Vaginal Birth After Two or More Cesarean Sections: A Five-Year Experience

ABSTRACT: Allowing a trial of labor in patients who have had a single low transverse cesarean section has become increasingly accepted and widespread in the United States. Evidence with regard to the safety of this practice in patients with two or more prior cesarean births has, however, been sparse. We performed a retrospective review of the charts of 170 patients who had undergone two or more low transverse cesarean deliveries and subsequently delivered at Wishard Memorial Hospital between January 1, 1983, and December 31, 1987. Of 35 of these women who underwent a trial of labor, 27 (77%) had a successful vaginal delivery. No increase in maternal or fetal morbidity or mortality was associated with labor. The women who underwent trial of labor had fewer postpartum complications and shorter hospital stays. Although the number of patients in this study was small, growing evidence appears to support a trial of labor in patients with two or more prior cesarean sections as a safe and successful alternative to elective repeat cesarean section.     

Postpartum Depression: A Review

ABSTRACT: Some studies link postpartum depression with the 4-day “blues,” and with severe postpartum mental illness, while other studies show differences between these or define each distinctly. Research on possible contributors to postpartum depression has moved from psychoanalytic and hormonal theories to factors in the pregnancy, birth, and postpartum periods. Interpersonal and adaptational models are presented in detail.     

Vaginal Birth After Caesarean Section: Review of Antenatal Predictors of Success

Objective: To determine antenatal factors that may predict successful vaginal birth after Caesarean (VBAC).Data Sources: The MEDLINE database was searched for all English-language articles describing the impact of various factors on outcomes when VBAC is attempted. Articles reviewed included published abstracts, retrospective and prospective studies, and meta-analyses.Criteria for Study Selection: Studies were included if they reported both a control group of pregnant women without the factor under evaluation and a study group with this factor, both undergoing a trial of labour (TOL). Other criteria included accountability for all individuals enrolled at study outset, and vaginal delivery rates in both study and control groups stated or easily calculated.Results: A nonrecurrent indication for previous Caesarean section (CS), such as breech presentation or fetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS. Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Fetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases.Conclusion: There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases.     

A Negative Birth Experience: Prevalence and Risk Factors in a National Sample

Abstract: Background : A woman's dissatisfaction with the experience of labor and birth may affect her emotional well‐being and willingness to have another baby. The aim of this study was to investigate the prevalence and risk factors of a negative birth experience in a national sample. Methods : A longitudinal cohort study of 2541 women recruited from all antenatal clinics in Sweden during 3 weeks spread over 1 year was conducted. Data were collected by three questionnaires, which measured women's global experience of labor and birth 1 year after the birth, and obtained information on possible risk factors during pregnancy and 2 months after the birth. Results : Seven percent of the women had a negative birth experience. The following risk factors were found: (1) factors related to unexpected medical problems, such as emergency operative delivery, induction, augmentation of labor, and infant transfer to neonatal care; (2) factors related to the woman's social life, such as unwanted pregnancy and lack of support from partner; (3) factors related to the woman's feelings during labor, such as pain and lack of control; and (4) factors that may be easier to influence by the caregivers, such as insufficient time allocated to the woman's own questions at antenatal checkups, lack of support during labor, and administration of obstetric analgesia. Conclusions : Many risk factors were related to unexpected medical problems and participants’ social background. Of the established methods to improve women's birth experience, childbirth education and obstetric analgesia seemed to be less effective, whereas support in labor and listening to the woman's own issues may be underestimated. (BIRTH 31:1 March 2004)     

Retrospective Review of Time to Uterotonic Administration and Maternal Outcomes After Postpartum Hemorrhage

ObjectiveDespite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion.MethodsWe reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH.ResultsOf 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively.ConclusionIn this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.     

Twin Delivery After a Previous Caesarean: A Twelve-Year Experience

Objectives: To compare maternal and neonatal morbidities between trial of labour (TOL) and elective Caesarean section in women with twin pregnancies who have had a prior Caesarean.Methods: An observational study was conducted of women with a prior Caesarean who delivered twins at 28 weeks’ gestation or greater in Ste-Justine Hospital between 1988 and 2001. Maternal and neonatal outcomes were compared between women who had a TOL (group I) and those who had an elective Caesarean delivery (group 2).Results: Twenty-six women and 52 fetuses were included in group 1 and compared to the 71 women and 142 fetuses in group 2. Maternal age, gestational age, and birth weight were comparable in both groups. In group 1, 22 (85%) out of 26 women delivered twin A vaginally and 19 (73%) delivered both vaginally. There was no significant difference in the umbilical artery cord pH, Apgar score, ventilatory support, and admission to the neonatal intensive care unit between the 2 groups. There was also no significant difference in the rate of postpartum maternal fever or decrease of serum hemoglobin between the 2 groups, but the median hospital stay was higher in the group with elective Caesarean (5.0 vs. 3.0 days, p <0.001). There were no uterine ruptures or other major complications in either group.Conclusion: There were no significant differences in maternal and neonatal morbidity outcomes between births by trial of labour and by elective Caesarean, in twin pregnancies after a prior Caesarean section. A trial of labour is associated with a shorter hospital stay.     

