A comparison of trends in cesarean delivery in Paraguay between 1995 and 2008

Objective

To identify maternal factors associated with the rise in the cesarean delivery rate in Paraguay.

Methods

Retrospective analysis of the 1995 and the 2008 National Survey on Demographic and Sexual and Reproductive Health data using multivariable logistic regression.

Results

In 2008, 1094 (37.3%) deliveries were cesarean compared with 781 (19.3%) in 1995. Home births had decreased by 72.9%, accounting for 33.3% of the change in the proportion of cesarean deliveries. Private facilities were associated with an increased odds ratio of cesarean delivery of 2.60 (95% confidence interval [CI], 2.02–3.34) and 4.89 (95% CI, 3.67–6.51) in 1995 and 2008, respectively, and accounted for 32.8% of the increase in cesarean deliveries between 1995 and 2008. Cesarean delivery was also associated with a prior cesarean, insurance status, and maternal higher educational and economic status.

Conclusion

Between 1995 and 2008 the cesarean delivery rate in Paraguay almost doubled. More than one-third of deliveries were cesarean. Shifts toward facility- (particularly private) based deliveries and repeat cesarean for women with a previous cesarean influenced this increase. Practice guidelines, regulation, and oversight of facilities, along with education and information for pregnant women, are needed to curb unnecessary and potentially harmful surgical delivery interventions.     

Obstetric complications and cesarean delivery in Nepal

Objective

To determine the incidence of obstetric complications, the stillbirth rate, and the factors associated with cesarean delivery in central Nepal.

Methods

A community-based prospective cohort study was undertaken in the Kaski district during 2011–2012. In total, 701 women who were at least 5 months pregnant were recruited and interviewed. Participants were followed-up and interviewed again within 45 days after delivery.

Results

Of the 658 women who remained in the cohort after 43 were lost to follow-up, 12 (1.8%) had stillbirths. Cesareans accounted for 13.3% of the total deliveries. Age, urban residency, college-level education, and particularly presence of intrapartum symptoms significantly increased the likelihood of cesarean delivery. Prepartum, intrapartum, and postpartum symptoms were reported by 21.1%, 24.4%, and 10.2% of women, respectively. Common danger signs included prolonged labor, severe abdominal pain, swollen hand and body, and heavy bleeding.

Conclusion

Obstetric complications and stillbirth rates were relatively high in central Nepal. Cesarean delivery appeared to meet obstetric need and was performed with medical indication, particularly after the onset of labor.     

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.     

Route of delivery following successful external cephalic version

Objective

To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV).

Methods

A retrospective matched case–control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status.

Results

Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63).

Conclusion

Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery.     

Pronóstico perinatal y materno de la gestación múltiple en función del protocolo intraparto

Objectives

To evaluate maternal and fetal outcomes of multiple pregnancy according to route of delivery.

Material and methods

We performed a retrospective study of all twin deliveries in the previous 5 years and evaluated the route of delivery, especially in the final year. The information was recorded with Microsoft EXCEL and was analyzed with the statistical program SPSS 12.0 for Windows.

Results

The mean gestational age was 35.3 weeks. Route of delivery was through cesarean section in 59.8%. The mean interval between twins was 7.82 minutes when the first twin was delivered vaginally. Neonatal morbidity was found in 49%, and was higher in the second twin and in preterm deliveries.

Conclusions

Multiple pregnancies are associated with a large number of maternal and perinatal complications, as well as with a greater number of cesarean sections. Consequently, correct intrapartum management is required to reduce neonatal morbility as far as possible.     

Prophylactic ampicillin versus cefazolin for the prevention of post-cesarean infectious morbidity in Rwanda

Objective

To evaluate the efficacy of ampicillin versus cefazolin as prophylactic antibiotics prior to cesarean delivery in Rwanda.

Methods

In a prospective, randomized, open-label, single-site study conducted between March and May 2012, the effects of prophylactic ampicillin versus cefazolin were compared among women undergoing cesarean delivery at the Centre Hospitalier Universitaire de Kigali, Rwanda. Postoperatively, participants were evaluated daily for infectious morbidity while in the hospital. Follow-up was done by phone and by appointment at the hospital within 2 weeks of delivery.

Results

During the study period, there were 578 total deliveries and 234 cesarean deliveries (40.4%). Overall, 132 women were enrolled in the study and randomized to receive either ampicillin (n = 66) or cefazolin (n = 66). No women were lost to follow-up. The overall infection rate was 15.9% (21/132). The infection rate in the ampicillin group and the cefazolin group was 25.8% (17/66) and 6.1% (4/66), respectively.

Conclusion

Implementing a universal protocol in Rwanda of prophylactic cefazolin prior to cesarean delivery might reduce postoperative febrile morbidity, use of postoperative antibiotics, and number of postoperative days in hospital.     

