Randomised trial of assigned mode of delivery after a previous cesarean section – Impact on maternal psychological dynamics

Objective.?This randomised trial was designed to study the psychological status and morbidity during and after delivery among women with a previous cesarean section (CS) who were randomised to planned vaginal birth (VBAC) or planned CS.

Methods.?Two hundred and ninety-eight women with one previous lower segment CS were randomised to either planned VBAC or planned CS. Women were asked to complete psychometric scales during their pregnancy till 6 months after confinement. The primary outcome studied was the differences in psychometric scores between the two study groups.

Results.?There were no differences in anxiety, depression, psychological well-being or satisfaction scores between the two groups. Significantly more women in planned VBAC (27/123) requested to change to elective CS, compared to those who were randomised to planned CS (15/135) initially requested to change to planned VBAC (OR: 2.25; 95% CI: 1.13–4.47). Subgroup analyses showed that women who changed from planned CS to VBAC had lower satisfaction at delivery [Client Satisfaction Score: 24.0 (23.0–24.3), 23.0 (22.0–24.0); p?=?0.009] compared to women who did not change their plan for elective CS.

Conclusions.?The planned mode of delivery, either elective CS or VBAC, in pregnant women who had one previous CS did not influence the psychological dynamic during the course of or after the pregnancy. VBAC was not associated with higher psychological morbidity and therefore should be encouraged.     

Pregnant women’s preference for cesarean section and subsequent mode of birth – a six-country cohort study

Introduction: The rate of cesarean section (CS) for non-medical reasons has risen and it is a concern for health care. Women’s preferences may vary across countries for psychosocial or obstetric reasons.

Methods: A prospective cohort study of 6549 women in routine antenatal care giving birth in Belgium, Iceland, Denmark, Estonia, Norway or Sweden. Preference for mode of birth was self-reported in mid-pregnancy. Birth outcome data were collected from hospital records.

Results: A CS was preferred by 3.5% of primiparous women and 8.7% of the multiparous women. Preference for CS was associated with severe fear of childbirth (FOC), with a negative birth experience in multiparous women and with depressive symptoms in the primiparous. Women were somewhat more prone to prefer a cesarean in Iceland, odd ratio (OR) 1.70 (1.02–2.83), adjusted for age, education, depression, FOC, history of abuse, previous cesarean and negative birth experience. Out of the 404 women who preferred CS during pregnancy, 286 (70.8%) delivered by CS, mostly for a medical indication. A total of 9% of the cesareans in the cohort had a non-medical indication only.

Conclusions: Women’s preference for CS often seems to be due to health concerns. Both medical and psychological factors need to be addressed in antenatal counseling. Obstetricians need to convey accurately to women the risks and benefits of CS in her specific case. Maternity professionals should identify and explore psychosocial reasons for women’s preferences.     

A case–control study of caesarean delivery on maternal request: who and why?

Objective: The current study aimed to evaluate the profile of women who are most likely to undergo caesarean delivery on maternal request (CDMR) and clarify their reasons for this decision.

Methods: For this multicentre case–control study, data were collected from 429 women who underwent CDMR and 429 matched controls who delivered vaginally from June, 2008 through February, 2009. Participants were interviewed by telephone regarding sociodemographic variables, health and lifestyle.

Results: CDMR predictors were as follows: increasing age (OR?=?1.09/year; 95%CI: 1.05–1.14), family status (unmarried without a steady partner versus married – OR?=?3.60; 95%CI: 1.08–11.97), decreasing level of religiosity (secular versus ultra-orthodox – OR?=?11.82; 95%CI: 3.75–37.21), and never having engaged, or ceasing sports activity during pregnancy (OR?=?1.79; 95%CI: 1.09–2.91 and 2.38; 95%CI: 1.28–4.43, respectively). Above average income reduced the probability of CDMR (OR?=?0.56; 95%CI: 0.33–0.94). The most frequent reasons for choosing CDMR were concern for pain (21.9%), concern for their own or baby's health (20.4% and 16.5%, respectively) and emotional aspects (10.0%).

