Why do primigravidae request caesarean section in a normal pregnancy? A qualitative study in Iran

Objective

to gain a deeper understanding of why Iranian primigravidae request caesarean section without any medical indication.

Design

qualitative study. Data were gathered through semi-structured interviews, and thematic analysis was undertaken.

Setting

four health care centres at Hamadan University of Medical Sciences, Hamadan, Iran.

Participants

14 primigravidae who requested caesarean section without any medical indication.

Findings

reasons for requesting caesarean section were related to fear of childbirth (labour pain, injury to mother or infant), complications after vaginal delivery (vaginal prolapse, urinary incontinence, sexual dysfunction), trust in obstetricians, and lack of trust in maternity ward staff.

Key conclusions and implications for practice

the main reasons given for requesting caesarean section show that there is urgent need for effective antenatal assessment to enable pregnant women to ask questions and express their concerns. In order to promote vaginal birth, there is a need to develop antenatal education and strategies to enhance women's knowledge, confidence and competence about vaginal birth. Health care providers should be re-educated about the observance of medical ethics and professional rules in their practices, and change their attitudes and behaviours to vaginal birth. Evaluation, improvement and change in maternity care policies are recommended to promote natural childbirth.     

Iron supplementation during pregnancy – a cross-sectional study undertaken in four German states

Background

Iron deficiency but also iron overload during pregnancy has been associated with unwanted health effects. In Germany, iron supplements are only recommended for pregnant women with diagnosed iron deficiency/anaemia. Prevalence of anaemia among pregnant women was reported at 24.4% in 2011. However, limited data suggest that more than 60% of women in Germany use iron supplements during gestation. Against this background, we investigated the prevalence of iron supplement intake among pregnant women and explored determining factors in order to assess whether women are following the advice to only supplement iron in case of a diagnosed iron deficiency/anaemia.

Methods

A cross-sectional study was carried out in four German states in 2015 where, with the help of midwives, women in childbed were asked to retrospectively answer a questionnaire about iron intake from various sources and reasons for supplementing iron during their recent pregnancy. We used Chi-square-tests and logistic regression analysis to evaluate associations between iron supplementation and other nutritional, sociodemographic and maternal variables and to assess attitudes of women meeting versus not meeting the official recommendation on iron supplement intake during pregnancy.

Results

Of 207 participants, 65.2% had supplemented iron. 84.4% reported to have done this because of a diagnosed iron deficiency/anaemia. Iron intake ranged from 5 to 200?mg/day, and duration of supplementation varied between two weeks and throughout gestation. Of women who reported to have been diagnosed with iron deficiency/anaemia, 47.5% had supplemented ≥80?mg/day iron, while 26.2% had taken iron in lower amounts ≤40?mg/day. Six percent of the participating women had not supplemented iron in spite of a diagnosed iron deficiency/anaemia, whereas 19.7% of women without iron deficiency/anaemia still had supplemented iron (range: 7 to 80?mg/day).

Conclusion

The majority of pregnant women used iron supplements in case of a diagnosed iron deficiency/anaemia. However, not all women with iron deficiency/anaemia supplemented (sufficient amounts of) iron, while there was also indiscriminate use of iron supplements in women without iron deficiency/anaemia. Further research is warranted to confirm these findings in representative samples.

     

Risks and benefits of the skin-to-skin cesarean section – a retrospective cohort study

Objective: Comparing maternal and neonatal outcomes after conventional cesarean section (CS) versus a “natural” or “skin-to-skin” cesarean section (SSCS).

Methods: Retrospective cohort of women who underwent a SSCS (01-2013 until 12-2013) compared to conventional CS (08-2011 to 08-2012). CS before 37 weeks, under general anesthesia and in case of fetal distress were excluded. Main outcome measures were maternal blood loss, post-operative infection and admission; neonatal infection and admission; procedural outcomes.

