Risks and benefits of the skin-to-skin cesarean section – a retrospective cohort study

Objective: Comparing maternal and neonatal outcomes after conventional cesarean section (CS) versus a “natural” or “skin-to-skin” cesarean section (SSCS).

Methods: Retrospective cohort of women who underwent a SSCS (01-2013 until 12-2013) compared to conventional CS (08-2011 to 08-2012). CS before 37 weeks, under general anesthesia and in case of fetal distress were excluded. Main outcome measures were maternal blood loss, post-operative infection and admission; neonatal infection and admission; procedural outcomes.

Results: We analyzed 285 (44%) women in the SSCS-group and 365 (56%) in the conventional CS-group. There were no significant differences in surgical site infection (2.1% versus 1.6%; RR 1.1; 95%CI 0.64–2.0), or other maternal outcomes. Fewer neonates born after SSCS were admitted to the pediatric ward (9.5% versus 18%; RR 0.58; 95%CI 0.41–0.80) and fewer neonates had a suspected neonatal infection (2.0% versus 7.3%; RR 0.40; 95%CI 0.19–0.83). No differences were observed for other outcomes. Mean operation time was 4m42s longer in the SSCS-group compared to the conventional CS-group (58m versus 53m; 95%CI 2m44s–6m40s). Mean recovery time was 14m46s shorter (114m versus 129m; 95%CI 3m20s–26m).

Conclusion: Adverse maternal and neonatal outcomes were not increased after skin-to-skin cesarean compared to conventional cesarean delivery.     

Puerperal psychosis – a qualitative study of women’s experiences

Objective: This study explored women’s experience of puerperal psychosis (PP) and their perceptions of its cause, in order to contribute to an increased understanding of PP and promote consideration of new management perspectives. Background: Out of every 1000 live births, approximately one to two women will develop PP. The numbers are relatively small, yet the consequences can be devastating. Key theoretical explanations for the aetiology of PP are genetic, biochemical and endocrine. A small and relatively tenuous evidence base considers PP from a psychological perspective, despite acknowledgement of the need for broader understanding. A stress–vulnerability model has offered a contemporary explanation of psychotic symptoms in other contexts and non-clinical populations and may offer useful insight in relation to a psychobiological model of PP. Methods: In a qualitative study, seven women who had been diagnosed with PP previously were interviewed and the data subjected to an inductive thematic analysis. Trustworthiness and rigour of the study was assured by careful monitoring of the research process and data checking. Results: Four themes were identified – The path to PP; Unspeakable thoughts and unacceptable self; ‘Snap out of it’; and Perceived causes. While women attributed their PP to the physiological changes associated with childbirth, their accounts of PP began before and during pregnancy. Women highlighted stressful pregnancies characterised by significant challenges and emotions, difficult births and unsupportive family relationships postnatally. The experience of PP was extremely distressing. Conclusion: Findings add to the debate about a more multifaceted explanation of PP and potentially offer a psychobiological model of understanding.     

The Charité cesarean birth: a family orientated approach of cesarean section

Objective: To evaluate the safety and patients delivery experience of the Charité Cesarean Birth (CCB), a modified cesarean section (CS). Parents are actively integrated in the delivery process by direct visualization of the birth, cutting the umbilical cord and early skin-to-skin contact (STS).

Methods: Women with an indication for a planned primary CS at term were included. Trial was conducted at the Charité University Hospital Berlin as a prospectively randomized controlled trial. Parameters of perinatal outcome for both mother and infant were assessed using modified Likert-Scales and a standardized questionnaire. Primary outcome measures were birth experience and satisfaction for parents. Parameters of breast feeding and consecutive problems. APGAR Scores, blood loss, perioperative complications were secondary outcome measures.

Results: Birth experiences were rated significantly higher in the CCB group compared to a classical caesarean section (p?<?0.05). There were no significant differences between APGAR Scores, need for admission to an intensive care unit. Also perioperative blood loss and cardiovascular disorders did not differ between the two groups. Early STS was achieved in the 72% of the cases with higher rates of breast-feeding in the CCB group.

Conclusions: The CCB leads to a significantly better birth experience. The procedure seems to be safe for both mother and infant. Patients become an active part of the CS by direct visualization of the birth and cutting the umbilical cord. The presented modification is a useful and safe option when a CS is medically indicated and necessary. It improves the breast-feeding and the early mother-infant interaction.     

Turkish obstetricians’ personal preference for mode of delivery and attitude toward cesarean delivery on maternal request

Objective(s)  

(1) To investigate the cesarean rate among actively practicing obstetricians in Turkey and reasons why they choose this mode of delivery for themselves/partners. (2) To investigate the attitudes, practices, and beliefs with respect to cesarean delivery on maternal request (CDMR) among actively practicing obstetricians in Turkey.     

