Caesarean delivery and outcome in very low birthweight infants

OBJECTIVE: To determine the relationship between mode of delivery, intraventricular haemorrhage (IVH), and mortality in very low birthweight (VLBW) infants. STUDY DESIGN: A historical cohort study of infants admitted to a single level III neonatal intensive care unit during a five-year period. Infants < 1500 g born by caesarean delivery (n = 400) were compared to those born by vaginal delivery (n = 305). RESULTS: After controlling for potential confounding variables including: gestational age, fetal presentation, and multiple birth, caesarean delivery was not associated with a decreased odds of IVH (odds ratio 1.2, 95% CI 0.7-2.0), severe IVH (1.9, 0.9-4.0), or mortality (1.2, 0.6-2.4). CONCLUSIONS: In our population of very low birthweight infants, caesarean delivery is not associated with a decreased risk for mortality or intraventricular haemorrhage.     

Hypertension during pregnancy in South Australia, part 1: pregnancy outcomes

BACKGROUND: There have been conflicting reports about pregnancy outcome in the hypertensive disorders of pregnancy. The present study was undertaken to examine outcomes using a population database. AIMS: To examine for differences in a range of pregnancy outcomes between three different groups of hypertensive women and normotensive women in South Australia. METHODS: Nine pregnancy outcomes were compared for 70,386 singleton pregnancies in the South Australian perinatal data collection in 1998-2001, consisting of 639 women with pre-existing hypertension, 5356 women with pregnancy hypertension, 448 women with superimposed pre-eclampsia and 63 943 normotensive women. Means for the four groups were calculated for birthweight, gestational age, the baby's and mother's length of stay. The groups were also compared for perinatal deaths with an earlier period, 1991-1997. RESULTS: While all three hypertensive groups had high incidences of induction of labour and emergency Caesarean, only pre-existing hypertension and superimposed pre-eclampsia were significantly associated with elective Caesarean section. All hypertensive groups had increased risks for low birthweight and preterm birth and special and neonatal intensive care. Uncomplicated pre-existing hypertension was not associated with small for gestational age infants, but with preterm delivery between 32 and 36 weeks' gestation. Superimposed pre-eclampsia had the worst prognosis for perinatal and maternal morbidity. While pregnancy hypertension held the intermediate position, it was not associated with an increase in perinatal mortality. The perinatal mortality rate for women with hypertensive disorders in 1998-2001 was significantly lower than that of an earlier period and equivalent to that for normotensive women. CONCLUSIONS: Superimposed pre-eclampsia occurs in approximately 40% of pregnancies of women with pre-existing hypertension and has the most severe outcomes. The hypertensive disorders are associated with high levels of morbidity and intervention, but the high perinatal mortality associated with these disorders has fallen significantly.     

Perinatal mortality in breech presentations as compared to vertex presentations in singleton pregnancies: an analysis based upon 57819 computer-registered pregnancies in The Netherlands

In 1982, nationwide registration of obstetric data was instituted in The Netherlands with about 70% of all Dutch hospitals participating. The resultant data from 57819 singleton pregnancies in vertex or breech presentation at delivery was studied. The vertex and breech groups were compared. The proportion of breech presentations relative to vertex presentations was greater in low gestational age infants and those of low birthweight. After correction for gestational age and birthweight, the perinatal mortality was higher in the breech groups than in the vertex groups. Congenital malformations occurred more frequently in the breech group but, even after exclusion of infants with congenital malformations, perinatal mortality remained higher in the breech group at any gestational age. Caesarean section was more frequently performed in the breech group than in the vertex group but did not appear to improve the outcome of breech presentation. It is possible that breech presentation is not coincidental but is a consequence of poor fetal quality, in which case medical intervention is unlikely to reduce the perinatal mortality associated with breech presentation to the level associated with vertex presentation.     

