Severe preeclampsia and delivery outcomes: is immediate cesarean delivery beneficial?

OBJECTIVE: This study was designed to determine whether immediate cesarean delivery for patients with severe preeclampsia confers any benefit to the mother or neonate. STUDY DESIGN: This retrospective chart review included all deliveries complicated by severe preeclampsia between July 1, 1999, and June 30, 2000. Cesarean deliveries performed for malpresentation, previous classic incision, multiple gestation, placenta previa, and herpetic outbreak were not included. Demographic variables, maternal outcomes, and neonatal outcomes were collected. RESULTS: Of 114 patients, 93 had an option regarding route of delivery. Thirty-four had an immediate cesarean section and 59 had induction of labor. Thirty-seven of 59 were delivered vaginally and 22 of 59 underwent cesarean delivery. Pulmonary complications in the mother and neonate were more common in cesarean delivery (P <.05). No morbidity was decreased by cesarean delivery. Bishop score and gestational age did not affect the labor induction success rate. CONCLUSION: Immediate cesarean delivery confers no benefit to patients with severe preeclampsia.     

Vaginal delivery or cesarean section at term breech delivery – chance or risk?

Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes.

Material and methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student's-t test, χ² likelihood ratio, and the Fisher's exact test. The level of statistical significance was set at p?<0.05.

Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p?=?0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths.

Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.     

Cesarean delivery technique: evidence or tradition? A review of the evidence-based cesarean delivery

Cesarean delivery is the most common surgical procedure performed in the United States, yet the techniques used during this procedure often vary significantly among providers. The purpose of this review was to evaluate and outline current evidence behind the cesarean delivery technique. A search of the PubMed database was conducted using the terms cesarean section and cesarean delivery and the technique of interest, for example, cesarean section prophylactic antibiotics. Few aspects of the cesarean delivery were found to have high-quality consistent evidence to support use of a particular technique. Because many aspects of the procedure are based on limited or no data, more studies on specific cesarean delivery techniques are clearly needed. Providers should be aware of which components of the cesarean delivery are evidence-based versus not when performing this procedure.     

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.     

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.     

Turkish obstetricians’ personal preference for mode of delivery and attitude toward cesarean delivery on maternal request

Objective(s)  

(1) To investigate the cesarean rate among actively practicing obstetricians in Turkey and reasons why they choose this mode of delivery for themselves/partners. (2) To investigate the attitudes, practices, and beliefs with respect to cesarean delivery on maternal request (CDMR) among actively practicing obstetricians in Turkey.     

Normal birth or spontaneous vertex delivery?

The declining normal birth rate and increasing Caesarean Section (CS) rates have been a worldwide cause for concern and debate for two decades. In the United Kingdom (UK) normal birth rates have fallen from 70 per cent in the 1970s to 46.7 per cent in 2009 (Birth Choice UK 2011). As normal birth rates continue to fall, researchers and advocates of normality are focusing on the midwife's role in response to this decline. The language and definitions used to classify normality and normal birth are contentious issues leading to confusion for midwives and women. This paper seeks to contribute to the debates around defining and promoting normality.     

Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?

OBJECTIVE: We sought to test the hypothesis that vaginal delivery compared with elective cesarean delivery results in improved neonatal outcome in fetuses with a known isolated ventral wall defect. STUDY DESIGN: We performed a retrospective chart review. RESULTS: Between 1989 and 1999, we identified 102 infants with a confirmed antenatal diagnosis of an isolated ventral wall defect with either the diagnosis of an omphalocele or gastroschisis. Sixty-six infants were delivered by cesarean and 36 were delivered vaginally. There were no significant demographic differences between the study groups or between the two sites except that one center (Cincinnati) usually delivered these fetuses by cesarean whereas the other (Louisville) usually delivered such fetuses vaginally. Overall, there were a greater number of infants with gastroschisis than omphalocele (gastroschisis, n = 71; omphalocele, n = 31). After we controlled for primary versus staged closure of ventral wall defect and gestational age at delivery; the medians and interquartile ranges for cesarean and vaginal delivery were 39 (25, 63) days versus 42 (26, 75) days, respectively (P =.32), for neonatal length of stay and 13 (9, 18) days versus 13 (9, 26) days, respectively (P =.16), for days to enteral feeding. After we controlled for the size of the defect and the amount of bowel resected, the odds of primary closure given a vaginal delivery was about half that given a cesarean delivery (odds ratio, 0.56; 95% confidence interval, 0.18-1. 69), but this was not statistically significant. There was no statistically significant difference in the rates of neonatal death (2 [3%] vs 2 [6%]; P =.61) and neonatal sepsis (2 [3%] vs 4 [11%]; P =.18) for cesarean versus vaginal delivery. Maternal length of stay after delivery was found to be 1 day less after vaginal delivery [vaginal, 2 (2, 2) days; cesarean, 3 (2, 3) days; P =.0001]. There were 5 instances of maternal complications, and all 5 pregnancies were delivered by cesarean (P =.16). CONCLUSION: Fetuses with an antenatal diagnosis of an isolated ventral wall defect may safely be delivered vaginally, and cesarean delivery should be performed for obstetric indications only.     

Does oocyte donation equal cesarean delivery?

