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.     

Effect of Operative Delivery in the Second Stage of Labor on Breastfeeding Success

Abstract: Background: Operative delivery rates are currently rising in many countries, but the effects of this factor on the initiation and duration of breastfeeding are unclear. The purpose of this study was to evaluate breastfeeding success after instrumental vaginal delivery or cesarean section at full dilatation, and to investigate whether timing of discharge after operative delivery affects breastfeeding rates. Methods: A prospective cohort study was conducted of 393 women with term, singleton, live, cephalic pregnancies who required delivery in theater during the second stage of labor between February 1999 and February 2000. Postal questionnaires were mailed to participants at 6 weeks and 1 year. Logistic regression models were used to explore the relationships between infant feeding and mode of delivery, controlling for factors previously correlated with breastfeeding success. Results: Rates of exclusive breastfeeding at discharge and 6 weeks postpartum were 70 and 44 percent, respectively. No significant differences occurred when instrumental vaginal delivery was compared with cesarean section, adjusted OR 0.84 (95% CI 0.50, 1.41) and 1.15 (95% CI 0.69, 1.93) respectively. Breastfeeding rates after failed instrumental delivery were similar to those after immediate cesarean section, adjusted OR 0.99 (95% CI 0.72, 1.38) and 1.28 (95% CI 0.91, 1.78). Women who had a longer in‐patient stay after cesarean section were more likely to achieve exclusive breastfeeding at hospital discharge (78% vs 66%, p = 0.03). Conclusions: Method of operative delivery in the second stage of labor does not appear to influence initiation or duration of exclusive breastfeeding. A longer inpatient stay may help cesarean‐delivered women to initiate breastfeeding. (BIRTH 30:4 December 2003)     

Périnée et grossesse

Congenital factor, obesity, aging, pregnancy and childbirth are the main risk factors for female pelvic floor disorders (urinary incontinence, anal incontinence, pelvic organ prolapse, dyspareunia). Vaginal delivery may cause injury to the pudendal nerve, the anal sphincter, or the anal sphincter. However the link between these injuries and pelvic floor symptoms is not always determined and we still ignore what might be the ways of prevention. Of the many obstetrical methods proposed to prevent postpartum symptoms, episiotomy, delivery in vertical position, delayed pushing, perineal massage, warm pack, pelvic floor rehabilitation, results are disappointing or limited. Caesarean section is followed by less postnatal urinary incontinence than vaginal childbirth. However this difference tends to disappear with time and following childbirth. Limit the number of instrumental extractions and prefer the vacuum to forceps could reduce pelvic floor disorders after childbirth. Ultrasound examination of the anal sphincter after a second-degree perineal tear is useful to detect and repair infra-clinic anal sphincter lesions. Scientific data is insufficient to justify an elective cesarean section in order to avoid pelvic floor symptoms in a woman without previous disorders.     

Risk of cesarean delivery with elective induction of labor at term in nulliparous women.

OBJECTIVE: To quantify the risk of cesarean delivery associated with elective induction of labor in nulliparous women at term. METHODS: We performed a cohort study on a major urban obstetric service that serves predominantly private obstetric practices. All term, nulliparous women with vertex, singleton gestations who labored during an 8-month period (n = 1561) were divided into three groups: spontaneous labor, elective induction, and medical induction. The risk of cesarean delivery in the induction groups was determined using stepwise logistic regression to control for potential confounding factors. RESULTS: Women experiencing spontaneous labor had a 7.8% cesarean delivery rate, whereas women undergoing elective labor induction had a 17.5% cesarean delivery rate (adjusted odds ratio [OR] 1.89; 95% confidence interval [CI] 1.12, 3.18) and women undergoing medically indicated labor induction had a 17.7% cesarean delivery rate (OR 1.69; 95% CI 1.13, 2.54). Other variables that remained significant risk factors for cesarean delivery in the model included: epidural placement at less than 4 cm dilatation (OR 4.66; 95% CI 2.25, 9.66), epidural placement after 4 cm dilatation (OR 2.18; 95% CI 1.06, 4.48), chorioamnionitis (OR 4.61; 95% CI 2.89, 7.35), birth weight greater than 4000 g (OR 2.59; 95% CI 1.69, 3.97), maternal body mass index greater than 26 kg/m2 (OR 2.36; 95% CI 1.61, 3.47), Asian race (OR 2.35; 95% CI 1.04, 5.34), and magnesium sulfate use (OR 2.18; 95% CI 1.04, 4.55). CONCLUSION: Elective induction of labor is associated with a significantly increased risk of cesarean delivery in nulliparous women. Avoiding labor induction in settings of unproved benefit may aid efforts to reduce the primary cesarean delivery rate.     

