Preterm caesarean section

Summary. A retrospective study of 1921 caesarean sections at Rutherglen Maternity Hospital in Glasgow during the years 1979–1983, inclusive, showed that 229 (12%) were performed at less than 37 weeks gestation. Of these 229 preterm caesarean sections 41% were elective, 21% were for antepartum haemorrhage and 38% took place during labour. Of the 254 babies born 18 (7%) died in the neonatal period. These deaths comprised 31% of all neonatal deaths during the study period in this hospital. The neonatal death rate was 70% for babies weighing <1000 g (7 of 10) and 23% for babies weighing 1000–1500 g (6 of 26), but only 3% for babies heavier than this (7 of 217). Of the 75 women with a subsequent pregnancy after the preterm caesarean section 56% were again delivered by caesarean section. In view of the maternal morbidity associated with caesarean section and the poor neonatal outcome at birthweights of <1500g, the use of operative delivery for very low birthweight infants deserves further scrutiny.     

Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-2003

We conducted a retrospective analysis of perinatal mortality at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania 1999-2003 in order to categorise/classify perinatal deaths as well as to identify key factors in perinatal care that could be improved. Data were retrieved from the MNH obstetric database and causes of early neonatal deaths were traced from the neonatal ward register. The study includes all foetuses weighing =500g. A modified Nordic-Baltic classification was used for classification of perinatal deaths. Over a 5-year period there were 77,815 babies born with a perinatal mortality rate of 124 per 1000 births, 78% of which was labour related stillbirth. The PMR was 913/1000 for singleton births and 723/1000 for multiple births for babies weighing less than 1500 grams and 65/1000 for singleton births and 116/1000 for multiple births for babies weighing 2500 grams or more. Babies weighing less than 1500 grams contributed 26% of PMR, whereas 41% occurred in babies weighing 2500 grams or more. The majority (79%) of neonatal deaths had Apgar score <7 at 5 minutes and the most common causes of neonatal mortality were birth asphyxia (37%) and prematurity (29%). Labour related deaths were more common in multiple pregnancies. The majority of the perinatal deaths should be essentially avoidable through improved quality of intrapartum care. Establishment of perinatal audit at MNH can help identify key actions for improved care.     

Caesarean or vaginal delivery for preterm very-low-birth weight (≤1,250 g) infant: experience from a district general hospital in UK

Objective To determine whether delivery by caesarean is associated with a better neuro-developmental outcome at two years for preterm infants born weighing 1,250 g or less. Setting District General Hospital, United Kingdom. Design All inborn infants weighing <1,250 g born at St Helier University Hospital between January 1995 and December 2003 were identified from contemporaneously collected computer database. All hospital records were retrieved. Details of the mother, delivery route, Apgar score, details of resuscitation and details of the baby, neonatal progress and neuro-developmental status at two years was transcribed on a pre-designed proforma. Neuro-developmental status assessment at two years of age was carried out by an independent neurodevelopmental paediatrician. Neuro-developmental status was classified as normal, severe, moderate or mild disability. Statistical analysis Analysis was done by creating a simple two by two table. Statistical significance was set at p = 0.05. Multivariate and univariate analysis was carried out for a number of confounding variables. Sample Total of 411 babies were identified from the data-base. Of these 59 were still born and fourteen though born alive died in the delivery suit. 125 (37%) were excluded from analysis as they were returned to their referring hospitals prior to discharge from hospital. Information about their two-year follow-up was either incomplete or not robust enough to be included in the analysis. Analysis was carried out on 213(63%) for whom we had complete data set at two years of age (103 infants born via vaginal delivery and 110 infants were born by caesarean section). Outcome measure Primary outcome measure was to compare survival at discharge and neurodevelopmental status at two years of age of this cohort. Secondary outcome included determining the incidence of grade III or IV intraventricular haemorrhage (IVH), chronic lung disease and necrotising enterocolitis (NEC). Results The overall caesarean delivery rate for this cohort was 51.6% while the overall caesarean rate for all births at our hospital during the study period varied between 20 and 23%. Neonatal mortality for those delivered by caesarean was 12.7% compared to 14.5% for those delivered vaginally (p = ns). Overall incidence of any neuro-disability at two years of age was 46.8% for those delivered by caesarean compared to 47.7% for those delivered vaginally (p = ns). There was no difference in those with severe (23.5% vs. 25.0%), moderate (10.4% vs. 9%) or mild (12.5% vs. 13.6%) neuro-disability between the groups nor was there any difference in the number of babies with IVH, chronic lung disease and NEC. Neuro-disability was equally greater in both groups for babies born weighing 750 grams or less and/or born at 26 weeks or less gestation. Conclusion Despite the increasing tendency to deliver extremely preterm babies by caesarean, we did not find that it was associated with either reduced mortality or neuro-disability at two years of age. Therefore the method of delivery of very-low-birth weight premature infants should be based on obstetric or maternal indications rather than the perceived outcome of the baby.     

