioimmunoassays (insulin, IGFBP-1 and IGFBP-3) and immunoradiometric assay (IGF-I). RESULTS: Maternal circulating IGFBP-1 levels in parturients with normal spontaneous delivery (NSD) and in subjects receiving Cesarean section (CS) due to arrest of cervical dilatation during active phase of labor were higher than those undergoing scheduled CS without labor. By contrast, insulin levels in both maternal and umbilical cord serum were higher in parturients with CS without labor than those with NSD. No difference in maternal serum IGFBP-3 levels was observed between NSD and CS at the time of delivery. As for all measurements (insulin, IGF-I, IGFBP-1 and IGFBP-3), serum levels in pregnant women (from both NSD and CS) were strikingly higher than those in the fetus. Serum levels of IGFBP-1 in umbilical cords from both groups of NSD (p < 0.02) and scheduled CS (p < 0.01) were inversely correlated with birthweight (BW). By contrast, serum concentration of insulin and IGF-I in umbilical cords from NSD (p < 0.005 and p < 0.01; respectively) and scheduled CS (p < 0.01 and p < 0.05; respectively) were positively related to BW. CONCLUSIONS: From the present results, we conclude that insulin appears to be a regulator for circulating IGFBP-1 during pregnancy. The fetal growth may not be well reflected by maternal serum IGFBP-1 levels, nor by IGFBP-3. By contrast, cord serum IGFBP-1 from CS group without labor may preeminently reflect fetal weight. In additional, serum concentration of insulin and IGF-I in umbilical cord may also be good indicators to reflect the result of neonatal birthweight.

Adult↗

Effect of acupressure on nausea, vomiting, anxiety and pain among post-cesarean section women in Taiwan.

The purpose of this study was to examine the effectiveness of acupressure for controlling post-cesarean section (CS) symptoms, such as nausea and vomiting, anxiety perception and pain perception. A total of 104 eligible participants were recruited by convenience sampling of operating schedules at two hospitals. Participants assigned to the experimental group received acupressure, and those assigned to the control group received only postoperative nursing instruction. The experimental group received three acupressure treatments before CS and within the first 24 hours after CS. The first treatment was performed the night before CS, the second was performed 2-4 hours after CS, and the third was performed 8-10 hours after CS. The measures included the Rhodes Index of Nausea and Vomiting, Visual Analog Scale for Anxiety, State-Trait Anxiety Inventory, Visual Analog Scale for Pain, and physiologic indices. Statistical methods included percentages, mean value with standard deviation, t test and repeated measure ANOVA. The use of acupressure reduced the incidence of nausea, vomiting or retching from 69.3% to 53.9%, compared with control group (95% confidence interval = 1.65-0.11; p = 0.040) 2-4 hours after CS and from 36.2% to 15.4% compared with control group (95% confidence interval = 0.59-0.02; p = 0.024) 8-10 hours after CS. Results indicated that the experimental group had significantly lower anxiety and pain perception of cesarean experiences than the control group. Significant differences were found in all physiologic indices between the two groups. In conclusion, the utilization of acupressure treatment to promote the comfort of women during cesarean delivery is strongly recommended.

Acupressure↗