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PubMed2005

Prelabor rupture of membranes at term in low-risk women: induce or wait?

OBJECTIVE: To compare the outcomes of expectant versus induction of labor management of patients presenting with prelabor rupture of membranes (PROM) at term. STUDY DESIGN: Observational case-control study over a period of 36 months. SETTING: King Abdulaziz University Hospital, Jeddah, Saudi Arabia. SUBJECTS: All obstetric patients with no obstetric risk factors, other than PROMs at term, were included in our study. Each patient was matched with a control case, whose labor started with intact membranes. OUTCOME MEASURES: Length of labor duration, fetal distress, intrapartum pyrexia, rate of cesarean delivery, and Apgar scores at birth. RESULTS: The length of labor duration was shorter in patients with PROMs at term compared to the control group, but the difference was not statistically significant. Furthermore, cesarean section (CS) rate was 4.5% in the PROMs group versus 5.5% in the control group. Among patients with PROM who received induction of labor management, the rates of intrapartum pyrexia and CS were almost twice than in patients who were managed expectantly. However, the differences were not statistically significant. CONCLUSION: In the absence of other obstetric and maternal or fetal risk factors, PROMs at term does not seem to constitute additional obstetric risks. Furthermore, expectant management of PROM at term enhances the patient's chance of normal vaginal delivery without an increase in fetal and/or maternal morbidity.

Adult↗

PubMed1999

The Misgav Ladach method for cesarean section compared to the Pfannenstiel method.

OBJECTIVE: The aim of the study was to evaluate the outcome of two different methods of cesarean section (CS). DESIGN: The study was designed as a prospective, randomized, controlled trial. SETTING: All CS were performed at the University Hospital in Uppsala, Sweden. POPULATION: Fifty women admitted to hospital for a first elective CS were consecutively included in the study. They were randomly allocated to two groups. METHODS: One group was operated on by the Misgav Ladach method for CS and the other group by the Pfannenstiel method. All operations were performed by the same surgeon. MAIN OUTCOME MEASURES: Duration of operation, amount of bleeding, analgesics required, scar appearance and length of hospitalization. RESULTS: Operating time was significantly different between the two methods, with an average of 12.5 minutes with the Misgav Ladach method and 26 minutes with the Pfannenstiel method (p<0.001). The amount of blood loss differed significantly, with 448 ml and 608 ml respectively (p=0.017). Significantly less analgesic injections and tablets (p=0.004) were needed after the Misgav Ladach method. CONCLUSION: The Misgav Ladach method of CS has advantages over the Pfannenstiel method by being significantly quicker to perform, with a reduced amount of bleeding and diminished postoperative pain. The women were satisfied with the appearance of their scars. In this study no negative effects of the new operation technique were discovered.

Adult↗

PubMed2003

The outcome of pregnancy in elderly primigravidas.

OBJECTIVE: To investigate the effect of advancing age of 35 years and more (elderly primigravida) on the outcome of pregnancy in nulliparous women and to compare the type of complications observed in this group of women to those in the age of 20-34 years. METHODS: This was a retrospective analysis of 2517 primigravidas delivered at King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia between 1996-2000. All were consecutive patients. The data were collected from the records of the labor room and the medical records were screened for maternal age, antenatal complications, gestational age, birth-weight of the neonate, sex of the neonate and the Apgar score. RESULTS: Three-hundred and sixty-two nulliparous were below the age of 19 years; hence, excluded from the study group. Between age of 20-34 years (Group A) there were 1950 patients with the mean age of 24.79 years (range 20-34) and in women over the age of 35 years (Group B) there were 205 patients with the mean age of 38.72 years (range 35-48 years). Group B had significantly less number of normal deliveries 59.9 compared to group A 81% with p value of <0.001. Diabetes mellitus was common in group B as compared to group A and was statistically significant at p value <0.001. The gestational age in group B was 36.06 weeks and in group A it was 38.84 weeks (p value was markedly significant at <0.001). Women in group B had more deliveries by cesarean section (CS) 23.8% as in group A 12.6%, a significant p value <0.001. The Apgar score at 1 and 5 minutes was significant at p value <0.001 and <0.004. The birth-weight in group B was less compared to group A, p value of <0.002. CONCLUSION: Childbearing in elderly primigravidas does have higher rates of complications due to diseases such as diabetes mellitus and preeclamptic toxemia. They are liable to have more deliveries by CS than by other methods, in spite of lower gestational age and birth weight. The overall outcome however does not appear grim, as was once believed. This study suggests that women in the age group of >35 years should be informed of their pregnancy expectations and outcomes.