Agreement between hospital records and maternal recall of mode of delivery: evidence from 12 391 deliveries in the UK Millennium Cohort Study

OBJECTIVE: The objective of this study was to measure the agreement between hospital records and maternal reporting of mode of delivery in a representative UK sample. DESIGN: Population-based survey (Millennium Cohort Study). SETTING: UK. POPULATION: A total of 12,391 singleton infants born in 2000-2002. METHODS: Mothers were interviewed when infants were approximately 9 months old. Information was collected by interview on many obstetric and perinatal factors including mode of delivery. Record linkage to the mother's delivery hospital records was undertaken in those who gave consent (90%). A matching record was found for 83%. Maternal report and hospital records were compared using mode of delivery classified into three (normal, assisted and caesarean) and six groups. Factors associated with disagreement between the two data sources were identified. MAIN OUTCOME MEASURE: Proportion of records in which there was agreement between the two data sources. RESULTS: Agreement between maternal report and hospital records was at least 94% using six mode of delivery groups and 98% using three groups. Much of the disagreement (57-63%, depending on country) was between forceps and ventouse, and between planned and emergency caesarean. Disagreement was more common in women whose babies were first born and in women not born in the UK. CONCLUSION: Our study confirms that maternal reporting of mode of delivery is highly reliable. This is important for clinical staff caring for women and those conducting epidemiological studies. Additional data sources may be necessary to gather reliable data from ethnic minority women, particularly those born outside the UK, or to distinguish forceps from ventouse, or planned from emergency caesarean section.     

An increasing proportion of infants weigh more than 4000 grams at birth

BACKGROUND: To investigate how mean birthweight has changed in the past decade, and to describe changes in the proportion of infants with a birthweight above 4000 grams (g). METHODS: We analyzed data on 43,561 singleton infants born between 1990 and 1999 at Aarhus University Hospital, Denmark. Information on birthweight, gestational age, stillbirths, malformations, mode of delivery, prelabor intervention, and maternal diabetes was obtained from birth registration forms. RESULTS: For all infants mean birthweight increased by 45 g (95% CI: 20-70 g) from 3474 g in 1990 to 3519 g in 1999. For infants born at term the mean increase was 62 g (95% CI: 41-83 g). During the same period the percentage of infants born with a birthweight above 4000 g increased from 16.7% in 1990 to 20.0% in 1999 (p<0.05). Simultaneously we found a decrease in gestational age and an increase in the frequency of induction of labor. There was a statistically significantly higher risk of giving birth to an infant with a birthweight above 4000 g throughout the decade, when gestational age and prelabor intervention was taken into account. CONCLUSIONS: In Denmark mean birthweight has risen during the past decade independently of gestational age and prelabor intervention. Simultaneously the risk of having a baby with a birthweight above 4000 g has increased. Further studies on potential risk factors for birth of large infants are needed.     

Immunohistochemical localization of aromatase and apoptosis-associated proteins in ovarian serous cystadenocarcinoma arising from ovarian endometriosis

OBJECTIVE: To determine the risk of neonatal death (NND) in relation to birth weight for gestational age and the presence or absence of maternal hypertensive disease in preterm neonates. DESIGN: Record linkage of maternity data and neonatal mortality data. SETTING: Scotland, UK. POPULATION: A group of 6946 live singleton preterm neonates without lethal congenital abnormalities born at 24-32 weeks between 1986 and 1992 inclusive. This group included 1448 cases of maternal hypertensive disease and 850 neonatal deaths. MAIN OUTCOME MEASURE: Neonatal death. RESULTS: The median birth weight for each gestational week was estimated from a fitted curve and each birth weight was recalculated as a multiple of the relevant median. The frequency of NND was much higher at lower gestations (73% at 24 weeks down to 2% at 32 weeks). Though the overall frequency of NND was lower in cases with hypertensive disease (8.6% versus 13.2%) this can be attributed to the fact that there were relatively fewer hypertensive cases in the high risk group at 24-27 weeks. In the 5498 cases not associated with maternal hypertensive disease, there were 726 NNDs. The mean MoM of birthweight for these NNDs was 0.982 (95% CI 0.967-0.996); this was only marginally different from the population mean (0.998; 95% CI 0.993-1.004). In the 1448 cases with maternal hypertensive disease, there were 124 NNDs. The overall birthweight for gestational age in the hypertensive group was substantially less than that of the whole population (mean MoM 0.84; 95% CI 0.83-0.85) and that of the 124 NNDs was still lower (mean MoM 0.75; 95% CI 0.724-0.782). For both hypertensive and non-hypertensive cases, inspection of the data categorised into deciles showed that there was a continuous increase in the frequency of NND throughout the weight range, being lowest for the heaviest babies and highest for those in the lower centiles. CONCLUSION: (1) There is a relationship between birthweight for gestational age and risk of NND in infants born at 24-32 weeks; (2) this relationship is a continuum throughout the whole range of birthweight, not focused exclusively on a group defined as SGA; (3) provided appropriate birthweight standards are used, there is no extra effect on mortality from maternal hypertensive disease.     

