Indications for cesarean deliveries in Norway

OBJECTIVE: The purpose of this study was to investigate the indications for cesarean deliveries in Norway, related to type of operation, parity, and gestational age. STUDY DESIGN: This was a prospective survey that used information provided by clinicians at 24 maternity units. Two thousand seven hundred seventy-eight cesarean deliveries were included, which represents 69.7% of all cesarean deliveries in Norway during the study period. RESULTS: The cesarean delivery rate varied by maternal and gestational age, parity, and hospital of delivery. Seven indications accounted for 77.7% of the operations: fetal stress (21.9%), failure to progress (20.7%), previous cesarean delivery (8.9%), breech presentation >or=34 weeks of gestation (8.4%), maternal request (7.6%), preeclampsia (6.2%) and failed induction (4.0%). Of the total deliveries, 64.3% were emergency operations. CONCLUSION: Accurate information about indications for cesarean deliveries in Norway has been obtained. Two thirds of all deliveries were emergency operations; the most important indications were fetal stress and failure to progress. In the elective cesarean delivery group, the two most important indications were previous cesarean delivery and maternal request.     

Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience

BACKGROUND: To investigate birth experience and medical outcome in women with elective cesarean section (CS) compared with women with intended vaginal delivery. METHODS: A total of 1050 pregnant women were included in this prospective trial. Psychological factors, pain levels and birth experience were investigated using a self-designed questionnaire and three established psychological tests in gestational week 38, and 3 days and 4 months postpartum. In addition, medical data were evaluated from the records. RESULTS: Out of 903 women with planned vaginal birth, in 484 women (53.6%) minimal perineal surgery had to be performed after birth, 41 women (4.5%) had vacuum deliveries, and in 93 cases (10.3%) emergency CS had to be performed. In the 147 elective CS (103 based on medical and 44 on psychological factors), a significantly lower rate of maternal and fetal complications was observed when compared with vaginal birth (5.4% vs. 19.3%; p < 0.0001). Birth experience (Salmon test) was significantly better in elective CS compared with vaginal delivery, but worse in women with emergency CS and worst in those with vacuum delivery. We found that 83.5% of women with vaginal delivery would choose the same mode of birth again, 74.3% of women with CS on demand, and 66% of women with medically necessary CS. Only 30.1% of women with emergency CS wanted to receive CS at the next birth. CONCLUSIONS: Elective CS is a safe and psychologically well tolerated procedure. The results are comparable with uncomplicated vaginal delivery and far superior to secondary intervention such as vacuum delivery or emergency CS.     

Cesarean section, gestational age, and transient tachypnea of the newborn: timing is the key

The purpose of this study was to identify risk factors and to characterize infants with transient tachypnea of the newborn (TTN). A total of 67 newborns with TTN, born at gestational age (GA)>or=35 weeks, were studied. Newborns delivered before and after each study case served as controls. Mean GA was lower and cesarean section (CS) rate was higher in the TTN group (38.2+/-2.3 versus 39.5+/-1.4 weeks, p<0.001; 50.7% versus 22.4%, p<0.001). GA<38 weeks was found to be associated with increased risk for TTN in infants delivered by elective CS. TTN was associated with significant morbidities and longer hospital stay (7.2+/-5.6 versus 2.9+/-1.4 days; p<0.001). Delivery by CS and younger GA are risk factors for TTN. Although TTN is a self-limited disease, it is associated with significant morbidities. Scheduling elective CS at GA of not less than 38 weeks may decrease the frequency of TTN.     

Maternal complications associated with cesarean section

OBJECTIVE: To assess the prevalence of cesarean section (CS) related maternal complications and to evaluate post-CS complications in relationship with relative risk factors. METHOD: 3010 patients who had a CS in the University Hospital of Bari during the period 1988-98 were retrospectively included into the study and 1007 women delivered vaginally at the same institution and in the same period of time, were randomly selected as the control group. For each single patient delivered by CS, the following risk factors were taken into account: age, parity, pre-pregnancy body mass index (BMI), and any disease antedating pregnancy or diagnosed during pregnancy. Additionally, therapeutic procedures such as blood transfusion, number of days in hospital, and admission into intensive care were followed. The prevalence of puerperal complications was assessed for vaginal deliveries and CS by Student's t-test and a correlation of CS complications with risk factors was performed by multivariate analysis. RESULTS: In the cohort of abdominal delivery, puerperal complications were significantly more frequent compared with those following vaginal delivery (p < 0.05). In the group of CS, obese women have higher prevalence of maternal complications, particularly hypertension and intestinal complications (p < 0.05). CONCLUSION: Compared with vaginal delivery, CS delivery carries a higher number of postpartum complications, and the higher rate is mainly related to obesity.     