Adult↗

PubMedDate not supplied

[Cesarean section before the end of 32 weeks' gestation. Apropos of 91 neonatal case reports].

78 cesarean sections (CS) were performed before 32 weeks of gestation over a period of six years in a obstetric clinic; 91 premature infants were born; the rate of CS at this period of time represented 0,47% of total birth. 84 premature infants were transferred to the neonatal unit located in the same clinic; 3 were dead in utero and 4 just after delivery. 69 infants survived (78%) but 6 had severe sequelae (spastic diplegia, epilepsy and RLF) at one year of age and 7 had minor sequelae.

Birth Weight↗

PubMed1987

Cesarean section; changing patterns in Saudi Arabia.

Analysis of 8000 cesarean births in the Maternity and Children's Hospital, Riyadh, Saudi Arabia documents an increase in the cesarean section (CS) rate from 3.9% in 1979 to 9.9% in 1984. This increase is mainly attributed to indications such as repeat section (37.2%) and fetal distress (28.5%). Increase in the diagnosis of fetal distress was related to the introduction of electronic fetal monitoring and this diagnosis was not substantiated by Apgar score of the neonate. Because of the social preference for large families in Saudi Arabia, over-use of cesarean section should be avoided. For this reason, critical analysis of fetal distress and adequate trial of labor for patients with previous cesarean section is mandatory.

Apgar Score↗

PubMed2005

Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound.

INTRODUCTION AND OBJECTIVE: Cesarean section (CS) is the most common operation in obstetrics, with rising incidence in most countries. As a result of this operation late scar dehiscence may occur, which may lead to uterine rupture in a subsequent pregnancy. In this case series we have described sonographic detection of scar dehiscence after CS and feasibility of vaginal or combined laparoscopic and vaginal scar excision and uterine repair. METHODS: Five consecutive patients underwent vaginal or laparoscopic assisted vaginal approach for repair of suspected scar dehiscence following CS, during a 5 year period. In all cases, transvaginal sonography detected suspicious features of scar dehiscence over the anterior uterine wall. Except of one, all patients had reported recurrent pelvic pain and/or irregular menstrual bleedings. Furthermore all patients planned for a further pregnancy. RESULTS: Resection of the uterine defect and re-constitution of the uterine wall was successfully achieved in all five patients. There were no intra-operative complications and none of the patients required blood transfusion. The mean operation time was 117 min (27-192). Presence of scar tissue was confirmed on histology in all specimens. Four patients remained free of symptoms with no evidence of recurrent scar dehiscence on sonography over a median follow up of 30 months (3-46). One patient had an uneventful pregnancy 24 months after scar removal and was delivered by repeat CS at 39 weeks' gestation. CONCLUSION: Patients with a history of CS should undergo transvaginal sonography of the scar region in order to detect latent scar dehiscence in combination with uterine wall thinning prior to planning further pregnancy. In suspected cases, a combined laparoscopic - vaginal or vaginal approach can be employed to repair the defect.

Adult↗

PubMed1990

A comparative randomized study of oral prostaglandin E2 (PGE2) tablets and intravenous oxytocin in induction of labor in patients with premature rupture of membranes before 37 weeks of pregnancy.