A Waste of Life: Fathers' Experience of Losing a Child Before Birth

Background: The prenatal loss of an expected child entails parental despair and grief. The grief after a stillborn child is sometimes described as a “forgotten form of grief” and the fathers as the “forgotten mourners.” Our aim was to describe how fathers experienced losing a child as a result of intrauterine death. Method: Eleven men were interviewed 5 to 27 months after the intrauterine death of their child during weeks 32 to 42 of pregnancy. The interviews were analyzed using a phenomenological methodology. Results: After being informed of the infant's death, most fathers first wanted their partners to have a cesarean section, but all later thought that it would be right for the child to be delivered vaginally. A strong feeling of frustration and helplessness came over them during and after the delivery. Several men found meaning and relief in their grief by supporting their partner. Tokens of remembrance from the child were invaluable, and fathers appreciated that the staff collected these items, even if the parents declined them. The perceived prerequisite for resuming their everyday lives consisted of the support they received from the hospital staff and precious memories of the child. The most important comfort in their grief was a good relationship with their partner. Some fathers missed having a man to talk to both at the time of the stillbirth and subsequently. Conclusion: The fathers' general trust in life and the natural order was suddenly and unexpectedly severely tested by the death of their child, which they perceived as a terrible waste of life. They sought understanding as grieving men and fathers from both the hospital personnel and their partners, as well as from relatives. Being able to protect their partner and to grieve in their own way was important to the fathers.     

The Sexuality of Women in Pregnancy and Postpartum: A Review

Current knowledge about sexual response in the nonpregnant woman is compared to that during each trimester of pregnancy and during the postpartum period. Circumstances which may contraindicate sexual activity, especially intercourse and orgasm, during pregnancy are specified. It is noted that pregnancy may be an opportunity to enhance marital intimacy and stability. Recommendations for those who counsel childbearing couples are outlined.     

A Systematic Review of the Relationship Between Postpartum Sleep Disturbance and Postpartum Depression

ObjectiveTo examine the relationship between postpartum sleep disturbance and postpartum depression and describe the characteristics and demographics of the samples.Data SourcesElectronic databases Medline, PubMed, Cochrane, EPOC, CINAHL, ProQuest, and Psych INFO. In addition, hand searches of bibliographies supplemented the electronic search.Study SelectionEnglish language primary studies on the relationship between postpartum sleep disturbance and postpartum depression were included. Thirteen observational studies met the inclusion criteria.Data ExtractionData that specified the relationship between sleep disturbance and postpartum depression were extracted from the studies. The data were organized per author, year, participants, setting, country, demographics, design, sample size, outcomes, evidence, and effect size.Data SynthesisThe effect size indicating the relationship between sleep disturbance and postpartum depression across the studies ranged between 0.4 and 1.7. There was evidence of a strong relationship between sleep disturbance and postpartum depression; however, the participants in the 13 studies were predominantly educated, middle class, older than age 30 years, and White. Likewise, the definition and measurement of postpartum sleep varied across the studies, which increased the possibility of bias.ConclusionsFurther research within the postpartum period involving underserved, younger women and samples with more diversity in race and ethnicity are needed.     

Women's Birth Beliefs During Pregnancy and Postpartum in the Netherlands: A Quantitative Cross-Sectional Study

Introduction

Women and care providers increasingly regard childbirth as a medical process, resulting in high use of medical interventions, which could negatively affect a woman's childbirth experience. Women's birth beliefs may be key to understanding the decisions they make and the acceptance of medical interventions in childbirth. In this study we explore women's beliefs about birth as a natural and medical process and the factors that are associated with women's birth beliefs.

Methods

Data were obtained from a cross-sectional survey of women living in the Netherlands asking them about their experiences during pregnancy and childbirth, including their beliefs about birth as a natural and medical process.

Results

A total of 3494 women were included in this study. Mean scores of natural birth beliefs ranged between 3.73 and 4.01 points, and medical birth belief scores ranged between 2.92 and 3.12 points. There were significant but very small changes between prenatal and postnatal birth beliefs. Regression analyses showed that (previous) childbirth experiences were the most consistent predictor of women's birth beliefs.

Discussion

Women's high scores on natural birth beliefs and lower scores on medical birth beliefs correspond with the philosophy of Dutch perinatal care that considers pregnancy and childbirth to be natural processes. Perinatal care providers must be aware of women's birth beliefs and recognize that they as professionals influence women's birth beliefs. They make an important contribution to women's perinatal experiences, which affects both women's natural and medical birth beliefs.     

Postpartum Depression and Adolescent Mothers: A Review of Assessment and Treatment Approaches

Postpartum depression (PPD) affects a significant proportion of adolescent mothers. Adolescence presents unique challenges that may make the young mother more vulnerable than her adult counterparts to PPD. PPD impacts a mother's ability to care for her infant and has been associated with adverse effects on child development. A review of the literature on adolescent PPD was undertaken. The prevalence and the effects of PPD are reviewed, common screening instruments for PPD are compared, and the results of treatment outcome studies are highlighted. There is a need for randomized controlled studies of interventions for adolescents with PPD. Findings from treatment outcome studies with adults with PPD and pregnant adolescents who are depressed suggest that psychosocial interventions may also be effective for adolescents with PPD. Issues in assessment and treatment of PPD among adolescents are considered.     

