Previous cesarean delivery and risks of placenta previa and placental abruption

OBJECTIVE: To examine the association between cesarean delivery and previa and abruption in subsequent pregnancies. METHODS: A retrospective cohort study of first 2 (n = 156,475) and first 3 (n = 31,102) consecutive singleton pregnancies using the 1989-1997 Missouri longitudinally linked data were performed. Relative risk (RR) was used to quantify the associations between cesarean delivery and risks of previa and abruption in subsequent pregnancies, after adjusting for several confounders. RESULTS: Rates of previa and abruption were 4.4 (n = 694) and 7.9 (n = 1,243) per 1,000 births, respectively. The pregnancy after a cesarean delivery was associated with increased risk of previa (0.63%) compared with a vaginal delivery (0.38%, RR 1.5, 95% confidence interval [CI] 1.3-1.8). Cesarean delivery in the first and second births conferred a two-fold increased risk of previa in the third pregnancy (RR 2.0, 95% CI 1.3-3.0) compared with first two vaginal deliveries. Women with a cesarean first birth were more likely to have an abruption in the second pregnancy (0.95%) compared with women who had a vaginal first birth (0.74%, RR 1.3, 95% CI 1.2-1.5). Two consecutive cesarean deliveries were associated with a 30% increased risk of abruption in the third pregnancy (RR 1.3, 95% CI 1.0-1.8). A second pregnancy within a year after a cesarean delivery was associated with increased risks of previa (RR 1.7, 95% CI 0.9-3.1) and abruption (RR 1.5, 95% CI 1.1-2.3). CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption. LEVEL OF EVIDENCE: II-2.     

Risk of maternal postpartum readmission associated with mode of delivery

OBJECTIVE: To determine whether cesarean and operative vaginal deliveries are associated with an increased risk of maternal rehospitalization compared with spontaneous vaginal delivery. METHODS: A population-based cohort study was conducted by using the Canadian Institute for Health Information's Discharge Abstract Database between 1997/1998 and 2000/2001, which included 900,108 women aged 15-44 years with singleton live births (after excluding several selected obstetric conditions). RESULTS: A total of 16,404 women (1.8%) were rehospitalized within 60 days after initial discharge. Compared with spontaneous vaginal delivery (rate 1.5%), cesarean delivery was associated with a significantly increased risk of postpartum readmission (rate 2.7%, odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8-1.9); ie, there was 1 excess postpartum readmission per 75 cesarean deliveries. Diagnoses associated with significantly increased risks of readmission after cesarean delivery (compared with spontaneous vaginal delivery) included pelvic injury/wounds (rate 0.86% versus 0.06%, OR 13.4, 95% CI 12.0-15.0), obstetric complications (rate 0.23% versus 0.08%, OR 3.0, 95% CI 2.6-3.5), venous disorders and thromboembolism (rate 0.07% versus 0.03%, OR 2.7, 95% CI 2.1-3.4), and major puerperal infection (rate 0.45% versus 0.27%, OR 1.8, 95% CI 1.6-1.9). Women delivered by forceps or vacuum were also at an increased risk of readmission (rates 2.2% and 1.8% versus 1.5%; OR forceps: 1.4, 95% CI 1.3-1.5; OR vacuum: 1.2, 95% CI 1.2-1.3, respectively). Higher readmission rates after operative vaginal delivery were due to pelvic injury/wounds, genitourinary conditions, obstetric complications, postpartum hemorrhage, and major puerperal infection. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery, and operative vaginal delivery increase the risk of maternal postpartum readmission. LEVEL OF EVIDENCE: II-2.     