The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth

Background

Knowledge, attitudes and practices of community members and healthcare providers in rural northern Ghana regarding clean delivery are not well understood. This study explores hand washing/use of gloves during delivery, delivering on a clean surface, sterile cord cutting, appropriate cord tying, proper cord care following delivery, and infant bathing and cleanliness.

Methods

In-depth interviews and focus group discussions were audiotaped, transcribed, and analyzed using NVivo 9.0.

Results

253 respondents participated, including women with newborn infants, grandmothers, household and compound heads, community leaders, traditional birth attendants, and formally trained health care providers. There is widespread understanding of the need for clean delivery to reduce the risk of infection to both mothers and their babies during and shortly after delivery. Despite this understanding, the use of gloves during delivery and hand washing during and after delivery were mentioned infrequently. The need for a clean delivery surface was raised repeatedly, including explicit discussion of avoiding delivering in the dirt. Many activities to do with cord care involved non-sterile materials and practices: 1) Cord cutting was done with a variety of tools, and the most commonly used were razor blades or scissors; 2) Cord tying utilized a variety of materials, including string, rope, thread, twigs, and clamps; and 3) Cord care often involved applying traditional salves to the cord - including shea butter, ground shea nuts, local herbs, local oil, or ??red earth sand.?? Keeping babies and their surroundings clean was mentioned repeatedly as an important way to keep babies from falling ill.

Conclusions

This study suggests a widespread understanding in rural northern Ghana of the need for clean delivery. Nonetheless, many recommended clean delivery practices are ignored. Overarching themes emerging from this study included the increasing use of facility-based delivery, the disconnect between healthcare providers and the community, and the critical role grandmothers play in ensuring clean delivery practices. Future interventions to address clean delivery and prevention of neonatal infections include educating healthcare providers about harmful traditional practices so they are specifically addressed, strengthening facilities, and incorporating influential community members such as grandmothers to ensure success.     

Randomised trial of assigned mode of delivery after a previous cesarean section – Impact on maternal psychological dynamics

Objective.?This randomised trial was designed to study the psychological status and morbidity during and after delivery among women with a previous cesarean section (CS) who were randomised to planned vaginal birth (VBAC) or planned CS.

Methods.?Two hundred and ninety-eight women with one previous lower segment CS were randomised to either planned VBAC or planned CS. Women were asked to complete psychometric scales during their pregnancy till 6 months after confinement. The primary outcome studied was the differences in psychometric scores between the two study groups.

Results.?There were no differences in anxiety, depression, psychological well-being or satisfaction scores between the two groups. Significantly more women in planned VBAC (27/123) requested to change to elective CS, compared to those who were randomised to planned CS (15/135) initially requested to change to planned VBAC (OR: 2.25; 95% CI: 1.13–4.47). Subgroup analyses showed that women who changed from planned CS to VBAC had lower satisfaction at delivery [Client Satisfaction Score: 24.0 (23.0–24.3), 23.0 (22.0–24.0); p?=?0.009] compared to women who did not change their plan for elective CS.

Conclusions.?The planned mode of delivery, either elective CS or VBAC, in pregnant women who had one previous CS did not influence the psychological dynamic during the course of or after the pregnancy. VBAC was not associated with higher psychological morbidity and therefore should be encouraged.     

First birth and the trajectory of women’s empowerment in Egypt

Background

Women’s empowerment is often used to explain changes in reproductive behavior, but no consideration is given to how reproductive events can shape women’s empowerment over time. Fertility may cause changes in women’s empowerment, or they may be mutually influencing. Research on women’s empowerment and fertility relies on cross-sectional data from South Asia, which limits the understanding of the direction of association between women’s empowerment and fertility in other global contexts. This study uses two waves of a panel survey from a prominent Middle Eastern country, Egypt, to examine the trajectory of women’s empowerment and the relationship between first and subsequent births and empowerment over time.

Methods

Using longitudinal data from the 2006 and 2012 Egyptian Labor Market Panel Survey, a nationally representative sample of households in Egypt, for 4660 married women 15 to 49 years old, multilevel negative binomial, ordinary least squares, and logistic regression models estimate women’s empowerment and consider whether a first and subsequent births are associated with empowerment later in life. Women’s empowerment is operationalized through four measures of agency: individual household decision-making, joint household decision-making, mobility, and financial autonomy.

