Impact of First Childbirth on Changes in Women’s Preference for Mode of Delivery: Follow‐up of a Longitudinal Observational Study

ABSTRACT: Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty‐four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women’s wish to change to elective cesarean section. (BIRTH 35:2 June 2008)     

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.     

Risk of cesarean delivery with elective induction of labor at term in nulliparous women.

OBJECTIVE: To quantify the risk of cesarean delivery associated with elective induction of labor in nulliparous women at term. METHODS: We performed a cohort study on a major urban obstetric service that serves predominantly private obstetric practices. All term, nulliparous women with vertex, singleton gestations who labored during an 8-month period (n = 1561) were divided into three groups: spontaneous labor, elective induction, and medical induction. The risk of cesarean delivery in the induction groups was determined using stepwise logistic regression to control for potential confounding factors. RESULTS: Women experiencing spontaneous labor had a 7.8% cesarean delivery rate, whereas women undergoing elective labor induction had a 17.5% cesarean delivery rate (adjusted odds ratio [OR] 1.89; 95% confidence interval [CI] 1.12, 3.18) and women undergoing medically indicated labor induction had a 17.7% cesarean delivery rate (OR 1.69; 95% CI 1.13, 2.54). Other variables that remained significant risk factors for cesarean delivery in the model included: epidural placement at less than 4 cm dilatation (OR 4.66; 95% CI 2.25, 9.66), epidural placement after 4 cm dilatation (OR 2.18; 95% CI 1.06, 4.48), chorioamnionitis (OR 4.61; 95% CI 2.89, 7.35), birth weight greater than 4000 g (OR 2.59; 95% CI 1.69, 3.97), maternal body mass index greater than 26 kg/m2 (OR 2.36; 95% CI 1.61, 3.47), Asian race (OR 2.35; 95% CI 1.04, 5.34), and magnesium sulfate use (OR 2.18; 95% CI 1.04, 4.55). CONCLUSION: Elective induction of labor is associated with a significantly increased risk of cesarean delivery in nulliparous women. Avoiding labor induction in settings of unproved benefit may aid efforts to reduce the primary cesarean delivery rate.     

Subsequent pregnancy outcome after preterm breech delivery,a population based cohort study

Objective: The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy.

Methods: Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999–2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies.

Results: We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55–4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).

Conclusion: In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.     

Maternal pre-pregnancy overweight status and obesity as risk factors for cesarean delivery

Objective.?To determine the extent to which, if at all, maternal pre-pregnancy adiposity and other anthropometric factors are related to risk of cesarean delivery.

Methods.?This hospital-based prospective cohort study included 738 nulliparous women who initiated prenatal care prior to 16 weeks gestation. Participants provided information about their pre-pregnancy weight and height and other sociodemographic and reproductive covariates. Labor and delivery characteristics were obtained from maternal and infant medical records. Risk ratios (RR) and 95% CI were estimated by fitting generalized linear models.

Results.?The proportion of cesarean deliveries in this population was 26%. Women who were overweight (BMI 25.00–29.99?kg/m²) were twice as likely to deliver their infants by cesarean section as lean women (BMI <?20.00?kg/m²) (RR?=?2.09; 95% CI 1.27–3.42). Obese women (BMI ??30.00?kg/m²) experienced a three-fold increase in risk of cesarean delivery when compared with this referent group (RR?=?3.05; 95% CI 1.80–5.18). The joint association between maternal pre-pregnancy overweight status and short stature was additive. When compared with tall (height ??1.63?m), lean women, short (?<?1.63?m), overweight (BMI ??25.00?kg/m²) women were nearly three times as likely to have a cesarean delivery (RR?=?2.79; 95% CI 1.72–4.52).

Conclusion.?Our findings suggest that nulliparous women who are overweight or obese prior to pregnancy, and particularly those who are also short, have an increased risk of delivering their infants by cesarean section.     

The incidence and risk factors for retained placenta after vaginal delivery – a single center experience

Abstract

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center.

Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly.

Results: Overall, 33?925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23–2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68–0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30–2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27–2.00) and vacuum delivery (OR 1.89, 95% CI 1.48–2.41) were independently associated with uterine revision for retained placenta.

Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.     

