Absence of conception after caesarean section: voluntary or involuntary?

BACKGROUND: Women who deliver by caesarean section have been shown to be less likely to have a subsequent pregnancy. It is not clear whether this is due to a direct effect of the procedure on future fertility or due to deliberate avoidance of a future pregnancy. OBJECTIVE: To investigate whether absence of conception following caesarean section is voluntary or involuntary. DESIGN: Follow up of a population-based retrospective cohort. SETTING: Grampian region, Scotland. POPULATION: Women who had no further viable pregnancies within 5 years of an initial delivery. METHODS: Cases included women who delivered their first child by caesarean section between 1980 and 1995 but had no further viable pregnancies by December 2000. Controls included women who delivered their first child during the same period, by means of either spontaneous vaginal delivery (SVD) or instrumental vaginal delivery (IVD), and who had no further viable pregnancies by December 2000. Eligible women were identified from the Aberdeen Maternity and Neonatal Databank (AMND) and sent postal questionnaires to determine the extent to which not conceiving after first delivery was voluntary and the reasons for avoiding further pregnancies. Characteristics of the different mode of delivery groups were compared using univariate techniques. MAIN OUTCOME MEASURES: Extent to which absence of conception following an initial delivery by caesarean section is voluntary. RESULTS: Questionnaires were returned by 3204 (60%) of 5300 women identified from the AMND. Of these, 1675 women had not conceived at all during the follow-up period (median duration = 13 years). Absence of conception was voluntary in 488 (69%; 95% CI 66-73%) women following caesarean section, 340 (71%; 95% CI 67-76%) following SVD and 354 (72%; 95% CI 68-76%) following IVD. Few women considered seeking fertility treatment (caesarean section = 72 [10%], SVD = 50 [11%], IVD = 39 [8%]). Of the women who decided to delay or avoid a further pregnancy, fewer women who delivered by SVD reported that the birth experience influenced their decision (caesarean section = 163 [32%], SVD = 67 [18%], IVD = 136 [35%]; P < 0.001). CONCLUSIONS: Irrespective of mode of delivery, not conceiving following the birth of the first child is mainly voluntary. The experience of the previous birth is one of several factors affecting women's decisions to avoid a subsequent pregnancy.     

Persistent urinary incontinence and delivery mode history: a six-year longitudinal study

OBJECTIVE: To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery. DESIGN: Longitudinal study. SETTING: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION: Women (4214) who returned postal questionnaires three months and six years after the index birth. METHODS: Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery mode history. MAIN OUTCOME MEASURES: Urinary incontinence-persistent (at three months and six years after index birth) and long term (at six years after index birth). RESULTS: The prevalence of persistent urinary incontinence was 24%. Delivering exclusively by caesarean section was associated with both less persistent (OR=0.46, 95% CI 0.32-0.68) and long term urinary incontinence (OR=0.50, 95% CI 0.40-0.63). Caesarean section birth in addition to vaginal delivery, however, was not associated with significantly less persistent incontinence (OR 0.93, 95% CI 0.67-1.29). There were no significant associations between persistent or long term urinary incontinence and forceps or vacuum extraction delivery. Other significantly associated factors were increasing number of births and older maternal age. CONCLUSIONS: The risk of persistent and long term urinary incontinence is significantly lower following caesarean section deliveries but not if there is another vaginal birth. Even when delivering exclusively by caesarean section, the prevalence of persistent symptoms (14%) is still high.     

Trial of labour after caesarean section in sub-Saharan Africa: ameta-analysis

Objective To evaluate the safety and effectiveness of apolicy of trial of labour for women with a previous caes are an section, delivering in hospitals in sub-Saharan Africa.
Design Ameta-analysis of 17 published reports. Setting Hospitals located in sub-Saharan Africa.
Main outcome measures The probability of vaginal delivery, the risk of mortality and morbidity, and the risk difference for specific obstetrical condition swere computed using an approach equivalent to a random effects model.
Results The proportion of women who were allowed a trial of labour ranged from 37% to 97% across reports. The probability of a vaginal delivery among these women was 69% (95% CI63–75%). Maternal mortality among all women with aprevious caesarean section was 1.9/1000 (95%CI0–4.3). Uterine rupture and scar dehiscence occurred in 2.1% (95%CI1.0–3.2). Criteria used to select women foratrial of labour appeared to have a limited impact on the probability of vaginal delivery.
Conclusions In hospitals in sub-Saharan Africa a selective policy of trial of labour after a previous caesarean section has a success rate comparable to that observed in developed countries. The policy appears to be relatively safe and applicable in this context.     