Results

A first birth and subsequent births are significantly positively associated with all measures of empowerment except financial autonomy in 2012. Women who have not had a birth make 30% fewer individual household decisions and 14% fewer joint household decisions in 2012 compared to women with a first birth. There is also a positive relationship with mobility, as women with a first birth have more freedom of movement compared to women with no births. Earlier empowerment is also an important predictor of empowerment later in life.

Conclusions

Incorporating the influence of life events like first and subsequent births helps account for the possibility that empowerment is dynamic and that life course experiences shape women’s empowerment. This and the notion that empowerment builds over time helps portray women’s lives more completely, demonstrates the importance of empowerment early in the life course, and addresses issues of temporality in empowerment fertility research.

     

Risk factors for intrapartum acidemia – a cohort study

Purpose: Birth acidemia is associated with short- and long-term morbidity in the child. Optimal intrapartum surveillance and timely interventions may reduce the incidence of these outcomes. Knowledge about conditions which increase the risks might be beneficial for optimal care. The aim with this study was to identify factors which increased the risk for lactacidemia in fetal scalp blood.

Materials and methods: A secondary analysis of a cohort study performed at Karolinska University Hospital Stockholm Sweden between February 2009 and February 2011. The study population included 1070 women in labor where fetal scalp blood sampling (FBS) was performed.

Results: In a univariate logistic regression analysis for lactate >4.8?mmol/L at FBS, minor language barriers (OR 2.54; 95%CI 1.26–5.11), active bearing down (OR 2.46; 95%CI 1.12–5.39) and maternal height <155?cm (OR 2.15; 95%CI 1.08–4.26) were found as risk factors. In a multivariate logistic regression analysis, minor language barriers (OR 2.21; 95%CI 1.05–4.67) and active pushing (OR 2.68; 95%CI 1.20–6.00) remained significant.

Conclusions: Language barriers, active pushing and short stature were found to be significant risk factors for intrapartum lactacidemia. In the group with minor language problems better use of interpreters might be beneficial.     

Prognostic factors for successful vaginal birth after cesarean section — Analysis of 162 cases

Objective

To analyze the success rate of VBAC (Vaginal birth after cesarean section) with reference to various factors and derive simple and easily usable prognostic factors to predict successful VBAC.

Methods (Study Design)

In this retrospective observational study, 162 women who had undergone successful trial of labor were analyzed to study the factors which contributed to successful trial of labor over a study period of one year. Maternal age, prior antenatal visits, prior obstetric history, neonatal weight and interconceptional period were studied with reference to outcome of VBAC. Success of VBAC when compared with prior indication for CS was studied. The role of instrumental deliveries for VBAC was analyzed. Maternal and perinatal mortality and morbidity were assessed. Chi square test was used to analyze the significance of each factor.

Results

Success rate of VBAC was 75%. Maternal age, prior antenatal care, prior vaginal delivery, neonatal weight and interconceptional period were all statistically significant predictors (P<0.001) of successful VBAC. Instrumental deliveries were helpful in successful VBAC and can be used prophylactically to cut short second stage. VBAC had no adverse maternal or perinatal outcome.

Conclusion

VBAC can be successfully tried in all women with prior cesarean section by careful selection and employing simple predictive factors.     

Effects of women’s body mass index on in vitro fertilization success: a retrospective cohort study

Background: The purpose of this study is to evaluate the influence of body mass index (BMI) on the reproductive outcomes and clinical pregnancy rate after in vitro fertilization (IVF). Methods: This retrospective study was performed on 230 women undergoing first cycle of standard IVF between October 2008 and February 2010. The patients were classified into three groups according to their BMI (BMI < 20?kg/m², 20?kg/m² < BMI < 27.9?kg/m² and BMI > 28?kg/m²). Information regarding clinical pregnancy was compared within these three groups. Results: There was no significant relation between BMI and age, the number of aspirated follicles, transferred embryos, mature oocytes, days of taking human menopausal gonadotropin (HMG) ampules and the total number of HMG ampules among three BMI studied groups. Statistically significant difference was detected between BMI and endometrial thickness. Conclusions: BMI has no effect on IVF outcomes and clinical pregnancy after IVF. However, losing weight in obese women seems reasonable to prevent possible obstetrics complications.     

Amnion protective cesarean section – method for gentle delivery of preterm and/or VLBW neonates

Abstract

More than 50 percent of preterm neonates below 28 gestational weeks in our institution are delivered by cesarean section (CS).

Aim: To present advantages of less used method of delivery of premature and/or very low birth weight (VLBW) neonates by Amnion Protective Cesarean Section (APCS) when indicated and to review our experience with the method. It can be used in all deliveries by CS with unruptured amniotic membranes, at all gestational ages.