The peri-partum management of pregnancies with macrosomic babies weighing > or =4,500 g at a tertiary University Hospital.

The management of fetal macrosomia diagnosed antenatally presents a dilemma to the obstetrician. We retrospectively reviewed the peripartum management of singleton pregnancies, which ended in the delivery of a macrosomic baby (birth weight >/=4,500 g) in our unit between 1995 and 1999. This was to determine first, the associated maternal and neonatal morbidity and second, whether the lack of consensual management in our unit influences outcome. Over the 5-year period, there were 380 macrosomic births out of 26,974 deliveries; an incidence of macrosomia of 1.4%. The mean birth weight was 4,697 +/- 330 g (range 4,500 - 5,560 g). The onset of labour was spontaneous in 234 (61.6%) cases, 120 (31.6%) were inductions and 26 (6.8%) were elective caesarean sections. Of the 354 planned vaginal deliveries, 233 (65.8%) were spontaneous, 62 (17.5%) were operative vaginal deliveries and 59 (16.7%) were emergency caesarean sections. There was no relationship between the rate of successful vaginal delivery and birth weight. There were 40 (13.6%) cases of shoulder dystocia compared with 0.9% in the non-macrosomic population (p < 0.001). Emergency caesarean sections and shoulder dystocia were significantly more common with babies weighing >/=5,000 g (28.9% vs 15.2%, p < 0.002 for caesarean section and 25.8% vs 11%, p < 0.001 for dystocia). We therefore recommend that where the estimated fetal weight is >5,000 g, an elective caesarean section should be considered. Variations in the care provided by different consultants did not have any effect on outcome. Induction for fetal macrosomia alone did not improve outcome but was associated with a significantly higher emergency caesarean section rate and should therefore be discouraged.     

Vaginal versus cesarean section oriented approaches in the management of breech delivery

In a 5-year retrospective study, 543 singleton breech presented infants weighing more than 1000 g were reviewed in two obstetric departments. Department "A" actively conducted the labor with lower cesarean section rate (26%). Department "B" attempted a trial of labor with less invasive procedures and performed more cesarean sections (38% P less than 0.05 S). The management of labor, fetal and maternal outcome were compared between the two departments. Both vaginal and abdominal routes of delivery in fetuses weighing more than 1500 g resulted in the same fetal and maternal outcome. For fetuses weighing 1000-1500 g cesarean section is probably the recommended delivery route.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Summary. Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1·5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0·3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1.5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0.3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230 g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Perinatal Death: Audit and Classification

Two hundred and thirteen perinatal deaths occurred in a population of 10,539 deliveries over a 4-year period. The associated obstetric complications and circumstances were analysed. The majority of perinatal deaths occurred in fetuses in whom there was a serious malformation, or whose birth weight was less than 800 g. Of the 110 deaths which occurred in normal babies weighing 800 g or more, 54 were antepartum, 5 were intrapartum, and 51 were neonatal. The clinical features surrounding these deaths were classified, and their implications discussed.     

