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

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

Effect of mode of delivery on neonatal outcome of twins with birthweight under 1500 g

Objective: The purpose of this retrospective study was to evaluate. The mode of delivery on neonatal outcome of twins weighing <1500 g. Methods: We reviewed the effect of birth order, presentation, and method of delivery on neonatal outcome in twin gestation under 1500 g at Princess Badeea’ Teaching Hospital in North Jordan over the 6-years from 1994 to 1999. Results: During the study period, there were 51475 deliveries of which 695 were twin gestations. One hundred and eight (108) sets of twins weighing <1500 g were included in the study (15.5%), of which 41 were in vertex-vertex presentation, 40 in vertex-nonvertex, and 27 with first twin in nonvertex presentation. The second twin pregnancies characterized by a higher incidence of respiratory distress syndrome (82 vs. 70%; p=0.02) more neonatal mortality (23 vs 17.6%), and lower Apgar score at 1 and 5 min. Cesarean delivery for vertex-vertex presentation did not improve the neonatal outcome. Rather, the incidence of RDS was significantly greater in this group delivered by cesarean section (65.6 vs. 42%, p=0.012). For nonvertex presentation, those delivered by cesarean section had a lower incidence of neonatal mortality. Conclusion: We concluded there was no advantage for cesarean delivery that could be demonstrated after multivariate analysis to correct the differences in birthweight between the groups. Therefore, the differences in the neonatal outcome of non vertex twins presentation accounted for the differences in birthweight, rather than in mode of delivery. Received: 14 March 2000 / Accepted: 9 May 2000     

Timing of elective repeat caesarean section: maternal and neonatal morbidity and mortality

Timing of elective repeat caesarean section should take into account both fetal and maternal considerations. The percentage of caesarean deliveries has dramatically increased during the last decades. It undoubtedly leads to an increase in the number of women having multiple caesarean sections. While maternal morbidity increases with increased number of caesarean sections, when compared with their term counterparts, late pre-term infants face increased morbidity. Establishing the optimal time of delivery for both mother and child is a major challenge faced by clinicians. The aim of this review is to better understand neonatal and maternal morbidity and mortality that are associated with elective repeat caesarean section, and to provide an educated decision regarding the optimal timing for elective repeat caesarean section.     

Term breech singletons and caesarean section: A population study, Australia 1991–2005

Objective: To describe the method of birth of term breech singletons in Australia.
Design, setting and participants:  A retrospective population-based study of women who gave birth to term breech singletons in Australia between 1 January 1991 and 31 December 2005 using data from the National Perinatal Data Collection.
Main outcome measures:  Caesarean section, vaginal breech birth.
Results:  Method of birth changed for term breech singletons from 1991 (vaginal breech birth 23.1% versus caesarean (no labour 55.6%, labour 21.2%)) to 2005 (vaginal breech birth 3.7% versus caesarean (no labour 76.6%, labour 19.7%)). Overall, the population attributable risk percentage of term breech singletons for all caesarean sections declined from 10.2% in 1991 to 6.9% in 2005.
Conclusion:  Planned caesarean section is the standard method of birth for term breech singletons in Australia. Active measures including external cephalic version should be supported to reduce the rate of caesarean section where clinically indicated. Retention of a skilled clinical workforce is essential in the provision of the latter and to assist the minority of women having vaginal breech births. Breech presentation is not a major factor in the overall rise in caesarean section experienced by Australia since 1996.     

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.     

Lack of correlation between a high caesarean section rate and improved prognosis for low-birthweight twins (<2500 g)

Summary. The impact of birth by caesarean section on perinatal mortality was estimated for 9368 low-birthweight twins (<2500 g) born in Sweden between 1973 and 1985, by using national data from the Medical Birth Registry, National Board of Health and Welfare, Stockholm. During this period the caesarean section rate increased from 7–10% to 45–50% while concomitantly a sharp decrease in the perinatal mortality rate occurred. A causal relation between the increased rate of abdominal delivery and the improved prognosis for low birthweight twins might be expected. However, analysis of the results failed to show any correlation between these two variables. Factors other than route of delivery seem to have a greater impact on fetal outcome.     

