Maternal age and the likelihood of a maternal request for cesarean delivery: a 5-year population-based study

OBJECTIVE: The purpose of this study was to examine associations between maternal age and maternal request cesarean deliveries. STUDY DESIGN: Five-year population-based data from Taiwan (1997-2001) that covered 904,657 singleton deliveries without a clinical indication for cesarean delivery that were judged by the attending physician were subjected to multiple logistic regression, year-wise, to examine the association of maternal age with request cesarean delivery, adjusted for health care institutional characteristics. RESULTS: Request cesarean delivery rates steadily increased over the study period within each age group, disproportionately so among the 34+ age group. Women aged < 25 years were less likely than women aged 25 to 34 years (reference group) to request a cesarean delivery (odds ratio range, 0.67-0.88) and women aged 34+ were more likely than the reference group to have a request cesarean delivery (odds ratio range, 1.96-2.01), adjusted for health care institutional characteristics. CONCLUSION: Population-based data confirms the expectancy that request cesarean delivery propensity increases with maternal age.     

The effect of maternal obesity on outcomes in patients undergoing tertiary or higher cesarean delivery

Objective: To estimate the association between maternal obesity and adverse outcomes in patients without placenta previa or accreta undergoing a tertiary or higher cesarean delivery.

Study design: Retrospective cohort of patients cared for by a single MFM practice undergoing a tertiary or higher cesarean delivery from 2005 to 2013. Patients attempting vaginal delivery and patients with placenta accreta and/or placenta previa were excluded. We estimated the association of maternal obesity (prepregnancy BMI?≥?30?kg/m²) and maternal outcomes. The primary outcome was a composite of severe maternal morbidity (uterine rupture, hysterectomy, blood transfusion, cystotomy requiring repair, bowel injury requiring repair, intensive care unit admission, thrombosis, re-operation, or maternal death).

Results: Three hundred and forty four patients met inclusion criteria, 73 (21.2%) of whom were obese. The composite outcome was significantly higher in the obese group (6.8% versus 1.8%, p?=?0.024, aOR 4.36, 95% CI 1.21, 15.75). The incidence of several individual adverse outcomes were also increased in obese women, including blood transfusion (4.1% versus 0.7%, p?=?0.033, aOR 7.36, 95% CI 1.19, 45.34), wound separation or infection (20.5% versus 5.9%, p?p?=?0.024, aOR 4.40, 95% CI 1.21, 15.94).

Conclusions: In patients undergoing a tertiary or higher cesarean delivery without placenta previa or accreta, obesity increases the risk of adverse outcomes. Obese patients are at risk for blood transfusion, low 1-min Apgar scores and postoperative wound complications.     

Maternal pre-pregnancy overweight status and obesity as risk factors for cesarean delivery

Objective.?To determine the extent to which, if at all, maternal pre-pregnancy adiposity and other anthropometric factors are related to risk of cesarean delivery.

Methods.?This hospital-based prospective cohort study included 738 nulliparous women who initiated prenatal care prior to 16 weeks gestation. Participants provided information about their pre-pregnancy weight and height and other sociodemographic and reproductive covariates. Labor and delivery characteristics were obtained from maternal and infant medical records. Risk ratios (RR) and 95% CI were estimated by fitting generalized linear models.

Results.?The proportion of cesarean deliveries in this population was 26%. Women who were overweight (BMI 25.00–29.99?kg/m²) were twice as likely to deliver their infants by cesarean section as lean women (BMI <?20.00?kg/m²) (RR?=?2.09; 95% CI 1.27–3.42). Obese women (BMI ??30.00?kg/m²) experienced a three-fold increase in risk of cesarean delivery when compared with this referent group (RR?=?3.05; 95% CI 1.80–5.18). The joint association between maternal pre-pregnancy overweight status and short stature was additive. When compared with tall (height ??1.63?m), lean women, short (?<?1.63?m), overweight (BMI ??25.00?kg/m²) women were nearly three times as likely to have a cesarean delivery (RR?=?2.79; 95% CI 1.72–4.52).

Conclusion.?Our findings suggest that nulliparous women who are overweight or obese prior to pregnancy, and particularly those who are also short, have an increased risk of delivering their infants by cesarean section.     

Maternal obesity,gestational hypertension,and preterm delivery

Objective.?To study maternal obesity as a risk factor for preterm delivery.

Methods.?Maine State Birth Records Database from 1996 through 2006 was evaluated to investigate obese pregnant women compared with normal weight women regarding risk for preterm delivery. Multiple risk factors and outcomes were studied in univariable and multivariable models.