The effect of mode of delivery on neonatal outcome of twins with birthweight under 1500 grams.

The purpose of this retrospective study was to evaluate the mode of delivery on neonatal outcome of twins weighing <1500 grams. We reviewed the effect of birth order, presentation, and method of delivery on neonatal outcome in twin gestation under 1500 grams at Princess Badeea' Teaching Hospital in North Jordan over the 6 years from 1994 to 1999. During the study period, there were 51 475 deliveries of which 695 were twin. One hundred and eight (108) sets of twins weighing <1500 grams were included in the study (15.5%), of which 41 were in vertex-vertex presentation, 40 in vertex-nonvertex, and 27 with first twin in nonvertex presentation. The second twin was characterised by a higher incidence of respiratory distress syndrome (82% vs. 70%; P = 0.02), more neonatal mortality (23% vs. 17.6%), and lower Apgar scores at 1 and 5 minutes. Cesarean delivery for vertex-vertex presentation did not improve the neonatal outcome. Rather, the incidence of RDS was significantly greater in this group delivered by caesarean section (65.6% vs. 42%; P = 0.012). For nonvertex presentation, those delivered by caesarean section had a lower incidence of neonatal mortality. We conclude that there was no advantage in caesarean delivery after multivariate analysis to correct for differences in birthweight between the groups. The differences in the neonatal outcome of nonvertex twin presentation was accounted for by the differences in birthweight, rather than in mode of delivery.     

Obstetric and neonatal outcome of babies weighing more than 4.5 kg: an analysis by parity

OBJECTIVES: To analyse by parity the obstetric and neonatal outcome of babies delivered weighing more than 4.5 kg. METHODS: All deliveries resulting in a baby weighing more than 4.5 kg, in the 5 years from 1991 to 1995, were identified using a computerised database. The following variables confined to singleton, cephalic pregnancies were recorded: mode of delivery, duration of labour, incidence of shoulder dystocia and admission to the neonatal centre. Outcome measures in primigravidae and multigravidae were compared using the Epi Info package (WHO, Version 6.0b January 1997). RESULTS: There were 32,834 deliveries over the study period and 828 (2.5%) weighed more than 4.5 kg. Birthweight more than 4.5 kg occurred in 1.6% (n=198) of primigravidae and 3.1% (n=630) of multigravidae (P<0.05). Primigravidae had a higher risk of prolonged labour (27.7% vs. 4.9%), operative vaginal delivery (32% vs.9%) and emergency caesarean section (24.2% vs. 5.7%) compared to multigravidae. When delivering a macrosomic baby, primigravidae had a higher incidence of prolonged labour (27% vs. 7.9%), operative vaginal delivery (32% vs.25%) and emergency caesarean section (24.2% vs. 5.7%) compared to normal weight babies. The incidence of shoulder dystocia and elective caesarean section were similar in both primigravidae and multigravidae. CONCLUSIONS: Macrosomic infants have an increased incidence of prolonged labour, operative vaginal delivery and emergency caesarean section compared with normal weight babies and these complications are more pronounced in primigravidae compared to multigravidae. Shoulder dystocia occurs with equal frequency in primigravidae and multigravidae. The poor antenatal predictability of macrosomia, the high rate of vaginal delivery and the low incidence of shoulder dystocia would not support the use of elective caesarean section for delivery of the macrosomic infant either in primigravidae or multigravidae.     

Delivery of very premature infants: does the caesarean section rate relate to mortality,morbidity, or long-term outcome?

