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.     

Prior cesarean: a contraindication to labor induction?

In 2004, cesarean rates were the highest ever in the United States. Simultaneously, the vaginal birth after cesarean (VBAC) rate fell, largely a result of reports of uterine rupture associated with VBAC attempts. This chapter reviews the efficacy and safety of VBAC associated with labor induction. Mechanical and pharmacologic methods of labor induction (notably misoprostol) are associated with increased maternal and perinatal morbidity compared with spontaneous VBAC attempts. However, the absolute risks remain low. Labor induction is not contraindicated in women with a prior cesarean but sound judgment, clinical precautions and specific consent are required.     

Can a vaginal birth after cesarean delivery be a normal labor and birth? Lessons from midwifery applied to trial of labor after a previous cesarean delivery

Women who undergo a trial of labor after a previous cesarean delivery (TOLAC) have special needs prenatally and during the intrapartum period. Counseling about the choice of TOLAC versus an elective repeat cesarean delivery involves complex statistical concepts. Prenatal counseling that is patient centered, individualized, and presented in a way that addresses the health literacy and health numeracy of the recipient encompasses best practices that support patient decision making. Evidence-based practices during labor that support vaginal birth and increase patient satisfaction are of special value for this population.     

Once a pregnancy, always a cesarean? Rationale and feasibility of a randomized controlled trial

Although vaginal delivery has long been assumed to be the preferred route of delivery in women who have not had a prior cesarean delivery, some have recently advocated that women be offered the option of elective, primary cesarean delivery in all pregnancies. Available outcome data, however, do not permit ready comparison of these alternate plans for delivery. Important maternal outcomes include short-term complications such as death, bleeding, infection, and damage to pelvic organs as well as long-term effects on future pregnancies, fecal and urinary incontinence, and pelvic organ prolapse. Important neonatal outcomes include asphyxic and traumatic birth injury, infection, respiratory complications, and stillbirth. To weigh the relative merits of elective primary cesarean delivery and a trial of labor, a randomized controlled trial is needed. Such a trial would be both ethical and feasible.     

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.     

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.     

Is vaginal birth after cesarean less expensive than repeat cesarean delivery?

OBJECTIVE: This study was undertaken to compare total medical costs of trial of labor after cesarean with those of elective repeat cesarean without labor, with both short- and long-term neonatal costs associated with such procedures taken into account. STUDY DESIGN: Costs associated with All Patient Refined diagnosis-related groups and Current Procedural Terminology for a large not-for-profit health care system were applied to an algorithm describing maternal and neonatal outcomes of trial of labor. Perinatal morbidity rates and cost estimates for long-term neurologic damage associated with uterine rupture were derived from published literature. RESULTS: If a 70% vaginal birth rate for women undergoing a trial of labor and delivery in a tertiary center with a mean uterine rupture to delivery time of 13 minutes is assumed, the net cost differential ranged from a saving of $149 to a loss of $217, depending on morbidity assumptions. For vaginal birth after cesarean success rates <70%, trial of labor in the presence of two previous scars, and institutional factors increasing the perinatal morbidity rate by just 4% with respect to that seen in tertiary centers, trial of labor resulted in a net financial loss to the health care system regardless of all other assumptions made. CONCLUSIONS: When costs as opposed to charges are considered and the cost of long-term care for neurologically injured infants is taken into account, trial of labor after previous cesarean is unlikely to be associated with a significant cost saving for the health care system. Recent government-mandated length-of-stay requirements are likely to make the economic benefit of vaginal birth after cesarean even less favorable. Factors other than cost must govern decisions regarding trial of labor or repeat cesarean.     

Can we consider cesarean myomectomy as a safe procedure without long-term outcome?

Aim: To investigate short- and long-term outcomes in women undergoing cesarean myomectomy (CM).

Methods: This was a retrospective study that explored short-term outcomes of women, who underwent cesarean operations with or without myomectomies (CM controls) in a single tertiary center throughout a 6-year-period. For long-term outcomes, the mean duration of follow-up was 6.3?±?1.0 years.

Results: There were no differences among the CM (n=?91) and control groups (n?=?60) considering mean change in hemoglobin and hematocrit levels, hemorrhage, as well as requirement for blood transfusions with a slightly increased operative time. Multiple myomas, and cervical and cornual localization were associated with an increased drop of hemoglobin and hematocrit (p?n?=?1, 3.1%), uterine dehiscence (n?=?1, 3.1%), placenta previa (n?=?1, 3.1%) and mild-to-severe post-CM adhesions (n?=?8, 25%) were observed in subsequent pregnancies. Recurrence was identified in five of the nonpregnant (5.5%) women, and three of these (4.1%) underwent an additional major surgery. There was no recurrence in subsequent pregnancies.

Conclusion: The recurrence of myoma was relatively low following CM. Subsequent pregnancy is protective for recurrence of myoma without increased adhesion formation and obstetric complications.     

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.     

Does the increasing cesarean section rate reflect a shift in indications or a decline in quality?

The cesarean section rate is continuously increasing at our department, from 13.8 to 17.2% between 1999 and 2000. The mother's wishes regarding the mode of delivery weigh increasingly on our obstetric decisions. Patient acceptance of elective cesarean section is high, and the increasing cesarean section rate is influenced by paramedical factors. Obstetrics appears to be developing into a mostly surgical discipline. The effect this has on quality (and costs) remains to be seen.