Results: We analyzed 285 (44%) women in the SSCS-group and 365 (56%) in the conventional CS-group. There were no significant differences in surgical site infection (2.1% versus 1.6%; RR 1.1; 95%CI 0.64–2.0), or other maternal outcomes. Fewer neonates born after SSCS were admitted to the pediatric ward (9.5% versus 18%; RR 0.58; 95%CI 0.41–0.80) and fewer neonates had a suspected neonatal infection (2.0% versus 7.3%; RR 0.40; 95%CI 0.19–0.83). No differences were observed for other outcomes. Mean operation time was 4m42s longer in the SSCS-group compared to the conventional CS-group (58m versus 53m; 95%CI 2m44s–6m40s). Mean recovery time was 14m46s shorter (114m versus 129m; 95%CI 3m20s–26m).

Conclusion: Adverse maternal and neonatal outcomes were not increased after skin-to-skin cesarean compared to conventional cesarean delivery.     

Incidence of post-operative adhesions following Misgav Ladach caesarean section–A comparative study

Aim. To evaluate the incidence of peritoneal adhesions as a post-operative complication after caesarean section following the Misgav Ladach method and compare it with peritoneal adhesions following traditional caesarean section methods (Pfannenstiel-Dörffler, low midline laparotomy-Dörffler).

Methods. The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina (data from 1 January 2001 to 31 December 2005). We analysed previous caesarean section dependent on caesarean section method (200 by Misgav Ladach method, 100 by Pfannenstiel-Dörffler method and 100 caesarean section by low midline laparotomy-Dörffler). Adhesion scores were assigned using a previously validated scoring system.

Results. We found statistically significant difference (p < 0.05) in incidence of peritoneal adhesions in second and third caesarean section between Misgav Ladach method and the Pfannestiel-Dörffler and low midline laparotomy-Dörffler method. Difference in incidence of peritoneal adhesions between low midline laparotomy-Dörffler and Pfannenstiel-Dörffler method was not statistically different (p > 0.05). The mean pelvic adhesion score was statistically lower in Misgav Ladach group (0.43 ± 0.79) than the mean score in the Pfannestiel-Dörffler (0.71 ± 1.27) and low midline laparotomy-Dörffler groups (0.99 ± 1.49) (p < 0.05).

Conclusions. Our study showed that Misgav Ladach method of caesarean section makes possible lower incidence of peritoneal adhesions as post-operative complication of previous caesarean section.     

Second trimester medical abortion in a woman with prior classical caesarean section and a uterine leiomyoma – A case report

Abstract

Background Medical abortion in women with the scar of a classical caesarean section (CS) and a large uterine leiomyoma is rarely attempted; it carries the risk of uterine rupture and haemorrhage.

Case A 34-year-old multiparous woman with prior classical CS and a 14 × 10 × 9 cm leiomyoma arising from the uterine isthmus had an induced abortion at 14 weeks’ gestation. Mechanical cervical priming with Dilapan^®-S followed by vaginal misoprostol administration resulted in the uncomplicated expulsion of the uterine contents.

Conclusions An early second trimester medical abortion with misoprostol was successfully performed in a woman with prior classical CS and a large uterine leiomyoma.     

Influence of sex hormones in women on breast elasticity measured by shear wave sonoelastography – a cross-sectional study

The physiology of breast depends on age, hormonal status, menstrual cycle, lactation, and others. The aim of our study was to evaluate correlations between hormonal status and breast glandular and fat tissue elasticity in healthy women. We examined 77 women aged 20–55 with shear wave sonoelastography and estimated their hormonal levels. There were no important correlations between breast elasticity, follicle-stimulating hormone (FSH), estrogen, prolactine, and thyroid hormones (p > 0.05). Androgens negatively influenced glandular to fat elasticity ratio (Rs = ?0.25, p < 0.005). Luteinizing hormone to FSH ratio correlated positively with glandular and fat elasticity, especially in outer-upper quadrant (Rs = 0.24, p = 0.003).     