Changed prognosis of breech-presenting low birth weight infants

Summary. We have compared the mortality and morbidity of low birthweight breech-presenting singleton infants born in the Coventry Maternity Hospital during the years 1973 and 1974 with those born during 1979 and 1980. During this period changes in management have included an increase in the caesarean section rate and the continuing development of methods of intensive care for the newborn infants. The neonatal mortality rate has fallen but the increased survival rate is accounted for largely by the survival of handicapped infants. The value of routine caesarean section in the absence of other obstetric pathology for low birthweight breeches is unproven and may be deleterious to mother and baby.     

Mode of delivery in the preterm gestation and maternal and neonatal outcome

Objective.?To determine if the mode of delivery in preterm gestations is associated with changes in maternal and neonatal outcome.

Methods.?A retrospective cohort study that included all singleton deliveries occurring after spontaneous onset of labour between 25?+?0 and 32?+?6 weeks of gestation. Cases of early preterm delivery were identified from clinical records and classified according to the mode of delivery. The following outcomes were derived for each case and compared between caesarean and vaginal deliveries: perinatal death, cranial findings compatible with haemorrhage or white matter disease in the neonate, new-onset of maternal severe anaemia or pyrexia.

Results.?From 1990 to 2007, 109 cases of spontaneous preterm labour were retrospectively selected, including 50 (45.8%) caesarean sections and 59 (54.2%) vaginal deliveries. Perinatal death occurred in 10 infants (9.1%), whereas among survivors abnormal cerebral findings were detected in 20, including 6 cases with haemorrhage, 12 with white matter findings and 2 with both. At multiple logistic regression, a birthweight lower than 1100?g was the only predictor of all adverse outcomes, whereas male sex increased the risk of white matter findings. Caesarean section compared to vaginal delivery conferred a higher risk of maternal complications (23/50 or 46% vs. 6/59 or 10.2%; OR: 11.9, CI 95%: 4.2–333; p?<?0.0005).

Conclusions.?In severely premature infants born after spontaneous onset of labour, the risk of adverse perinatal outcome does not seem to depend upon the mode of delivery, whereas the risk of maternal complications is significantly increased after Caesarean section.     

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.     

The premature breech presentation: outcome of newborn infants born by vaginal or abdominal delivery

There is ample documentation that breech full-term infants delivered vaginally have a higher perinatal morbidity and mortality rate than breech infants born via cesarean section. Until now, little emphasis has been placed on the risks to premature newborns born in breech presentation. Therefore, the authors have considered all singleton pregnancies with infants in breech presentation admitted to the Department of Obstetrics, University of Padova, from January 1978 to December 1979 and delivered before 36-weeks gestation. On the basis of obstetric management, the authors have obtained two groups: Group A comprised 36 infants born by vaginal delivery; Group B totaled 32 newborns delivered by cesarean section. Mean gestational age and birthweight were comparable. Of the neonatal events considered, the following were significantly different: Apgar score at 5 minutes less than 7 (A = 30.6%; B = 9.3%), mortality (A = 13.8%; B = 0), neurologic sequelae in the infants discharged from the neonatal intensive care unit (NICU) (A = 50%; B = 9.1%) and the sum of mortality and long term sequelae (A = 22.2%; B = 3.1%). The authors conclude that cesarean section performed in mothers with impending preterm breech delivery decreases the neonatal mortality rate and improves the long-term outcome.     