In a randomized prospective study, we compared the use of intravenous oxytocin with oral PGE2 tablets for stimulation of labor in cases of premature rupture of membranes (PROM) before term, where the onset of spontaneous labor did not occur within the first 3 h. This study represents the first of its kind in which oral PGE2 and oxytocin have been directly compared as oxytocic agents for PROM before 37 weeks. Labor induction was successful in 96% of patients in the PGE2 group compared with 84% in the oxytocin group. The incidence of cesarean section (CS) was 5% and 16% in the PGE2 and the oxytocin groups, respectively. While 10% of the CS were performed due to fetal bradycardia in the oxytocin group, none was performed in the PGE2 group despite the fact that the latter group had relatively lower Bishop scores. The data presented indicate that oral PGE2 is safe and effective in initiating active labor in healthy women at pre-term with PROM. Thus we recommend its use to induce labor 3 h after rupture of membranes before 37 weeks gestation.

Administration, Oral↗

PubMed1997

[Zinc blood levels in 73 puerperal women. Correlation with obstetric and neonatal complications].

BACKGROUND: Low plasma zinc concentrations in pregnant women have been associated with certain obstetric and foetal complications. However, there is no agreement in previous studies and mediterranean populations have not been extensively studied. METHODS: The plasmatic zinc was tested in 73 mothers, within 24 hours post-partum, in order to evaluate an association between plasmatic zinc and various obstetric and fetal complications. The women were all from the Florence province and were admitted for delivery at the II Maternity Ward of the University of Florence (Third level Center); mothers of twins and foreign mothers were excluded. Subjects were consecutively included in the study. The values pointed out in a control group (n = 28) were compared with the hematic zinc of a) women who delivered by cesarean section (CS) for acute fetal distress or by operative delivery with vacuum extractor (n = 9), b,c) mothers whose children weighted over the 90th (LGA: n = 11) or under the 10th percentile (SGA: n = 13), and d) mothers who delivered prematurely (n = 12). The subjects included in two or more groups, were not considered. RESULTS: The plasmatic zinc of the control group has been significantly higher than that of mothers who delivered by vacuum extractor or by urgent CS (p < 0.0001) and than that of mothers whose newborns were LGA (p < 0.0024). The hematic zinc of the control group is not higher than that of mothers with SGA or premature children. CONCLUSIONS: The conclusions is drawn that even a relative zinc deficiency may negatively potentiate certain obstetric abnormalities in fetal development or in delivering.

Adult↗

PubMed1989

Microbial flora of the lower genital tract of women in labour at Harare Maternity Hospital. The Puerperal Sepsis Study Group.

The vaginal flora of 214 women who had been referred, in labour, to Harare Maternity Hospital was investigated by examination of vaginal washings and of cervical and urethral swabs taken before and/or after delivery. Four groups of patients were studied: women who had a normal vaginal delivery (NVD), women who were referred because of meconium stained liquor (MSL), women with a history of prolonged rupture of membranes (PROM), and women who were delivered by cesarean section (CS). The first three groups had received no antibiotics during the 7 days preceding specimen collection, while specimens were collected from CS patients only after at least 48 hr of i.v. penicillin and chloramphenicol. T. vaginalis was identified in 19 percent of women, but was not associated with any specific patient group. Chlamydial antigen was detected in 13 percent of patients, but in only one patient (2 percent) in the MSL group. N. gonorrhoeae were isolated from 7 percent of women overall and 25 percent of the strains were penicillinase-producing. Gonococci were recovered significantly more frequently from the PROM patients than from NVD patients as were Group B streptococci and pigment-producing Bacteroides species. Lactobacilli were isolated from only 20 percent of women, despite the use of specific transport and isolation media for these organisms. Specimens from CS patients were taken after these had received parenteral penicillin and chloramphenicol and it was therefore not surprising to find major differences in their vaginal flora with a virtual absence of Gram-positive bacteria, and a high-rate of carriage of multi-resistant coliforms.(ABSTRACT TRUNCATED AT 250 WORDS)

Carrier State↗

PubMed2004

Labor promotes neonatal neutrophil survival and lipopolysaccharide responsiveness.