Obstetric management of a woman's first delivery and the implications for pelvic floor surgery in later life

OBJECTIVE: To determine the influence of intrapartum care during a first delivery on the risk of pelvic floor surgery in later life. DESIGN: Nested case-control study with record linkage of a historical cohort and a current morbidity database. SETTING: Hospital births in Dundee 1952-1966. POPULATION: The 7556 primiparous women from the Walker cohort. METHODS: The cases (n= 352) were women who delivered a first singleton baby at term (> or =37 weeks) and subsequently had pelvic floor surgery. Controls (n= 1403) were women who delivered their first baby during the same time period and did not undergo surgery. Univariate and multivariate logistic regression analyses were performed taking account of demographic, anthropometric and obstetric factors. MAIN OUTCOME MEASURE: Pelvic floor surgery. RESULTS: Caesarean section was associated with a reduced risk of pelvic floor surgery compared with spontaneous vaginal delivery (odds ratio 0.16, 95% CI 0.05-0.55). Forceps delivery and infant birthweight >4.0 kg were not identified as significant risk factors (OR 0.94, 95% CI 0.71, 1.25, and OR 0.94, 95% CI 0.50, 1.75, respectively). Episiotomy and prolonged labour (>12 hours) may be associated risk factors but were of borderline significance (OR 1.46, 95% CI 0.99, 2.10, and OR 1.51, 95% CI 1.00, 2.27). CONCLUSION: Caesarean section in a first pregnancy appears to protect against pelvic floor surgery in later life.     

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version

Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2–6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1–8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.     

Emergency cesarean delivery in induction of labor: an evaluation of risk factors

BACKGROUND: Induction of labor has been associated with an increased risk of emergency cesarean delivery. Knowledge of factors that influence the risk of cesarean delivery in women with induced labor is limited. METHODS: We performed a case-control study, nested within a population-based cohort of women with induced labor at term during 1991-1996 in Uppsala County, Sweden. Cases were women delivered with emergency cesarean delivery, and controls were women vaginally delivered (n = 193, respectively). Using logistic regression, analyses were performed. Odds ratio (OR) with 95% confidence intervals (CI) was used as a measure of relative risk. RESULTS: Women with a previous cesarean delivery had high risks of cesarean delivery (adjusted OR = 10.10, 95% CI = 3.30-30.92). The risk of cesarean delivery was also increased among nulliparous (adjusted OR = 4.92, 95% CI = 2.81-8.61), short (adjusted OR = 2.20, 95% CI = 1.06-4.59), and obese women (adjusted OR = 2.03, 95% CI = 1.07-3.84). A cervix dilatation less than 1.5 cm doubled the risk of cesarean delivery (adjusted OR = 2.26, 95% CI = 1.09-4.66). Mother's age, epidural analgesia, oxytocin augmentation, gestational age, and birthweight were not significantly associated with risks of cesarean delivery. CONCLUSIONS: Women with a previous cesarean delivery, nulliparous, short, and obese women with induced labor are at high risk of a cesarean delivery. When there is a need to deliver a woman with a previous cesarean section or a nulliparous woman with other risk factors for cesarean delivery, it may be prudent to consider an elective cesarean section.     

Parity, mode of delivery, and pelvic floor disorders

OBJECTIVE: This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders. METHODS: The prevalence of pelvic organ prolapse, stress urinary incontinence, overactive bladder, and anal incontinence was assessed in a random sample of women aged 25-84 years by using the validated Epidemiology of Prolapse and Incontinence Questionnaire. Women were categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated with logistic regression, controlling for age, body mass index, and parity. RESULTS: In the 4,458 respondents the prevalence of each disorder was as follows: 7% prolapse, 15% stress urinary incontinence, 13% overactive bladder, 25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder. CONCLUSION: The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery. LEVEL OF EVIDENCE: II-2.     

