Obstetric complications and cesarean delivery in Nepal

Objective

To determine the incidence of obstetric complications, the stillbirth rate, and the factors associated with cesarean delivery in central Nepal.

Methods

A community-based prospective cohort study was undertaken in the Kaski district during 2011–2012. In total, 701 women who were at least 5 months pregnant were recruited and interviewed. Participants were followed-up and interviewed again within 45 days after delivery.

Results

Of the 658 women who remained in the cohort after 43 were lost to follow-up, 12 (1.8%) had stillbirths. Cesareans accounted for 13.3% of the total deliveries. Age, urban residency, college-level education, and particularly presence of intrapartum symptoms significantly increased the likelihood of cesarean delivery. Prepartum, intrapartum, and postpartum symptoms were reported by 21.1%, 24.4%, and 10.2% of women, respectively. Common danger signs included prolonged labor, severe abdominal pain, swollen hand and body, and heavy bleeding.

Conclusion

Obstetric complications and stillbirth rates were relatively high in central Nepal. Cesarean delivery appeared to meet obstetric need and was performed with medical indication, particularly after the onset of labor.     

Pelvic floor morbidity up to one year after difficult instrumental delivery and cesarean section in the second stage of labor: a cohort study

OBJECTIVE: This study was undertaken to assess symptoms of pelvic floor morbidity at 6 weeks and at 1 year after difficult instrumental vaginal delivery or cesarean section during the second stage of labor. STUDY DESIGN: Prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required operative delivery in surgery at full dilatation between February 1999 and February 2000. Postal questionnaires were used for follow-up at 6 weeks and at 1 year. RESULTS: Instrumental delivery was associated with a greater risk of urinary incontinence at 6 weeks and at 1-year postdelivery, adjusted odds ratio [OR] 7.8 (95% CI, 2.6-23.6) and OR 3.1 (95% CI, 1.3-7.6), respectively. Although instrumental delivery was associated with an increased risk of moderate-to-severe dyspareunia at 6 weeks, adjusted OR 3.35 (95% CI, 1.36-8.25), this difference was not significant at 1 year. Cesarean section after attempted instrumental delivery was associated with an increased risk of moderate-to-severe pain during intercourse at 1 year compared with immediate cesarean section, (18% vs 9%) P=.01. CONCLUSION: Although cesarean section at full dilatation does not completely protect women from pelvic floor morbidity, those that followed instrumental delivery had a significantly greater prevalence of urinary symptoms and dyspareunia. Urinary symptoms persist up to 1 year after delivery.     

Delivery-related complications and early postpartum morbidity in Dhaka, Bangladesh.

OBJECTIVE: To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh. METHOD: From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum. RESULT: Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions. CONCLUSION: A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed.     

Medically indicated late preterm delivery and its impact on perinatal morbidity and mortality: a retrospective population-based cohort study

Objective: In the last few decades, attention has been focused on morbidity and mortality associated with late preterm delivery (34–36?+?6/7 weeks), accounting for 60–70% of all preterm births. This study is aimed to determine (1) the prevalence of late preterm deliveries (spontaneous and medically indicated) in our population; and (2) the rate of neonatal morbidity and mortality as well as maternal complications associated with the different phenotypes of late preterm deliveries.

Study design: This retrospective population-based cohort study, included 96,176 women who had 257,182 deliveries, occurred between 1988 and 2011, allocated into three groups: term (n?=?242,286), spontaneous (n?=?10,063), and medically indicated (n?=?4833) late preterm deliveries.

Results: (1) Medically indicated late preterm deliveries were associated with increased maternal morbidity, as well as neonatal morbidity and mortality, in comparison with other study groups (p?Conclusions: (1) Medically indicated late preterm deliveries were independently associated with adverse composite neonatal outcome; and (2) to benefit in term of neonatal outcome from the tool of medically indicated late preterm birth, their proportion should be kept below 35% of all late preterm deliveries, while exceeding this threshold increases the risk of neonatal mortality.     

Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India

Objective

To determine the cost-effectiveness of prenatal iron supplementation and misoprostol use as interventions to prevent maternal mortality in home births in rural India.

Methods

A cost-effectiveness analysis depicted three hypothetical cohorts of 10 000 pregnant women delivering at home in rural India: one with no intervention, one receiving standard prenatal iron supplements, and 1 receiving 600 µg of misoprostol in the third stage of labor.