Emergency cesarean delivery in induction of labor: an evaluation of risk factors

BACKGROUND: Induction of labor has been associated with an increased risk of emergency cesarean delivery. Knowledge of factors that influence the risk of cesarean delivery in women with induced labor is limited. METHODS: We performed a case-control study, nested within a population-based cohort of women with induced labor at term during 1991-1996 in Uppsala County, Sweden. Cases were women delivered with emergency cesarean delivery, and controls were women vaginally delivered (n = 193, respectively). Using logistic regression, analyses were performed. Odds ratio (OR) with 95% confidence intervals (CI) was used as a measure of relative risk. RESULTS: Women with a previous cesarean delivery had high risks of cesarean delivery (adjusted OR = 10.10, 95% CI = 3.30-30.92). The risk of cesarean delivery was also increased among nulliparous (adjusted OR = 4.92, 95% CI = 2.81-8.61), short (adjusted OR = 2.20, 95% CI = 1.06-4.59), and obese women (adjusted OR = 2.03, 95% CI = 1.07-3.84). A cervix dilatation less than 1.5 cm doubled the risk of cesarean delivery (adjusted OR = 2.26, 95% CI = 1.09-4.66). Mother's age, epidural analgesia, oxytocin augmentation, gestational age, and birthweight were not significantly associated with risks of cesarean delivery. CONCLUSIONS: Women with a previous cesarean delivery, nulliparous, short, and obese women with induced labor are at high risk of a cesarean delivery. When there is a need to deliver a woman with a previous cesarean section or a nulliparous woman with other risk factors for cesarean delivery, it may be prudent to consider an elective cesarean section.     

Uterine rupture and risk factors for caesarean delivery following induced labour in women with one previous lower segment caesarean section

Objective: To determine the outcome of induction of labor, specifically incidence of uterine rupture and reliable predictors of repeat caesarean delivery, in women undergoing induction of labor after previous caesarean section. Methods: A review of obstetric and perinatal records of 167 women who had their labor induced after one transverse lower uterine incision performed at previous caesarean delivery in a referral tertiary hospital in Nigeria between January 2006 and December 2009. Results: The incidence of uterine rupture was 2.4%. Independent risk factors for repeat caesarean delivery were absence of prior vaginal delivery (OR 3.7; 95% CI 1.9–7.1), duration of latent phase >2?h (OR 4.3; 95% CI 1.7–11.2), postdated pregnancy (OR 2.2; 95% CI 1.1–4.0) and previous caesarean for non-recurrent indication (OR 2.1; 95% CI 1.1–4.0). Conclusion: Choice of appropriate delivery option for this cohort of women based on the identified risk factors is essential to minimize the incidence of failed vaginal birth and its associated adverse maternal and neonatal outcome.     

Elevated vaginal pH in the absence of current vaginal infection,still a challenging obstetrical problem

Abstract

Objective: To assess the association of vaginal pH?≥?5 in the absence of vaginal infection with systemic inflammation and adverse pregnancy outcome.

Methods: Four-hundred sixty pregnant women completed the study, upon enrollment Vaginal pH was measured for all women, maternal and umbilical sera were obtained for determining C-reactive protein (CRP) and uric acid levels. Umbilical blood was tested for gas parameters, 1 and 5?min Apgar scores, the need for neonatal resuscitation and neonatal intensive care unit (NICU) admission were recorded.

Results: Elevated vaginal pH was significantly associated with preterm birth (odds ratio (OR), 2.23; 95% confidence interval (CI), 1.04–4.76), emergency cesarean section (OR 2.57; 95% CI 1.32–5), neonatal resuscitation in the delivery room (OR 2.85; 95% CI 1.1–7.38), elevated cord base deficit (OR 8.01; 95% CI 1.61–39.81), low cord bicarbonate (OR 4.16, 95% CI 1.33–12.92) and NICU admission (OR 2.02; 95% CI 1.12–3.66). Increased vaginal pH was also significantly associated with maternal leukocytosis, hyperuricemia and elevated CRP levels in maternal and umbilical sera.

Conclusions: Elevated vaginal pH in the absence of current vaginal infection still constitutes a risk for adverse pregnancy outcome which is mediated by systemic inflammatory response.     

Term induction of labor and risk of cesarean delivery by parity

Abstract

Objective: To evaluate the risk of cesarean delivery among both nulliparous and multiparous women undergoing a term induction of labor compared to women that present in spontaneous labor at term.

Methods: We performed a retrospective cohort study of term (≥37 weeks) singleton pregnancies between 2005 and 2010 comparing women that had an induction to those that presented in spontaneous labor. Multiparity was defined as a prior delivery after 20 weeks’ gestation. Chi-square was used to compare categorical variables. Multivariable logistic regression was used to control for confounders. Analyses were stratified by parity.