Obstetric and neonatal outcomes in a home-like birth centre: A case-control study

ObjectivesTo compare intervention rates associated with labor in low-risk women who began their labor in the “home-like birth centre” and the traditional delivery room.Patients and methodsThis retrospective study used data that were collected from January 2005 through June 2008, from women admitted to the “home-like birth centre” (n = 316) and compared to a group of randomly selected low-risk women admitted to the traditional labor ward (n = 890) using the Baysian Information Criterion to select the best predictive model.ResultsWomen in the “home-like birth centre” had spontaneous vaginal deliveries more often (88.6% versus 82.8%, P value 0.034) and perineal lesions less often (60.1% versus 62.5%, P value 0.013). The frequency of adverse neonatal outcomes did not differ statistically between the two groups, although mean clamped at birth umbilical arterial pH level was higher in the “home-like birth centre” group. The transfer rate from “home-like birth centre” to traditional labor ward was 31.3%.Discussion and conclusionsIt appears that women could benefit from “home-like birth centre” care in settings such as the one studied. Larger observational studies are warranted to validate these results.     

The effect of caesarean section on self-esteem amongst primiparous women in South-Western Nigeria: A case-control study

Objective.?This study aims to assess the level of self-esteem of newly delivered mothers who had caesarean section (CS) and evaluate the sociodemographic and obstetrics correlates of low self-esteem in them.

Methods.?Newly delivered mothers who had CS (n?=?109) and who had spontaneous vaginal delivery (SVD) (n?=?97) completed questionnaires on sociodemographic and obstetrics variables within 1 week of delivery. They also completed the Rosenberg self-esteem scale.

Results.?Women with CS had statistically significant lower scores on the self-esteem scale than women with SVD (p?=?0.006). Thirty (27.5%) of the CS group were classified as having low self-esteem compared with 11 (11.3%) of the SVD group (p?=?004). The correlates of low self-esteem in the CS group included polygamy (odd ratio (OR) 4.99, 95% confidence interval (95% CI) 1.62–15.33) and emergency CS (OR 4.66, 95% CI 1.55–16.75).

Conclusions.?CS in South-Western Nigerian women is associated with lowered self-esteem in the mothers.     

重复剖宫产对妊娠结局的影响

目的 探讨重复剖宫产对孕产妇及围产儿结局的影响.方法 回顾性分析1998年1月1日至2007年12月31日,在北京协和医院妊娠超过28周行再(多)次剖宫产手术分娩的产妇共412例,根据剖官产次数分为再次剖宫产组(repeated caesarean section group,RCS组,394例)和多次剖宫产组(multiple caesarean section group,MCS组,18例),随机选取同期行初次剖宫产手术分娩的480例为初次剖宫产组(first caesarean section group,FCS组)作为对照,分析三组孕妇的一般临床资料、产时产后并发症及围产儿结局.结果 近十年我院再次剖官产率为4.1%,呈逐年上升趋势.(1)一般临床资料比较:RCS组及MCS组平均年龄分别为(33.7±4.3)岁,(34.5±5.1)岁,大于FCS组(31.5±4.3)岁(P<0.05).RCS组及MCS组平均孕次分别为(3.5±1.4)次,(4.7±1.5)次,多于FCS组(2.1±1.2)次(P<0.05).(2)盆腔粘连发生率:RCS组及MCS组分别为13.5%和50.0%,高于FCS组(0.4%)(P<0.05).(3)子宫破裂发生率:RCS组(1%)高于FCS组(0%)(P<0.05).(4)RCS组及MCS组平均分娩孕周分别为(38.1±1.8)周,(37.3±2.5)周,与FCS组[(38.9±2.1)周]比较差异有统计学意义(P<0.05).结论 再 (多)次剖宫产发生率逐年上升,其显著增加盆腔粘连及子官破裂的发生率,但并不增加围产儿并发症的发生率.     