Conclusions: Older, unmarried and/or secular women had increased probability of CDMR. Addressing specific concerns regarding vaginal delivery may provide the basis for a patient-oriented intervention for preventing unnecessary surgery.     

Risk-adjusted cesarean rates: what risk factors for cesarean delivery are important to practicing obstetricians?

OBJECTIVE: To determine which primary cesarean delivery risk factors are important to practicing physicians. STUDY DESIGN: A sample of current members of the American College of Obstetrician Gynecologists were surveyed about the risk factors for primary cesarean delivery that they thought were most important. Data on demographic and practice characteristics were also collected. Sample size was determined by theoretical saturation. RESULTS: Theoretical saturation was reach at 60 responses. A total of 290 surveys were returned. The 10 most common factors listed by physicians as preexisting patient risk factors for primary cesarean delivery were, in descending order of importance, medical problems, maternal obesity, macrosomic infant, malpresentation, multiple gestation, maternal age, Bishop score, patient's fear, preterm labor, and postdate pregnancy. Six of the 10 factors listed by respondents are in previously published risk-adjustment models. CONCLUSION: Our study suggested that the addition of obesity and birth weight to previously published risk-adjustment models should improve representation of practicing obstetricians' views.     

Preference toward future mode of delivery: how do antepartum preferences and prior delivery experience contribute?

Objective: Examine postpartum preferences toward future mode of delivery (MOD), considering recent MOD, antepartum preferences, and demographics.

Study design: Prospective cohort study where a survey was distributed in outpatient obstetrics clinics to pregnant women over 18 years at 28 weeks gestation or later. Surveys gathered demographics, obstetric history, and preference toward vaginal delivery (VD) versus cesarean delivery (CD). Women were again surveyed at 6–8 weeks postpartum. Chi-square test compared proportions, and logistic regression controlled for potential confounders.

Results: A total of 299 women returned postpartum surveys and expressed preferences. Comparing women who experienced VD versus CD, the majority who had a VD (92.1%) would choose this again, while only 1.9% preferred CD. Among the CD group, preferences were mixed: 29.4% desired repeat CD, 34.1% preferred VD, and 36.5% were undecided (p?<?0.001). Adjusted odds were 34.4 (95% CI 9.4–126.1) for preferring VD over CD among women who experienced a recent VD, adjusting for parity, age, ethnicity, education, possible depression, and type of provider.

Conclusions: The majority of women preferred VD postpartum. Of the minority who desired CD, antenatal preference for cesarean and prior experience with CD were important factors. This highlights the impact of individual desires and experience, and underscores importance of antenatal counseling.     

Cesarean delivery on maternal request: wise use of finite resources? A view from the trenches

Cesarean section rates are rising in the United States and were at an all time high of 29 percent in 2004. Within this context, the issue of cesarean section on maternal request has been described as being part of a "perfect storm" of medical, legal and personal choice issues, and the lack of an opposing view. An increasing cesarean section rate adds an economic burden on already highly stressed medical systems. There is an incremental cost of cesarean section compared to vaginal delivery. The issue of cost must also be considered more broadly. Rising cesarean section rates are associated with a longer length of stay and a higher occupancy rate. This high occupancy rate leads to the diversion of critical care obstetric transports and has dramatically reduced patient satisfaction. These diversions, and the resultant inability to provide needed care to pregnant women, represent a profound societal cost. These critical care diversions and reduced patient satisfaction also negatively impact a health care institution's financial bottom line and competitiveness. The impact of a rising cesarean section rate on both short and long-term maternal and neonatal complications, and their associated costs, must also be taken into account. The incidence of placenta accreta is increasing in conjunction with the rising cesarean section rate. The added costs associated with this complication (MRI, Interventional Radiology, transfusion, hysterectomy, and intensive care admission) can be prohibitive. It has also been demonstrated that infants born by scheduled cesarean delivery are more likely to require advanced nursery support (with all its associated expense) than infants born to mothers attempting vaginal delivery. The practice of maternal request cesarean section, with limited good data and obvious inherent risk and expense, is increasing in the USA. Patient autonomy and a woman's right to choose her mode of delivery should be respected. However, in our opinion, based on the current evidence regarding cesarean delivery on maternal request, promotion of primary cesarean section on request as a standard of care or as a mandated part of patient counseling for delivery will result in a highly questionable use of finite resources. As of 2004, 46 million Americans did not even have basic health insurance. It is critical that we not allow ourselves to be dragged into the eye of a "perfect storm." This conference is an important step in the rational and objective analysis of this issue.     