Results: 863 women were included in the analysis. There were 605 inductions (cesarean rate 23%) and 257 spontaneous labor (cesarean rate 7%), OR 3.4, 95% CI [2.1–5.4]. Stratified by parity, nulliparas undergoing induction had an increased cesarean rate compared to spontaneous labor (27% versus 11%, OR 3.13, 95% CI [1.76–5.57]) as did multiparas (13% versus 3%, OR 4.04, 95% CI [1.36–11.94]). This increased risk for cesarean after induction remained in both nulliparous and multiparous women even after controlling for confounders (aOR 2.90, 95% CI [1.60–5.25] and aOR 3.47, 95% CI [1.12–10.67], respectively). Neither starting cervical exam nor indication for induction altered this increased risk.

Conclusions: The increased risk of cesarean in women undergoing an induction is present regardless of parity and indication for induction. This should be taken into account when counseling women regarding risks of induction, regardless of parity. Future studies should focus on other clinical characteristics of induction that may mitigate this risk.     

Does dystocia during labor pose a risk factor for another non-progressive labor during the subsequent delivery?

Objective: To establish whether failure to progress during labor poses a risk factor for another non-progressive labor (NPL) during the subsequent delivery.

Methods: A retrospective cohort study including singleton pregnancies that failed to progress during the previous labor and resulted in a cesarean section (CS) was conducted. Parturients were classified into three groups for both previous and subsequent labors: CS due to NPL stage I, stage II and an elective CS as a comparison group.

Results: Of 202?462 deliveries, 10?654 women met the inclusion criteria: 3068 women were operated due to NPL stage I and 1218 due to NPL stage II. The comparison group included 6368 women. Using a multivariable logistic regression models, NPL stage I during the previous delivery was found as an independent risk factor for another NPL stage I in the subsequent labor (adjusted odds ratio [OR]?=?2.9; 95% confidence interval [CI]?=?2.4–3.7; p?p?=?0.033; adjusted OR?=?5.3; 95% CI?=?3.7–7.5; p?Conclusion: A previous CS due to a NPL is an independent risk factor for another NPL in the subsequent pregnancy and for recurrent cesarean delivery.     

Maternal and neonatal outcome after failed ventouse delivery: Comparison of forceps versus cesarean section

Objectives.?To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery.

Methods.?Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed.

Results.?Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 – 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 – 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 – 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity.

Conclusions.?Failure of ventouse delivery is 3 – 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.     

Elective cesarean delivery for term breech

OBJECTIVE: To compare the maternal complications of elective cesarean delivery for breech at term with those after vaginal or emergency cesarean delivery. METHODS: We conducted a population-based, retrospective cohort study of 15441 primiparas who delivered singleton breech at term. Information was obtained from the Danish Medical Birth Register, the Register of Death Causes, and the Denmark Patient Register. RESULTS: Elective cesarean delivery was associated with lower rates of puerperal fever and pelvic infection (relative risk [RR] 0.81; 95% confidence interval [CI] 0.70, 0.92), hemorrhage and anemia (RR 0.91; 95% CI 0.84, 0.97), and operations for wound infection (RR 0.69; 95% CI 0.57, 0.83) than emergency cesarean delivery. There was a higher rate of puerperal fever and pelvic infection (RR 1.20; 95% CI 1.11, 1.25) than for vaginal delivery. Thromboembolic disease occurred in 0.1% of women with cesarean delivery, and anal sphincter rupture occurred in 1.7% of women with vaginal delivery. Elective cesarean delivery was not associated with subsequent ectopic pregnancy, miscarriage, placental complications, uterine rupture, or adverse neonatal outcome. Women with elective cesarean delivery were more often delivered by elective cesarean in their second pregnancy, compared with women delivered vaginally (RR 1.25; 95% CI 1.21, 1.29). Elective cesarean delivery was associated with a lower rate of a subsequent delivery during the study period and a longer mean delivery interval than for vaginal delivery. CONCLUSION: Elective cesarean delivery for term breech carries a low risk of severe maternal complications.     