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.     

How much influence do women in Sweden have on caesarean section? A follow-up study of women's preferences in early pregnancy

OBJECTIVE: to investigate factors associated with having a caesarean section, with special emphasis on women's preferences in early pregnancy. DESIGN: a cohort study using data from questionnaires in early pregnancy and 2 months after childbirth, and data from the Swedish Medical Birth Register. SETTING: women were recruited from 97% of all antenatal clinics in Sweden at their booking visit during 3 weeks between 1999 and 2000, and followed up 2 months after birth. PARTICIPANTS: a total of 2878 Swedish-speaking women were included in the study (87% of those who consented to participate and 63% of all women eligible for the study). FINDINGS: Of 236 women who wished to have their babies delivered by caesarean section when asked in early pregnancy, 30.5% subsequently had an elective caesarean section and 14.8% an emergency caesarean section. The logistic regression analyses showed that, a preference for caesarean section in early pregnancy (odds ratio [OR] 9.63, 95% confidence interval [CI] 5.94-15.59), a medical diagnosis (OR 9.03, 95% CI 5.68-14.34), age (OR 1.08, 95% CI 1.03-1.13), parity (OR 0.58, 95% CI 0.37-0.91), a previous elective caesarean section (OR 15.11, 95% CI 6.83-33.41) and a previous emergency caesarean section (OR 18.29, 95% CI 10.00-33.44) was associated with having an elective caesarean section. Having an emergency caesarean section was associated with a preference for a caesarean section (OR 2.59, 95% 1.61 to 4.18), a medical diagnosis (OR 4.12, 95% CI 2.91-5.88), age (OR 1.08, 95% CI 1.05-1.12), primiparity (OR 3.34, 95% CI 1.78-6.27), a previous emergency caesarean section (OR 10.69, 95% CI 6.03-18.94), and a previous elective caesarean section (OR 7.21, 95% CI 2.90-17.92). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: a woman's own preference about caesarean section was associated with the subsequent mode of delivery. Asking women about their preference regarding mode of delivery in early pregnancy may increase the opportunity to provide adequate support and possibly also to reduce the caesarean section rate.     

Chilean women's preferences regarding mode of delivery: which do they prefer and why?

OBJECTIVE: Caesarean section rates in Chile are reported to be as high as 60% in some populations. The purpose of this study was to determine pregnant Chilean women's preferences towards mode of delivery. DESIGN: Interviewer-administered cross-sectional survey. SETTING: Prenatal clinics in Santiago, Chile. Population Pregnant women in Santiago, Chile. METHODS: Of 180 women completing the questionnaire, 90 were interviewed at a private clinic (caesarean delivery rate 60%) and 90 were interviewed at a public clinic (cesarean delivery rate 22%). Data collected included demographics, preferred mode of delivery, and women's attitudes towards vaginal and caesarean deliveries. MAIN OUTCOME MEASURES: Mode of delivery preferences, perceptions of mode of delivery measured on a 1-7 Likert scale. RESULTS: The majority of women (77.8%) preferred vaginal delivery, 9.4% preferred caesarean section, and 12.8% had no preference. There was no statistical difference in preference between the public clinic (11% preferred caesarean) and the private clinic (8% preferred caesarean, P= 0.74). Overall, women preferring caesarean birth were slightly older than other groups (31.6 years, versus 28.4 years for women who preferred vaginal and 27.3 years for women who had no preference, P= 0.05), but there were otherwise no differences in parity, income, or education. On a scale of 1-7, women preferring caesarean birth rated vaginal birth as more painful, while women preferring vaginal birth rated it as less painful (5.8 versus 3.7, P= 0.003). Whether vaginal or caesarean, each group felt that their preferred mode of delivery was safer for their baby (P < 0.001). CONCLUSIONS: Chilean women do not prefer caesarean section to vaginal delivery, even in a practice setting where caesarean delivery is more prevalent. Thus, women's preferences is unlikely to be the most significant factor driving the high caesarean rates in Chile.     