Neonatal mortality in infants born weighing 501 to 1000 grams. The influence of changes in birth weight distribution and birth weight-specific mortality rates on neonatal survival

We analyzed changes over time in neonatal mortality rates for infants born weighing 501 to 1000 gm. The decline in total mortality in this weight group due to improved small-group, birth weight-specific mortality was contrasted to the increase in mortality caused by changes in the birth weight distribution resulting from the care of smaller infants. Had the birth weight distribution remained unchanged, the total improvement in neonatal mortality for the entire 501 to 1000 gm group would have been substantially greater.     

Lack of correlation between a high caesarean section rate and improved prognosis for low-birthweight twins (less than 2500 g)

The impact of birth by caesarean section on perinatal mortality was estimated for 9368 low-birthweight twins (less than 2500 g) born in Sweden between 1973 and 1985, by using national data from the Medical Birth Registry, National Board of Health and Welfare, Stockholm. During this period the caesarean section rate increased from 7-10% to 45-50% while concomitantly a sharp decrease in the perinatal mortality rate occurred. A causal relation between the increased rate of abdominal delivery and the improved prognosis for low birthweight twins might be expected. However, analysis of the results failed to show any correlation between these two variables. Factors other than route of delivery seem to have a greater impact on fetal outcome.     

Prognosis for twins with birth weight less than 1500 gm: the impact of cesarean section in relation to fetal presentation

The purpose of this study of twins weighing less than 1500 gm was to evaluate the impact of cesarean section on intrapartum and neonatal mortality, as well as on cerebral palsy and mental retardation. National data held at the Medical Birth Registry was used for identification of cases. The original medical records were retrieved for 862 such twins born between 1973 and 1983. Twins with cerebral palsy and/or mental retardation born between 1973 and 1980 were identified by questionnaires to all rehabilitation centers for disabled children, offices for the Provision of Care for the Mentally Retarded, and to all local Boards of Education throughout Sweden. The analyses, including calculation of relative risk and 95% confidence interval, were performed after stratification for birth weight (250 gm classes) and period of delivery (1973 to 1976, 1977 to 1980, 1981 to 1983). The cesarean section rate increased from 7.7% (1973 to 1976), and 40.5% (1977 to 1980) to 68.9% (1981 to 1983). Concomitantly, intrapartum and neonatal mortality decreased markedly (51.7% to 29.1%) particularly for twin II but to a much lesser extent for twin I. The relative risk for intrapartum and neonatal mortality (vaginal/abdominal birth) did not increase significantly for twin I in vertex presentation (relative risk 2.0, 95% confidence limits 0.9 to 4.3), for twin I in breech presentation (relative risk 1.8, 95% confidence limits 0.7 to 4.3), for twin II in vertex presentation (relative risk 0.6, 95% confidence limits 0.2 to 1.6), or for twin II in breech presentation (relative risk 1.5, 95% confidence limits 0.7 to 3.0). The rate of cerebral palsy and/or mental retardation was 8.8% during 1973 to 1976 and 8.0 during 1977 to 1980 (chi 2 = 0.1, p greater than 0.05). For twins born in breech presentation the handicap rate in the first period (cesarean section rate 6.0%) was the same as in the second period (cesarean section rate 59.6%). The analysis failed to reveal any significant impact of abdominal birth on the fetal outcome for low-birth-weight twins, even when fetal presentation was taken into consideration.     

A study of birth weight, placental weight and mortality of twins as compared to singletons.

A study was made of 1655 sets of twins born between 1931 and 1975 in two clinical centres. Compared to singletons, twins were born three weeks earlier, weighed less at birth from 33 weeks to term and had smaller placentae from 21 to 22 weeks to term. The influence on birth weight fo sex was smaller in twins, the influence of parity greater. Because, compared to singletons, lower placental indices were found in twins up to 37 to 38 weeks, the conclusion is drawn that the retardation of growth in twins is to some extent due to the placenta itself. When singletons and twins of the same gestational age were compared, the mortality was found to be similar, somewhat lower in twins up to 37 to 38 weeks and higher afterwards. Monochorial twins were found to be born earlier, weigh less at birth and have a higher mortality than dichorial twins. Placental weights were not different and the conclusion is drawn that the retardation of growth in monochorial twins is to some extent due to the higher incidence of marginal and velamentous insertions of the umbilical cord associated with lower birth weights.     