Emergency Peripartum Hysterectomy: A 13-Year Review at a Tertiary Center in Kuwait

Objective

To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy (EPH) and to evaluate total versus subtotal hysterectomy for EPH.

Materials and Methods

This is a retrospective case series involving thorough examination of the files of all women who had EPH between January 2000 and December 2012 in the department of Obstetrics and Gynecology, Al-Jahra hospital, Kuwait after taking approval from the ethics committee. Incidence, indications, risk factors, type of hysterectomy, and complications of EPH were obtained from patient files.

Results

There were 63,337 deliveries of which 70.3 % were vaginal deliveries, and 29.6 % were by cesarean section (CS). Sixty-eight women underwent EPH representing an overall incidence of 1 case per 1,000 deliveries. The indications for EPH included abnormal placentation (77.4 %), uterine atony (14.5 %), and uterine rupture (8.1 %). There was one maternal death. Maternal morbidity occurred in 25 (40.3 %) women. The most common complications were mild to severe coagulopathy (19.35 %) and injury to the urinary tract (17.74 %). Injury to the ureter was avoided by placing ureteric stents preoperatively. Our population was significant in having higher rate of CS deliveries (91.9 %), women with prior CS (83.87 %), and high parity (mean 5.8).

Conclusion

Abnormal placentation was the most common indication to perform EPH. The relative risk of EPH was 27 for CS deliveries as compared to vaginal deliveries. There was no significant difference between subtotal versus total hysterectomy with respect to age, parity, previous CS, operative time, blood transfusion, and intra and post operative complications.     

Prediction of dystocia-related cesarean section risk in uncomplicated Taiwanese nulliparas at term

Purpose

We aimed to assess risk factors for dystocia-related cesarean section (CS) in uncomplicated Taiwanese nulliparas at term

Methods

We reviewed 1,272 deliveries by 1 obstetrician in a Taiwanese hospital between February 2004 and December 2011. These parturients were nulliparas with singleton pregnancies ≥37 weeks gestation who had liveborn cephalic deliveries. The CS group consisted of parturients with dystocia-related CS for the following indications: prolonged latent phase, failure to progress, or arrest of descent. Eight confounding variables [maternal age, height, weight, body mass index (BMI) in labor, gestational age, infant birth weight, gender, and cervical dilatation] were obtained from the medical records. Multivariate logistic regression analysis was used to determine the association between each variable and route of delivery. A predictive formula for CS probability was generated using a logistic regression model.

Results

Overall 15.0 % of nulliparas in our population underwent CS. Logistic regression analysis revealed a significant association between maternal BMI and CS (adjusted OR 1.112; 95 % CI 1.065–1.161; P < 0.001). The association between maternal age and CS was also statistically significant (adjusted OR 1.074, 95 % CI 1.033–1.116, P = 0.001). Maternal height, weight in labor, gestational age, infant birth weight, gender, and cervical dilatation were not significantly associated with the route of delivery. A predictive formula for CS probability was developed based on a combination of maternal BMI and age.

Conclusions

Our results show that maternal age and BMI in labor are significantly associated with dystocia-related CS in uncomplicated Taiwanese nulliparas at term. We develop a practical formula to predict the probability for CS. Using this formula, obstetricians can estimate the risk of CS according to maternal age and BMI in labor.     

Does cesarean section prevent mortality and cerebral ultrasound abnormalities in preterm newborns?