Quality cesarean delivery in Ouagadougou, Burkina Faso: A comprehensive approach

Objective

To assess the effects of a comprehensive intervention (staff training, equipment, internal clinical audits, cost sharing system, patients-providers meetings) in improving cesarean delivery access and quality in an urban district of Burkina Faso.

Methods

We conducted a before-after study in the health district sector 30 in Ouagadougou between 2003 and 2006. We measured cesarean delivery quality (accessibility, diagnosis, procedure, postoperative follow-up) and maternal and neonatal health in 1371 sections.

Results

The number of cesarean deliveries performed increased each year, from 42 in 2003 to 630 in 2006. This increase happened without increase in maternal and perinatal post-cesarean mortality (respectively 1.1% and 3.6% in 2006). The cesarean delivery rate for women of the district increased from 1.9% to 3.3% of expected births between 2003 and 2005.

Conclusion

To improve access to quality cesarean delivery, we have shown that it was necessary to have a systemic approach combining technical, operational, sociocultural, and political factors.     

Effect of instrument preference for operative deliveries on obstetrical and neonatal outcomes

Objectives

To examine the relationship between physicians’ instrument preference and obstetrical and neonatal outcomes.

Study design

A retrospective cohort study comparing obstetrical and neonatal outcomes of second stage deliveries between obstetricians who prefer forceps (forceps ≥90%) with obstetricians with no preference to forceps (either instrument <90%) was completed using the McGill Obstetrical and Neonatal Database. Logistic regression analysis was used to obtain an adjusted odds ratio controlling for maternal, intrapartum and neonatal confounders.

Results

Two thousand and three hundred thirteen infants were delivered by 5 obstetricians who preferred forceps, and 9261 infants were delivered by 15 obstetricians with no instrument preference. Baseline characteristics were similar between the two groups. As compared to obstetricians who preferred forceps, obstetricians with no instrument preference had a higher rate of operative vaginal deliveries 1.5 (1.1–2.0), a higher cesarean section rate 2.5 (1.3–4.9) and a higher episiotomy rate in non-operative vaginal deliveries 3.4 (2.7–4.3). Infants delivered by obstetricians with no instrument preference were less likely to have significant bruising 0.3 (0.2–0.6) but more likely to have a cephalohematoma 3.0 (1.1–8.3).

Conclusion

Physician instrument preference is an important determinant of outcomes that should be considered in studies evaluating instrumental deliveries.     

Comparison of outcomes between operative vaginal deliveries and spontaneous vaginal deliveries in southeast Nigeria

Objective

To evaluate the incidence of, indications for, and outcome of operative vaginal deliveries compared with spontaneous vaginal deliveries in southeast Nigeria.

Methods

A retrospective cohort study was conducted involving cases of operative vaginal delivery performed at Ebonyi State University Teaching Hospital over a 10-year period. Data on the procedures were abstracted from the operation notes of the medical records of parturients.

Results

An incidence of 4.7% (n = 461) was recorded. The most common indications for vacuum and forceps delivery were prolonged second stage of labor (44.9%) and poor maternal effort (27.8%). The only indication for destructive operation was intrauterine fetal death (3.7%). The risk ratio (RR) for hemorrhage/vulvar hematoma was 1.14 (95% confidence interval [CI], 0.53–2.48) for vacuum-assisted delivery and 5.49 (95% CI, 0.82–36.64) for forceps delivery. The RR for genital laceration was 1.21 (95% CI, 0.44–3.30) for vacuum-assisted delivery and 9.41 (95% CI, 1.33–66.65) for forceps delivery. The risk of fetal scalp bruises and caput succedaneum was higher for operative vaginal delivery than for spontaneous vaginal delivery, with no significant difference in maternal morbidity. The perinatal mortality rate was 0.9 per 1000 live births.

Conclusion

Operative vaginal delivery by experienced healthcare providers is associated with good obstetric outcomes with minimal risk.     

Factors associated with maternal intrapartum transfers from a freestanding birth centre in São Paulo,Brazil: A case control study

Objectives

to identify factors associated with maternal intrapartum transfer from a freestanding birth centre to hospital.

Design

case-control study with retrospective data collection.

Participants and settings

cases included all 111 women transferred from a freestanding birth centre in Sao Paulo to the referral hospital, from March 2002 to December 2009. The controls were 456 women who gave birth in the birth centre during the same period who were not transferred, randomly selected with four controls for each case.

Methods

data were obtained from maternal records. Factors associated with maternal intrapartum transfers were initially analysed using a χ² test of association. Variables with p<0.20 were then included in multivariate analyses. A multiple logistic regression model was built using stepwise forward selection; variables which reached statistical significance at p<0.05 were considered to be independently associated with maternal transfer.