Short-term postnatal quality of life in women with previous Misgav Ladach caesarean section compared to Pfannenstiel–Dorffler caesarean section method

Objective.?To examine whether short-term postnatal health-related quality of life differed among women after different methods of cesarean sections.

Methods.?One hundred forty-five women were evaluated with previous CS (85 by Misgav Ladach and 60 by Pfannenstiel–Dörffler). Short-time quality of life was measured using the Croatian version of Short Form Health Survey (SF – 36). Short-term postoperative recovery was assessed using two criteria: febrile morbidity and degree of pain. Incidence of peritoneal adhesions was assigned using Bristow scoring system.

Results.?Four weeks after delivery women with previous Misgav Ladach cesarean section significantly scored higher on the bodily pain (72.4 vs. 56.7, p?<?0.05), social functioning (71.5 vs. 60.4, p?<?0.05), and the vitality (61.7 vs. 50.3, p?<?0.05) subscales. These differences disappeared in the second assessment (12-weeks postpartum) except in the bodily pain (74.7 vs. 61.2, p?<?0.05) subscale. There was a significant trend toward a higher requirement for postoperative analgesics in the Pfannenstiel–Dörfler group (doses: 5.4 vs. 8.7, p?<?0.05; hours: 17.9 vs. 23.3, p?<?0.05), and they had a significantly higher rate of febrile morbidity than the Misgav Ladach group (5.7 vs. 9.4%, p?<?0.05). Hospitalization time was reduced in the Misgav Ladach group (4.2 vs. 7.3, p?<?0.05). The incidence of adhesions was significantly lower in patients who had undergone a previous operation using the original Misgav Ladach method (0.47 vs. 0.77, p?<?0.05).

Conclusion.?Misgav Ladach cesarean section method might lead to better short-time quality of life resulting in reducing postoperative complications compared to Pfannenstiel–Dörfler cesarean section method.     

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.     

Association of young and advanced age of pregnant women with the risk of isolated congenital abnormalities in Hungary – a population-based case-matched control study

Objective: To analyze the possible association of maternal age with the risk of all congenital abnormalities (CAs) in a population-based large case-matched control data set.

Methods: The Hungarian Case-Control Surveillance of Congenital Abnormalities included 21?494 cases with isolated CA and their 34?311 matched controls. First the distribution of maternal age groups in 24 CA-groups and their matched controls was compared. In the second step, young (19 years or less) and advanced (35 years or more) age groups were compared. Finally, the subgroups of neural-tube defects, congenital heart defects and abdominal wall's CA were evaluated separately.

Results: A higher risk of gastroschisis, congenital heart defects, particularly left-sided obstructive defects, undescended testis and clubfoot was found in the youngest age group (19 years or less) of cases. The higher proportion of pregnant women with advanced age (i.e. 35 years or more) showed only a borderline excess in cases with clubfoot. The so-called U-shaped risk of maternal age distribution was found in cases with clubfoot and in the total group of isolated CAs.

Conclusions: The maternal age is a contributing factor to the origin of some isolated CAs mainly in young pregnant women.     

Why do women request caesarean section in a normal,healthy first pregnancy?

Background and context

a growing number of childbearing women are reported to prefer a caesarean section in the absence of a medical reason. Qualitative research describing factors influencing this preference in pregnant women is lacking.

Objective

to describe Australian women's request for caesarean section in the absence of medical indicators in their first pregnancy.

Design

advertisements were placed in local newspapers inviting women to participate in a telephone interview exploring women's experience of caesarean section. Thematic analysis was used to analyse data.

Setting

two states of Australia: Queensland and Western Australia.

Participants

a community sample of women (n=210) responded to the advertisements. This paper presents the findings elicited from interviews conducted with 14 women who requested a caesarean section during their first pregnancy in the absence of a known medical indication.

Findings

childbirth fear, issues of control and safety, and a devaluing of the female body and birth process were the main themes underpinning women's requests for a non-medically-indicated caesarean section. Women perceived that medical discourses supported and reinforced their decision as a ‘safe’ and ‘responsible’ choice.