OBJECTIVE: Despite the increased use of the cesarean section (CS), the rates of cerebral palsy, a frequent consequence of brain damage, have remained stable over the last decades. Whether an actual decrease in cerebral palsy has been masked by increased survival of infants delivered by CS or not, remains undefined. To investigate the role of CS, we compared risks of mortality and brain damage, as defined by ultrasound (US) abnormalities, in preterm newborns by mode of delivery. METHODS: Information on fetal, maternal, and neonatal risk factors was collected from the paired clinical records of preterm newborns and mothers. Crude and adjusted odds ratios (OR) of mortality and ultrasound abnormalities, according to mode of delivery (i.e., vaginal, elective CS, and emergency CS) were calculated. All the analyses were controlled for possible confounding by indication. RESULTS: In newborns of gestational age <32 weeks, no effect of CS on cerebral US abnormalities was found (OR 0.71 and 0.73 for emergency CS and elective CS, respectively). None of the maternal and neonatal factors were associated with both cerebral US abnormalities and mode of delivery. Among newborns of gestational age >or=32 weeks, after controlling for known and potential confounders in a multivariate model, the adjusted ORs remained close to one for both elective CS and emergency CS. CONCLUSIONS: CS does not reduce overall mortality in preterm newborns. No protective effect of CS on US abnormalities was found after stratifying by gestational age and controlling for possible confounding. These results do not encourage the widespread use of CS in preterm labor.     

Differences in postpartum morbidity in women who are infected with the human immunodeficiency virus after elective cesarean delivery, emergency cesarean delivery, or vaginal delivery

OBJECTIVE: The aim of this study was to assess the impact of elective cesarean delivery on postpartum morbidity in women who are infected with the human immunodeficiency virus (HIV). STUDY DESIGN: We performed a retrospective study of 401 women who were infected with HIV who were delivered in a single reference center from 1989 through 1999. Women who had cesarean deliveries (n = 201), of which 109 were elective and 92 were emergency, were compared with a group of women who were delivered vaginally (n = 200), composed of the women who were infected with HIV preceding each cesarean delivery. RESULTS: One or more serious complications occurred after 12% of emergency cesarean deliveries, after 6.4% of elective cesarean deliveries, and after 4% of vaginal deliveries (P =.04). In a multivariate analysis, which was adjusted for maternal CD4 lymphocyte count and antepartum hemorrhage, the relative risk of any postpartum complication (serious or minor) was increased by 1.85 (range, 1.00-3.39) after elective cesarean delivery and 4.17 (range, 2.32-7.49) after emergency cesarean delivery, compared with vaginal deliveries (P =.0001). CONCLUSION: Postpartum morbidity in women who are infected with HIV was highest after emergency, rather than elective, cesarean deliveries.     

Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy

Objectives

The purpose of this study was to evaluate the incidence, risk factors, indications, outcomes, and complications of emergency hysterectomy performed after cesarean deliveries (cesarean hysterectomy) and vaginal deliveries (postpartum hysterectomy).

Study design

We conducted a retrospective cohort study from 1990 to 2002 of patients who had peripartum hysterectomies at a single tertiary hospital. Comparisons were made between cesarean and postpartum hysterectomies.

Results

There were 55 cases of emergency peripartum hysterectomy (38 cesarean hysterectomies, and 17 postpartum hysterectomies), for a rate of 0.8 per 1000 deliveries. Overall, the most common indication for hysterectomy was uterine atony (56.4%), followed by placenta accreta (20.0%). Average estimated blood loss was 3325.6±1839.2 mL, average operating time was 157.1±75.4 minutes, average time from delivery to completing the hysterectomy was 333.8±275.7 minutes, and the average length of hospitalization was 11.0±7.9 days. The cesarean delivery rate at Grady Memorial Hospital during the study period was 14.2%. There were no statistically significant differences between variables examined when comparisons were made by cesarean vs postpartum hysterectomy.

Conclusion

Uterine atony is the leading indication for emergency hysterectomy performed following cesarean and vaginal deliveries.     