Maternal and neonatal outcomes of assaults during pregnancy

OBJECTIVE: To assess perinatal outcomes of women hospitalized for assault during pregnancy as a function of timing of delivery. METHODS: A retrospective population-based study analyzing maternal discharge records linked to birth/death certificates in California from 1991 to 1999 was performed. International Classifications of Disease, Ninth Clinical Modification (ICD-9-CM) codes were used to identify injury types and outcomes. External causation codes identified assaults as the mechanism of the injuries. Injury Severity Scores were assessed. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and multivariate logistic regression was used for analysis of outcomes. RESULTS: A total of 2,070 women were hospitalized during pregnancy after sustaining an assault. Assaulted women were younger, multiparous, and with delayed prenatal care compared with unassaulted controls. Women delivering at the assault hospitalization had high rates of prematurity: 24%, OR 2.4 (95% CI 1.8-3.3), maternal death: 0.71%, OR 19 (95% CI 2.7-144.7), fetal death: 9.3%, OR 8 (95% CI 4.6-14.3), uterine rupture: 0.71%, OR 46 (95% CI 6.5-337.8), and other adverse outcomes compared with unassaulted women. Women discharged after an assault, delivering at a subsequent hospitalization, had increased risks of abruption: 2%, OR 1.8 (95% CI 1.3-2.5), hemorrhage: 3.2%, OR 1.8 (95% CI 1.4-2.5), prematurity: 15%, OR 1.3 (95% CI 1.2-1.5), and low birth weight: 13.4%, OR 1.7 (95% CI 1.5-1.9) at delivery. CONCLUSION: Women sustaining an assault during pregnancy experience both immediate (uterine rupture, increased fetal and maternal mortality) and long-term sequelae (prematurity and low birth weight infants), which have significant negative effects on pregnancy outcome. LEVEL OF EVIDENCE: III.     

Obstetric outcome in women with subfertility

BACKGROUND: It has been suggested that a history of subfertility is associated with increased obstetric and perinatal risks. It is unclear if the cause is inherent characteristics in the women or the fertility treatment. OBJECTIVES: To compare the obstetric and perinatal risks of singleton pregnancies in women with a history of subfertility in comparison with the general population. DESIGN: Population cohort. SETTING: Aberdeen, Scotland. POPULATION: Cases were women attending the Fertility Clinic between 1989 and 1999 who subsequently went on to have singleton pregnancies. Controls included the general population of women who delivered singletons over the same period. METHODS: We performed a retrospective cohort study to investigate the obstetric outcome of singleton pregnancies in women with subfertility. The general population of women who delivered singletons over the same period served as controls. MAIN OUTCOME MEASURES: Obstetric and perinatal complications in singleton pregnancies. RESULTS: Maternity records were available for a total of 1437 subfertile women and 21,688 controls. Subfertile women were older [mean (SD) age: 31 (4.7) years vs 27 (5.4) years, P < 0.01] and more likely to be primiparous (70% vs 65%, P < 0.001). After adjusting for age and parity, subfertile women were at increased risk of pre-eclampsia (OR 1.9, 95% CI 1.5-2.5), placenta praevia (OR 3.9, 95% CI 2.2-7.0) and placental abruption (OR 1.8, 95% CI 1.1-3.0), and more likely to undergo induction of labour (OR 1.5, 95% CI 1.3-1.6), caesarean section (OR 2.1, 95% CI 1.8-2.4) and instrumental delivery (OR 2.2, 95% CI 1.8-2.6), and deliver low birthweight (OR 1.4, 95% CI 1.3-1.7) and preterm (OR 1.7, 95% CI 1.2-2.2) infants. There were no differences between treatment-related and treatment-independent pregnancies. CONCLUSION: Subfertile women are at higher risk of obstetric complications, which persist after adjusting for age and parity.     

Risk factors for wound infection following cesarean deliveries.

OBJECTIVE: To identify risk factors for early wound infection (diagnosed prior to discharge) following cesarean delivery. METHODS: A population-based study comparing women who have and have not developed a wound infection prior to discharge from Soroka University Medical Center, Ben Gurion University of the Negev, between 1988 and 2002. RESULTS: Of the 19,416 cesarean deliveries performed during the study period, 726 (3.7%) were followed by wound infection. Using a multivariable logistic regression model, the following risk factors were identified: obesity (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.6-3.1); hypertensive disorders (OR = 1.7; 95% CI, 1.4-2.1); premature rupture of membranes (OR = 1.5; 95% CI, 1.2-1.9); diabetes mellitus (OR = 1.4; 95% CI, 1.1-1.7); emergency cesarean delivery (OR = 1.3; 95% CI, 1.1-1.5); and twin delivery (OR = 1.6; 95% CI, 1.3-2.0). Combined obesity and diabetes (gestational and pregestational) increased the risk for wound infection 9.3-fold (95% CI, 4.5-19.2; P < .001). CONCLUSION: Independent risk factors for an early wound infection are obesity, diabetes, hypertension, premature rupture of membranes, emergency cesarean delivery, and twin delivery. Information regarding higher rates of wound infection should be provided to obese women undergoing cesarean delivery, especially when diabetes coexists.     