Caesarean sections and maternal mortality in Sao Paulo

OBJECTIVES: To evaluate caesarean section in both public and private sectors; maternal mortality associated with mode of delivery in the public sector (Sistema Unico de Saude, SUS) in Sao Paulo State, Brazil. STUDY DESIGN: 610,630 births in both public and private sectors for 2003; 1,153,034 deliveries and 314 maternal deaths in the public sector for 2001-2003. The study estimated caesarean section rates and odds ratios for caesarean section in association with maternal characteristics in both public and private sectors; maternal mortality associated with mode of delivery in the public sector, adjusted for hypertension, other disorders, problems and complications, as well as maternal age. RESULTS: The caesarean section rate was 32.9% in the public sector, and 80.4% in the private sector. The odd ratio for caesarean section was 2.6 (95% CI: 2.6-2.7) for women with 12 or more years of education. The odd ratio for maternal mortality associated with caesarean section in the public sector was 3.3 (95% CI: 2.6-4.3). CONCLUSIONS: Sao Paulo presented high caesarean section rates. Caesarean section compared to vaginal delivery in the public sector presented higher risk for mortality even when adjusted for hypertension, other disorders, problems and complications, as well as maternal age.     

Fertility outcomes of IVF/ICSI after Caesarean section: a cohort study

Research questionThe study objective was to evaluate the impact of a previous Caesarean section on fertility outcomes in women undergoing IVF/intracytoplasmic sperm injection (ICSI).DesignA retrospective cohort study was designed that included 1793 women undergoing IVF/ICSI who had had a previous delivery from January 2015 to December 2016. The primary outcome was live birth. Secondary outcomes were implantation, clinical pregnancy, miscarriage, ectopic pregnancy, multiple pregnancy and perinatal complications.ResultsOf the 1793 women included, 796 had had a previous Caesarean section and 997 a previous vaginal delivery. Propensity score matching in a 1:1 ratio resulted in 538 women per group. Compared with women with a previous vaginal delivery, women with a previous Caesarean section had a lower live birth rate (30.1% versus 38.1%, odds ratio [OR] 0.70, 95% confidence interval [CI] 0.54–0.90) and a higher miscarriage rate (25.9% versus 17.5%, OR 1.65, 95% CI 1.06–2.56). Among other secondary outcomes, implantation rates were 32.9% and 37.1% (OR 0.83, 95% CI 0.69–1.01), and clinical pregnancy rates were 42.4% and 46.8% (OR 0.84, 95% CI 0.66–1.06), in the Caesarean section group and vaginal delivery group, respectively. There were no statistically significant differences in terms of ectopic pregnancy, multiple pregnancy or perinatal outcomes between the groups. Further adjustment for confounders did not change the result of the primary outcome (OR 0.64, 95% CI 0.49–0.84).ConclusionsWomen undergoing IVF/ICSI who have had a previous Caesarean section have a lower live birth rate and a higher miscarriage rate than those with a previous vaginal delivery.     

Large babies and unplanned Caesarean delivery

OBJECTIVE: The relationship between birth weight > or =4000 g and unplanned Caesarean delivery was examined. DESIGN: A retrospective cohort study. SETTING: A district general hospital. Population: Two thousand three hundred and ninety-three women who delivered babies weighing > or =2500 g. METHODS: The mode of delivery of babies who weighed > or =4000 g was compared with those who weighed between 2500 and 4000 g. Comparative analysis of data was followed by regression analysis of explanatory variables. The effect of increasing birth weight on unplanned Caesarean delivery was determined. RESULTS: Women who had an unplanned Caesarean were delivered at an earlier gestation (OR = 0.89, 95% CI 0.81-0.97; P = 0.007), and were more likely to be primiparous (OR 5.4, 95% CI 4.1-7.1; P = 0.0001). Further, women who had an unplanned Caesarean were more likely to have babies weighing > or =4000 g (OR = 2.24, 95% CI 1.61-3.12; P = 0.003). The odds of having an unplanned Caesarean were increased 16.9-fold with a previous Caesarean (95% CI 9.24-30.8; P = 0.001). When a previous Caesarean was combined with a baby weighing > or =4000 g, the odds of having an unplanned Caesarean increased 37.8 times (95% CI 18.8-75.8), compared to a woman who previously had a normal vaginal birth and a baby weighing between 2500 and 4000 g. CONCLUSION: Birth weight > or =4000 g is associated with more than a two-fold increased risk of an unplanned Caesarean delivery. The risk increased further (37.8 x) when a previous Caesarean delivery was combined with a birth weight > or =4000 g.     