Results

Misoprostol used to prevent postpartum hemorrhage resulted in a 38% (95% CI, 5%-73%) decrease in maternal deaths, while prenatal iron supplementation resulted in a 5% (95% CI, 0%-47%) decrease. Misoprostol cost a median US $1401 (IQR US $1008-$1848) prenatal iron supplementation cost a median US $2241 (IQR No Lives Saved-$3882) per life saved compared with the standard care outcome.

Conclusion

Misoprostol is a cost-effective maternal mortality intervention for home births. Iron supplementation may be worthwhile to improve women's health, but it is uncertain whether it can prevent mortality after hemorrhage.     

The continuum of maternal morbidity and mortality: factors associated with severity

OBJECTIVE: The goal of this study was to examine whether sociodemographic, clinical, and other service-related factors, as well as preventability issues affect a woman's progression along the continuum of morbidity and mortality. STUDY DESIGN: This was a case-control study of pregnancy-related deaths, women with near-miss morbidity, and those with other severe, but not life threatening, morbidity. Factors associated with maternal outcome were examined. RESULTS: Provider factors (related to preventability) and clinical diagnosis were significantly associated with progression along the continuum after controlling for sociodemographic characteristics (P < .01 for both associations). CONCLUSION: In order to improve mortality rates, we must understand maternal morbidity and how it may lead to death. This study shows that important initiatives include addressing preventability, in particular, provider factors, which may play a role in moving women along the continuum of morbidity and mortality.     

Pelvic floor morbidity at 3 years after instrumental delivery and cesarean delivery in the second stage of labor and the impact of a subsequent delivery

OBJECTIVE: To compare pelvic floor symptoms at three years following instrumental delivery and cesarean section in the second stage of labor and to assess the impact of a subsequent delivery. STUDY DESIGN: We conducted a prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required instrumental vaginal delivery in theatre or cesarean section at full dilatation between February 1999 and February 2000. 283 women (72%) returned postal questionnaires at three years. RESULTS: Urinary incontinence at three years post delivery was greater in the instrumental delivery group as compared to the cesarean section group (10.5% vs 2.0%), OR 5.37 (95% CI, 1.7, 27.9). There were no significant differences in ano-rectal or sexual symptoms between the two groups. Pelvic floor symptoms were similar for women delivered by cesarean section after a failed trial of instrumental delivery compared to immediate cesarean section. A subsequent delivery did not increase the risk of pelvic floor symptoms at three years in either group. CONCLUSION: An increased risk of urinary incontinence persists up to three years following instrumental vaginal delivery compared to cesarean section in the second stage of labor. However, pelvic floor symptoms are not exacerbated by a subsequent delivery.     

Effects of different timing selections of labor analgesia for primiparae on parturition and neonates

ObjectiveTo explore the effects of labor analgesia for primiparae with different stages of cervical dilation on parturition and neonates.Materials and methodsIn the past three years, 530 cases of primiparae who had delivered in the Second People's Hospital of Hefei and were eligible for a vaginal trial of parturition were enrolled as the research subjects. Of these, 360 puerperae had labor analgesia, and the remaining 170 were taken as the control group. Those given labor analgesia were divided into three groups based on the different stages of cervical dilation at that time. There were 160 cases in Group I (cervical dilation <3 cm), 100 cases in Group II (cervical dilation of 3–4 cm), and 100 cases in Group III (cervical dilation of 4–6 cm). The labor and neonatal outcomes were compared among the four groups.ResultsThe first, second, and total stages of labor in the three groups receiving labor analgesia were all longer than in the control group, and the differences were statistically significant (p < 0.05 in all). Group I had the longest duration of each stage and the total stage of labor. The differences in labor stages and the total stage of labor were not statistically significant between Group II and Group III (P > 0.05). In the three groups with labor analgesia, the usage rate of oxytocin was higher than in the control group, and the differences were statistically significant (P < 0.05). The differences in the incidence of postpartum hemorrhage, the incidence of postpartum urine retention, and the episiotomy rate were not statistically significant among the four groups (P > 0.05). The differences in the neonatal Apgar score were not statistically significant among the four groups (P > 0.05).ConclusionLabor analgesia might prolong the stages of labor but does not affect the neonatal outcomes. It would be optimal to conduct labor analgesia when cervical dilation reaches 3–4 cm.     