Factors Predicting Cesarean Delivery for American Indian Women in New Mexico

Background: American Indian women have one of the lowest cesarean delivery rates among all ethnic groups evaluated in the United States. Our objective was to identify risk factors for cesarean delivery among American Indian women in New Mexico. Methods: Live birth certificate data (1994) from the New Mexico Bureau of Vital Records and Health Statistics were used to compare American Indian women who had a cesarean delivery with those who had a vaginal delivery. We examined demographic, prenatal, and intrapartum factors to determine risk factors for cesarean delivery. Results: In 1994 American Indian women in New Mexico had a cesarean delivery rate of 12 percent. Risk factors for cesarean delivery included age equal to or over 35 years (OR = 1.8, 1.3–2.5) and nulliparity (OR = 1.9, 1.5–2.5). Obstetric risk factors included prematurity (OR = 2.3, 1.5–3.6), low birthweight (OR = 2.6, 1.7–4.2), diabetes (OR = 1.7, 1.1–2.5), pregnancy-induced hypertension (OR = 2.6, 1.8–3.8), and labor and delivery complications (OR = 9.5, 7.5–12.1). Age less than 20 years was negatively associated with cesarean delivery (OR = 0.5, 0.3–0.7). Conclusion: American Indian women have risk factors for cesarean delivery that are similar to those reported in other populations. Future prospective research evaluating intrapartum management may help identify reasons for the low cesarean birth rate.     

Risk factors for arrest of descent during the second stage of labor.

OBJECTIVE: To define obstetrical risk factors for arrest of descent during the second stage of labor and to determine perinatal outcome. STUDY DESIGN: All singleton, vertex, term deliveries with an unscarred uterus, between the years 1988 and 1999 were included. Univariable and multivariable analysis were performed to investigate independent risk factors associated with arrest of descent during the second stage of labor and the perinatal outcome. RESULTS: The study included 93266 deliveries, of these 1545 (1.7%) were complicated with arrest of descent during the second stage of labor. Using a multivariable analysis, the following obstetric risk factors were found to be significantly associated with arrest of descent: nulliparity (OR=7.8, 95% CI=6.9-8.7; P<0.001), birth weight >4 kg (OR=2.3, 95% CI=1.9-2.8; P<0.001), epidural analgesia (OR=1.8, 95% CI=1.6-2.0; P<0.001), hydramnios (OR=1.6, 95% CI=1.3-2.0; P<0.001), hypertensive disorders (OR=1.5, 95% CI=1.3-1.8; P<0.001), gestational diabetes A1 and A2 (OR=1.5, 95% CI=1.2-1.8; P<0.001), male gender (OR=1.4, 95% CI=1.2-1.5; P<0.001), premature rupture of membranes (PROM, OR=1.3, 95% CI=1.04-1.6; P=0.021), and induction of labor (OR=1.2, 95% CI=1.02-1.4; P=0.030). Deliveries complicated by arrest of descent resulted in cesarean section in 20.6%, vacuum extraction in 74.0%, and forceps delivery in 5.4%. Newborns delivered after arrest of descent during the second stage of labor had significantly higher rates of low Apgar scores (<7) at 1 and 5 min, as compared to the controls (12.7 vs. 2.1%, P<0.001; and 0.9 vs. 0.2%, P<0.001, respectively). Nevertheless, no significant differences were noted between the groups regarding perinatal mortality (0.38 vs. 0.44%; P=0.759). CONCLUSIONS: Major risk factors for arrest of descent during the second stage of labor were nulliparity, fetal macrosomia, epidural analgesia, hydramnios, hypertensive disorders and gestational diabetes mellitus. These risk factors should be carefully evaluated during pregnancy in order to actively manage high-risk pregnancies.     