Cesarean delivery (CD) rates have been reported as rising constantly in the last decade. Cesarean deliveries continue to be the most common major surgical procedure for women in the United States. We looked at a subgroup of eight oocyte donation pregnancies in 2007 examining obstetric outcomes and modes of delivery vs. deliveries in the general population. Data were collected from the computerized perinatal database of deliveries occurring in the year 2007 at the Soroka University Medical Center. Statistical analysis was performed using the Fisher exact test for categorical variables. During 2007, there were eight pregnancies following oocyte donation and these were compared with 12,611 total deliveries. Pregnancies with oocyte donation were significantly associated with CD, with an odds ration of 29.1 (95% CI 3.6–629.8; P?<?0.001; 87.5% versus 19.4%). The obstetric outcomes were generally favorable in terms of Apgar scores, birthweight, and gestational age. Pregnancies following infertility treatments are managed as high risk throughout the pregnancy. Pregnant women and physicians should be aware of potential risks when planning an elective CD. With an increasing body of research on the harms and benefits of medically elective cesarean versus vaginal delivery, decision making in this regard will be evidence based.     

Does cesarean delivery prevent anal incontinence?

OBJECTIVE: To compare the incidence and severity of anal incontinence in primiparas after cesarean delivery versus spontaneous vaginal delivery. METHODS: A total of 184 primiparas who delivered by cesarean (104 emergency, 80 elective) and 100 who delivered vaginally were interviewed 10 +/- 2 months postpartum. A comprehensive bowel function questionnaire was completed. Bowel-specific questions included bowel habits, laxative use, urgency, flatus, urge and passive incontinence, soiling, and pad use, before and during pregnancy and postpartum. Obstetric details were confirmed from obstetric records. RESULTS: Anal incontinence was first present in nine (5%) mothers after cesarean delivery and eight (8%) after vaginal delivery (relative risk 0.611, 95% confidence interval 0.25, 1.53). Severe symptoms necessitating pad use affected two (3%) mothers after elective cesarean and one (1%) after vaginal delivery. Two (3%) mothers after elective cesarean, one (1%) after emergency cesarean, and two (2%) after vaginal delivery had at least two symptoms. Anal incontinence followed prelabor emergency cesarean in two mothers. Of the 22 mothers who sustained a second-degree tear, five (23%) had new anal incontinence compared with only one (3%) of 40 mothers with an intact perineum (Fisher exact test value = 9.697, P =.014). CONCLUSION: Because severe anal incontinence followed elective and prelabor emergency cesarean, it seems that pregnancy itself can lead to pelvic floor disorders. A high incidence of anal incontinence is associated with a second-degree tear. Measures to detect and reduce postpartum anal incontinence should target all pregnant women and mothers, even after prelabor cesarean delivery.     

Urinary incontinence: is cesarean delivery protective?

About half of all women develop transient urinary incontinence during pregnancy. Three months postpartum, the prevalence and incidence rates of urinary incontinence are 9% to 31% and 7% to 15%, respectively. Antenatal incontinence increases the risk of postpartum incontinence, which in turn increases the risk of long-term persistent incontinence. After the first delivery, women delivered vaginally have two-fold more incontinence than those delivered by cesarean. The protective effect of cesarean on urinary incontinence may dissipate after further deliveries, decreases with age, and is not present in older women. Data are mixed about whether cesarean done before labor confers greater protection than cesarean done after labor. To understand the true impact of cesarean delivery on urinary incontinence, future studies must compare incontinence by planned (not actual) delivery modes, consider a woman's entire reproductive career, focus on leakage severe enough to be problematic, consider other bladder symptoms as well as incontinence, and take into account other risk factors, particularly antepartum urinary incontinence.     

Perimortem cesarean delivery: were our assumptions correct?

OBJECTIVE: The recommendation to perform a perimortem cesarean delivery within 4 minutes of maternal cardiac arrest was introduced in 1986. This recommendation was based on the assumptions that cardiopulmonary resuscitation is ineffective in the third trimester because of aortocaval compression, and that fetal and perhaps maternal outcomes would be optimized by timely delivery. Our objective was to review the outcomes of perimortem cesarean deliveries to attempt to validate those assumptions. STUDY DESIGN: Ovid MEDLINE searches using maternal mortality, cardiopulmonary resuscitation, perimortem cesarean delivery, heart attack, and cardiac arrest from 1985 until 2004. Citations from bibliographies of identified publications were perused and cross-referenced for other potential articles. Case reports were included for analysis when mothers had complete cardiopulmonary arrest, and cardiopulmonary resuscitation had been initiated before cesarean delivery. RESULTS: There were 38 cases of perimortem cesarean delivery identified; 34 infants survived (3 sets of twins, 1 set of triplets); 4 other infants survived initially, but died several days after the deliveries from complications of prematurity and anoxia. Of the 34 infants (25-42 weeks' gestation), time of delivery after maternal cardiac arrest was available for 25. Eleven infants were delivered within 5 minutes, 4 were delivered from 6 to 10 minutes, 2 were delivered from 11 to 15 minutes, and 7 were delivered more than 15 minutes. Of 20 perimortem cesarean deliveries with potentially resuscitatable causes, 13 mothers were resuscitated and discharged from the hospital in good condition. One other mother was successfully resuscitated after the delivery, but died within 24 hours from complications related to her amniotic fluid embolism. In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery. We wish to emphasize the large selection bias in this data. CONCLUSION: Published reports from 20 years support, but fall far from proving, that perimortem cesarean delivery within 4 minutes of maternal cardiac arrest improves maternal and neonatal outcomes.