Vaginal birth after Caesarean section: a survey of practice in Australia and New Zealand

AIMS: Women with a single prior Caesarean section (CS) in a subsequent pregnancy will be offered either a planned elective repeat CS or vaginal birth after Caesarean (VBAC). Recent reports of VBAC have highlighted risks of increased morbidity, including uterine rupture, and adverse infant outcome. A survey of practice was sent to fellows and members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists to determine current care for women in a subsequent pregnancy with a single prior CS, and to assess variations by length and type of obstetric practice. METHODS: Questions asked about the safety of VBAC, induction of labour with a uterine scar, and requirements to conduct VBAC and elective repeat CS. RESULTS: A total of 1641 surveys were distributed, with 1091 (67%) returned, 844 from practicing obstetricians (51% of college membership). Almost all respondents (96%) agreed or strongly agreed that VBAC should be presented as an option to the woman, varying from 90% where the indication for primary CS was breech, 88% for fetal distress, and 55% for failure to progress. Forty percent of respondents agreed or strongly agreed that VBAC was the safest option for the woman, and associated with fewer risks than CS. In contrast, 44% of respondents disagreed or strongly disagreed that VBAC was the safest option for the infant, and opinions varied as to whether risks of VBAC outweighed those of CS for the infant. Almost two-thirds of practitioners would offer induction of labour to a woman with a prior CS in a subsequent pregnancy, one-third indicating a willingness to use vaginal prostaglandins, and 77% syntocinon. Most respondents preferred to conduct VBAC in a level two or three hospital (86%); required the availability within 30 min of an anaesthetist (81%), a neonatologist (84%), and operating theatre (97%); recommended continuous electronic fetal heart rate monitoring (86%); intravenous access (90%); and routine group and hold (79%) during labour. For an elective repeat CS, most practitioners request routine blood for group and hold (78%), a neonatologist in theatre (77%), the use of an in-dwelling urinary catheter (96%), and the use of intraoperative antibiotics (82%). CONCLUSIONS: Most obstetricians indicated VBAC to be the safest option for the woman, but were less certain about benefits and risks for the infant. The consensus of practice is to present VBAC as an option and induce labour if needed. Vaginal birth after Caesarean is preferred in a level two or three hospital, with an anaesthetist, neonatologist and operating theatre available within 30 min. The use of continuous electronic fetal heart rate monitoring and intravenous access are recommended. In planned CS, a neonatologist in theatre is preferred, and an in-dwelling urinary catheter an;! intraoperative antibiotics will be used.     

Neonatal respiratory morbidity after elective cesarean section.

OBJECTIVE: The objective of this study was to examine the rate of respiratory morbidity in neonates delivered by elective cesarean delivery (ECD) at term, with a definite confirmation of gestational age (GA) by 1st-trimester ultrasound. METHODS: Consecutive women carrying a singleton pregnancy and undergoing ECD at term (>38 1/7 weeks), confirmed by 1st-trimester ultrasound, were included in the study group. Multiple gestations, cesarean section (CS) in labor, CS performed after rupture of membranes and induced deliveries were excluded. The control group included women with a singleton pregnancy at term (>38 1/7 weeks) who delivered spontaneously. This group of women was randomly selected during the study period. RESULTS: The study group included 277 women delivered by ECD. The control group consisted of 311 women. Five newborns in the study group and none in the control group were admitted to the neonatal intensive care unit (NICU) due to respiratory disorders (p < 0.02). Excluding diabetic women did not change the results. On multivariate analysis, no other factors were found to independently influence the risk of respiratory complications. CONCLUSION: In our study, the rate of respiratory morbidity was found to be significantly higher in neonates delivered by ECD compared to those delivered vaginally. The fact that GA was confirmed by 1st-trimester ultrasound makes iatrogenic prematurity an unlikely sole cause for this excess morbidity.     

The risk of caesarean section in obese women analysed by parity

Objective

This study looked at the association between caesarean section (CS) and Body Mass Index (BMI) in primigravidas compared with multigravidas.

Study design

We enrolled women at their convenience, in the first trimester after an ultrasound examination confirmed an ongoing pregnancy. Weight and height were measured digitally and BMI calculated. After delivery, clinical details were again collected from the Hospital's computerised database.