Obesity-related complications in Danish single cephalic term pregnancies

OBJECTIVE: Our objective was to investigate the relationship between prepregnancy and obstetric body mass index (BMI) as well as fetal complications in a large, unselected cohort of Danish women with single cephalic pregnancies. METHODS: A cohort of 8,092 women from the Copenhagen First Trimester Study with a registered prepregnancy BMI and a single cephalic term delivery were stratified into 3 BMI groups: normal weight (BMI < 25 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)), and obese (BMI >/= 30 kg/m(2)). The effects of BMI and parity on the outcome were analyzed using multivariate logistic regression analyses. RESULTS: Overweight women had an odds ratio (OR) of 3.4 for diabetes, 1.9 for hypertension, 1.7 for preeclampsia, and 1.5 for cesarean delivery. The corresponding figures for obese women were 15.3, 4.8, 2.7, and 1.7, respectively. No relationship was found between BMI and vacuum extraction. Obese women had an increased risk of delivering macrosomic but also low birth weight children. No differences existed among the 3 weight groups with regard to neonatal morbidity estimated by Apgar score, umbilical cord pH, or admittance to a neonatal intensive care unit. Nulliparous women had an increased incidence of preeclampsia (OR 2.8), hypertension (OR 1.9), emergency cesarean delivery (OR 3.4), vacuum extraction (OR 5.6), and perineal rupture (OR 1.7) but a lower frequency of elective cesarean delivery (OR 0.25). CONCLUSION: The rate of complications during pregnancy and delivery increases with an increasing prepregnancy BMI in women with single cephalic term pregnancies, particularly in nulliparous women.     

Is meconium passage a risk factor for maternal infection in term pregnancies?

OBJECTIVE:To study the association between meconium and maternal infection. METHODS:This was a retrospective cohort study of 678 pregnant women. All term deliveries during a 31-month period with meconium passage were included. Each meconium delivery was matched with a consecutive delivery without meconium at the same gestational age. RESULTS: The overall infection rate was 16%, with 13% of the infections directly related to the pregnancy, labor, and delivery. The endometritis rate was 5%, with 7.1% and 3% in the meconium and no-meconium group, respectively. The chorioamnionitis rate was 8.3%, with 9.5% in the meconium and 7.1% in the no-meconium group. Factors found to be associated with overall obstetric infections had the following odds ratios (ORs) and 95% confidence intervals (CIs): meconium (OR 1.8, 95% CI 1.1, 2.8), internal monitoring (OR 3.4, 95% CI 1.9, 5.9), amnioinfusion (OR 2.0, 95% CI 1.3, 3.3), number of vaginal exams (OR 4.5, 95% CI 2.8, 7.1), length of labor (OR 2.8, 95% CI 1.8, 4.4), and cesarean (OR 3.1, 95% CI 1.9, 5.1). Logistic regression analyses revealed the following ORs and 95% CIs: 1) for endometritis-cesarean (OR 4.2, 95% CI 1.9, 8.9), internal monitoring (OR 2.5, 95% CI 1.1, 5.9), and meconium (OR 2.5, 95% CI 1.1, 5.5), and 2) for chorioamnionitis-length of labor greater than 10 hours (OR 2.7, 95% CI 1.4, 5.6), number of vaginal exams greater than seven (OR 3.4, 95% CI 1.7, 6.6), and use of internal monitors (OR 2.5, 95% CI 1.2, 5.3). CONCLUSION: Meconium passage increases the risk of postpartum endometritis but not chorioamnionitis. Length of labor, internal monitoring, and number of vaginal exams are risk factors for chorioamnionitis.     

Is grandmultiparity an independent risk factor for adverse perinatal outcomes?