Labor is a mild proinflammatory state that is associated with fetal leukocytosis. Elective cesarean section has been linked with increased neonatal morbidity, which may be partially immune mediated. We hypothesized that labor may alter neutrophil phenotype and thereby decrease neonatal complications. We characterized neutrophil function and survival in normal neonates after either uncomplicated vaginal delivery (VD) or elective cesarean section (CS) without labor. Spontaneous neutrophil apoptosis is delayed in cord blood neutrophils of neonates after normal labor (VD) compared with CS, as assessed by propidium iodide DNA incorporation using flow cytometry. This demonstrates their ability to maintain an inflammatory response. CD11b expression on neonatal neutrophils after CS is decreased, providing further evidence of altered activation or priming. Lipopolysaccharide responsiveness, characterized by CD11b and apoptosis, is similar in VD and adults, but CS-derived neutrophils are unresponsive. Baseline TLR-4 levels are elevated in CS in contrast to the other groups, although expression is not up-regulated by lipopolysaccharide co-incubation. Neonatal neutrophil survival and function are altered by labor and may increase antibacterial function and neutrophilia. This suggests that labor of any duration may be immunologically beneficial to the normal term neonate.

Apoptosis↗

PubMed1990

Influence of elective cesarean section and breech delivery on neonatal neurological condition.

Fifty-three infants born after elective cesarean section (CS), and 28 infants born vaginally in breech presentation were compared with 45 full-term controls. A quantitative neurological assessment consisting of 31 items was performed on days 1, 2 and 5 after birth. A tonus score, an excitability score and the number of optimal responses were calculated. A follow-up examination was done at 6 months of age, with a standardized neurological and developmental examination. The results showed that infants born after elective CS in both vertex and breech presentation had significantly reduced number of optimal responses during the first five days after delivery, compared to controls. They were more hypotonic and less excitable than the control infants during the first 2 days. There were no significant differences in neurological results between infants born after CS with general or epidural anaesthesia. The infants born in vaginal breech presentation showed no differences neurologically as compared to the controls on the first day. On days 2 and 5, however, they were less excitable and showed a reduced number of optimal responses. There were few differences in neurological condition between the infants born after elective CS and the infants born vaginally in breech presentation. Growth, psychomotor development and neurological status at 6 months did not differ significantly between the three groups. Our findings indicate that infants born after elective CS and vaginal breech presentation have a delayed neurological adaptation during their first days of life. These differences did not affect the physical well-being of the infants, which showed normal growth, neurology and development at the follow-up at 6 months of age.

Apgar Score↗

PubMed2004

Mode of delivery in pregnancies with premature rupture of membranes at or before term following induction of labor with vaginal prostaglandin E2.

Our aim was to evaluate the mode of delivery in pregnancies complicated with premature rupture of the membranes (PROM) at or before term following induction of labor with vaginal application of prostaglandin E2 (PGE2), and to identify possible predictors leading to cesarean section (CS). The study sample consisted of 220 women with term-PROM who did not enter spontaneous labor after 24 hours of expectant management and 42 with preterm (P)-PROM, who underwent labor induction with vaginal PGE2. Findings were compared with 115 women admitted for elective induction of labor, and 510 women with normal spontaneous-onset labor. There were no between-group differences in gravidity, parity, nulliparity rate, or number of PGE2 tablets used. Women with P-PROM were admitted at 34.6 +/- 2.4 weeks gestation, and delivered at 36.1 +/- 1.6 weeks (mean interval, 5.0 +/- 7.9 days; range, 0.5 to 40 days). The rate of CS was different only between the term-PROM (18.6%) and spontaneous onset of labor (9%) groups (odds ratio, 2.08; 95% confidence interval, 1.4 to 3.4). The rate of low 5-minute Apgar score (< 7) was similar in all groups, but the incidence of nonreassuring fetal heart rate pattern leading to CS was significantly lower in the PROM groups. A logistic regression model and forward likelihood analysis in the PROM groups yielded parity, higher number of PGE2 tablets used, and higher birth weight as independent and significant variables associated with increased risk of CS. Using our management protocol, 36.4% and 20.4% of women with term-PROM and P-PROM, respectively, required labor induction with PGE2, which was successful in more than 80% of cases, with no apparent serious maternal or fetal complications.