Haemodynamic changes in the brain after vaginal delivery and caesarean section in healthy term infants

Objective To investigate whether the mode of delivery may affect neonatal cerebral haemodynamics during the first hour of life.
Design Prospective study.
Sample Healthy infants with gestational age ≥37 weeks and birthweight appropriate for gestational age, born after uncomplicated pregnancy by vaginal delivery or elective caesarean section, two to five hours after the delivery.
Methods Near infra-red spectroscopy was used to measure changes of oxygenated haemoglobin, deoxygenated haemoglobin, oxidized-reduced cytochrome aa3, and mean cerebral oxygen saturation (mixed cerebral oxygen saturation = oxygenated haemoglobin/total haemoglobin). Changes in cerebral blood volume were calculated.
Results Near infra-red spectroscopy data did not show significant differences between infants born by vaginal delivery or by caesarean section. There was a significant decrease of oxygenated haemoglobin and change of cerebral blood volume values at 120 and 180 minutes in both the groups, while deoxygenated haemoglobin and oxidized-reduced cytochrome aa3 were unchanged.
Conclusions A decrease of cerebral blood volume occurs after birth and this occurs both in infants born by vaginal delivery and by caesarean section.     

Doppler ultrasonography in singleton pregnancies at risk of intrauterine growth retardation-- a national estimate

BACKGROUND: In order to assess the organizational and economical implications of Doppler ultrasonography used in high risk pregnancies, a national estimate of the use in singleton pregnancies with risk of small for gestational age (>2 SD below mean birthweight) (SGA) or intrauterine growth retardation (IUGR) was needed. METHODS: Through retrospective analyzes of both national registry data, and local clinical and ultrasonic records from Copenhagen University Hospital annual populations of singleton pregnant women with suspected IUGR and/or infants born SGA were described. The antenatal care program for assessing pregnancies with suspected IUGR was described. RESULTS: In 1996 2.8% of all singleton infants were born SGA. The population had increased risk of perinatal mortality and morbidity, and about 40% had labor induced or were delivered by caesarean section, compared to 15% of the infants with normal birthweight. In the local population 79 (3.3%) of singleton infants were born SGA and 2/3 of these were considered SGA or IUGR before delivery. Of all singleton pregnancies, a total of 88 (3.7%) were assessed by ultrasonic fetometry because of a risk or clinical suspicion of SGA, and 49 (55.7%) of these pregnancies resulted in a SGA infants. Combining national and local data it is estimated that in Denmark, about 2000 women (3.1%) will be referred for ultrasonic fetometry each year because of a risk or clinical suspicion of SGA and have a mean of 2.5 fetometries. About 75% (1500) will be further assessed by Doppler ultrasonography and have a mean of 3.4 Doppler examinations. CONCLUSION: The annual number of Doppler ultrasonography examinations in singleton pregnancies with increased risk of or signs of IUGR is estimated to be about 5000.     

Outcome of term breech births: 10-year experience at a district general hospital

OBJECTIVE: To review the short and long term outcomes among singleton infants with breech presentation at term delivered in a geographically defined population over a 10-year period. DESIGN: Retrospective, cohort study. SETTING: District General Hospital. POPULATION: 1433 term breech infants alive at the onset of labour and born between January 1991 and December 2000. METHODS: Data abstracted from birth registers, neonatal discharge summaries and the child health database system were used to compare the short and long term outcomes of singleton term breech infants born by two different modes of delivery (prelabour caesarean section and vaginal or caesarean section in labour). Fisher's exact test was used to compare the categorical variables. MAIN OUTCOME MEASURES: Short term outcomes: perinatal mortality, Apgar scores, admission to the neonatal unit, birth trauma and neonatal convulsions. Long term outcomes: deaths during infancy, cerebral palsy, long term morbidity (development of special needs and special educational needs). RESULTS: Of 1433 singleton term infants in breech presentation at onset of labour, 881 (61.5%) were delivered vaginally or by caesarean section in labour and 552 (38.5%) were born by prelabour caesarean section. There were three (0.3%) non-malformed perinatal deaths among infants born by vaginal delivery or caesarean section in labour compared with none in the prelabour caesarean section cohort. Compared with infants born by prelabour caesarean section, those delivered vaginally or by caesarean section in labour were significantly more likely to have low 5-minute Apgar scores (0.9% vs 5.9%, P < 0.0001) and require admission to the neonatal unit (1.6% vs 4%, P= 0.0119). However, there was no significant difference in the long term morbidity between the two groups (5.3% in the vaginal/caesarean section in labour group vs 3.8% in the prelabour caesarean group, P= 0.26); no difference in rates of cerebral palsy; and none of the eight infant deaths were related to the mode of delivery. CONCLUSIONS: Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term mortality and morbidity. However, the long term outcome was not influenced by the mode of delivery.     