Key conclusions and recommendations for practice

these findings assist women and health professionals to better understand how childbirth can be constructed as a fearful event. In light of the evidence about the risks associated with surgical birth, health-care professionals need to explore these perceptions with women and develop strategies to promote women's confidence and competence in their ability to give birth naturally.     

Evaluation of a modified “Triple-P” procedure in women with morbidly adherent placenta after previous caesarean section

Aim

To describe a modified “Triple-P” procedure and evaluate its outcome in women with morbidly adherent placenta (MAP) after previous caesarean section (CS).

Methods

A retrospective cohort study of 96 women with MAP after CS was recruited with 45 women receiving the modified “Triple-P” procedure as study group and the other 51 cases receiving the conventional managements as the control. The maternal outcomes were compared.

Results

The modified “Triple-P” procedure was described in step by step. Women in study group demonstrated reduction of blood loss, transfusion blood volume and operation time, as well as less hospital days and lower hospitalization cost (P < 0.05). In addition, there was no difference in uterine healing rate, hysterectomy rate, and ICU transferring rate (P > 0.05).

Conclusion

Our modified “Triple-P” procedure for MAP after previous CS maintained the advantages of Chandraharan’s “Triple-P” procedure in preservation of uterus for further fertility, less intraoperative blood loss, shorter hospital stays, and lower hospitalization cost but also advanced in feasibility and convenience during introducing into routine clinical practice.

     

Percutaneous administration of testosterone gel in postmenopausal women – a pharmacological study

We wished to investigate if a testosterone gel administered percutaneously to postmenopausal women could result in stable serum levels of the hormone and which dose was required to produce levels within the normal premenopausal range. Fifteen postmenopausal women, mean age 55.3 years (range 45–70 years), volunteered to participate in the study and were divided into three groups. They received 10, 20 or 30?mg of testosterone as a 1% testosterone hydroalcoholic gel at 09.00?hours daily for 14 days. The gel was applied in a thin layer on the outside of the thigh each morning, over an area of approximately 15?cm². Blood samples were collected hourly between 09.00 and 17.00?hours on days 1 and 14, and also at 08.00?hours on days 3, 5, 11, 12, 13 and finally day 16, i.e. 2 days after termination of treatment. The mean basal serum level of testosterone was 1.1?±?0.9?nmol/l and for 5α-dihydrotestosterone 208?±?143?pmol/l. There was a clear increase from the 10?mg to the 20?mg treatment (mean testosterone level during treatment 3.2 and 7.2?nmol/l, respectively) while serum testosterone values after 30?mg showed very little further increase (mean 7.5?nmol/l). Values for days 3–5 were quite similar to those for days 13–14. The present study suggests that adequate and acceptable serum levels of testosterone can be achieved with 10?mg testosterone applied transdermally.     

IMA and IMAR in serum and saliva of preeclampsia – a preliminary study

Introduction: Oxidative stress could play a role in the development of preeclampsia. Ischemia modified albumin (IMA) is a oxidatively modified form of albumin. Objective: To evaluate the levels of salivary and serum IMA and IMA: albumin ratio (IMAR) in preeclampsia and with its severity and investigate their correlation with the fetal birth weight. Methods: This case control study was conducted on 50 preeclamptic (32 mild and 18 severe cases) and 50 normal pregnant controls. Blood and saliva were obtained to measure albumin, IMA and IMAR was calculated. Results: serum and salivary IMA and IMAR were significantly increased in preeclampsia. Although the increase in serum was in accordance with the severity, it was not so in the saliva. Yet, salivary IMAR showed significant difference between controls and mild preeclampsia. There was a negative correlation between IMA and albumin in both serum and saliva. A weak negative correlation was seen between the serum IMAR and fetal birth weight (r?=??0.293; p?Conclusion: This study is an evidence for involvement of oxidative stress in the pathogenesis of preeclampsia, which is reflected in serum and saliva. Salivary IMAR could be a better marker for early prediction of preeclampsia.     

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.     