Factors associated with maternal near-miss morbidity and mortality in Kowloon Hospital,Suzhou, China

Objective

To investigate factors associated with acute maternal morbidity and mortality in Kowloon Hospital, Suzhou, China.

Methods

Data from cases of near-miss and maternal death between January 2008 and December 2012 were reviewed retrospectively. Maternal characteristics and related factors were identified, and multiple regression analysis was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

Results

During the study period, there were 18 104 deliveries, 69 near-miss cases, and 3 maternal deaths. Women who had no health insurance (aOR, 4.55; 95% CI, 0.87–21.8), had fewer than 6 prenatal consultations (aOR, 6.76; 95% CI, 0.76–45.8), were part of a migrant population (aOR, 2.34; 95% CI, 0.45–24.9), or delayed seeking healthcare (aOR, 4.76; 95% CI, 0.89–13.6) had a greater risk of near-miss morbidity or death. Admission to intensive care (aOR, 6.75; 95% CI, 0.89–34.6) and blood transfusion within 30 min (aOR, 3.79; 95% CI, 0.65–8.67) were protective factors in disease progression.

Conclusion

The factors associated with maternal near-miss morbidity and mortality were closely related to health insurance and socioeconomic status, suggesting that the government should take an active role in the community in preventing morbidity and mortality in pregnancy.     

Caesarean delivery at full cervical dilatation versus caesarean delivery in the first stage of labour: comparison of maternal and perinatal morbidity

OBJECTIVE: To compare perinatal and maternal morbidity associated with caesarean sections performed in the first with that performed in the second stages of labour. PATIENTS AND METHODS: Comparative analyses between nulliparous women with singleton term pregnancies who had a caesarean section in the first stage of labour and those who had a second stage caesarean section were completed using standard statistical methods. A subgroup analysis, according to indication for caesarean section, was also performed. RESULTS: Of 627 women, 81% had caesarean delivery in the first stage and 19% had caesarean delivery in the second stage of labour. Women undergoing caesarean delivery at full cervical dilatation were 1.9 times more likely to have an augmented labour (95% CI 1.2-3.4, P < 0.001) and 2.8 times more likely to have epidural anaesthesia in labour (95% CI 1.5-5.2, P < 0.001) than those in the first stage. Compared with caesarean delivery in the first stage of labour, women undergoing caesarean delivery at full cervical dilatation were 4.6 times more likely to have composite intraoperative complications (95% CI 2.7-7.9, P < 0.001), 3.1 times more likely to have blood loss greater than 1,000 ml (95% CI 1.3-7.4, P = 0.01), and 2.9 times more likely to have a blood transfusion (95% CI 1.5-5.6, P < 0.001). The risk of neonatal morbidity was higher in first stage caesareans when they were performed for presumed fetal compromise (66.3 vs. 26.3%, P = 0.002), and lower when they were performed for failure to progress (18.4 vs. 42%, P = 0.02). CONCLUSION: Caesarean section in the second stage of labour is associated with a higher risk of maternal but not perinatal morbidity.     

The impact of labor at term on measures of neonatal outcome

OBJECTIVE: The purpose of this study was to determine risk assessments for a spectrum of neonatal outcomes with elective cesarean delivery versus a trial of labor for previous cesarean section and otherwise healthy patients who deliver at term. STUDY DESIGN: The perinatal/neonatal database of St. Joseph's Health Care, London, Ontario, Canada, was used to obtain the umbilical cord pH and base excess values, incidence of adverse neonatal outcomes, and patient demographics for all term (> or =37 weeks of gestation), singleton, liveborn, or intrapartum demise infants with no major anomalies who were delivered between January 1992 and March 2002 (n = 33,709 infants). Patient groupings (all patient, patient with previous cesarean delivery, and low-risk patient) with no labor versus labor were studied by a comparison of mean values/incidences for those neonatal outcomes that were available from the database with the use of linear and logistic regression analysis and controlling for potentially confounding variables. RESULTS: Labor was associated with a small drop in umbilical artery pH from approximately 7.27 to 7.25 and base excess from approximately -3.1 to -5.4 mmol/L, but this was generally well tolerated, with no difference in the incidence of 5-minute Apgar scores of <7 for any of the patient population groupings. Neonatal respiratory morbidity was increased generally in the group of elective cesarean delivery patients, which resulted in increased neonatal intensive care unit triage/admission even out to 7 days; some of this risk was likely to persist even with a policy of elective cesarean delivery after 39 weeks of gestation. Although we found no significant difference in the incidence of pathologic acidemia at birth with an umbilical artery pH <7.00, there was a risk for intrapartum/neonatal death that could be attributed to labor events per se that ranged from 1 of 882 for the patients with previous cesarean delivery to 1 of 3406 for the low-risk patients. CONCLUSION: For otherwise healthy patients at term, the risk of adverse neonatal outcomes is low, with the choice between elective cesarean delivery and trial of labor in general balancing the low risk of increased respiratory morbidity and thereby neonatal intensive care unit triage/admission against the extremely low risk of labor-related infant death and severe morbidity. However, this balance for the patients with previous cesarean delivery appears shifted, with less benefit from a trial of labor in terms of reduced respiratory morbidity and neonatal intensive care unit triage/admission and with increased labor-related severe morbidity/death, albeit with all of these still at a low level.     