剖宫产分娩对婴儿健康影响的前瞻性研究

目的:了解剖宫产分娩对婴儿健康的影响。方法:采用配对前瞻性队列研究,选取602名不具备剖宫产术绝对指征的妇女及其新生儿为对象,其中301名妇女为剖宫产分娩,301名妇女为阴道分娩,二组对象按照手术指征进行配对,分别在产后1个月、6个月及12个月进行随访,了解婴儿的健康状况。结果:产后近期及各次随访期间未发现剖宫产、阴道分娩二组婴儿疾病发生危险的差异。产后1个月剖宫产儿因病住院率相对低于阴道分娩儿,但1年总计,二组婴儿因病住院比例的差别无统计学意义。婴儿常见病1年总计比较的结果发现剖宫产后发生婴儿腹泻的危险是阴道分娩儿的1.25倍(95%CI:1.01-1.56)。结论:不具备剖宫产术绝对指征的妇女,剖宫产与婴儿疾病的发生没有关联,但有增加婴儿腹泻发生的危险。     

Epidural analgesia with sufentanil during labor and operative delivery

BACKGROUND: It has been argued that by adding an opioid to the local anesthetic drug used for epidural analgesia during childbirth, one can reduce the risk of operative delivery. Objective. In a population-based observational study, to evaluate the effect of adding an opioid to a local anesthetic drug on the risk of instrumental delivery or cesarean section. DESIGN: Comparison of delivery units adding/not adding opioid to the local anesthetic for epidural analgesia in labor. SETTING: All deliveries using epidural analgesia in Sweden during 1992-96 were evaluated on the basis of information stored at the Medical Birth Registry, the National Board of Health and Welfare, Stockholm. METHOD: A questionnaire was sent to all delivery units (n=61), as well as to the Head of corresponding Anesthesiology Department in each hospital, requesting information regarding the period when opioids (sufentanil) were first added to the local epidural analgesic. Parturients given epidural analgesia were divided into three time-related groups: those delivered before the introduction of opioids (n=34,071), when opioids were first added (n=7,236), and since the introduction of opioids (n=44,384). Odds ratio (OR) with 95% confidence interval (CI) was used to assess the effect of sufentanil versus no sufentanil, on the risk of operative delivery. The parturients were stratified for year of delivery, age, and parity. Main outcome measures. Instrumental delivery, cesarean section, length of stay in hospital post partum. RESULTS: A significant reduction was observed in the incidence of instrumental delivery (OR 0.72; 95% CI 0.68-0.76). A similar though less pronounced effect was evident concerning the risk of cesarean section for nulliparae (OR 0.79; 95% CI 0.72-0.88) but not for multiparae (OR 0.93; 95% CI 0.80-1.07). Fewer women with an opioid added to the local anesthetic spent more than 4 (or more than 7) days in hospital post partum, compared with those given epidural analgesia without an opioid. CONCLUSION: When added to the local anesthetic used for epidural analgesia, as in Sweden during the last 5 years, opioids appear to reduce the incidence of instrumental delivery and cesarean section and also the post partum hospital stay.     

Non-medical factors affecting antenatal preferences for delivery route and actual delivery mode of women in southwestern Iran

Objective: Assessment of the contribution of non-medical factors to mode of delivery and birth preference in Iranian pregnant women in southwestern Iran.

Study design: This cohort study used data from a structured questionnaire completed in early pregnancy and information about the subsequent delivery obtained through personal contact. Women were recruited by random sampling from antenatal clinics when scheduling visits over the course of 5 weeks from December 2012 to February 2013 and were followed-up 1 month after birth. Of the 2199 women recruited, 99.63% were eligible for the study.

Results: Of the 748 women who expressed a desire to deliver their babies by cesarean section (CS) in early pregnancy, 87% had an elective cesarean section. The logistic regression analyses showed that normative beliefs (odds ratio [OR] 1.792, 95% confidence interval (1) 1.073–2.993), control beliefs (OR: 0.272, 95% CI: 0.162–0.459), and evaluation of outcomes (OR: 0.431, 95% CI: 0.268–0.692) favored the preference for cesarean section. The desire for delivery by elective cesarean section was associated with normative beliefs (OR: 1.138; 95% CI: 1.001–1.294), control beliefs (OR: 0.804; 95% CI: 0.698–0.927), and expectations about maternity care (OR: 0.772; 95% CI: 0.683–0.873), medical influences (OR: 1.150; 95% CI: 1.023–1.291), evaluation of outcome (OR: 0.789; 95% CI: 0.696–0.894), age, preference for cesarean section (OR: 5.445; 95% CI: 3.928–7.546), spouse educational level, and number of live births.

