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.     

Maternal complications associated with cesarean section

OBJECTIVE: To assess the prevalence of cesarean section (CS) related maternal complications and to evaluate post-CS complications in relationship with relative risk factors. METHOD: 3010 patients who had a CS in the University Hospital of Bari during the period 1988-98 were retrospectively included into the study and 1007 women delivered vaginally at the same institution and in the same period of time, were randomly selected as the control group. For each single patient delivered by CS, the following risk factors were taken into account: age, parity, pre-pregnancy body mass index (BMI), and any disease antedating pregnancy or diagnosed during pregnancy. Additionally, therapeutic procedures such as blood transfusion, number of days in hospital, and admission into intensive care were followed. The prevalence of puerperal complications was assessed for vaginal deliveries and CS by Student's t-test and a correlation of CS complications with risk factors was performed by multivariate analysis. RESULTS: In the cohort of abdominal delivery, puerperal complications were significantly more frequent compared with those following vaginal delivery (p < 0.05). In the group of CS, obese women have higher prevalence of maternal complications, particularly hypertension and intestinal complications (p < 0.05). CONCLUSION: Compared with vaginal delivery, CS delivery carries a higher number of postpartum complications, and the higher rate is mainly related to obesity.     

Maternal mortality and morbidity in cesarean section

The maternal mortality rate after cesarean section is currently very low, but cesarean section is more hazardous than vaginal delivery by a factor of 2-11. Maternal mortality rates of 0 in large series of cesareans have been achieved in some settings, and this suggests that careful attention to good surgical technique and postoperative care could lower mortality after cesarean even further. Infection is the most common cause of morbidity after cesarean, transfusion being second. A large number of factors modify the risk of infection, the most important being prophylactic antibiotics. There is weak evidence that women are slightly more depressed after cesarean than after vaginal delivery. On average, cesarean sections cost more than vaginal deliveries.     

Maternal febrile morbidity after cesarean section

The frequency of puerperal febrile complications is considerably higher following cesarean section than after vaginal delivery. In a retrospective investigation of 234 planned operations and 506 emergency operations, a significantly different frequency of febrile morbidity (FM) was found following the two types of operation (7.7% vs. 20.9%). The development of FM following emergency operation was investigated in relation to factors such as age, parity, repeat cesarean section, surgeon's experience, peroperative bleeding, rupture of membranes, frequency of vaginal exploration, gestational weeks, pre- and postoperative anemia. We found some predisposing factors to FM and of these five, each was significant, but a multiple regression analysis showed that only rupture of the membranes, and pre- and postoperative anemia have an independent significant explanatory value (p less than 0.01).     

Effect of epidural analgesia on the primary cesarean section and forceps delivery rates

OBJECTIVE: To determine the impact of introducing epidural analgesia for labor pain relief on the primary cesarean and forceps delivery rates. STUDY DESIGN: The control group consisted of 1,720 women who delivered on a charity hospital service between September 1, 1992, and August 31, 1993; epidural analgesia was not available for this cohort of patients. The study group consisted of 1,442 patients who delivered on the same service between September 1, 1993, and August 31, 1994; elective epidural analgesia for labor pain relief was available for this cohort of patients. A computerized obstetric database was analyzed to compare the two groups regarding demographics, parity, pregnancy complications, labor characteristics, type of delivery, low birth weight incidence and five-minute Apgar scores. RESULTS: The two groups were similar with respect to demographics and pregnancy complications. No control group patient received epidural analgesia for labor pain relief; 734 of 1,285 (57%) laboring patients in the study group elected epidural analgesia for pain relief. The primary cesarean delivery rate for the control group was 9.6% and for the study group 11.0% (not statistically significant). The control group had 34 (2.0%) forceps deliveries and the study group, 88 (6.1%), for a statistically significant difference. There were significantly more vaginal births after cesarean in the study group (42 vs. 26). CONCLUSION: Epidural analgesia was not associated with an increase in the primary cesarean delivery rate but was associated with an increase in the operative vaginal delivery rate.     