Review: Effects of maternal micronutrient supplementation on placental function

Pregnancy is a physiological challenge that may require additional nutritional support. Suboptimal micronutrient intakes and micronutrient deficiencies during pregnancy are a global problem, often leading to poor maternal and child outcomes. Micronutrient supplementation is commonly recommended during pregnancy to support and enhance maternal metabolism. Recent studies suggest that the use of multiple micronutrient supplements may be of benefit during a normal pregnancy and may significantly reduce the risk of preeclampsia, preterm delivery, gestational diabetes, and improve pregnancy outcomes. Given the crucial role that the placenta plays in mediating pregnancy outcomes, it is important to consider the impact of micronutrient supplementation on the mechanisms associated with placental function, as well as maternal and fetal homeostasis. This review will consider the role of key micronutrients in supporting pregnancy and the possible mechanisms by which multiple micronutrients influence placental function and modulate placental oxidative stress and inflammation.     

Effect of combined spinal-epidural analgesia versus epidural analgesia on labor and delivery duration

Objective

To determine whether combined spinal-epidural analgesia (CSEA) can decrease the known epidural effect of lengthening delivery.

Methods

Between April and May 2010, 144 women undergoing childbirth in hospital with epidural pain relief were randomized to receive either low-dose epidural analgesia (LEA) or CSEA. The spinal component included 2.5 mg of bupivacaine, 25 μg of fentanyl, and 200 μg of morphine. The epidural component of the CSEA procedure was started once pain returned. The primary outcome was total labor duration measured from the time of initiation of labor analgesia to delivery.

Results

The difference in duration between LEA (n = 72) and CSEA (n = 72) was 5 minutes for labor (P = 0.82), 2 minutes for delivery (P = 0.60), and 7 minutes for total labor duration (P = 0.75). The combined group used less levobupivacaine (P < 0.001) and had lower sensory blockade at the dermatomal level (P = 0.037). Women in the CSEA group had a higher incidence of pruritus (P = 0.002) and lightheadedness (P = 0.02) during labor; and a higher incidence of pruritus (P = 0.002), nausea-vomiting (P = 0.026), and drowsiness (P = 0.003) in the postpartum period.

Conclusion

As compared with LEA, CSEA did not shorten the duration of labor length; however, it did reduce levobupivacaine consumption and motor weakness.     

Women's opinions and experiences with induction of labor and cesarean delivery on request in south eastern Nigeria

Objective

To assess the opinions and experiences of women regarding induction of labor and cesarean delivery on request in south eastern Nigeria.

Method

Women were interviewed using questionnaires on their awareness of their right to request labor induction and/or a cesarean delivery, and of their experience and opinion of the procedures.

Results

Of the 15.1% of the respondents who knew they could request a cesarean delivery, 2.4% had requested one; and of the 56.3% who knew they could request labor induction, 6.9% had requested one. Only 5.3% and 11.3% of the respondents who would chose the former or the latter procedure, respectively, said that they would insist on receiving it. Fear of their physicians' negative attitude regarding the procedures, and/or abandonment of care, ranked highest among their reasons for not insisting.

Conclusion

In south eastern Nigeria few women are aware of their right to a cesarean delivery on request and the rate of refusal to perform such deliveries is high among physicians; more women are aware of their right to receive induction of labor on request and the acceptance rate is higher among physicians; and most women are unwilling to insist that their physician respect their choice.