Anal sphincter injury during vaginal delivery--an argument for cesarean section on request?

AIMS: Fear of damage to the pelvic floor from vaginal delivery and long-term sequelae (urinary and anal incontinence) sometimes being cited as an indication for cesarean section on request. The aim of the present study was to compare the effects of vaginal delivery versus elective cesarean section on anal sphincter function. MATERIAL AND METHODS: We studied 71 consecutive women six weeks before delivery, 52 of them 4-6 weeks after delivery, and all patients with occult sphincter lesions 3 months after delivery. A bowel function questionnaire was completed, and anal endosonography, manometry, and measurement of the pudendal-nerve terminal motor latency were performed. RESULTS: Forty-two (80.8 percent) patients were delivered vaginally, ten (19.2 percent) by elective cesarean section at term. Clinically recognized anal sphincter injuries occurred in 9.5 percent (4) of patients, two of them developed incontinence for gas. The overall incidence of anal incontinence after vaginal delivery was 4.8 percent. Occult sphincter defects were identified endosonographically in 19 percent (8) of women, there was no reported case of any anal incontinence 3 months after delivery. No woman delivered by cesarean section had altered anal continence or any significant change in anal pressures, rectal sensibility, and PNTML. CONCLUSION: Severe sphincter tear is the single most important factor leading to anal incontinence in women, whereas occult sphincter defects are rarely associated with short-term sequelae, but may predispose to the development of anal incontinence later on in life. Elective cesarean section should be recommended for women at increased risk for anal incontinence.     

Maternal request: a reason for rising rates of cesarean section?

Objective

The rising rate of cesarean sections (CS), especially those on maternal request, is an important obstetric care issue. The aim of this two-point cross-sectional study was to evaluate the prevalence of CS and their indications.

Methods

We performed a retrospective chart review of the indications of all CS performed at a tertiary care clinic in Switzerland in 2002 and 2008. Chi-square, Student??s t and Mann?CWhitney U tests were performed to identify significant differences.

Results

The number of CS rose from 23.3% (371 out of 1,594 total life births) in 2002 to 27.5% (513 out of 1,866) in 2008 (p?=?0.005). Of all deliveries, the rate of CS on maternal request and, among these, especially those requested after previous CS, increased significantly (2.1 vs. 5.1% and 0.3 vs. 1.2%, respectively). The number of CS due to previous traumatic birth experience nearly doubled (0.7 vs. 1.2%, not significant). Maternal and fetal complications were rare but not negligible in the subset of low-risk patients requesting CS.

Conclusions

The study demonstrated a significant increase in CS on maternal request, especially in case of previous CS. The findings of this study support the need for specific counseling strategies for women requesting delivery by CS.     

Influence of women's request and preference on the rising rate of caesarean section – a comparison of reviews

The rising caesarean section (CS) rates have been, in part, attributed to women's requests. Several individual studies and literature reviews have attempted to determine the degree of influence of women's requests on overall CS rates, and the common reasons behind these requests, from women's, midwives’ and obstetricians’ viewpoints. Despite many similarities in their findings, there is both a lack of clarity and disparity on the degree of influence women's requests actually has on the decision to perform a CS. This paper presents a critique of a key finding from a recently published systematic review of clinicians’ (midwives’ and obstetricians’) views of factors that influenced their decision to perform a CS, which identified their belief in ‘women's request’ as a key factor. This finding is contrasted with findings from three other published reviews, which concluded that women's request contributed minimally to the overall rising rates of CS indicating a disparity in evidence around influence and contribution of women's request. Some of the possible reasons for this disparity can be explained by differences in views of women and clinicians, women's decision being guided by clinicians’ beliefs of what is ‘safe’ and unsafe’, and women's concerns being interpreted as their request and preferences to birth by CS. An insight into the possible reasons for the disparity in findings can help explain whether maternal request has any influence on the rising rates of CSs.     