Materials and methods: Including criteria were singleton pregnancies, gestation of 26 to 35 weeks and birth body weight between 700 to 1500?g. According to the criteria, during the studied period 10 neonates were delivered by APCS. We compared the outcomes of APCS neonates with ones delivered by coventional CS who matched them in mentioned criteria.

Results: Compared to CS cases, APCS neonates had statistically significant better first minute AS. Stay in NICU was shorter for APCS neonates but not statistically significant. From our experience APCS neonates had clinically better appearance (less bruises and hematomas).

Conclusion: APCS is promising method for delivery of preterm and/or VLBW neonates when indicated, although prospective studies are needed in order to prove its effectiveness compared to conventional CS.     

Placental disorders of pregnancy in subsequent IVF pregnancies – a sibling cohort

Research questionTo assess whether the incidence of placental disorders of pregnancy decreases with increasing parity in repeat IVF pregnancies, in the same way as natural pregnancies.DesignThis was a retrospective cohort of deliveries between November 2008 and January 2020, in a single university-affiliated medical centre. The study included women with only IVF-attained singleton pregnancies (no natural conception) with at least two deliveries, and compared the obstetric and perinatal outcomes between first, second and third deliveries. Each woman served as her own control. The primary outcome was the incidence of placental-related disorders of pregnancy, defined as small for gestational age (SGA) neonates and/or pre-eclampsia.ResultsA total of 307 first deliveries, 307 second deliveries and 49 third deliveries by the same women were compared. A trend for a decreased rate of pre-eclampsia was noted with increased parity (P = 0.06) and a significant decrease in the rate of SGA: 11.7% for first delivery, 7.8% for second delivery and 2.0% for third (P = 0.04). This difference in SGA incidence was maintained in a matched sub-analysis of the 49 women with three deliveries (P = 0.04), and after adjustment for fresh/frozen embryo transfer (P = 0.03). Although SGA and pre-eclampsia were generally more common in IVF than natural pregnancies, their decrease with increasing parity mimicked that in natural pregnancies.ConclusionIVF pregnancies are associated with an increased risk of placental disorders of pregnancy. However, they exhibit a decrease in incidence with increasing parity.     

Influence of women's request and preference on the rising rate of caesarean section – a comparison of reviews

The rising caesarean section (CS) rates have been, in part, attributed to women's requests. Several individual studies and literature reviews have attempted to determine the degree of influence of women's requests on overall CS rates, and the common reasons behind these requests, from women's, midwives’ and obstetricians’ viewpoints. Despite many similarities in their findings, there is both a lack of clarity and disparity on the degree of influence women's requests actually has on the decision to perform a CS. This paper presents a critique of a key finding from a recently published systematic review of clinicians’ (midwives’ and obstetricians’) views of factors that influenced their decision to perform a CS, which identified their belief in ‘women's request’ as a key factor. This finding is contrasted with findings from three other published reviews, which concluded that women's request contributed minimally to the overall rising rates of CS indicating a disparity in evidence around influence and contribution of women's request. Some of the possible reasons for this disparity can be explained by differences in views of women and clinicians, women's decision being guided by clinicians’ beliefs of what is ‘safe’ and unsafe’, and women's concerns being interpreted as their request and preferences to birth by CS. An insight into the possible reasons for the disparity in findings can help explain whether maternal request has any influence on the rising rates of CSs.     

Maternal request: a reason for rising rates of cesarean section?

Objective

The rising rate of cesarean sections (CS), especially those on maternal request, is an important obstetric care issue. The aim of this two-point cross-sectional study was to evaluate the prevalence of CS and their indications.

Methods

We performed a retrospective chart review of the indications of all CS performed at a tertiary care clinic in Switzerland in 2002 and 2008. Chi-square, Student??s t and Mann?CWhitney U tests were performed to identify significant differences.

Results

The number of CS rose from 23.3% (371 out of 1,594 total life births) in 2002 to 27.5% (513 out of 1,866) in 2008 (p?=?0.005). Of all deliveries, the rate of CS on maternal request and, among these, especially those requested after previous CS, increased significantly (2.1 vs. 5.1% and 0.3 vs. 1.2%, respectively). The number of CS due to previous traumatic birth experience nearly doubled (0.7 vs. 1.2%, not significant). Maternal and fetal complications were rare but not negligible in the subset of low-risk patients requesting CS.

Conclusions

The study demonstrated a significant increase in CS on maternal request, especially in case of previous CS. The findings of this study support the need for specific counseling strategies for women requesting delivery by CS.