Results.?Among 58,112 pregnant women, 8% (n?=?4653) gave birth to preterm infants. Univariable analyses revealed a relationship between obesity and increased risk of prematurity. In multivariable regressions, the most important intermediate variable appears to be gestational hypertension/preeclampsia.

Conclusions.?As maternal body mass index increases in pregnancy, the risk of preterm delivery and other maternal complications increases. The obesity–prematurity relationship is complex, with hypertensive disorders of pregnancy playing a crucial role. More detailed analyses of causal pathways are warranted.     

Comparing grades of urgency for classification of cesarean delivery

Objective

To evaluate the agreement between the traditional binary system and a new system for classifying urgency of cesarean delivery among obstetricians in The Netherlands and Belgium.

Methods

A total of 212 obstetricians were requested to grade a list of 18 obstetric scenarios using 3 classification systems: traditional binary classification; a new classification using 4 grades of urgency without additional interpretation; and the new classification with additional interpretation. Agreement was assessed by weighted kappa.

Results

Seventy-nine obstetricians responded (The Netherlands 62.2%, Belgium 9.9%). There was substantial agreement among them for all 3 classification systems (κ = 0.71, traditional classification; κ = 0.70, new classification; κ = 0.67, new classification with additional interpretation).

Conclusion

The traditional binary system and the new classification of cesarean delivery based on 4 grades of urgency, with and without additional interpretation, have similar but relatively low interobserver agreement. We suggest that the new classification should be used, but future studies are necessary to evaluate the effect of this implementation.     

Examining the Effect of Maternal Obesity on Outcome of Labor Induction in Patients with Preeclampsia

Objective?The objective of this investigation was to evaluate the effect of maternal obesity, as measured by prepregnancy body mass index (BMI), on the mode of delivery in women undergoing indicated induction of labor for preeclampsia.?Study Design Following Institutional Review Board (IRB) approval, patients with preeclampsia who underwent an induction of labor from 1997 to 2007 were identified from a perinatal information database, which included historical and clinical information. Data analysis included bivariable and multivariable analyses of predictor variables by mode of delivery. An artificial neural network was trained and externally validated to independently examine predictors of mode of delivery among women with preeclampsia. Results?Six hundred and eight women met eligibility criteria and were included in this investigation. Based on multivariable logistic regression (MLR) modeling, a 5-unit increase in BMI yields a 16% increase in the odds of cesarean delivery. An artificial neural network trained and externally validated confirmed the importance of obesity in the prediction of mode of delivery among women undergoing labor induction for preeclampsia.?Conclusion?Among patients who are affected by preeclampsia, obesity complicates labor induction. The risk of cesarean delivery is enhanced by obesity, even with small increases in BMI. Prediction of mode of delivery by an artificial neural network performs similar to MLR among patients undergoing labor induction for preeclampsia.     

Cesarean delivery complications in women with morbid obesity

Objective: To compare cesarean complication rates between women with body mass index (BMI) 40–49.9?kg/m² and BMI?≥?50?kg/m² and associations with surgical techniques.

Methods: This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI?≥?50 and an equal number with BMI 40–49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use.

Results: Among 498 patients (249 with BMI?≥?50 and 249 with BMI 40–49.9) there were no differences in estimated blood loss >1000?mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI?≥?50 and 162 with BMI 40–49.9), those with BMI?≥?50 had a significantly higher rate of wound separations (p?=?0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons.

Conclusion: Wound complications, particularly separations, increase with BMI?≥?50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.     

Women's opinions and experiences with induction of labor and cesarean delivery on request in south eastern Nigeria

Objective

To assess the opinions and experiences of women regarding induction of labor and cesarean delivery on request in south eastern Nigeria.

Method

Women were interviewed using questionnaires on their awareness of their right to request labor induction and/or a cesarean delivery, and of their experience and opinion of the procedures.

Results

Of the 15.1% of the respondents who knew they could request a cesarean delivery, 2.4% had requested one; and of the 56.3% who knew they could request labor induction, 6.9% had requested one. Only 5.3% and 11.3% of the respondents who would chose the former or the latter procedure, respectively, said that they would insist on receiving it. Fear of their physicians' negative attitude regarding the procedures, and/or abandonment of care, ranked highest among their reasons for not insisting.

Conclusion

In south eastern Nigeria few women are aware of their right to a cesarean delivery on request and the rate of refusal to perform such deliveries is high among physicians; more women are aware of their right to receive induction of labor on request and the acceptance rate is higher among physicians; and most women are unwilling to insist that their physician respect their choice.     

Adnexal masses encountered during cesarean delivery

Objective

To outline and discuss the clinical features and outcomes of adnexal masses that were treated during cesarean delivery at a tertiary referral hospital located in Ankara, Turkey.