OBJECTIVE: To compare maternal and neonatal outcomes among grandmultiparous women to those of multiparous women 30 years or older. METHODS: A database of the vast majority of maternal and newborn hospital discharge records linked to birth/death certificates was queried to obtain information on all multiparous women with a singleton delivery in the state of California from January 1, 1997 through December 31, 1998. Maternal and neonatal pregnancy outcomes of grandmultiparous women were compared to multiparous women who were 30 years or older at the time of their last birth. RESULTS: The study population included 25,512 grandmultiparous and 265,060 multiparous women 30 years or older as controls. Grandmultiparous women were predominantly Hispanic (56%). After controlling for potential confounding factors, grandmultiparous women were at significantly higher risk for abruptio placentae (odds ratio OR: 1.3; 95% confidence intervals CI: 1.2-1.5), preterm delivery (OR: 1.3; 95% CI: 1.2-1.4), fetal macrosomia (OR: 1.5; 95% CI: 1.4-1.6), neonatal death (OR: 1.5; 95% CI: 1.3-1.8), postpartum hemorrhage (OR: 1.2; 95% CI: 1.1-1.3) and blood transfusion (OR: 1.5; 95% CI: 1.3-1.8). CONCLUSION: Grandmultiparous women had increased maternal and neonatal morbidity, and neonatal mortality even after controlling for confounders, suggesting a need for closer observation than regular multiparous patients during labor and delivery.     

Perinatal factors associated with cerebral palsy in children born in Sweden

OBJECTIVE: To identify perinatal factors associated with cerebral palsy (CP). METHODS: This was a case-control study based on the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry, including 2,303 infants born in Sweden 1984-1998 with a diagnosis of CP and 1.6 million infants without this diagnosis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Infants born preterm had a highly increased risk for CP, and constituted 35% of all cases; OR 34 (95% CI 29-39) in weeks 23-27, OR 37 (95% CI 32-42) in weeks 28-29, OR 26 (95% CI 23-30) in weeks 30-31, and OR 3.9 (95% CI 3.4-4.4) in weeks 32-36. Boys had a higher risk (sex ratio 1.36:1), particularly before term (sex ratio 1.55:1). Other factors associated with CP were being small or large for gestational age at birth, abruptio placentae (OR 8.6, 95% CI 5.6-13.3), maternal insulin-dependent diabetes mellitus type 1 (OR 2.1, 95% CI 1.4-3.1), preeclampsia (OR 1.5, 95% CI 1.3-2.4), being a twin (OR 1.4, 95% CI 1.1-1.6), maternal age older than 40 years (OR 1.4, 95% CI 1.1-1.8) or 35-39 years (OR 1.2, 95% CI 1.1-1.4), primiparity (OR 1.2, 95% CI 1.1-1.3), and smoking (OR 1.2, 95% CI 1.1-1.3). In term infants, low Apgar scores were associated with a high risk for CP; OR 62 (95% CI 52-74) at score 6 at 5 minutes, OR 498 (95% CI 458-542) at score 3. Other factors associated with CP in term infants were breech presentation at vaginal birth (OR 3.0, 95% CI 2.4-3.7), instrumental delivery (OR 1.9, 95% CI 1.6-2.3), and emergency cesarean delivery (OR 1.8, 95% CI 1.6-2.0). CONCLUSION: Preterm birth entails a high risk for CP, but 65% of these children are born at term. Several obstetric factors and low Apgar scores are associated with CP. LEVEL OF EVIDENCE: II-2.     

Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991. METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery. RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births. CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.     