Findings

during the study data collection period, 111 (4%) of 2,736 women admitted to the centre were transferred intrapartum. Variables identified as independently associated factors for intrapartum transfer included nulliparity (OR 5.1, 95% CI 2.7–9.8), maternal age ≥35 years (OR 5.4, 95% CI 2.1–13.4), not having a partner (OR 2.8, 95% CI 1.5–5.3), cervical dilation ≤3 cm on admission to the birth centre (OR 1.9, 95% CI 1.1–3.2) and between 5 and 12 antenatal appointments at the birth centre (OR 3.8, 95% CI 1.9–7.5). In contrast, a low correlation between fundal height and pregnancy gestation (OR 0.3, 95% CI 0.2–0.6) appeared to be protective against transfer.

Conclusions and implications for practice

identifying factors associated with maternal intrapartum transfer could support decision making by women considering options for place of birth, and support the content of appropriate information about criteria for admission to a birth centre. Findings add to the evidence base to support identification of women in early labour who may experience later complications and could support timely implementation of appropriate interventions associated with reducing transfer rates.     

Maternal obesity and rate of cesarean delivery in Djibouti

Objective

To calculate the prevalence of maternal obesity and to determine the relation between obesity and cesarean delivery in an urban hospital in Djibouti.

Methods

In an observational cohort study, all women who had a live birth or stillbirth between October 2012 and November 2013 were considered for inclusion. Body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was calculated throughout pregnancy, and women with a BMI of at least 30.0 were deemed to be obese. Multivariate logistic regression analyses were used to evaluate the relation between cesarean and obesity.

Results

Overall, 100 (24.8%) of 404 women were obese before 14 weeks of pregnancy, as were 112 (25.2%) of 445 before 22 weeks, and 200 (43.2%) of 463 at delivery. Obesity before 22 weeks was associated with a 127% excess risk of cesarean delivery (adjusted odds ratio 2.27; 95% CI 1.07–4.82; P = 0.032). Similar trends were found when the analyses were limited to the subgroup of women without a previous cesarean delivery or primiparae.

Conclusion

Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables.     

Resultados perinatales en gestantes mayores de 40 años

Objective

To evaluate obstetric and neonatal morbidity and mortality in pregnant women aged 40 years or more with singleton pregnancies in our hospital.

Material and methods

We selected deliveries occurring in Hospital Parc Taulí in Sabadell, Spain, in a 12-month period. Multiple deliveries were excluded. A total of 3308 pregnant women were divided into two groups: group 1 consisted of women aged less than 40 years and group 2 consisted of women aged 40 years or more. Maternal and neonatal morbidity were analyzed in both groups to identify any differences.

Results

Only 115 (3.5%) pregnant women were aged 40 years or more. Compared with group 2, group 1 had undergone a higher number of assisted reproductive technologies and showed a higher incidence of hypertensive diseases, diabetes, and cesarean delivery (p <0.05).

Conclusions

Pregnant women aged 40 years more have higher morbidity but advanced age does not directly influence neonatal morbidity and mortality.     

Maternal infection rates after cesarean delivery by Pfannenstiel or Joel–Cohen incision: A multicenter surveillance study

Objective

Our purpose was to evaluate maternal nosocomial infection rates according to the incision technique used for caesarean delivery, in a routine surveillance study.

Study design

This was a prospective study of 5123 cesarean deliveries (43.2% Joel–Cohen, 56.8% Pfannenstiel incisions) in 35 maternity units (Mater Sud Est network). Data on routine surveillance variables, operative duration, and three additional variables (manual removal of the placenta, uterine exteriorization, and/or cleaning of the parieto-colic gutter) were collected. Multiple logistic regression analysis was used to identify independent risk factors for infection.

Results

The overall nosocomial infection and endometritis rates were higher for the Joel–Cohen than Pfannenstiel incision (4.5% vs. 3.3%, 0.8% vs. 0.3%, respectively). The higher rate of nosocomial infections with the Joel–Cohen incision was due to a greater proportion of patients presenting risk factors (i.e., emergency delivery, primary cesarean, blood loss ≥800 mL, no manual removal of the placenta and no uterine exteriorization). However, the Joel–Cohen technique was an independent risk factor for endometritis.

Conclusion

The Joel–Cohen technique is faster than the Pfannenstiel technique but is associated with a higher incidence of endometritis.     

Obstetric interventions for women with type 1 or type 2 diabetes

Objective

To determine whether differences exist in the rates of obstetric intervention between women with type 1 diabetes and those with type 2 diabetes, and whether there has been any change in cesarean rates over time, paralleling that seen in the general obstetric population.

Methods

Data were examined from a prospectively collected series on the outcomes of 1030 deliveries (382 by women with type 1 diabetes, 648 by women with type 2 diabetes) from 1988 to 2008.