Administration, Intravaginal↗

PubMed1993

Serum levels of creatine kinase and its isoenzymes during the 1st postpartum day in healthy newborns delivered vaginally or by cesarean section.

The purpose of this study is to investigate the relationship of creatine kinase (CK) and its isoenzyme levels in the newborn to the mode of delivery, time interval from birth (divided in four 6-hour time periods), parity and sex of the neonates. During the 1st postpartum day, serum levels of CK and its isoenzymes (CK-MM, CK-MB, CK-BB) were determined from 115 healthy full-term neonates born consecutively either by spontaneous vaginal delivery (VD, n = 85) or by elective cesarean section (CS, n = 30). The multiple regression analysis was applied. Total CK levels were positively correlated with VD (p < 0.0003). This was mainly attributed to a rise in the CK-MM activity which presented a similar pattern to CK. CK-MB activity was also positively correlated with VD. In contrast, CK-BB was negatively correlated to the postpartum time period. Neonatal sex and parity did not influence CK and its isoenzyme levels significantly. In conclusion, VD contributes significantly to an increase in CK levels during the 1st day of extrauterine life.

Cesarean Section↗

PubMed1983

Prostaglandin output in relation to parturition by cells dispersed from human intrauterine tissues.

Collagenase-dispersed cells from human amnion, chorion, decidua, and placenta have been maintained in short term cultures to study prostaglandin (PG) biosynthesis in relation to parturition. Cells retained metabolic function during the 6-h incubation period, as determined by the apparently linear utilization of radioactive glucose and the formation of tritiated water. All cells synthesized PGs (E, F, and 6-keto F1 alpha) from endogenous precursors. The output of all three PGs significantly increased in amnion and chorion, but not in decidua or placenta, obtained from women who had entered labor spontaneously at term and delivered vaginally (SL) when compared to women at term, but not in labor, delivered by elective cesarean section (CS). For example, PGE output (picograms per 10(5) cells/6 h) increased from 207 +/- 77 (n = 5) to 908 +/- 334 with labor (mean +/- SEM). The addition of indomethacin (10(-7)-10(-5) M) to SL amnion cells significantly decreased (P less than 0.001, by analysis of variance) PGE and PGF, but not 6-keto PGF1 alpha output. Comparison of PGF output with its metabolite, 13,14-dihydro-15-keto PGF2 alpha (PGFM); indicated that PGF values were similar to or higher than PGFM for all tissues other than CS chorion, where PGFM output was significantly greater (142 +/- 63 vs. 486 +/- 95; n = 5; P less than 0.05). PGFM levels in amnion increased with labor [104 +/- 51 (n = 5) to 341 +/- 96 (n = 5); P less than 0.05], suggesting that PG output increased with labor in the fetal membranes as a result of increased synthesis and not decreased metabolism.

6-Ketoprostaglandin F1 alpha↗

PubMed2002

Mode of delivery following successful external cephalic version.

Mode of delivery of pregnancies following successful external cephalic version (ECV) was evaluated in a retrospective case-controlled study. Successful ECV was performed in 105 of 223 (47%) attempts. Data were obtained in 96 of 105 (91.4%) pregnancies that were matched 1:2 fashion to the next consecutive singleton deliveries for maternal age, gravidity, parity, and ethnic origin. The groups were compared for mode of delivery, indications for cesarean section (CS) and instrumental delivery, gestational age at delivery, birth weight and Apgar score. There was no significant difference between the groups in maternal age or the rates of low 5-minute Apgar score (</= 7) and instrumental delivery. The rate of intrapartum CS in the study group was 19.8% (19 of 96), which was 3.2 times higher than that of the control group (12 of 192, 6.25%, p <0.001). Gestational age at delivery was significantly higher in the study group (40.0 +/- 1.2 vs. 39.3 +/- 1.5 weeks, p <0.001) as was the birth weight (3,411 +/- 426 vs. 3,291 +/- 490 g, p = 0.041). There was no significant difference in the rate of non-reassuring fetal heart rate patterns, but the rates of labor dystocia and malpresentation were higher in the study group. Patients in the study group who underwent CS and instrumental delivery ( n = 24) were characterized by a significantly higher nulliparity rate and birth weight and a near-significantly longer interval from ECV to delivery. In conclusion, pregnancies after a successful ECV are at higher risk of CS, which is not associated with fetal distress, but might be attributable to higher rates of labor dystocia and malpresentation, higher nulliparity rate birth weight, and gestational age at delivery. ECV to delivery interval may also be an important factor.