Subsequent pregnancy outcome after preterm breech delivery,a population based cohort study

Objective: The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy.

Methods: Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999–2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies.

Results: We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55–4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).

Conclusion: In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.     

Is gestational age an independent variable affecting uterine scar rupture rates?

OBJECTIVE: To evaluate the influence of gestational age on uterine scar rupture. METHODS: This was a population-based study of data from Cardiff Births Survey over a 10-year (1990-1999) period. Women with only one previous lower segment caesarean section with singleton uncomplicated pregnancy of 37 or more week's gestation, undergoing trial of vaginal delivery were included. SPSS version 10 was used for statistical analysis. Mann-Whitney, Fisher's exact test and Chi-square tests were used wherever appropriate. Odds ratio (OR) with confidence intervals (CI) was used to quantify the risk. Potential confounding by other factors was controlled using logistic regression and corrected odds ratios with 95% confidence intervals were calculated. The data was analysed separately for induced and spontaneous labours. Primary outcome measure assessed was uterine scar rupture rate. Secondary outcome measures were repeat caesarean section rates, maternal and perinatal mortality and morbidity. RESULTS: Total sample number was 1620. Eighty percent (n = 1301) of the population went into spontaneous labour and 20% (n = 319) were induced. Successful trial of vaginal birth was accomplished in 60% and trial of scar after estimated date of delivery did not alter this outcome significantly (39.1% versus 43.6%, p > 0.05). We noted an overall scar rupture rate of 0.9% (n = 14) and caesarean section rate of 40.4% (n = 654). Scar rupture rates significantly increased in women who underwent trial of labour after estimated date of delivery (p < 0.001, OR 6.3, CI 1.9-20.2) without a corresponding increase in caesarean section, maternal and perinatal morbidity figures. The influence of gestational age on scar rupture persisted even after controlling for other confounding factors such as birth weight, induction of labour and BMI (corrected OR 1.9, CI 1.1-3.5). CONCLUSIONS: The overall incidence of scar rupture and success of trial of scar after previous caesarean section in our population was similar to that quoted in the literature. Previous evidence has suggested that it is safe for these women to exceed 40 weeks gestation but our data do not support this.     

Induction of labour after a previous caesarean section: a retrospective study in a district general hospital.

A retrospective study was undertaken in a district general hospital to identify factors associated with vaginal delivery, as opposed to caesarean section, in women undergoing induction of labour after a previous caesarean section. The study was undertaken over 9 years (April 1994 - May 2003) and included patients in their second or subsequent pregnancy who had previously had one lower segment caesarean delivery and in whom labour had been induced. Records were extracted from a database and anonymised. Vaginal delivery after induction of labour was attempted in 81 patients of whom 64 (79.0%) subsequently delivered vaginally. There were few complications and no cases of uterine rupture. Two factors had a statistical significant relationship with vaginal birth after induction of labour; occipito-anterior position (OR 10.18, 95% CI 1.42 - 112.7, Yates corrected chi2; p = 0.001) and more than one previous birth (OR 4.76, 95% CI 1.28 - 21.67, p = 0.017). Other associations were explored but were not statistically significant. This paper contributes to the literature on factors associated with vaginal delivery after induction of labour and previous caesarean section, which may inform the selection of cases, and consequent success rates for vaginal delivery.     

Subsequent obstetric performance related to primary mode of delivery.

OBJECTIVE: To relate subsequent obstetric performance with primary mode of delivery. DESIGN: Postal questionnaire survey of women who delivered their first child five years ago. SETTING: Huddersfield Royal Infirmary. POPULATION: Women who were delivered of their first baby in 1991: 250 by normal vaginal delivery; 250 by instrumental vaginal delivery; and 250 by caesarean section. MAIN OUTCOME MEASURES: Answers to fixed choice questions on fear of future childbirth, number of subsequent children and reasons for no further children. RESULTS: The response rate was 64%. Overall, 222 (46.6%) women were initially frightened about future childbirth. According to mode of delivery: 93 (57.1%) after instrumental vaginal; 79 (47.9%) after caesarean section; and 50 (33.8%) after normal vaginal delivery. Five years after the primary delivery, 99 women (20.8%) were still frightened about future childbirth: instrumental vaginal group 41 (25.2%); caesarean section group 43 (26.1%); and normal vaginal group 15 (10.1%). In the group of women who were delivered by caesarean section 13% more women had not had a second child after five years compared with the normal vaginal delivery group ((P < 0.03, relative risk 1.46 (1.07-1.99)). In the group of women who had a vaginal instrumental delivery 6% more had not had a second child after five years compared with normal vaginal delivery group. Of the women who had no further children, 30% who had caesarean section and 28% vaginal instrumental delivery had involuntary infertility. CONCLUSIONS: Caesarean section or vaginal instrumental delivery leaves many mothers frightened about future childbirth. Primary caesarean section and to some extent vaginal instrumental delivery is associated with an increased risk of voluntary and involuntary infertility.     