Conclusions: A woman’s preference for delivery by cesarean section influenced their subsequent mode of delivery. Asking women in early pregnancy about their preferred mode of delivery provides the opportunity to extend their supports which might reduce the rate of elective cesarean section. This decision is affected by age, spouse educational level, number of live births, and preconceived maternal attitudes about delivery.     

Cohort study of operative delivery in the second stage of labour and standard of obstetric care

Objective To assess the maternal and neonatal morbidity following operative delivery in the second stage of labour in relation to the standard of obstetric care.
Design Cohort study.
Setting Maternity units in two teaching hospitals in Bristol, United Kingdom.
Population Three hundred and ninety-three women with term, singleton, cephalic pregnancies who required operative delivery in theatre at full dilatation between February 1999 and February 2000.
Methods Morbidity was compared for completed instrumental delivery, failed instrumental delivery and immediate caesarean section in relation to duration of second stage of labour, number of pulls at attempted instrumental delivery, number of instruments used and operator experience.
Main outcome measures Maternal trauma, admission to special care baby unit, neonatal trauma.
Results Failed instrumental delivery after a long second stage of labour was associated with increased maternal trauma (adjusted odds ratios [OR] 4.1, 95% confidence interval [CI] 1.1, 16.5). More than three pulls at attempted instrumental delivery was associated with increased neonatal trauma for completed (adjusted OR 4.2, 95% CI 1.6, 9.5) and failed deliveries (adjusted OR 7.2, 95% CI 2.1, 24.0). Babies delivered after failed instrumental delivery with more than three pulls were at increased risk of admission to special care baby unit (adjusted OR 6.2, 95% CI 1.6, 22.8) The use of multiple instruments was associated with increased neonatal trauma (adjusted OR 3.1, 95% CI 1.5, 6.8; adjusted OR 4.4, 95% CI 1.3, 14.4, for completed and failed deliveries, respectively). Excessive pulls and multiple instrument use were associated with an initial attempt at vaginal delivery by an inexperienced operator, 25/48 (52%) and 34/75 (45%).
Conclusion Guidelines for safe operative delivery in the second stage of labour should be developed and adhered to in order to reduce morbidity, particularly neonatal trauma.     

Stress urinary incontinence 4 years after the first delivery: a retrospective cohort survey

BACKGROUND: Our aim was to estimate the prevalence of stress urinary incontinence 4 years after the first delivery and analyze its risk factors. METHODS: A retrospective cohort survey was conducted in a French university hospital. The 669 primiparous women who delivered in our department in 1996 a singleton in a vertex position between 37 and 41 weeks of amenorrhea were included. A mailed questionnaire was sent 4 years after the indexed delivery. The main outcome measure was stress urinary incontinence 4 years after the first delivery. RESULTS: Three hundred and seven women replied, 274 had moved and 88 did not respond. Four years after the first delivery, prevalence of stress urinary incontinence was 29% (89/307). According to multiple logistic regression analysis, the independent risk factors were urine leakage before the first pregnancy [odds ratio (OR) 18.7; 95% confidence interval (CI) 3.6-96.4], urine leakage during the first pregnancy (OR 2.5; 95% CI 1.3-4.8), duration of first labor > or = 8 h (OR 3.1; 95% CI 1.7-5.7), mother's age > 30 years at the first delivery (OR 2.4; 95% CI 1.4-4.2) and cesarean section at the first delivery (OR 0.3; 95% CI 0.1-0.9). CONCLUSION: Our results suggest that stress urinary incontinence after pregnancy arises from a multifactorial condition. The main risk factors are: age, previous incontinence (before or during the first pregnancy), prolonged labor and vaginal delivery.     