Results

Of the 2000 women enrolled, there were 50.4% (n = 1008) primigravidas and 49.6% (n = 992) multigravidas. Of the 2000 8.5% were delivered by elective CS and 13.4% were delivered by emergency CS giving an overall rate of 21.9%. The overall CS rate was 30.1% in obese women compared with 19.2% in the normal BMI category (p < 0.001). In primigravidas the increase in CS rate in obese women was due to an increase in emergency CS (p < 0.005) and in multigravidas the increase was due to an increase in elective CS (p < 0.01). In obese primigravidas 20.6% had an emergency section for fetal distress. In obese multigravidas 17.2% had a repeat elective CS.

Conclusion

The influence of maternal obesity on the increase in CS rates is different in primigravidas compared with multigravidas.     

Incidence and risk factors predicting blood transfusion in caesarean section

Background: Routine preoperative evaluation for caesarean section (CS) has commonly included a blood type and screen evaluation due to risk of blood transfusion. However, there have been no objective local data to support such practices.
Aims: To evaluate the cost-effectiveness of blood type and screen testing for CS.
Methods: This retrospective study reviewed all singleton CS at a tertiary hospital using data from Blood Bank Registry and Obstetric Database, from 1 January 2004 to 31 December 2005. Clinical variables including demographic characteristics, estimated blood loss, indications for CS, preoperative haemoglobin and indications for transfusions were gathered. All patients who had blood transfusion recorded in Obstetric Database or in Blood Bank Registry had their medical records reviewed by two reviewers to confirm accuracy and identify risk factors for haemorrhage.
Results: Of 2212 patients with singleton pregnancy who underwent CS, 14 (0.63%) required a blood transfusion. The risk of blood transfusion for elective and emergency CS are 3.9 per 1000 and 9.8 per 1000, respectively. In the absence of risk factors identified in this study, no women (of a total of 1293 elective CS) required blood transfusion.
Conclusion: In the absence of significant risk factors for haemorrhage at CS in a tertiary setting, routine blood type and screen testing does not enhance patient care. In the rare event that a patient without previously identifiable risk factors requires an urgent blood transfusion, O negative blood could be given in the interim pending formal determination of type and cross-match.     

Maternal and neonatal outcome after cesarean section: the impact of anesthesia.

BACKGROUND: Among the anesthetic technologies used, regional anesthesia is becoming the most common in cesarean section (CS) deliveries. Aim. This retrospective survey examined the variables taken into account when selecting the anesthetic technique to be used, and how this choice affects the outcome for the mother and the newborn. METHODS: One thousand eight hundred and seventy elective and emergency CS were evaluated for anesthetic technique used, indications, and maternal and neonatal outcome. RESULTS: Of the 611 elective CS (32.6%), 206 (33.8%) were performed under general anesthesia and 405 (66.2%) under regional anesthesia. Of the 1259 emergency CS performed (67.4%), 525 (41.9%) were under general anesthesia and 734 (58.1%) under regional anesthesia. Conditions associated with a newborn 1-minute Apgar score of <7 were general anesthesia and multiple pregnancy (p<0.01); a 5-minute Apgar score of <7 was only associated with multiple pregnancy. The most important factor for very low Apgar scores was the presence of fetal malformations. Whatever the chosen technique, neither maternal deaths directly or indirectly due to the anesthesia nor major maternal and perinatal complications were found. CONCLUSIONS: This survey confirms the preference for regional anesthesia during elective cesarean sections and for general anesthesia in emergency situations. Moreover, newborn outcome was found not to be influenced either by the technique used or by the character of the procedure.     

Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital

OBJECTIVE: The purpose of this study was to investigate the incidence, type, location, and risk factors of accidental fetal lacerations during cesarean delivery. STUDY DESIGN: Total deliveries, cesarean deliveries, and neonatal records for documented accidental fetal lacerations were reviewed retrospectively in our level III university hospital. The gestational age, the presenting part of the fetus, the cesarean delivery indication, the type of incision, and the surgeon who performed the procedure were recorded. Cesarean deliveries were divided into scheduled, unscheduled, and emergency procedures. Fetal lacerations were divided into mild, moderate, and severe. Neonatal follow-up examinations regarding laceration sequelae were available for 6 months. RESULTS: Of 14926 deliveries, 3108 women were delivered by cesarean birth (20.82%). Neonatal records documented 97 accidental fetal lacerations. Of these accidental lacerations, 94 were mild; 2 were moderate, and 1 was severe. The overall rate of accidental fetal laceration per cesarean delivery was 3.12%; the accidental laceration rate in the cohort of fetuses was 2.46%. The crude odds ratios were 0.34 for scheduled procedures, 0.57 for unscheduled procedures, and 1.7 for emergency procedures. The risk for fetal accidental lacerations was higher in fetuses who underwent emergency cesarean birth and lower for unscheduled and scheduled cesarean births (P < .001). CONCLUSION: Fetal accidental laceration may occur during cesarean delivery; the incidence is significantly higher during emergency cesarean delivery compared with elective procedures. The patient should be counseled about the occurrence of fetal laceration during cesarean delivery to avoid litigation.     

Timing of antibiotic prophylaxis in cesarean section: retrospective,difference-in-differences estimation of the effect on surgical-site-infection

Background: Cesarean section (CS) is one of the most common surgical procedures performed worldwide. Surgical-site-infection (SSI) occurs in approximately 5–10% of CS. The benefit of prophylactic antibiotics for prevention of SSI has been demonstrated in the literature. The optimal timing of antibiotic prophylaxis (prior to surgical incision versus after cord clamping) was investigated in recent studies. In January 2014, the Israeli Ministry of Health introduced a national quality measure which monitors the administration of prophylactic antibiotics in CS. The custom clinical practice in our medical center was to administer prophylactic antibiotics immediately after cord clamping. Upon introduction of the national quality measurement program, the practice was changed to administration of antibiotics prior to surgical incision. Our objective was to examine the effect of timing of prophylactic antibiotics administration on the incidence of SSI following CS, in a single medical center that performs a large volume of deliveries, with a low rate of CS.

Material and methods: Taking advantage of a discrete change in clinical practice, we used retrospective data and applied difference-in-differences design to estimate the effect of the timing of prophylactic antibiotics administration on SSI rates. The analysis included all CSs performed during 2012–2015 and all hysterectomies conducted during the study period.

Results: The coverage rates of prophylactic antibiotics in CS before and after the policy change were 99.10% and 99.03%, respectively. The rates of SSI following CS, before and after the policy change, were 2.63% (n?=?2499) and 2.32% (n?=?3840), respectively. The rates of SSI following hysterectomy, before and after the policy, change were 6.82% (n?=?396) and 7.09% (n?=?437), respectively. Difference-in-differences (DID) estimates of the effect of policy change on the incidence of SSI in linear and logistic regression models were not significant (B?=??0.6%, p?=?.64; odds ratio?=?0.84, p?=?.58, respectively).

Conclusions: We found no effect of the timing of prophylactic antibiotic administration (prior to surgical incision versus after cord clamping) on SSI rates following CS.     

The risk of placenta accreta following primary cesarean delivery

Objective

To (a) evaluate the risk for placenta accreta following primary cesarean section (CS), in regard to the stage of labor, the cesarean section was taken (elective prelabor vs. unplanned during labor); and (b) investigate whether the association between placenta accreta and maternal and neonatal complications is modified by the type of the primary CS.

Study design

In a population-based retrospective cohort study, we included all singleton deliveries occurred in Soroka University Medical Center between 1991 and 2015, of women who had a history of a single CS. The deliveries were divided into three groups according to the delivery stage the primary CS was carried out: ‘Unplanned 1’ (first stage—up to 10 cm), ‘Unplanned 2’ (second stage—10 cm) and ‘Elective’ prelabor CS. We assessed the association between the study group and placenta accreta using logistic generalized estimation equation (GEE) models. We additionally assessed maternal and neonatal complications associated with placenta accreta among women who had elective and unplanned CS separately.

Results

We included 22,036 deliveries to 13,727 women with a history of one CS, of which 0.9% (n = 207) had placenta accreta in the following pregnancies: 12% (n = 25) in the ‘Unplanned 1’ group, 7.2% (n = 15) in the ‘ Unplanned 2’ group and 80.8% (n = 167) in the ‘elective’ group. We found no difference in the risk for subsequent placenta accreta between the groups. In a stratified analysis by the timing of the primary cesarean delivery, the risk for maternal complications, associated with placenta accreta, was more pronounced among women who had an unplanned CS (OR 27.96, P < 0.01) compared to women who had an elective cesarean delivery (OR 13.72, P < 0.01).