Repeat cesarean section and primary elective cesarean section: recently trained obstetrician-gynecologist practice patterns and opinions

OBJECTIVE: This study was undertaken to determine opinions of obstetrician-gynecologists regarding vaginal birth after cesarean (VBAC) section and elective cesarean section. STUDY DESIGN: A questionnaire was administered to obstetrician-gynecologists attending 2 review courses. RESULTS: Of 500 obstetrician-gynecologists, 304 completed the survey for a response rate of 61%. Most (92%) counseled VBAC candidates differently, and 84% quoted differential VBAC completion rates on the basis of the indication for prior cesarean section. Uterine rupture was virtually always discussed (99%). Pelvic floor risks were infrequently discussed with urinary incontinence, pelvic organ prolapse, and fecal incontinence discussed by less than one third of obstetricians (30%, 28%, and 25%, respectively). Fifty-nine percent of physicians would perform a primary elective cesarean section, and 67% would perform a primary elective cesarean section specifically to prevent pelvic floor disorders. CONCLUSION: Two thirds of recent graduates are willing to perform an elective cesarean section to prevent pelvic floor injury. Most offer VBAC; however, less than a third include risk of pelvic floor injury in their informed consent discussions.     

Maternal and neonatal morbidity and mortality in cesarean section

Maternal mortality rates after cesarean delivery are low, but cesarean section is more hazardous than vaginal delivery by a factor of two to four. Operative complications can be minimized by careful technique and are more often seen in emergency than elective cases. Prophylactic antibiotics are of some benefit in reducing postoperative endometritis in patients with risk factors. Cesarean birth rarely causes the death of a newborn. Nevertheless, significant newborn pulmonary problems, especially respiratory distress syndrome, may follow an inappropriately timed cesarean delivery. Careful attention to clinical measures and supporting evidence of pulmonary maturity from ultrasound will avoid most instances of iatrogenic prematurity. Amniocentesis, with a higher complication rate than ultrasound, may still be required to prove pulmonary maturity in some circumstances. If concern or doubt precludes elective delivery of patients with previous low transverse uterine incisions, one can wait for the patient to go into spontaneous labor.     

Increased cesarean section rates in Turkey.

The aim of this study was to examine the trend in Cesarean section deliveries and the factors associated with Cesarean sections in Turkey. Data come from the ever-married women questionnaire of the 1998 Turkish Demographic and Health Survey (TDHS-98). During the decade preceding the TDHS-98, the proportion of deliveries by Cesarean section increased from 5.7% to 20.8%. When only hospital births were considered, the percentage of Cesarean deliveries for the year 1998 was found to be 26.1%. The estimated rate for the year 2001 was around 30% (i.e. double the maximum rate of Cesarean sections defined by the World Health Organization). Logistic regression analysis performed for the births occurring in the most recent period of 1993-98 revealed that the highest Cesarean section rate was strongly associated with maternal education, maternal age, place of delivery, number with prenatal care and household welfare. These findings imply that women with higher socioeconomic status are more likely to accept Cesarean section than women with lower socioeconomic status. The trend of increasing Cesarean section rates is a problem in itself, but more importantly it may indicate that Turkey is headed toward a more costly medical delivery system. For all of these reasons, the reduction of Cesarean section rates should be a priority for any reproductive health program in Turkey in order to improve the quality of prenatal care and to reduce the number of maternal deaths and morbidity.     

Norwegian midwives and doctors have increased cesarean section rates

BACKGROUND: Increasing cesarean section (CS) rates over the last 3 decades may, in part, be explained by improved obstetric procedures, but socio-economic factors also play a major role. Much attention has been given to professionals' attitudes to operative delivery, and several studies have been performed to clarify the issue. The present study explored CS rates among Norwegian doctors and midwives, compared to other professionals with an education of 17-18 years (doctors) and 15-16 years (midwives). METHODS: Data on mode of delivery notified to the Medical Birth Registry of Norway for 1969-1998 (n=1,733,665) were linked with data on formal education from Statistics Norway. CS rates and crude and adjusted odds ratios (ORs) were calculated for the observation period. RESULTS: Female doctors and midwives had higher CS rates; the crude ORs were 1.18 (95% CI: 1.12-1.28) for doctors, and 1.35 (95% CI: 1.21-1.49) for midwives. Adjusted for age and birth order, the ORs were 1.22 (95% CI: 1.12-1.33) for doctors and 1.14 (95% CI: 1.03-1.27) for midwives. CONCLUSION: From 1969 to 1998, Norwegian female doctors and midwives had higher CS rates than other professionals with an education of comparable duration.     