Results

There was a secular trend to increasing maternal age (type 1, P < 0.003; type 2, P < 0.03). Intervention rates (induction of labor or elective cesarean) did not differ between type 1 (88%) and type 2 (85%) diabetes. The overall cesarean rate was 52%–55% with no secular trend. Poorer glycemic control in early pregnancy and primiparity were associated with primary cesarean in both groups. In women with type 1 diabetes, greater maternal obesity and retinopathy were also associated with primary cesarean.

Conclusion

Intervention rates are high in pregnancies among women with type 1 diabetes and those with type 2 diabetes but they have not changed significantly. Secular trends toward increasing maternal age and obesity suggest that intervention rates are unlikely to decrease in the near future.     

Demand and supply factors affecting the rising overmedicalization of birth in India

Objective

To understand the interaction between health systems and individual factors in determining the probability of a cesarean delivery in India.

Methods

In a retrospective study, data from the 2007–2008 District Level Household and Facility Survey was used to determine the risk of cesarean delivery in six states (Punjab, Delhi, Maharashtra, Andhra Pradesh, Kerala, and Tamil Nadu). Multilevel modeling was used to account for district and community effects.

Results

After controlling for key risk factors, the analysis showed that cesareans were more likely at private than public institutions (P < 0.001). In terms of demand, higher education levels rather than wealth seemed to increase the likelihood of a cesarean delivery. District-level effects were significant in almost all states (P < 0.001), demonstrating the need to control for health system factors.

Conclusion

Supply factors might contribute more to the rise in cesarean delivery than does demand. Further research is needed to understand whether the quest for increased institutional deliveries in a country with high maternal mortality might be compromised by pressures for overmedicalization.     

Maternal and neonatal copeptin levels at cesarean section and vaginal delivery

Objective

The objective of the study was to measure the copeptin levels in maternal serum and umbilical cord serum at cesarean section and vaginal delivery in normotensive pregnancy and pre-eclamptic women.

Study design

This was a prospective study at Mansoura University Hospital, Egypt. Ninety cases were included. They were divided into six groups: (1) normal pregnancy near term, as a control group, (2) primiparas who had vaginal delivery, (3) primiparas who had vaginal delivery and mild preeclampsia, (4) elective repeat cesarean section, (5) intrapartum cesarean section for indications other than fetal distress, and (6) intrapartum cesarean section for fetal distress. Serum copeptin concentrations were quantified with an enzyme-linked immunosorbent assay (ELISA). Mean, standard deviation, and paired t-test were used to test for significant change in quantitative data.

Results

The vaginal delivery groups had higher levels of maternal serum copeptin than the elective cesarean section group (P < 0.01). Higher maternal serum copeptin levels were found in cases with pre-eclampsia as compared with the normotensive cases. The maternal copeptin levels during intrapartum cesarean section were higher than that during elective repeat cesarean section. There was a significant correlation between maternal copeptin levels and the duration of the first stage. In the presence of fetal distress, umbilical cord serum copeptin levels were significantly higher than other groups.

Conclusion

Vaginal delivery can be very painful and stressful, and is accompanied by a marked increase of maternal serum copeptin. Increased maternal levels of serum copeptin were found in cases with pre-eclampsia as compared with the normotensive cases, and it may be helpful in assessing the disease. Intrauterine fetal distress is a strong stimulus to the release of copeptin into the fetal circulation.     

An analysis of the indications for cesarean section in a teaching hospital in China

Objectives

Cesarean delivery rates have increased remarkably worldwide. The indications for this increase are not fully understood and there may be regional, ethnic or health system differences in quoted indications which may explain, at least in part, the observed changes. In 2008 China was cited as having one of the highest rates of cesarean delivery in the world, but there was no accurate information about the indications for the high rate. This study sought to provide some information about the high cesarean section rate in China.

Study design

Data on all births in a university teaching hospital in northern China serving a general obstetric population, excluding premature births, were collected from the hospital database from January 2009 to September 2012. All indications on the mode of delivery were analyzed for live births.

Results

There were 5267 births and the cesarean delivery rate was 41.4% in the study period. There was no significant trend in the cesarean delivery rate from 2009 to 2012. Fetal indications contributed most to the rate. More than 50% of all cesarean deliveries were due to nuchal cord, previous cesarean delivery, fetal distress and malpresentation. The rate of cesarean delivery on maternal request was 9.07%. Smaller contributions to the indications for cesarean delivery came from cephalopelvic disproportion, preeclampsia, prolonged labor, uterine rupture and other obstetric conditions.

Conclusion

The data show increased fetal or maternal risk assessments are the main indications for cesarean delivery rather than cesarean delivery on maternal request in China.