Beta-thalassemia minor during pregnancy

OBJECTIVE: To investigate pregnancy outcome of patients with beta-thalassemia minor. METHODS: A population-based study comparing all pregnancies of women with and without beta-thalassemia minor was conducted. Deliveries occurred during the years 1988-2002 at Soroka University Medical Center. A multivariate logistic regression model, with backward elimination, was constructed to find independent risk factors associated with maternal beta-thalassemia minor. RESULTS: During the study period there were 159,195 deliveries, of which 261 (0.2%) occurred in patients with beta-thalassemia minor. The following conditions were significantly associated with beta-thalassemia minor: oligohydramnios (odds ratio [OR] 2.1; 95% confidence interval [CI] 1.2%, 3.7%), intrauterine growth restriction (IUGR; OR 2.4; 95% CI 1.4%, 4.2%), Jewish ethnicity (OR 1.5; 95% CI 1.2%, 1.9%), and previous cesarean delivery (OR 1.4; 95% CI 1.1%, 2.0%). No significant differences were noted between the groups regarding perinatal outcomes such as birth weight, low Apgar scores, congenital malformations, or perinatal mortality. Patients with beta-thalassemia minor were more likely to have cesarean deliveries than were the nonthalassemic parturients (16.9% and 12.2%, respectively; P =.021). However, while controlling for possible confounders such as IUGR, oligohydramnios, and previous cesarean delivery, with another multivariate analysis with cesarean delivery as the outcome variable, beta-thalassemia minor was not found as an independent risk factor for cesarean delivery (OR 1.3; 95% CI 0.9%, 1.9%). CONCLUSION: The course of pregnancy of patients with thalassemia minor, including perinatal outcomes, is favorable. Because higher rates of IUGR were found, we recommend ultrasound surveillance of fetal weight for early detection of IUGR. LEVEL OF EVIDENCE: II-2     

Gender does matter in perinatal medicine

OBJECTIVE: To investigate complications and outcome of pregnancies with male and female fetuses. METHODS: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. We compared pregnancies with male vs. female fetuses. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses with the Mantel-Haenszel technique and multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 55,891 deliveries of male and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01-1.12; p = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8-2.1; p < 0.001), failure to progress during the first and second stages of labor (OR = 1.2; 95% CI 1.1-1.3; p < 0.001 and OR = 1.4; 95% CI 1.3-1.5; p < 0.001, respectively), cord prolapse (OR = 1.3; 95% CI 1.1-1.6; p = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1-1.2; p < 0.001) and true umbilical cord knots (OR = 1.5; 95% CI 1.3-1.7; p < 0.001). Higher rates of CS were found among male compared with female neonates (8.7 vs. 7.9%; OR = 1.1; 95% CI 1.06-1.16; p < 0.001). Using three multivariate logistic regression models and controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring fetal heart rate patterns (OR = 1.5; 95% CI 1.4-1.6; p < 0.001), low Apgar scores at 5 min (OR = 1.5; 95% CI 1.3-1.8; p < 0.001) and CS (OR = 1.2; 95%CI 1.2-1.3; p < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, nonprogressive labor, fetal macrosomia, nuchal cord and true umbilical cord knots using the Mantel-Haenszel technique did not change the significant association between male gender and CS. CONCLUSION: Male gender is an independent risk factor for adverse pregnancy outcome.     

Impact of First Childbirth on Changes in Women’s Preference for Mode of Delivery: Follow‐up of a Longitudinal Observational Study

ABSTRACT: Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty‐four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women’s wish to change to elective cesarean section. (BIRTH 35:2 June 2008)     

Risk factors and outcomes associated with a short umbilical cord

OBJECTIVE: To identify risk factors and outcomes associated with a short umbilical cord. METHODS: We conducted a population-based case-control study using linked Washington State birth certificate-hospital discharge data for singleton live births from 1987 to 1998 to assess the association between maternal, pregnancy, delivery, and infant characteristics and short umbilical cord. Cases (n = 3565) were infants diagnosed with a short umbilical cord. Controls (n = 14260) were randomly selected from among births without a diagnosis of short umbilical cord. RESULTS: Case mothers were less likely to be overweight (body mass index 25 or more, odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6, 0.8) and more likely to be primiparous (OR 1.4; 95% CI 1.3, 1.6). Case infants were more likely to be female (OR 1.3; 95% CI 1.2, 1.4), have a congenital malformation (OR 1.6; 95% CI 1.4, 1.8), and be small for their gestational age (risk ratio [RR] 1.6; 95% CI 1.4, 1.9). A short cord was associated with increased risk for maternal labor and delivery complications, including retained placenta (RR 1.6; 95% CI 1.2, 2.3) and operative vaginal delivery (RR 1.4; 95% CI 1.3, 1.5). Adverse fetal and infant outcomes in cases included fetal distress (RR 1.8; 95% CI 1.6, 2.1) and death within the first year of life among term infants (RR 2.4; 95% CI 1.2, 4.6). CONCLUSION: Modifiable risk factors associated with the development of a short cord were not identified. Case mothers and infants are more likely to experience labor and delivery complications. Term case infants had a 2-fold increased risk of death, which suggests closer postpartum monitoring of these infants.     