Maternal and neonatal outcome after cesarean section: the impact of anesthesia.

BACKGROUND: Among the anesthetic technologies used, regional anesthesia is becoming the most common in cesarean section (CS) deliveries. Aim. This retrospective survey examined the variables taken into account when selecting the anesthetic technique to be used, and how this choice affects the outcome for the mother and the newborn. METHODS: One thousand eight hundred and seventy elective and emergency CS were evaluated for anesthetic technique used, indications, and maternal and neonatal outcome. RESULTS: Of the 611 elective CS (32.6%), 206 (33.8%) were performed under general anesthesia and 405 (66.2%) under regional anesthesia. Of the 1259 emergency CS performed (67.4%), 525 (41.9%) were under general anesthesia and 734 (58.1%) under regional anesthesia. Conditions associated with a newborn 1-minute Apgar score of <7 were general anesthesia and multiple pregnancy (p<0.01); a 5-minute Apgar score of <7 was only associated with multiple pregnancy. The most important factor for very low Apgar scores was the presence of fetal malformations. Whatever the chosen technique, neither maternal deaths directly or indirectly due to the anesthesia nor major maternal and perinatal complications were found. CONCLUSIONS: This survey confirms the preference for regional anesthesia during elective cesarean sections and for general anesthesia in emergency situations. Moreover, newborn outcome was found not to be influenced either by the technique used or by the character of the procedure.     

Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis

This study reviewed maternal morbidity following trial of labor (TOL) after cesarean section, compared with elective repeat cesarean delivery (ERCS). Articles were pooled to compare women planning vaginal birth after cesarean (VBAC) with those undergoing ERCS with regard to maternal morbidity (MM), uterine rupture/dehiscence (UR/D), blood transfusion (BT), and hysterectomy. The former group was subdivided into successful VBAC (S-VBAC) and failed TOL (F-TOL). VBAC was successful in 17,905 of 24,349 patients (73%). MM, BT, and hysterectomy were similar in women planning VBAC or ERCS, whereas UR/D was different (1.3%; 0,4%). MM, UR/D, BT and hysterectomy were more common after F-TOL (17%, 4.4%, 3%; 0.5%) than after S-VBAC (3.1%, 0.2%, 1.1%; 0.1%) or ERCS (4.3%, 0.4%, 1%; 0.3%). Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.     

Maternal and neonatal copeptin levels at cesarean section and vaginal delivery

Objective

The objective of the study was to measure the copeptin levels in maternal serum and umbilical cord serum at cesarean section and vaginal delivery in normotensive pregnancy and pre-eclamptic women.

Study design

This was a prospective study at Mansoura University Hospital, Egypt. Ninety cases were included. They were divided into six groups: (1) normal pregnancy near term, as a control group, (2) primiparas who had vaginal delivery, (3) primiparas who had vaginal delivery and mild preeclampsia, (4) elective repeat cesarean section, (5) intrapartum cesarean section for indications other than fetal distress, and (6) intrapartum cesarean section for fetal distress. Serum copeptin concentrations were quantified with an enzyme-linked immunosorbent assay (ELISA). Mean, standard deviation, and paired t-test were used to test for significant change in quantitative data.

Results

The vaginal delivery groups had higher levels of maternal serum copeptin than the elective cesarean section group (P < 0.01). Higher maternal serum copeptin levels were found in cases with pre-eclampsia as compared with the normotensive cases. The maternal copeptin levels during intrapartum cesarean section were higher than that during elective repeat cesarean section. There was a significant correlation between maternal copeptin levels and the duration of the first stage. In the presence of fetal distress, umbilical cord serum copeptin levels were significantly higher than other groups.

Conclusion

Vaginal delivery can be very painful and stressful, and is accompanied by a marked increase of maternal serum copeptin. Increased maternal levels of serum copeptin were found in cases with pre-eclampsia as compared with the normotensive cases, and it may be helpful in assessing the disease. Intrauterine fetal distress is a strong stimulus to the release of copeptin into the fetal circulation.