Conclusions

The stage in which CS is performed has no influence on the risk for placenta accreta in the following pregnancies, women who had an unplanned CS are in a higher risk for placenta accrete-associated maternal complications. This should be taken into consideration while counselling women about their risk while considering trial of labor after cesarean section.

     

Shoulder dystocia and the next delivery: outcomes and management.

OBJECTIVE: To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia. STUDY DESIGN: We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described. RESULTS: Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048). CONCLUSION: In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high--approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.     

剖宫产围手术期抗生素的预防性应用

目的 探讨低感染风险剖宫产产妇围手术期预防性应用抗生素的必要性及最佳用药方案.方法 前瞻性随机对照研究低感染风险子宫下段剖宫产产妇围手术期抗生素应用与否以及不同用药方案与术后病率和术后感染的关系.抗生素选择头孢唑肟钠或克林霉素,均为静脉给药.共纳入2007年11月至2008年10月在南京大学医学院附属鼓楼医院妇产科分娩的产妇720例,随机分成4组:A组176例,围手术期不使用抗生素,B组190例,术前30 min一次给药,术后不再使用;C组180例,术前30 min开始给药,术后继续使用2 d;D组174例,手术结束后开始给药,共5d.比较4组产妇术后体温恢复正常的时间、术后病率、术后感染及术后住院天数.统计学分析采用方差分析、卡方检验及Fisher精确概率法. 结果 720例产妇术后感染率、术后病率分别为0.83%(6/720)和4.58%(33/720),4组产妇剖宫产术后感染发生率差异无统计学意义(P>0.05),B组和C组产妇术后体温恢复正常时间、术后病率及术后平均住院天数均分别显著低于A组和D组[B组:(41.9±31.6)h、1.05 oA(2/190)、(4.8±1.1)d;C组:(41.1±36.5)h、1.11%(2/180)、(4.7±0.9)d;A组:(67.0±40.6)h,7.39%(13/176)、(5.7±1.0)d,D组:(70.1±39.9)h、9.20%(16/174)、(5.9±1.1 d),P均<0.01].但B、C组之间和A,D组之间各项指标比较差异无统计学意义(P>0.05). 结论 低感染风险产妇剖宫产术前30 min静脉使用抗生素能显著降低术后病率的发生,且一次性用药即可,无需对低感染风险的剖宫产产妇在术后重复应用抗生素预防感染.     

Emergency peripartum hysterectomy: our 12-year experience

Objective

The aim of this study was to determine the incidence, indications and the risk factors and complications of emergency peripartum hysterectomy (EPH).

Methods

We analyzed retrospectively 44 cases of EPH performed at tertiary obstetric center between January 2001 and April 2013. Data related to demographics, reproductive histories, indications for EPH, and postoperative follow-up were obtained by analyses of hospital records.

Results

The overall incidence of EPH was 0.48 per 1,000 deliveries during the study period. The most common indications of EPH were abnormal placentation (50 %), uterine atony (36 %) and uterine rupture (9 %). All patients who underwent EPH with abnormal placentation had one or more previous cesarean sections (CS) except one. In our series, 24 cases (54 %) underwent total hysterectomy, most of which had the diagnosis of abnormal placentation (75 %), whereas subtotal hysterectomy was the choice of management of bleeding in cases with uterine atony (60 %). Maternal mortality was seen in 2 patients (4.5 %). The causes were disseminated intravascular coagulation in one and adult respiratory distress syndrome in the other patient. Perinatal mortality was observed in 7 patients (16 %). The causes for perinatal mortality were placental abruption in 4 and prematurity in 3 patients.

Conclusions

In our series, abnormal placentation was the most common indication for EPH. The risk factors for EPH were previous CS for abnormal placentation and placental abruption for uterine atony and peripartum hemorrhage. Limiting the number of CS deliveries would bring a significant impact on decreasing the risk of EPH.