Methods

The operating room and pathology department databases for 2007–2012 were retrospectively reviewed for surgically managed adnexal masses during cesarean delivery. Clinicopathologic characteristics and maternal and neonatal outcomes were assessed.

Results

Adnexal masses occurred in 151 women (0.3% of all cesarean deliveries). Most (54.9%) masses were incidentally discovered during cesarean delivery. The mean mass size was 5.3 ± 3.7 cm (range, 3–30 cm). The majority (96.7%) of the women underwent excision of the mass and ovarian repair. Most masses were benign, with dermoid cysts constituting the most common diagnosis (23.8%). Rare tumors such as thecoma, hyperreactio luteinalis, hemangioma, and benign Brenner tumor were also encountered. Three (2.0%) women were postoperatively diagnosed with ovarian cancer. Preterm delivery and neonatal intensive care unit admission rates were 15.9% and 11.9%, respectively. There were no serious neonatal morbidities and no neonatal mortality.

Conclusion

Adnexal masses encountered during cesarean delivery generally have a favorable prognosis in terms of maternal and fetal outcome.     

Maternal anthropometric risk factors for caesarean delivery before or after onset of labour

Objective  To quantify the effects of pre-pregnancy body mass and gestational weight gain, above and beyond their known effects on birthweight, on the risk of primary and repeat caesarean delivery performed before or after the onset of labour.
Design  Hospital-based historical cohort study.
Setting  Canadian university-affiliated hospital.
Population  A total of 63 390 singleton term (≥37 weeks gestation) infants with cephalic presentation.
Methods  We studied prospectively archived deliveries at the Royal Victoria Hospital in Montreal, Canada, from 1 January 1978 to 31 March 2001 using multiple logistic regression models to estimate relative odds of caesarean delivery.
Main outcome measure  Caesarean delivery, primary or repeat and before or after the onset of labour.
Results  Pregravid obesity (body mass index ≥30 kg/m²) increased the likelihood of primary caesarean delivery before (OR = 2.01, 95% CI 1.39–2.90) and after (OR = 2.12, 95% CI 1.86–2.42) the onset of labour. High net rate of gestational weight gain (>0.50 kg/week) increased the risk but only after labour onset (OR = 1.40, 95% CI 1.23–1.60). Among women with a previous caesarean, high weight gain modestly increased risk but only before labour (OR = 1.38, 95% CI 1.04–1.83), whereas obesity increased the risk of caesarean delivery both before (OR = 1.85, 95% CI 1.44–2.37) and after (OR = 1.96, 95% CI 1.11–3.47) labour onset. Increased risks of macrosomia accounted for the association between pregravid adiposity and repeat caesarean delivery performed after but not before the onset of labour.
Conclusions  Pregravid obesity increases the risk of caesarean delivery both before and after the onset of labour and both with and without a history of caesarean.     

Obesity, obstetric complications and cesarean delivery rate--a population-based screening study

OBJECTIVE: This study was undertaken to determine whether obesity is associated with obstetric complications and cesarean delivery. METHODS: A large prospective multicenter database was studied. Subjects were divided into 3 groups: body mass index (BMI) less than 30 (control), 30 to 34.9 (obese), and 35 or greater (morbidly obese). Groups were compared by using univariate and multivariable logistic regression analyses. RESULTS: The study included 16,102 patients: 3,752 control, 1,473 obese, and 877 morbidly obese patients. Obesity and morbid obesity had a statistically significant association with gestational hypertension (odds ratios [ORs] 2.5 and 3.2), preeclampsia (ORs 1.6 and 3.3), gestational diabetes (ORs 2.6 and 4.0), and fetal birth weight greater than 4000 g (ORs 1.7 and 1.9) and greater than 4500 g (ORs 2.0 and 2.4). For nulliparous patients, the cesarean delivery rate was 20.7% for the control group, 33.8% for obese, and 47.4% for morbidly obese patients. CONCLUSION: Obesity is an independent risk factor for adverse obstetric outcome and is significantly associated with an increased cesarean delivery rate.     

肥胖与妊娠期糖尿病

妊娠期糖尿病(gestational diabetes mellitus,GDM)是妊娠期间首次发生或发现的糖代谢异常,是在妊娠期发展的一种对碳水化合物不耐受的状态。近年来肥胖及GDM的发病率逐年增高,成为必须重视的问题。肥胖是GDM发病的独立危险因素,可导致不良妊娠结局。本文从妊娠期肥胖的评价指标及妊娠期肥胖的管理等角度,阐述肥胖与GDM的关系。     

Attitudes towards mode of delivery and cesarean on demand in Turkey.