Obstetric outcomes subsequent to intrauterine death in the first pregnancy

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.
Design  Retrospective cohort study.
Setting  Grampian region of Scotland, UK.
Population  All women who had their first and second deliveries in Grampian between 1976 and 2006.
Methods  All women delivering for the first time between 1976 and 2002 had follow up until 2006 to study their next pregnancy. Those women who had an intrauterine death in their first pregnancy formed the exposed cohort, while those who had a live birth formed the unexposed cohort.
Main outcome measures  Maternal and neonatal outcomes in the second pregnancy, including pre-eclampsia, placental abruption, induction of labour, instrumental delivery, caesarean delivery, malpresentation, prematurity, low birthweight and stillbirth.
Results  The exposed cohort ( n = 364) was at increased risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7); placental abruption (OR 9.4, 95% CI 4.5–19.7); induction of labour (OR 3.2, 95% CI 2.4–4.2); instrumental delivery (OR 2.0, 95% CI 1.4–3.0); elective (OR 3.1, 95% CI 2–4.8) and emergency caesarean deliveries (OR 2.1, 95% CI 1.5–3.0); and prematurity (OR 2.8, 95% CI 1.9–4.2), low birthweight (OR 2.8, 95% CI 1.7–4.5) and malpresentation (OR 2.8, 95% CI 2.0–3.9) of the infant as compared with the unexposed cohort ( n = 33 715). The adjusted odds ratio for stillbirth was 1.2 and 95% CI 0.4–3.4.
Conclusion  While the majority of women with a previous stillbirth have a live birth in the subsequent pregnancy, they are a high-risk group with an increased incidence of adverse maternal and neonatal outcomes.     

Short stature--an independent risk factor for Cesarean delivery

OBJECTIVE: The present study was aimed to investigate pregnancy outcome of patients with short stature (height<155 cm), and specifically to elucidate if patients with short stature are at an increased risk for Cesarean section (CS) even after controlling for labor dystocia. METHODS: A population-based study comparing pregnancy outcome of patients with and without short stature, was performed. Deliveries occurred during the years 1988-2002, in a tertiary medical center. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: During the study period, 159,210 deliveries occurred. Of these, 5822 (3.65%) were of patients with short stature. Patients with short stature had statistically significant higher rates of CS compared with patients>or=155 cm (21.3% versus 11.9%, odds ratio (OR)=2.0; 95% confidence interval (CI): 1.9-2.1; P<0.001). Furthermore, there patients had higher rated of previous deliveries by CS (17.5% versus 10.3%, OR=1.8; 95% CI: 1.7-2.0; P<0.001), intrauterine growth restriction (IUGR, 3.2% versus 1.9%, OR=1.7; 95% CI: 1.4-1.9; P<0.001), premature rupture of membranes (PROM, 7.1% versus 5.6%, OR=1.3; 95% CI: 1.2-1.4; P<0.001), failed induction (0.7% versus 0.4%, OR=2.0; 95% CI: 1.5-2.8; P<0.001), labor dystocia (6.1% versus 3.5%, OR=1.8; 95% CI: 1.6-2.0; P<0.001), mal-presentations (7.6% versus 6.1%, OR=1.3; 95% CI: 1.1-1.4; P<0.001), and cephalopelvic disproportion (CPD, 0.9% versus 0.3%, OR=2.6; 95% CI: 1.9-3.4; P<0.001). No significant differences were noted between the groups regarding perinatal complications such as low birth-weight, meconium-stained amniotic fluid, perinatal mortality, and low Apgar scores at 5 min. Controlling for possible confounders such as previous CS, IUGR, PROM, failed induction, labor dystocia, mal-presentations and CPD, using the Mantel-Haenszel technique, did not change the significant association between short stature and CS. Moreover, a multiple logistic regression model was constructed with CS as the outcome variable, controlling for all these confounders. The model found short stature to be an independent risk factor for CS (OR=1.7; 95% CI: 1.6-1.9; P<0.001). CONCLUSION: Short stature is an independent risk factor for Cesarean delivery. Further studies investigating the actual indication for CS should be performed in order to make an informed recommendation regarding the preferred mode of delivery in short parturient women.     