Systematic Review of Expected Weight Changes After Birth for Full-Term,Breastfed Newborns

ObjectiveTo summarize the findings of recent studies on neonatal weight changes that occur in the early weeks of life among full-term, breastfed newborns.Data SourcesUsing the keywords breastfeeding, newborn, infant, weight, weight loss, and growth, we searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, and MEDLINE for primary studies and secondary analyses. We also reviewed the reference lists of retrieved articles.Study SelectionQuantitative studies published in the English language from 2015 through 2019 that focused on newborn weight changes. From a total of 827 records initially screened, we included 11 studies in this analysis.Data ExtractionTwo authors independently reviewed the selected articles with the use of the Johns Hopkins Nursing Evidence-Based Practice Synthesis and Recommendations Tool. To determine evidence levels and quality ratings, we evaluated the consistency and generalizability of study results, sample sizes, study designs, adequacy of controls, and definitive nature of the conclusions.Data SynthesisBy 2 days after birth, mean weight loss among neonates was 6% to 7% of birth weight, and by Day 3, mean weight loss was usually 7% to 8%. The nadir of lost birth weight occurred on Days 2, 3, or 4 after birth. At times, breastfed newborns lost 10% or more of their birth weight. By 10 to 14 days, most newborns regained their birth weight. Rates of exclusive breastfeeding decreased when newborns lost greater amounts of weight. Compared with past studies, more sample groups in this review included exclusively breastfed newborns and weight assessments beyond birth hospitalization.ConclusionWeight loss is commonly 7% to 8% of birth weight or greater by the third day after birth among healthy, full-term, breastfed newborns.     

Maternal Height and the Risk of Preterm Birth and Low Birth Weight: A Systematic Review and Meta-Analyses

ObjectivePreterm birth (PTB) and low birth weight (LBW) are the leading causes of neonatal morbidity and mortality, but the effect of maternal height on these outcomes continues to be debated. Our objective was to determine the relationships between maternal height and PTB and LBW.Data SourcesMedline and EMBASE were searched from their inceptions.Study SelectionStudies with a reference group that assessed the effect of maternal height on PTB (< 37 weeks) and LBW (< 2500 grams) in singletons were included.Data ExtractionData were extracted independently by two reviewers.Data SynthesisFifty-six studies were included involving 333 505 women. In the cohort studies, the unadjusted risk of PTB in short-statured women was increased (relative risk [RR] 1.23; 95% CI 1.11 to 1.37), as was the unadjusted risk of LBW (RR 1.81; 95% CI 1.47 to 2.23), although not all of the studies with adjusted data found the same association. Maternal tall stature was not associated with PTB (unadjusted RR 0.97; 95% CI 0.82 to 1.14), although LBW was decreased (unadjusted RR 0.56; 95% CI 0.46 to 0.69), but not in the adjusted data.ConclusionFrom our complete systematic review and metaanalyses, to our knowledge the first in this area, we conclude that short-statured women have higher unadjusted risks of PTB and LBW and tall women have approximately one half the unadjusted risk of LBW of women of reference height.     

Economic Implications of Home Births and Birth Centers: A Structured Review

ABSTRACT: Background: It is widely perceived that home births and birth centers may help decrease the costs of maternity care for women with uncomplicated pregnancies and deliveries. This structured review examines the literature relating to the economic implications of home births and birth center care compared with hospital maternity care. Methods: The bibliographic databases MEDLINE (from 1950), CINAHL (from 1982), EMBASE (from 1980), and an “in‐house” database, Econ2, were searched for relevant English language publications using MeSH and free text terms. Data were extracted with respect to the study design, inclusion criteria, clinical and cost results, and details of what was included in the cost calculations. Results: Eleven studies were included from the United Kingdom, United States, Australia, and Canada. Two studies focused on home births versus other forms and locations of care, whereas nine focused on birth centers versus other forms and locations of care. Resource use was generally lower for women cared for at home and in birth centers due to lower rates of intervention, shorter lengths of stay, or both. However, this fact did not always translate into lower costs because, in the U.K. where many studies were conducted, more midwives of a higher grade were employed to manage the birth centers than are usually employed in maternity units, and because of costs of converting existing facilities into delivery rooms. The quality of much of the literature was poor, although no studies were excluded for this reason. Selection bias was likely to be a problem in those studies not based on randomized controlled trials because, even where birth center eligibility was applied throughout, women who choose to deliver at home or in a birth center are likely to be different in terms of expectations and approach from women choosing to deliver in hospital. Conclusions: This review highlights the paucity of economic literature relating to home births and birth centers. Differences in results between studies may be attributed to differences in health care systems, differences in methods used, and differences in costs included. Further economic research that involves detailed bottom‐up costing of alternative options for place of birth and measures multiple outcomes, including women’s preferences, would help address the question of whether out‐of‐hospital birth is beneficial in economic terms. (BIRTH 35:2 June 2008)