Bipedalism and parturition: an evolutionary imperative for cesarean delivery?

Human biologic evolution involves a compromise between the physical adaptations for bipedalism with effects on birthing success and the much later increases in encephalization of our species. Much of what comes to define life history parameters like gestation length, and brain and birth weight in our species is best understood from this evolutionary perspective. Human populations have been dealing with the obstetric dilemma for many hundreds of thousands of years and modern biomedicine, using techniques like cesarean sections, has alleviated, but not eliminated, birthing as a "scar" of human evolution. If women begin to demand access to universal cesarean delivery, what will the outcome be for the future of human evolution? We can only speculate on the social, biologic, and demographic costs of this transition.     

Should delivery timing for repeat cesarean be reconsidered based on dating criteria?

Purpose: We sought to examine if the method of pregnancy dating at five increasing term gestational ages is associated with increasing neonatal morbidity.

Materials and methods: A cohort of women who underwent elective repeat cesarean delivery at ≥37 weeks’ gestation were identified from the NICHD MFMU Network registry. We excluded women who were in labor, those carrying a fetus with a congenital anomaly, those with a non-reassuring fetal heart tracing, and those with preeclampsia, preexisting chronic hypertension or diabetes. Composite neonatal morbidity was defined for our study as any of the following: NICU admission, hypotonia, meconium aspiration, seizures, need for ventilator support, NEC, RDS, TTN, hypoglycemia, or neonatal death. We compared composite neonatal morbidity rates among infants born at five different gestational age cutoffs according to their method of pregnancy dating.

Results: At 39 and 40 weeks’ gestation, the lowest rate of neonatal complications was seen in pregnancies dated by first trimester ultrasound (5.8% and 5.5%, respectively), while those with the highest neonatal morbidity rates were seen when dated by a second or third trimester ultrasound (8.1% and 6.0%, respectively); p?Conclusion: Even with suboptimal dating methods, amongst women undergoing elective repeat cesarean delivery, neonatal morbidity was lowest when delivery occurred between 40 and 40?+?6 weeks gestation.     

Trace elements’ concentrations in maternal and umbilical cord plasma at term gestation: a comparison between active labor and elective cesarean delivery

Objective.?Trace elements are minerals required in minute quantities to maintain proper physical functioning. The role of trace elements in the process of parturition is poorly understood. This study was aimed to determine levels of trace elements’ concentration in maternal plasma and umbilical venous and arterial plasma at term during active labor vs elective cesarean delivery (CD).

Study design.?A prospective case–control study was conducted. Forty healthy parturients in active labor at term with their newborns were compared to 40 healthy parturients matched for maternal age, parity, and gestational age, who delivered by elective CD (before commencement of labor). Samples of maternal venous blood and umbilical cord arterial and venous blood were drawn immediately following delivery. Trace elements’ concentrations were measured using the inductively coupled plasma mass spectrometer (ICP-MS).

Results.?Significant higher levels of manganese (Mn) and selenium were found in maternal venous plasma during active labor vs elective CD. Magnesium (Mg) levels were significantly higher in maternal venous blood during elective CD compared to active labor. Umbilical cord artery levels of Mg, Mn, and zinc (Zn) were significantly higher in active term labor vs elective CD. Also, significant higher levels of copper and Zn were found in umbilical cord vein between active labor and elective CD.

Conclusion.?Trace elements’ concentrations differ significantly in fetal blood during active labor vs elective CD. Hence, trace elements may play a crucial role in the process of human parturition.     

Amnion protective cesarean section – method for gentle delivery of preterm and/or VLBW neonates

Abstract

More than 50 percent of preterm neonates below 28 gestational weeks in our institution are delivered by cesarean section (CS).

Aim: To present advantages of less used method of delivery of premature and/or very low birth weight (VLBW) neonates by Amnion Protective Cesarean Section (APCS) when indicated and to review our experience with the method. It can be used in all deliveries by CS with unruptured amniotic membranes, at all gestational ages.