Summary A retrospective analysis of obstetric factors influencing mortality and morbidity of very premature infants (1500 g, ⩽ 32 weeks’ gestation) was undertaken. The study included 275 such infants born in the Department of Obstetrics of the University of Tübingen during the period January 1977 to June 1987. The caesarean section rate of very preterm infants increased from 28% during the period 1977–1982 to 87% during the period 1982–1987 (P<0.005), accompanied by an increase in survival rate from 63% to 70%. The improvement in survival rate was statistically significant for the group with birth weight 751–1000 g (P<0.01). The overall mortality rate was 31% after caesarean section and 36% after vaginal delivery. Amongst the causes of death of the non-survivors, acidosis was more frequent and amniotic infection syndrome less frequent in the infants delivered vaginally than in those delivered abdominally. The proportion of children with normal development at two years of age was significantly (P<0.02) greater amongst those born in 1982–1987 than in those born in 1977–1981. The interpretation of these findings is by no means clear but must include the hypothesis that the increased caesarean section rate may be incidental and in no way related to the improved outcome.     

A case-control study of the effects of birth by caesarean section on intrapartum and neonatal mortality among twins weighing 1500-2499 g

The aim of this nationally-based, matched case-control study was to assess the impact of birth by caesarean section on intrapartum, and neonatal mortality among twins weighing 1500-2499 g, born in Sweden between 1973 and 1983. By using data held at the National Medical Birth Registry, Stockholm, 91 such pregnancies (study cases) where one or both twins died were identified. For each case, two controls (in all 182 pregnancies) were allotted at random from the rest of the twin pregnancies, with similar birthweight (+/- 100 g) and year of delivery (+/- 1 year). The number of twins that died was reduced from 73 during the first four years to 22 between 1977 and 1980, and to 6 during the last 3 years of the study period. Almost a quarter (23.1%) had a lethal malformation. The caesarean section rate increased during the study period, but did not differ between cases and controls (chi 2 = 1.0; P greater than 0.05). The analysis could not confirm a significant difference between cases and controls regarding the number of infants born vaginally in non-vertex presentation (chi 2 = 0.1; P greater than 0.05). The results of this study appear to indicate that birth by caesarean section was not a major factor related to the improved fetal outcome.     

Introducing caesarean section audit in a regional teaching hospital in The Netherlands

OBJECTIVE: The increase in caesarean section rates is considered a reason for serious public health concern. With the objective to create awareness and initiate local discussion, obstetric audit was introduced in a regional teaching hospital in The Netherlands. STUDY DESIGN: Caesarean section audit was introduced during the existing daily reports meetings from August 1, 2005 to June 1, 2006 in The Haga hospital, a large teaching hospital in The Hague, The Netherlands. All caesarean sections were discussed with regard to indication, classification and audited for 'lack of necessity'. For comparing intervention rates with the period prior to audit, Chi-square test with Yates correction for 2 x 2 tables was used. RESULTS: Of 1221 deliveries, 228 were caesarean sections (18.7%) while prior to the audit period there were 1216 deliveries with 284 were caesarean sections (23.4%). The caesarean section rate is significantly lower during the audit period. Assisted vaginal deliveries, neonatal outcome, and induction of labor rates were comparable. Concerning the audit question 'could caesarean section have been prevented', there was discussion in 24.4% of cases. In 6.7% of caesarean sections, consensus about lack of necessity was achieved. CONCLUSION: Introducing caesarean section audit during the existing structure of daily report meetings in a regional teaching hospital is both feasible and practical. It creates awareness and encourages discussion among staff members concerning indications for caesarean sections and lack of necessity. Furthermore, there was a significant decrease in caesarean section rate during the audit period.     

Determinants of caesarean section rates in Italy.