Is the obstetric outcome of in vitro fertilized singleton gestations different from natural ones? A controlled study

Objective: To determine whether singleton IVF pregnancies carry adverse maternal or fetal outcome when compared with naturally conceived gestations.

Design: An analysis of the obstetric outcome of singleton IVF pregnancies in comparison with matched, naturally conceived singleton controls. Setting: In vitro fertilization unit and obstetric service at a tertiary medical center.

Patient(s): Two hundred sixty consecutive singleton IVF pregnancies and 260 naturally conceived singleton controls matched 1:1 for maternal age, parity, ethnic origin, and location and date of delivery.

Intervention(s): In vitro fertilization-ET.

Main Outcome Measure(s): The rate of antenatal obstetric complications, nonvertex presentation, cesarean section, preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality.

Result(s): The rates of most antenatal complications were similar in both groups. Urinary tract infection was the only complication diagnosed significantly more frequently after IVF (7.3% versus 1.2%); however, the rates of severe urinary tract infection necessitating hospitalization were similar. The incidence of nonvertex presentation was also similar. The cesarean section rate was significantly higher among IVF patients (41.9% versus 15.5%). The rates of preterm labor, low birth weight, small and very small for gestational age, neonatal intensive care unit admissions, and perinatal mortality were comparable.

Conclusion(s): When controlling for maternal age, parity, ethnic origin, and location and date of delivery, singleton IVF pregnancies do not carry an increased risk for prematurity, low birth weight, or maternal or fetal complications. Still, these pregnancies are associated with a high rate of cesarean sections.     

Mode of delivery and neonatal death in 17,587 infants presenting by the breech

OBJECTIVE--To study the effects of caesarean section on neonatal mortality in infants presenting by the breech. DESIGN--Population-based non-experimental comparison of infants presenting by the breech born vaginally with those born by caesarean section. Neonatal mortality rates were calculated for 250 g birthweight intervals. Weight-specific relative risks (RRs) were further adjusted for birthweight in 50 g categories. SETTING--New York City, 1978-1983. Data came from the Department of Health's computerized vital records on livebirths and infant deaths. SUBJECTS--17,587 singleton breech livebirths greater than or equal to 500 g birthweight, with congenital anomaly deaths excluded. 6178 were born vaginally and 11409 were born by caesarean section. MAIN OUTCOME MEASURES--Birthweight-specific and birthweight-adjusted neonatal mortality. RESULTS--At birthweights of 501 to 1750 g, the risk of neonatal death for breech infants born vaginally was significantly higher than the risk for those born by caesarean section (weight-adjusted RR = 1.7). For breech infants with birthweights over 3000 g, the weight-adjusted risk was 5.6 times greater for a vaginal birth compared with caesarean section. The addition of 16 additional control variables in multiple logistic regression analyses did not change these RRs. CONCLUSION--Population-based studies indicate that an increase in the caesarean section rate among breech singletons may be associated with increased neonatal survival, but a large multicentre randomized trial of management of breech presentation would answer the question much more definitively.     

Neonatal mortality amongst Scottish preterm singleton births (1985–1994)

Objective To provide a valid estimate of singleton neonatal mortality based on birthweight and gestational age at delivery.
Design Record linkage of maternity data and neonatal mortality data.
Setting Scotland, UK.
Population All singleton preterm deliveries from 24 to 36 weeks inclusive between 1985 and 1994.
Main outcome measure Neonatal death.
Results There were 625,646 liveborn singleton deliveries over the study period, of which 33,912 were preterm (5.4%). The overall neonatal mortality in the preterm group was 41/1000 and the data have been presented by both gestational age and birthweight. The neonatal mortality rate fell with advancing gestation from 795/1000 live births at 24 weeks to 9/1000 live births at 36 weeks and was higher at the extremes of birthweight for a given gestational age. There was a significant increase in the proportion of babies delivered iatrogenically over the study period (χ test for trend   P < 0.001  ).
Conclusion This is the largest recent series to consider neonatal mortality using both birthweight and gestational age. These figures will be of use in obstetric management when elective preterm delivery is considered, and for providing prognostic guidance following preterm delivery.     

Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth

OBJECTIVE: To determine the association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth. DESIGN: Multicentre prospective cohort study. SETTING: Ten European centres offering prenatal screening for toxoplasmosis. POPULATION: Deliveries after 23 weeks of gestation in 386 women with singleton pregnancies who seroconverted to toxoplasma infection before 20 weeks of gestation. Deliveries after 36 weeks in 234 women who seroconverted at 20 weeks or later, and tested positive before 37 weeks. METHODS: Comparison of infected and uninfected births, adjusted for parity and country of birth. MAIN OUTCOME MEASURES: Differences in gestational age at birth, birthweight and birthweight centile. RESULTS: Infected babies were born or delivered earlier than uninfected babies: the mean difference for seroconverters before 20 weeks was -5.4 days (95% CI: -1.4, -9.4), and at 20 weeks or more, -2.6 days (95% CI: -0.5, -4.7). Congenital infection was associated with an increased risk of preterm delivery when seroconversion occurred before 20 weeks (OR 4.71; 95% CI: 2.03, 10.9). No significant differences were detected for birthweight or birthweight centile. CONCLUSION: Babies with congenital toxoplasmosis were born earlier than uninfected babies but the mechanism leading to shorter length of gestation is unknown. Congenital infection could precipitate early delivery or prompt caesarean section or induction of delivery. We found no evidence for a significant association between congenital toxoplasmosis and reduced birthweight or small for gestational age birth.     

Influence of mode of delivery on neonatal mortality and morbidity in spontaneous preterm breech delivery

Objective

To study the association between mode of delivery and neonatal outcome in singleton pregnancy with breech presentation and preterm birth, due to premature labour (PTL) and/or preterm premature rupture of the membranes (pPROM).

Design and methods

Information on preterm (gestational week 25–36) singleton births in breech presentation in Sweden during 1990–2002 was obtained from the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry. The study groups included 1975 caesarean and 699 vaginal deliveries with a diagnosis of PTL or pPROM, without pregnancy complications implying a high risk of fetal compromise. The rates of infant respiratory distress syndrome (IRDS), intraventricular haemorrhage (IVH), low Apgar scores, and neonatal deaths were compared between infants delivered vaginally and by caesarean section. Odds ratios were calculated with adjustment for gestational age, year of birth, maternal age and parity.

Results

The risk of neonatal death and the risk of an Apgar score below 5 min postnatally were both lower after caesarean delivery (OR 0.4; 95% CI 0.2–0.7, and OR 0.4; 95% CI 0.3–0.7, respectively), whereas the risk of IRDS was increased (OR 2.1; 95% CI 1.4–3.2). A diagnosis of IRDS was not associated with mortality (OR 0.8; 95% CI 0.5–1.5). IVH was not associated with mode of delivery (OR 1.2; 95% CI 0.5–2.8).

Conclusion

The lower neonatal mortality after CS supports a policy of caesarean delivery of the preterm breech.     

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.     

Increased risk in the elderly parturient

PURPOSE OF REVIEW: The steady increase in age in primiparous and multiparous women raises questions concerning increased obstetric risk and outcome in such pregnancies. This review highlights the effects of maternal age on obstetric and perinatal outcome. RECENT FINDINGS: Complications have been associated with increasing maternal age, including abnormal weight gain, obesity, gestational diabetes, chronic and pregnancy-induced hypertension, antepartum haemorrhage, placenta praevia, multiple gestation, prelabour rupture of membranes, and preterm labour. Intrapartum complications of malpresentation, fetopelvic disproportion, abnormal labour, increased use of oxytocin in labour, caesarean section, instrumental delivery, sphincter rupture, and postpartum haemorrhage are more frequent in older women. Advanced maternal age is associated with a higher risk of stillbirth throughout gestation, and the peak risk period is 37-41 weeks. Perinatal outcomes differ with maternal age concerning gestational age, birth weight, prematurity, low birth weight, incidence of small-for-gestational-age infants, fetal distress, and perinatal morbidity and mortality. The increased risk cannot be explained only by intercurrent illness or pregnancy complications. SUMMARY: Increasing maternal age is independently associated with specific adverse outcomes. Increasing age is a continuum rather than threshold effect. More information about obstetric consequences of delayed childbearing is needed both for obstetricians and fertile women.