Materials and methods: Including criteria were singleton pregnancies, gestation of 26 to 35 weeks and birth body weight between 700 to 1500?g. According to the criteria, during the studied period 10 neonates were delivered by APCS. We compared the outcomes of APCS neonates with ones delivered by coventional CS who matched them in mentioned criteria.

Results: Compared to CS cases, APCS neonates had statistically significant better first minute AS. Stay in NICU was shorter for APCS neonates but not statistically significant. From our experience APCS neonates had clinically better appearance (less bruises and hematomas).

Conclusion: APCS is promising method for delivery of preterm and/or VLBW neonates when indicated, although prospective studies are needed in order to prove its effectiveness compared to conventional CS.     

The effect of the modes of delivery on the maternal and neonatal dynamic thiol–disulfide homeostasis

Abstract

Background: Thiols are organic compounds containing sulfhydryl groups which exert antioxidant effects via dynamic thiol–disulfide homeostasis. The shift towards disulfide indicates the presence of oxidative environment. The thiol–disulfide homeostasis has not been studied in different mode of delivery before.

Aims: To investigate the effects of mode of parturition on the thiol–disulfide homeostasis in mothers and term infants.

Study design: The participants were grouped according to the mode of their delivery: group vaginal delivery (VD, n?=?40) and group cesarean section (C/S, n?=?40). Three serum samples were collected: from mothers at the beginning of labor, from the cord blood (CB), and from the infants at the 24th hour after birth. The dynamic thiol–disulfide homeostasis in both groups were compared.

Results: The levels of native-thiol and total-thiol in CB were significantly higher in VD group than those with C/S group. The levels of disulfide were higher in infants born by C/S compared with those born by VD. The disulfide-to-native thiol ratio, disulfide-to-total thiol ratio, and native thiol-to-total thiol ratio were similar between two groups.

Conclusion: Our results showed that the dynamic thiol–disulfide homeostasis of the neonate was greatly influenced by the way of delivery and supported that vaginally delivered infants have less oxidative stress.     

Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life?

OBJECTIVE: This study was undertaken to investigate the impact of reproductive factors on the prevalence of urinary symptoms. STUDY DESIGN: Participants were women scheduled for hysterectomy (n=1299). Before surgery, urinary symptoms were assessed by questionnaire. Multiple logistic regression analysis was used to investigate the association between bladder symptoms and parity, route of delivery, and other characteristics. RESULTS: Stress incontinence and urinary urgency were more prevalent among parous than nulliparous women (P <.01). Controlling for parity and other characteristics, women who had a history of cesarean delivery were significantly less likely to report stress incontinence than women with a history of vaginal delivery (odds ratio 0.60; 95% CI 0.39-0.93). CONCLUSION: Women who have undergone vaginal delivery are more likely to report stress incontinence than women who have delivered by cesarean section. Although this suggests that cesarean delivery might reduce incontinence later in life, further research is needed to clarify the long-term risks, benefits, and costs of cesarean delivery.     

Comparison of maternal–and paternal–fetal attachment in Turkish couples

Objective

to compare maternal–fetal attachment (MFA) and paternal–fetal attachment (PFA) in terms of selected variables.

Design

cross-sectional study.

Setting

three training hospitals in Ankara, Turkey. The study was performed between December 2005 and March 2006.

Participants

a total of 144 pregnant women and 144 partners participated in the study; the response rate was 98%.

Findings

there was a statistically significant difference between MFA and PFA scores (p<0.001). A comparison of MFA and PFA scores according to the selected variables (education, employment status, planning of pregnancy, pregnancy risk status) revealed that the MFA scores for pregnant women were significantly higher than the PFA scores of their partners, except for unemployed partners. The MFA (ρ=−0.24, p<0.004) and PFA (ρ=−0.32, p<0.001) scores decreased with increasing age of both pregnant women and their partners.

Key conclusions and implications for practice

although partners have lower fetal attachment scores than pregnant women, it is important to recognise factors influencing the attachment of the mother and father towards their fetus. Prenatal midwives and nurses are in a unique position to assess attachment and to intervene to promote attachment behaviours.