OBJECTIVE: To analyse the determinants of caesarean section rates in Italy. DESIGN: Analysis of information using a standard form on all the deliveries after the 28th week of gestation routinely collected by the Italian Central Institute of Statistics. SETTING: National data of all Italian deliveries in the periods 1980-1983. SUBJECTS: A total of more than 2,400,000 deliveries occurred in Italy in the period and are considered in this analysis. RESULTS: The frequency of caesarean section rose from 11.2/100 deliveries in 1980 to 14.5/100 in 1983. Caesarean section rates were lower in the Southern (less rich) areas, and rose steadily with maternal age, being about three times higher in women aged greater than or equal to 40 years than in teenagers. Maternal education was directly associated with caesarean section rates: compared with women with only primary school education, those with a college education reported an about 40% higher rate of caesarean section, but this difference dropped markedly after allowance for maternal age and birthweight. The section rate was 13.3/100 deliveries in public hospitals and 11.8/100 in private ones, but this reflected the different utilization of public and private services in various geographical areas. Birthweight and gestational age at delivery were important determinants of caesarean section rates; lowest values were observed for very-low-birthweight and very preterm deliveries and babies weighing 3000-3999 g and term deliveries. Caesarean section rates were about 20% higher in nulliparous than in parous women and the rates increased with number of stillbirths or miscarriages; further, the rate ratio was about double in multiple than in single births. CONCLUSION: Caesarean section rates in Italy in the early 1980s were still lower than in North America, but their determinants share several similarities with those reported in other areas.     

Declining perinatal mortality in Finland between 1987 and 1994: Contribution of different subgroups

Objective: To examine the extent to which the decline in perinatal mortality is attributable to some subgroups, especially to certain birthweight or gestation groups. Study Design: A register study using the Finnish Medical Birth Register for years 1987 to 1994. Results: Of the overall reduction in perinatal mortality from 8.8 to 6.7 per 1000 births, 78% was due to stillbirths, compared with 22% due to early neonatal deaths. The decline in mortality among infants who weighed under 1500 g at birth was the major contributor (62%) to the overall reduction in perinatal mortality. The largest decline in mortality in the stillbirth group occurred among those weighing < 1000 g, while for early neonatal deaths the group most affected weighed 1000-1499 g. A similar pattern emerged when the gestation-week groups were examined. Conclusion: The decline in perinatal mortality is attributable to stillbirths of very low birthweight. The most likely explanations for this result are the improved antenatal and neonatal care and the wider use of malformation screening.     

Outcome of triplets and high-order multiple pregnancies

PURPOSE OF REVIEW: To present data related to the outcome of triplets and high-order multiple pregnancies. RECENT FINDINGS: Current frequencies of high-order multiple pregnancies in most developed countries range between 400 and 800% above the rates observed in the late 1970s. Of particular importance is the striking increase in pregnancies in older mothers. These epidemiological trends are the result of modern infertility treatments. The improved outcome of triplets may be attributed to close antenatal and perinatal care, both of which are more likely to be implemented in patients who can afford treatment for infertility. The overall odds of delivering at least one triplet infant weighing less than 1000 g is approximately 10%. The neonatal complications among triplets weighing less than 1500 g at birth are not much different from those among twins or singletons, except for a higher neonatal mortality rate. Despite this, the frequency of cerebral palsy bears a significant exponential relationship to the number of fetuses, and iatrogenic multiple births are clearly implicated in the increased cerebral palsy rate. In the past few years the perinatal mortality rate for triplets has been approximately 110/1000, three-quarters of which represent neonatal deaths. SUMMARY: Available data imply that in order to improve outcomes further, all multiple pregnancies deserve optimal perinatal care, something that is not always obtainable.     

Maternal morbidity after elective repeat caesarean section after two or more previous procedures

OBJECTIVES: To determine the incidence of maternal morbidity following elective caesarean section in women with a history of at least two previous caesarean sections, and to determine if the incidence of morbidity correlates with the number of previous sections. STUDY DESIGN: We conducted an individual chart review of all women who had an elective caesarean section because of a history of two previous sections from 1990 to 1999. RESULTS: There were 67,097 deliveries of babies weighing 500 g or more. The total number of cases eligible for the study was 250. There were 12 cases (4.8%) of placenta praevia of which four required a transfusion and two a hysterectomy. The incidence of wound infection was 6.3% and urinary tract infection was 11.2%. There were no cases of thromboembolism recorded. CONCLUSIONS: Maternal morbidity with elective repeat caesarean section is low. The major morbidity is associated with placenta praevia. We found no correlation between the incidence of maternal morbidity and the number of previous sections.     