OBJECTIVE: To assess the attitudes of healthcare providers and the public in Turkey towards mode of delivery and cesarean delivery on demand. METHODS: A written questionnaire was given to female healthcare providers and women from the general public, and their answers were analyzed. RESULTS: A total of 329 female healthcare providers and 347 women from the public group completed the survey. In response, 48.1% of healthcare providers and 69.6% of the public group chose vaginal delivery as the preferred mode of delivery (P<0.001). Some 45.3% of healthcare providers and 20.6% of the public group had undergone a cesarean delivery without any medical indications (P<0.001). In addition, 37.8% of healthcare providers and 36.2% of the public group believed that women should have the right to a cesarean delivery on demand. CONCLUSIONS: In the two groups studied the preference for cesarean delivery is higher in Turkish healthcare providers than in the public population. In both groups the attitude towards cesarean delivery on demand is high.     

Maternal and neonatal outcomes in triplet gestations by trial of labor versus planned cesarean delivery*

Objective: To determine the rate of vaginal delivery after vaginal trial of labor (TOL) among women with triplet gestations.

Study design: This is a retrospective cohort study of all women delivering a viable triplet gestation between 2005 and 2016. The primary outcome was rate of vaginal delivery among all women attempting vaginal delivery. Secondary outcomes included factors associated with undergoing triplet TOL, and maternal and neonatal complications by planned delivery approach.

Results: Of the 83 eligible women, 21 (25.3%) underwent TOL. A majority of these (57.1, 95% confidence interval 36.5–75.5%) achieved a vaginal delivery of all three triplets. Women who underwent TOL were more likely to be multiparous or to have spontaneous preterm labor. There were no differences in adverse maternal or neonatal outcomes by planned delivery approach.

Conclusions: The rate of vaginal delivery among women with triplet gestations is higher in this institution than in reported literature, without increased morbidity.     

Maternal obesity and neonatal Apgar scores

Objective.?To determine whether maternal obesity in early pregnancy is associated with low neonatal 5-min Apgar scores while adjusting for confounders.

Methods.?Data were obtained from Maine State Birth Records Database. Analyses were restricted to information on 58,089 white women and their newborns. Maternal weight status was defined using the recorded early second trimester maternal body mass index (BMI) and defined as normal weight (BMI <25), overweight (BMI 25 to <30), obese (BMI 30 to <40), and morbidly obese (BMI ≥40). Logistic regression analysis was used to assess the association of maternal weight status with low Apgar score while adjusting for confounders.

Results.?Compared with newborns of normal weight women, the risk to receive low Apgar scores (4–6) is increased in newborns of obese (OR 1.4, 95% CI 1.1–1.7) and morbidly obese mothers (OR 2.0, 95% CI 1.5–2.7). The association did not achieve significance for newborns of overweight mothers (OR 1.2, 95% CI 0.99–1.4). No association was identified between maternal weight status and very low Apgar scores (0–3).

Conclusions.?Maternal obesity is associated with a significantly increased risk for decreased Apgar scores at birth. Further studies are needed to clarify the relationships among maternal obesity, complications of pregnancy, and neonatal outcome.     

Antibiotic prophylaxis at cesarean delivery

Objective: Our aim was to compare the efficacy of ampicillin, cefotetan, and ampicillin/sulbactam in the prevention of post-Cesarean endomyometritis.

Methods: Consenting patients undergoing Cesarean delivery at the University of Louisville Hospital were enrolled in a prospective, double-blinded randomization to receive either ampicillin/sulbactam (Group 1), cefotetan (Group 2), or ampicillin (Group 3) single dose antibiotic prophylaxis following umbilical cord clamping. The primary outcome variable was the frequency of endomyometritis in the respective groups.

Results: Among 301 randomized patients, outcome data was available for 298 patients. Fourteen patients (4.7%), all of whom underwent non-elective Cesarean delivery, developed endomyometritis. The frequency of endomyometritis was not different among groups: Group 1, 4/101 (4%); Group 2, 4/96 (4.2%); and Group 3, 6/101 (5.9%). Wound infections were infrequently observed 4/298 (1.3%) without significant differences among groups. Stepwise discriminative analysis identified only last cervical dilatation as a significant predictor of endomyometritis (P = 0.006).

Conclusion: Post-Cesarean endomyometritis occurs infrequently following single dose antibiotic prophylaxis after umbilical cord clamping. An advantage of broader spectrum antibiotics over ampicillin was not demonstrated.     

Maternal deaths associated with cesarean section in Enugu, Nigeria.

Maternal deaths from cesarean sections in Nigeria are exceptionally high and result from avoidable causes such as hemorrhagic shock, sepsis and hypertensive disorders in pregnancy. Increased involvement of specialists in the care and improved intra and post-operative management of cases are advocated to reduce the high maternal mortality rate.