Neonatal mortality rates among growth-discordant twins, classified according to the birth weight of the smaller twin

OBJECTIVE: The purpose of this study was to evaluate neonatal mortality rates among discordant twins, classified according to the birth weight of the smaller twin. STUDY DESIGN: We compared neonatal mortality rates among three groups of discordant twins (>25%), distinguished by the birth weight of the smaller twin being <10th, 10th to 50th, or >50th percentile. RESULTS: Among the 10,683 pairs of twins who were studied, the respective proportions of the three groups were 62.4%, 32.9%, and 4.7%. The neonatal mortality rate was significantly higher among pairs in which the smaller twin weighed <10th birth weight percentile (29. vs 11.1 and 11 per 1000; odds ratio, 2.7; 95% CI, 1.3, 5.7). This difference results from the higher mortality rates among the smaller but not among the larger twins. CONCLUSION: Severely discordant twin pairs in whom the smaller twin is also small for gestational age are at an increased risk of neonatal death. Identification of this group is an imperative step in the management of birth weight discordance in twin gestations.     

Mean arterial pressure in very low birth weight (801 to 1500 g) concordant and discordant twins during the first day of life.

OBJECTIVE: To determine retrospectively mean arterial pressure (MAP) for stable and unstable concordant and discordant very low birth weight (VLBW: 801 to 1500 g) twins during the first 24 hours of life. BACKGROUND: Morbidity and mortality are much higher for extremely low birth weight (ELBW < or =800 g) than for VLBW twins. Recently, we reported MAP trends and reference values in concordant and discordant ELBW twins. No comparable information is available for VLBW infants. DESIGN: Retrospective cohort study. METHODS: We studied 48 sets of concordant and 40 sets of discordant (birth weight difference > or =20%) consecutively born VLBW twins. Stable patients were defined as having umbilical cord hemoglobin > or =14 g/dl, nonacidotic blood gases, never treated for hypotension and survived at least 7 days. MAPs (Torr) were measured by oscillometry in 3163 and by transducer via umbilical artery in 2028 instances. RESULTS: Concordant and discordant twins were similar in demographics, history of twin-twin transfusion (TTTX), antenatal steroids, chorioamnionitis, pre-eclampsia, cesarean delivery, cord hemoglobin, normal head ultrasounds or I to II intracranial hemorrhage (97 and 99%) and neonatal mortality (4 and 5%), but were different in incidence of preterm labor (83 and 58%), birth weight (1227 and 1509 g) and gestational age (GA) (30 and 32 weeks). In all, 66 (69%) concordant twins and 61 (76%) discordant twins were stable. Stable concordant twins, whether small or large, had comparable MAP on admission that increased to 24 hours. Twins of < or =32 weeks GA had lower MAP throughout than those of > or =33 weeks GA. Although their mean birth weights were similar (1262 and 1274 g), 23 stable concordant males had significantly higher MAP than 43 concordant females. Stable discordant twins were divided into 31 small (1241 g) and 30 large (1845 g); their MAPs were different (p<0.05): 35 and 39 (admission), 35 and 39 (1 hour), 36 and 46 (6 hours), 38 and 41 (12 hours), 40 and 41 (18 hours) and 42 and 42 (24 hours) Torr. In all, 88% of small discordant twins were IUGR and 91% of large discordant twins had normal growth. TTTX syndrome occurred in 12 monochorionic sets. Nine of 12 donors were IUGR while 10 of 12 recipients had normal growth. Four of 12 donors had grades III to IV intracranial hemorrhage, eight donors and all 12 recipients had normal ultrasounds. Although their cord hemoglobin levels were similar, donor and recipient MAPs were higher than in any other group and, opposite to concordant and discordant twins, their values decreased from birth to 24 hours. CONCLUSION: In stable concordant, stable discordant, and small and large discordant twins, MAP correlates with birth weight, GA and postnatal age, and increases during the first 24 hours. In recipient and donor twin-twin transfusion infants, MAP is higher throughout and declines over time.     