Mode of delivery and the risk of delivery-related perinatal death among twins at term: a retrospective cohort study of 8073 births

OBJECTIVE: To determine the risk of perinatal death among twins born at term in relation to mode of delivery. DESIGN: Retrospective cohort study. SETTING: Scotland 1985-2001. POPULATION: All twin births at or after 36 weeks of gestation, excluding antepartum stillbirths and perinatal deaths due to congenital abnormality (n= 8073). METHODS: The outcome of first and second twins was compared using McNemar's test and the outcome of twin pairs in relation to mode of delivery was compared using exact logistic regression. MAIN OUTCOME MEASURES: Intrapartum stillbirth or neonatal death of either twin. RESULTS: Overall, there were six deaths of first twins and 30 deaths of second twins (OR for second twin 5.00, 95% CI 2.00-14.70). The odds ratio for death of the second twin due to intrapartum anoxia was 21 (95% CI 3.4-868.5). The associations were similar for twins delivered following induction of labour and for sex discordant twins. However, there was no association between birth order and the risk of death among 1472 deliveries by planned caesarean section. There was death of either twin among 2 of 1472 (0.14%) deliveries by planned caesarean section and 34 of 6601 (0.52%) deliveries by other means (P= 0.05, odds ratio for planned caesarean section 0.26 [95% CI 0.03-1.03]). The association was similar when adjusted for potential confounders. Assuming causality, we estimate that 264 caesarean deliveries (95% CI 158-808) would be required to prevent each death. CONCLUSION: Planned caesarean section may reduce the risk of perinatal death of twins at term by approximately 75% compared with attempting vaginal birth. This is principally due to reducing the risk of death of the second twin due to intrapartum anoxia.     

Caesarean delivery at full cervical dilatation versus caesarean delivery in the first stage of labour: comparison of maternal and perinatal morbidity

OBJECTIVE: To compare perinatal and maternal morbidity associated with caesarean sections performed in the first with that performed in the second stages of labour. PATIENTS AND METHODS: Comparative analyses between nulliparous women with singleton term pregnancies who had a caesarean section in the first stage of labour and those who had a second stage caesarean section were completed using standard statistical methods. A subgroup analysis, according to indication for caesarean section, was also performed. RESULTS: Of 627 women, 81% had caesarean delivery in the first stage and 19% had caesarean delivery in the second stage of labour. Women undergoing caesarean delivery at full cervical dilatation were 1.9 times more likely to have an augmented labour (95% CI 1.2-3.4, P < 0.001) and 2.8 times more likely to have epidural anaesthesia in labour (95% CI 1.5-5.2, P < 0.001) than those in the first stage. Compared with caesarean delivery in the first stage of labour, women undergoing caesarean delivery at full cervical dilatation were 4.6 times more likely to have composite intraoperative complications (95% CI 2.7-7.9, P < 0.001), 3.1 times more likely to have blood loss greater than 1,000 ml (95% CI 1.3-7.4, P = 0.01), and 2.9 times more likely to have a blood transfusion (95% CI 1.5-5.6, P < 0.001). The risk of neonatal morbidity was higher in first stage caesareans when they were performed for presumed fetal compromise (66.3 vs. 26.3%, P = 0.002), and lower when they were performed for failure to progress (18.4 vs. 42%, P = 0.02). CONCLUSION: Caesarean section in the second stage of labour is associated with a higher risk of maternal but not perinatal morbidity.     

New postnatal urinary incontinence: obstetric and other risk factors in primiparae

OBJECTIVE: To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth. DESIGN: Questionnaire survey of women. SETTING: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION: A total of 3405 primiparous women with singleton births delivered during 1 year. METHODS: Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence. MAIN OUTCOME MEASURES: Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth. RESULTS: The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age. CONCLUSIONS: Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.     