Adult↗

PubMed2001

A survey of trainee obstetricians preferences for childbirth.

OBJECTIVE: To determine trainee obstetricians personal preferences regarding mode and place of delivery given various scenarios. STUDY DESIGN: An anonymous nationwide postal survey of 365 specialist registrars. RESULTS: The response rate was 76%. About 2.5% preferred a home birth. And 16% of men and 15% of women opted for elective cesarean section (CS). When faced with a proposed trial of instrumental delivery in theatre, 60% accepted and a further 12% accepted only if they could choose the obstetrician performing the delivery. Regarding a breech presentation at term, 78% would accept external cephalic version (ECV). CONCLUSIONS: The percentage of obstetricians who preferred vaginal delivery and ECV were considerably higher than previously reported, and there were no significant gender differences. This study shows a more balanced attitude from obstetricians and refutes the previously held view that they necessarily advocate high levels of intervention for themselves.

Attitude of Health Personnel↗

PubMed2005

Maternal hemodynamics during cesarean delivery assessed by whole-body impedance cardiography.

BACKGROUND: This descriptive study was designed to evaluate maternal hemodynamics and cardiovascular responses to delivery during cesarean section (CS) under spinal anesthesia. We also assessed the feasibility of a noninvasive and continuous method of measuring cardiac output, namely whole-body impedance cardiography (ICG(WB)), during elective CS. Because of the techniques used in previous studies, only fractionated data on maternal hemodynamics during CS are available to date. METHODS: We studied 10 healthy women with normal pregnancies and two pregnant women with heart disease undergoing elective CS. Mean arterial pressure (MAP), heart rate (HR), stroke index (SI), cardiac index (CI) and systemic vascular resistance index (SVRI) were recorded continuously during CS, during the period of dissipation of anesthesia and on the second to fifth postpartum day. Analysis of variance for repeated measurements (anova) and the paired sample t-test were used in statistical analysis. RESULTS: The hemodynamic parameters could be registered continuously during the whole procedure. At the point of delivery, a 47% increase in CI and a 39% decrease in SVRI were recorded, while MAP remained stable. These changes occurred within 2 min of delivery of the newborn and persisted on average for 10 min. CONCLUSION: Sudden and significant hemodynamic changes take place at the moment of delivery. Intact physiological cardiovascular compensation mechanisms are needed to adapt to these challenges. Whole-body impedance cardiography may offer a useful noninvasive tool to monitor hemodynamics during cesarean section.

Adult↗

PubMed1984

An epidemiologic study of postcesarean infection.

Cesarean section (CS) is associated with increased postpartum infectious morbidity, predominantly endometritis. In this prospective cohort study, endometritis was found in 28% of 229 patients who underwent consecutive CS from September 1979 to May 1980 at a university hospital. When the occurrence of bacteremia and wound infection was considered, the study found 31% of the patients were infected. Among the 20 potential epidemiologic and operative risk factors for infection that were studied, the most important were primary CS, membrane rupture, labor, and meconium staining (p = 0.0001). Failure to progress, breech presentation, and fetal distress were also significantly associated with infection (p = 0.001). Another factor correlated to the rate of infection was attendance by physician in training (p = 0.002). Discriminant function analysis was used to develop an equation that correctly classified, as infected or noninfected, 76% of a sample of CS patients (p = 0.004). This sample was not part of the original sample from which the discriminant function equation was developed. Finally toward the end of the study period, we observed a decrease in the infection rate among patients of house staff physicians. This decrease has resulted in similar infection rates for patients of attending physicians and patients of house staff physicians, which have continued to the present.

Bacterial Infections↗