A longitudinal observational study of preference for elective caesarean section among nulliparous Hong Kong Chinese women

Objective  To establish whether women's preference for elective caesarean section (ELCS) changes as gestation advances.
Design  A prospective longitudinal observational study.
Setting  Two units providing obstetric care in Hong Kong, one public and one private.
Sample  Five hundred and one nulliparous Chinese pregnant women attending their routine fetal anomaly scan in either unit.
Methods  Consented subjects had two interviews using a structured questionnaire at 18–22 weeks and 35–37 weeks of gestation, respectively. Multivariate analysis was performed to identify determinants for preferring ELCS at the two gestational ages.
Main outcome measure  The preferences for the mode of delivery at the two gestational ages.
Results  The prevalence of maternal preference for ELCS in the study cohort was 17.2% (95% CI 13.9–20.5) and 12.7% (95% CI 9.6–15.8) at mid-trimester and at term, respectively. Significantly more women who preferred ELCS at mid-trimester changed to a trial of vaginal delivery (VD) at term than vice versa (42.0 versus 3.8%). The partner's preference for ELCS was a significant determinant for women preferring ELCS throughout the antenatal period. Among the women booked in the public sector, more women who preferred ELCS at term changed to deliver in private hospitals than those who preferred VD (46.2 versus 9.7%).
Conclusions  Many women changed from preferring ELCS to preferring VD as their pregnancy approached term. The partner's preference was a significant determinant for the women's choice. If a decrease in the proportion of women preferring ELCS is desired, the intervention programme should target the women and their partners who hold such a preference at 20 weeks.     

Maternal mortality in England and Wales 1970–1985: an analysis by country of birth

Objective To determine the risk of maternal mortality in immigrants to England and Wales. Design Analysis of death registrations, 1970–1985, by country of birth. Setting England and Wales.
Population Women dying in England and Wales during regnancy, childbirth or the puerperium, or dying fiom malignant tumour of the placenta.
Main outcome measures The risk of dying in pregnancy, childbirth or the puerperium, adjusted for age and year of death, and the risk of cause-specific death, adjusted for age, in immigrants compared with women born in England and Wales.
Results Women born in West Africa (relative risk 10.3; 95% CI 8.0–13.2) and the Caribbean (4.6; 3.8–5.7) were at very elevated risk of maternal death and of the main causes of death. Women from Southern Asia (1.6; 1.3–2.0) and 'Europe and the USSR' (1.7; 1.2–2.3) were at moderate risk. Adjustment for year of death increased the estimates of risk and women born in the 'Rest of the World' and Scotland were at significantly elevated risk.
Conclusions An increased incidence of obstetric conditions in immigrant groups may account for the elevated risk but it is also possible that differences in care may account for some of the additional risk. The pattern of increased risk does not appear to be explicable by the parity or social class distribution of immigrants as far as data are available on these. Research is required into the aetiology of the differential incidence of obstetric disease. The collection of routine mortality data which include maternal reproductive and social factors would elucidate the significance of such factors to maternal health. Further investigation into possible differences in the process of antenatal care between immigrants and non-immigrants is required, and into whether this affects the risk of maternal mortality.     

A multi-country study of the “intrapartum stillbirth and early neonatal death indicator” in hospitals in low-resource settings

Objective

To determine the feasibility of introducing a simple indicator of quality of obstetric and neonatal care and to determine the proportion of potentially avoidable perinatal deaths in hospitals in low-income countries.

Methods

Between September 1, 2011, and February 29, 2012, data were collected from consecutive women who were admitted to the labor ward of 1 of 6 hospitals in 4 low-income countries. Fetal heart tones on admission were monitored, and demographic and birth data were recorded.

Results

Data were obtained for 3555 women and 3593 neonates (including twins). The doptone was used on 97% of women admitted. The overall perinatal mortality rate was 34 deaths per 1000 deliveries. Of the perinatal deaths, 40%–45% occurred in the hospital and were potentially preventable by better hospital care.

Conclusion

The results demonstrated that it is possible to accurately determine fetal viability on admission via a doptone. Implementation of doptone use, coupled with a concise data record, might form the basis of a low-cost and sustainable program to monitor and evaluate efforts to improve quality of care and ultimately might help to reduce the in-hospital component of perinatal mortality in low-income countries.