Cesarean delivery and peripartum hysterectomy

OBJECTIVE: To estimate the national incidence of peripartum hysterectomy and quantify the risk associated with cesarean deliveries and other factors. METHODS: A population-based, matched case-control study using the United Kingdom Obstetric Surveillance System, including 318 women in the United Kingdom who underwent peripartum hysterectomy between February 2005 and February 2006 and 614 matched control women. RESULTS: The incidence of peripartum hysterectomy was 4.1 cases per 10,000 births (95% confidence interval [CI] 3.6-4.5). Maternal mortality was 0.6% (95% CI 0-1.5%). Previous cesarean delivery (odds ratio [OR] 3.52, 95% CI 2.35-5.26), maternal age over 35 years (OR 2.42, 95% CI 1.66-3.58), parity of three or greater (OR 2.30, 95% CI 1.26-4.18), previous manual placental removal (OR 12.5, 95% CI 1.17-133.0), previous myomectomy (OR 14.0, 95% CI 1.31-149.3), and twin pregnancy (OR 6.30, 95% CI 1.73-23.0) were all risk factors for peripartum hysterectomy. The risk associated with previous cesarean delivery was higher with increasing numbers of previous cesarean deliveries (OR 2.14 with one previous delivery [95% CI 1.37-3.33], 18.6 with two or more [95% CI 7.67-45.4]). Women undergoing a first cesarean delivery in the current pregnancy were also at increased risk (OR 7.13, 95% CI 3.71-13.7). CONCLUSION: Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity greater than 3. LEVEL OF EVIDENCE: II.     

Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample

BACKGROUND: The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish-speaking women, and to identify possible predictors. METHODS: A cohort study, including 2390 women recruited from 593 antenatal clinics in Sweden during three 1-week periods evenly spread over 1 year (1999-2000), representing 53% of women eligible for the study and 75% of those who consented to participate. Data were collected by means of questionnaires in early pregnancy, 2 months and 1 year after the birth, and from the Swedish Medical Birth Register. RESULTS: One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery (OR 5.5, CI 95% 4.1-7.4) as well as after a cesarean section (OR 11.9, CI 95% 2.9-48.1). Other predictors in women with a vaginal delivery were: multiparity (OR 1.4; CI 95% 1.1-1.8), obesity (OR 1.6; CI 95% 1.1-2.4) and constipation 4-8 weeks postpartum (OR 1.4; CI 95% 1.1-1.9). CONCLUSION: Stress incontinence 1 year after childbirth is a common symptom, which could possibly be reduced by identifying women with urinary leakage at the postnatal check-up.     

Risk of maternal postpartum readmission associated with mode of delivery

OBJECTIVE: To determine whether cesarean and operative vaginal deliveries are associated with an increased risk of maternal rehospitalization compared with spontaneous vaginal delivery. METHODS: A population-based cohort study was conducted by using the Canadian Institute for Health Information's Discharge Abstract Database between 1997/1998 and 2000/2001, which included 900,108 women aged 15-44 years with singleton live births (after excluding several selected obstetric conditions). RESULTS: A total of 16,404 women (1.8%) were rehospitalized within 60 days after initial discharge. Compared with spontaneous vaginal delivery (rate 1.5%), cesarean delivery was associated with a significantly increased risk of postpartum readmission (rate 2.7%, odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8-1.9); ie, there was 1 excess postpartum readmission per 75 cesarean deliveries. Diagnoses associated with significantly increased risks of readmission after cesarean delivery (compared with spontaneous vaginal delivery) included pelvic injury/wounds (rate 0.86% versus 0.06%, OR 13.4, 95% CI 12.0-15.0), obstetric complications (rate 0.23% versus 0.08%, OR 3.0, 95% CI 2.6-3.5), venous disorders and thromboembolism (rate 0.07% versus 0.03%, OR 2.7, 95% CI 2.1-3.4), and major puerperal infection (rate 0.45% versus 0.27%, OR 1.8, 95% CI 1.6-1.9). Women delivered by forceps or vacuum were also at an increased risk of readmission (rates 2.2% and 1.8% versus 1.5%; OR forceps: 1.4, 95% CI 1.3-1.5; OR vacuum: 1.2, 95% CI 1.2-1.3, respectively). Higher readmission rates after operative vaginal delivery were due to pelvic injury/wounds, genitourinary conditions, obstetric complications, postpartum hemorrhage, and major puerperal infection. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery, and operative vaginal delivery increase the risk of maternal postpartum readmission. LEVEL OF EVIDENCE: II-2.     