Evaluation of foetal neurological behaviour in hypothyroid pregnant females – a pilot study

Objectives: Maternal hypothyroidism is known for its possible deleterious effect on the neurocognitive function of the offspring. The aim of the current study is to investigate if maternal hypothyroidism also affects foetal neurological behaviour.

Methods: Fifty foetuses were examined for abnormal neurological behaviour from 25 euthyroid and 25 hypothyroid age matched pregnant females, between 28 and 38 weeks gestation. The hypothyroid group was further subdivided into controlled (n?=?5) and uncontrolled (n?=?20) groups. Evaluation of foetal neurological behaviour using Kurjak’s antenatal neurodevelopmental test (KANET) test was performed.

Results: Mean total KANET score was significantly lower for foetuses in the hypothyroid group compared to the euthyroid (p?p?p?=?.017). Foetuses in the uncontrolled hypothyroid group showed lower mean KANET scores (9.650?±?2.907 versus 10.80?±?3.03) and higher frequency of pathological scores compared to controlled (8?=?40% versus 1?=?20%) although without statistical significance. The distribution of total KANET score was not statistically significant between the two groups (p?=?.893).

Conclusions: Overt maternal hypothyroidism may adversely affect foetal neurological behaviour. Correlation of prenatal findings with postnatal long-term neurological development is recommended in such cases.     

Ultrasonographic assessment of skin thickness in patients with PCOS – a case-control study

Abstract

Objective: To measure skin thickness in patients with polycystic ovary syndrome (PCOS) in comparison to controls and to examine a possible association with sex steroids, body mass index, lipid profile and hyperinsulinemia.

Methods: Thirty patients with confirmed PCOS were compared to thirty-two women presenting for infertility workup. Skin thickness was measured using high-resolution ultrasound in a standardized area, blood samples were collected once at presentation.

Results: Patients with PCOS showed a statistically significant thicker skin than women in the control group (0.95?mm (±0.093?mm) versus 0.85?mm (±0.077?mm, p?<?0.0001)). LH, estradiol, testosterone, the free androgen index, triglycerides, cholesterol, LDL-cholesterol and body mass index were significantly increased in PCOS – patients. No correlation between hyperinsulinemia and skin thickness was seen.

Conclusions: PCOS – patients showed a greater skin thickness in comparison to women without PCOS. This might be due to proliferative effects of sex steroids such as estrogens and testosterone and metabolic derangements on skin thickness.     

Experiences of a lifestyle intervention in obese pregnant women – A qualitative study

Objectiveto describe obese women's experiences of participating in a lifestyle intervention and its experienced impact on health and lifestyle.Designqualitative method with a phenomenological lifeworld approach. The interviews were analyzed in accordance with the phenomenological method.Participants and setting11 women who had participated in a lifestyle intervention project, targeting pregnant women with BMI ≥30 in southwestern Sweden, were interviewed a few weeks before delivery.Findingsthe essence of these women's experiences was expressed as: implementing new habits required support, from midwives, partners, relatives, friends, or obese pregnant women in the same situation, or by participating in the intervention itself. The support had to be non-judgmental and with a balanced outlook on weight. Participation had taught them about weight gain control. The women were motivated to try to control their gestational weight gain, although not all of them were initially convinced that this would be possible. The essential structure of participation can be described with the following constituents: ‘‘pregnancy encourages change’’, ‘‘to be supported by non-judgmental people’’, ‘‘from bad habits to conscious choices’’ and; ‘‘barriers to change’’.Key conclusionsin order to implement new habits, participants expressed a need for support, given with a non-judgmental attitude and a balanced outlook on weight. The women experienced that the lifestyle changes could be less burdensome than previously imagined, and that slight changes could yield unexpectedly successful results. In order to maintain a lifestyle change, obese women must perceive some kind of results, i.e. increased quality of life or weight gain control.Implications for practicenon-judgmental support from midwives is crucial. Affinity with other pregnant obese women in an exercise group or dietary group setting is supportive.