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version

Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2–6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1–8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.     

Current guidelines on management of HIV-infected pregnant women: impact on mode of delivery

OBJECTIVE: To evaluate acceptance, feasibility and difficulties in the application of a policy of vaginal delivery in selected cases in HIV-infected women. STUDY DESIGN: HIV-infected women delivering March 2002 to December 2004 and enrolled in a prospective observational study in a University hospital tertiary care center were included. A vaginal delivery was not considered if labor before 36 weeks of pregnancy, preterm premature rupture of membranes, on non-highly active antiretroviral therapy (HAART) or viral load >1000copies/mL. Main outcome measures were mode of delivery, prematurity, acceptance of vaginal delivery and mother-to-child transmission of HIV infection. RESULTS: The study included 91 pregnancies, with a total of 95 fetuses. Eighty percent (n=73) of women knew their HIV infection status before becoming pregnant and 57 (63%) were on HAART at conception. Median gestational age at delivery was 37 weeks (range 22-41). Twelve women delivered a live-born before 36 weeks, all with a caesarean section. Among 74 women who reached 36 weeks gestation, 47 (64%) met the pre-established criteria for vaginal delivery, of whom 21 (45%) delivered vaginally. The most common reason for not having a vaginal delivery was the woman's request for a caesarean section. No cases of HIV vertical transmission occurred (0/90, 95% CI 0-4.02%). CONCLUSION: Recommending vaginal delivery among HIV-infected women in selected cases was well accepted, particularly once the policy became established. Nevertheless, a high proportion of HIV-infected women will continue to require caesarean section delivery.     

剖宫产术对母乳喂养影响的前瞻性研究

目的研究剖宫产术对母乳喂养的影响.方法采用前瞻性研究方法,选择剖宫产（剖宫产组）、阴道分娩（阴道分娩组）各301例产妇为研究对象,比较两组产妇产后泌乳始动时间、产后1年内母乳喂养情况;用放射免疫法测定两组产妇产后血清催乳素含量.结果在分娩后6～24 h内的白天,剖宫产组产妇血清催乳素均值为8.48 nmol/L（95%CI：7.80～9.21 nmol/L）、阴道分娩组为9.61 nmol/L（95%CI：8.99～10.26 nmol/L）.剖宫产组产妇产后泌乳始动中位时间为产后12 h,晚于阴道分娩组的产后2 h.剖宫产组产妇产后1个月时乳量仅为阴道分娩组的90%.产后1、6、12个月时,剖宫产组母乳喂养率均低于阴道分娩组;剖宫产组产妇产后1年内母乳喂养失败的风险是阴道分娩组的1.21倍（95%CI：1.10～1.33）. 结论与阴道分娩组比较,剖宫产术后产妇泌乳始动时间晚,血清催乳素含量低,产后1年内母乳喂养失败的风险高.对剖宫产产妇更应加强促进泌乳、催乳的措施,以提高母乳喂养成功率.     

Faecal incontinence and mode of first and subsequent delivery: a six-year longitudinal study

OBJECTIVE: To investigate the prevalence of persistent and long term postpartum faecal incontinence and associations with mode of first and subsequent deliveries. DESIGN: Longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Four thousand two hundred and fourteen women who returned postal questionnaires three months and six years postpartum. METHODS: Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery history. MAIN OUTCOME MEASURES: Incontinence to bowel motions three months and six years after index birth. For delivery history, the outcome was incontinence only at six years. RESULTS: The prevalence of persistent faecal incontinence was 3.6%. Almost 90% of these women reported no symptoms before their first birth. The forceps delivery of a first baby was independently predictive of persistent symptoms (OR 2.06, 95% CI 1.40-3.04). A caesarean section first birth was not significantly associated with persistent symptoms (OR 1.07, 95% CI 0.64-1.81). Delivering exclusively by caesarean section also showed no association with subsequent symptoms (OR 1.04, 95% CI 0.72-1.50) but ever having forceps was significantly predictive (OR 1.48, 95% CI 1.18-1.87). Other factors independently associated with persistent faecal incontinence were older maternal age, increasing number of births and Asian ethnic group. Birthweight and long second stage were not significantly associated. CONCLUSIONS: The risk of persistent faecal incontinence is significantly higher after a first delivery by forceps. We found no evidence of a lower risk of subsequent faecal incontinence for exclusive caesarean section deliveries.