女性压力性尿失禁发生的危险因素分析

目的 调查城市社区女性压力性尿失禁发生的危险因素。方法 按照1：8随机抽样的方法,抽取福州市鼓楼区6066例妇女。调查项目包括：年龄、职业、文化程度、体重、血压、月经史、孕产史、分娩方式、新生儿体重、慢性疾病(高血压、糖尿病、慢性咳嗽、习惯性便秘)、腹腔或盆腔手术史、生活习惯(吸烟、酗酒、体育锻炼方式等)、尿失禁症状和发生频率、就医情况等。数据采用多因素回归分析。结果 问卷回收率为92．1％(5587／6066)。尿失禁发生率为18．1％,其中压力性尿失禁占8．8％。调查显示,诸因素中年龄[OR：1．010;95％可信限(CI)：1．001—1．025]、高体重指数(OR：1．092;95％CI：1．054—1．132)、高血压(OR：2．342;95％CI：1．026～5．349)、便秘(OR：1．448;95％CI：1．216—1．725)、多次流产(OR：1．306;95％,CI：1．113～1．533)、多次阴道分娩(OR：1．205;95％CI：1．009—1．440)、加腹压助产(OR．1．684;95％CI:1．140—2．489)、会阴直切(OR：2．244;95% CI：1．162～4．334)、会阴裂伤(OR：2．576;95％CI：1．724～3．851)、会阴切口感染(OR：5．988;95％CI：1．936—18．616)是尿失禁发生的危险因素。结论 压力性尿失禁的发生与多种因素有关,尤其与年龄和妊娠、分娩等产科因素关系密切。     

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.     

Extra-amniotic saline infusion increases cesarean risk versus other induction methods and spontaneous labor

Extra-amniotic saline infusion (EASI) via a Foley catheter has been thought to be comparable in efficacy to other induction and cervical ripening methods. This study examines the risk of cesarean delivery associated with EASI compared with spontaneous labor and other methods of cervical ripening. A retrospective cohort study based upon deliveries at Bellevue Hospital Center from August 2000 to December 2002 was conducted. Three groups were identified: EASI, other methods of induction such as prostaglandins and oxytocin administration, and spontaneous labor. Pairwise comparisons were performed using analysis of variance and multivariate logistic regression analysis to control for confounding variables. There were 625 charts evaluated: including 171 with EASI, 190 with other induction methods, and 264 with spontaneous labor. The rates of cesarean section were 33.9%, 17.9%, and 7.2%, respectively. When compared with spontaneous labor, there was a higher risk of cesarean delivery for subjects induced with other methods (adjusted odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.5; P < 0.001), and for those induced with EASI (adjusted OR, 5.5; 95% CI, 3.1 to 9.9; P < 0.001). When EASI was compared with other methods of induction, the risk of cesarean delivery was still increased (adjusted OR, 2.3; 95% CI, 1.4 to 3.8; P = 0.001). EASI is associated with an increased risk of cesarean delivery compared with spontaneous labor and other methods of cervical ripening.     

Perinatal factors associated with cerebral palsy in children born in Sweden

OBJECTIVE: To identify perinatal factors associated with cerebral palsy (CP). METHODS: This was a case-control study based on the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry, including 2,303 infants born in Sweden 1984-1998 with a diagnosis of CP and 1.6 million infants without this diagnosis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Infants born preterm had a highly increased risk for CP, and constituted 35% of all cases; OR 34 (95% CI 29-39) in weeks 23-27, OR 37 (95% CI 32-42) in weeks 28-29, OR 26 (95% CI 23-30) in weeks 30-31, and OR 3.9 (95% CI 3.4-4.4) in weeks 32-36. Boys had a higher risk (sex ratio 1.36:1), particularly before term (sex ratio 1.55:1). Other factors associated with CP were being small or large for gestational age at birth, abruptio placentae (OR 8.6, 95% CI 5.6-13.3), maternal insulin-dependent diabetes mellitus type 1 (OR 2.1, 95% CI 1.4-3.1), preeclampsia (OR 1.5, 95% CI 1.3-2.4), being a twin (OR 1.4, 95% CI 1.1-1.6), maternal age older than 40 years (OR 1.4, 95% CI 1.1-1.8) or 35-39 years (OR 1.2, 95% CI 1.1-1.4), primiparity (OR 1.2, 95% CI 1.1-1.3), and smoking (OR 1.2, 95% CI 1.1-1.3). In term infants, low Apgar scores were associated with a high risk for CP; OR 62 (95% CI 52-74) at score 6 at 5 minutes, OR 498 (95% CI 458-542) at score 3. Other factors associated with CP in term infants were breech presentation at vaginal birth (OR 3.0, 95% CI 2.4-3.7), instrumental delivery (OR 1.9, 95% CI 1.6-2.3), and emergency cesarean delivery (OR 1.8, 95% CI 1.6-2.0). CONCLUSION: Preterm birth entails a high risk for CP, but 65% of these children are born at term. Several obstetric factors and low Apgar scores are associated with CP. LEVEL OF EVIDENCE: II-2.