Anaesthetic management of patients with pre-eclampsia/eclampsia and perinatal outcome

Objective.?This study examined risk factors for perinatal mortality associated with anaesthesia for caesarean delivery in patients with pre-eclampsia/eclampsia. The study is apt because perinatal mortality rate is one of the indicators of health status of pregnant women, new mothers and their newborns. The information obtained may help to assess changes in public health policy and practise amongst women of child-bearing age.

Aim.?The role of anaesthesia in perinatal outcome in pre-eclamptics.

Methods and materials.?The hospital records (cases notes, labour ward and newborn special care unit and theatre records) of patients with pre-eclampsia/eclampsia, which had caesarean delivery and their babies at the University of Nigeria Teaching hospital (UNTH), Enugu, Nigeria from July 1998 to June 2006, were retrospectively reviewed. The term perinatal mortality refers to stillbirths and neonatal deaths within 7 days of birth.

Results.?There were a total of 6798 deliveries and 1579 women delivered through caesarean section. Of these, 196 were patients with pre-eclampsia/eclampsia. There were a total of 19 stillbirths (9%) and 19 (9%) early neonatal deaths in the pre-eclampsia/eclampsia group going a perinatal mortality of 180/1000 births. Amongst these women, 157 delivered under general anaesthesia, 34 under spinal anaesthesia and five under epidural block. Of the 38 perinatal deaths, 30 delivered by general anaesthesia and eight by regional anaesthesia.

Conclusion.?Pre-eclampsia/eclampsia continues to be a cause of foetal loss in the developing world even where essential obstetric services are available. Early onset management of severe pre-eclampsia with maintenance of adequate placental perfusion during anaesthesia may result in lower perinatal deaths.     

Wessex perinatal mortality survey 1982

A survey of 335 perinatal deaths in the Wessex region revealed a perinatal mortality rate of 10.1 per 1000 total births. Lethal malformations accounted for 82 (24%) deaths. Of the 253 normally formed infants, 124 (49%) died during pregnancy and 33 (13%) in labour. More than 60% of the stillbirths weighed greater than 1500 g. Of the 96 postpartum deaths, half occurred within 24 h of delivery, mostly following complications of labour and circumstances suggesting hypoxia. The Aberdeen classification showed half of the mothers had pregnancy complications: other predisposing factors were identified in 10% of perinatal deaths. There were 185 neonatal deaths of which 150 occurred within 7 days and 35 within the next 3 weeks. Sixteen (46%) of the late neonatal deaths were due to a congenital abnormality; pregnancy or labour complications were present in six (32%) of the remaining 19 normally formed infants. Review of existing methods of antenatal supervision in particular, followed by the use of better monitoring systems for earlier detection of fetal distress and prompt action when indicated, together with improvement in neonatal care in the first 24 h after birth should further reduce the perinatal mortality.     

Can Anything Be Done About Mid-Trimester Fetal Wastage?

In Victoria in the triennium 1982-1984, perinatal losses between 22 and 28 weeks' gestation accounted for 32% of the overall perinatal wastage of 12.7 per 1,000 births. Over the same period only 1.2% of babies were delivered weighing less than 1,500g, but this group made up 40% of the total stillbirths and 50% of the neonatal deaths. By contrast the perinatal wastage was only 7 per 1,000 births in babies born weighing more than 1,500g and this included lethal congenital malformations. The major antenatal risk factors contributing to the high mid-trimester fetal wastage were premature labour (17.7%), multiple pregnancy (13.9%), cervical incompetence (12.9%), antepartum haemorrhage (12.9%), premature rupture of the membranes (11.5%), lethal congenital malformations (10.6%) and hypertensive disorders (7.4%). Cognizant of the frequency of preventable factors, the Consultative Council on Maternal and Perinatal Mortality and Morbidity in Victoria recommends that, where feasible, the mother of these high-risk pregnancies be transferred to a centre where facilities are available to monitor the pregnancy and labour, and which offers intensive care facilities for the baby.