Umbilical cord prolapse and perinatal outcomes.

OBJECTIVES: To determine obstetric risk factors and perinatal outcomes of pregnancies complicated by umbilical cord prolapse. METHODS: A population-based study was performed comparing all deliveries complicated by cord prolapse to deliveries without this complication. Statistical analysis was performed using multiple logistic regression models. RESULTS: Prolapse of the umbilical cord complicated 0.4% (n=456) of all deliveries included in the study (n=121,227). Independent risk factors for cord prolapse identified by a backward, stepwise multivariate logistic regression model were: malpresentation (OR=5.1; 95% CI 4.1-6.3), hydramnios (OR=3.0; 95% CI 2.3-3.9), true knot of the umbilical cord (OR=3.0; 95% CI 1.8-5.1), preterm delivery (OR=2.1; 95% CI 1.6-2.8), induction of labor (OR=2.2; 95% CI 1.7-2.8), grandmultiparity (>five deliveries, OR=1.9; 95% CI 1.5-2.3), lack of prenatal care (OR=1.4; 95% CI 1.02-1.8), and male gender (OR=1.3; 95% CI 1.1-1.6). Newborns delivered after umbilical cord prolapse graded lower Apgar scores, less than 7, at 5 min (OR=11.9, 95% CI 7.9-17.9), and had longer hospitalizations (mean 5.4+/-3.5 days vs. 2.9+/-2.1 days; P<0.001). Moreover, higher rates of perinatal mortality were noted in the cord prolapse group vs. the control group (OR=6.4, 95% CI 4.5-9.0). Using a multiple logistic regression model controlling for possible confounders, such as preterm delivery, hydramnios, etc., umbilical cord prolapse was found to be an independent contributing factor to perinatal mortality. CONCLUSIONS: Prolapse of the umbilical cord is an independent risk factor for perinatal mortality.     

Early discharge revisited: problems encountered with the home visit follow-up after the liberalization of eligibility criteria

Objective.?To compare maternal and neonatal outcomes among grandmultiparous women to those of multiparous women 30 years or older.

Methods.?A database of the vast majority of maternal and newborn hospital discharge records linked to birth/death certificates was queried to obtain information on all multiparous women with a singleton delivery in the state of California from January 1, 1997 through December 31, 1998. Maternal and neonatal pregnancy outcomes of grandmultiparous women were compared to multiparous women who were 30 years or older at the time of their last birth.

Results.?The study population included 25,512 grandmultiparous and 265,060 multiparous women 30 years or older as controls. Grandmultiparous women were predominantly Hispanic (56%). After controlling for potential confounding factors, grandmultiparous women were at significantly higher risk for abruptio placentae (odds ratio OR: 1.3; 95% confidence intervals CI: 1.2–1.5), preterm delivery (OR: 1.3; 95% CI: 1.2–1.4), fetal macrosomia (OR: 1.5; 95% CI: 1.4–1.6), neonatal death (OR: 1.5; 95% CI: 1.3–1.8), postpartum hemorrhage (OR: 1.2; 95% CI: 1.1–1.3) and blood transfusion (OR: 1.5; 95% CI: 1.3–1.8).

Conclusion.?Grandmultiparous women had increased maternal and neonatal morbidity, and neonatal mortality even after controlling for confounders, suggesting a need for closer observation than regular multiparous patients during labor and delivery.