Pregnancy outcome in women aged 40 years or more

Objective: The study aimed to analyze the pregnancy outcome of women aged 40 years or more. Methods: A matched retrospective cohort study comparing women aged 40 years or more with a control group aged 20 to 30 years is described. Multivariate logistic regression models were fitted for the prediction of preterm birth and cesarean delivery. Results: Pregnancy-induced hypertension, preeclampsia and placenta previa were similar in both groups, but a higher rate of gestational diabetes was found in elderly patients (odds ratio [OR] 3.820, 95% confidence interval [CI] = 1.400–10.400; p < 0.0001). Preterm delivery was significantly more frequent in elderly women (OR 1.847, 95% CI = 1.123–3.037; p = 0.020). Gestational diabetes and pregnancy-induced hypertension were strongly associated with preterm delivery and advanced maternal age was not an independent risk factor for preterm delivery. The cesarean delivery rate was significantly higher in the study group (OR 3.234, 95% CI = 2.266–4.617; p < 0.0001). The variables most influencing the cesarean delivery rate were maternal age, analgesia, parity, premature rupture of the membranes and gestational hypertension. No significant differences were detected in neonatal birth weight and Apgar score. Conclusions: Patients aged 40 years or more have been demonstrated to carry a favorable pregnancy and neonatal outcome, similar to younger patients. The risk of cesarean delivery was higher in patients with advanced maternal age, in nulliparous and in women with a previous cesarean section. The risk of preterm delivery was not related to age but it was strongly associated with gestational diabetes and pregnancy-induced hypertension.     

The effect of cigarette smoking during pregnancy on mode of delivery in uncomplicated term singleton pregnancies

Abstract

Objective: To examine the influence of cigarette smoking during pregnancy on mode of delivery.

Methods: A retrospective analysis of 6105 uncomplicated term singleton pregnancies for mode of delivery was performed with respect to smoking status.

Results: Of all, 680 (84.0%) smokers and 4588 (86.7%) non-smokers had a spontaneous vaginal delivery, 65 (8.0%) smokers and 393 (7.4%) non-smokers had an instrumental delivery and 65 (8.0%) smokers and 314 (5.9%) non-smokers had a cesarean delivery (p?=?0.051). Smoking during pregnancy increased the risk of any operative or instrumental intervention by OR 1.240, 95% CI 1.012–1.523. Non-reassuring fetal heart rate pattern that warranted either cesarean or instrumental intervention was present in 99 (12.2%) out of 810 smokers and in 392 out of 5295 (7.4%) non-smokers, p?<?0.001). Smoking during pregnancy increased the risk of non-reassuring fetal heart rate pattern that warranted either cesarean or instrumental intervention by OR 1.650 (95% CI 1.341–2.022).

Conclusion: Women with uncomplicated term singleton pregnancies who smoke during pregnancy are at an increased risk of fetal compromise during labor (as judged by non-reassuring fetal heart rate pattern), leading to increased rates of operative delivery (cesarean either instrumental).     

Is abnormal 50-g glucose-challenge testing an independent predictor of adverse pregnancy outcome?

Objective: To determine whether an abnormal 50-g glucose-challenge test (GCT) is independently associated with adverse pregnancy outcome. Methods: A retrospective study of women with abnormal GCT (>140?mg/dL) but normal subsequent 100-g oral glucose-tolerance test (OGTT). Pregnancy outcome was compared with that of women with normal GCT (<140?mg/dL). Results: Of the 79,153 women delivered during the study period, the results of the GCT were available for 14,268. Of these, 809 (5.7%) had an abnormal GCT and normal OGTT and were eligible for the study group. An abnormal GCT was independently associated with an increased risk for macrosomia (odds ratio [OR] = 2.0, 95% CI: 1.5–2.7), large for gestational age (OR = 1.6, 95% CI: 1.3–2.0), cesarean section (OR = 1.3, 95% CI: 1.1–1.6), respiratory morbidity (OR = 1.6, 95% CI: 1.1–2.7) and neonatal hypoglycemia (OR = 1.8, 95% CI: 1.1–3.2). In contrast, an abnormal GCT was associated with decreased risk for preterm delivery at less than 37 weeks (OR = 0.7, 95% CI: 0.5–0.9) and 34 weeks (OR = 0.3, 95% CI: 0.1–0.6). The association between abnormal GCT and adverse pregnancy outcome was unrelated to the degree of GCT abnormality except for cases in which the GCT was extremely high (≥180?mg/dL). Conclusion: Women with abnormal-GCT result are at increased risk for adverse pregnancy outcome even in the presence of a normal subsequent OGTT.     

Cesarean delivery and peripartum hysterectomy

OBJECTIVE: To estimate the national incidence of peripartum hysterectomy and quantify the risk associated with cesarean deliveries and other factors. METHODS: A population-based, matched case-control study using the United Kingdom Obstetric Surveillance System, including 318 women in the United Kingdom who underwent peripartum hysterectomy between February 2005 and February 2006 and 614 matched control women. RESULTS: The incidence of peripartum hysterectomy was 4.1 cases per 10,000 births (95% confidence interval [CI] 3.6-4.5). Maternal mortality was 0.6% (95% CI 0-1.5%). Previous cesarean delivery (odds ratio [OR] 3.52, 95% CI 2.35-5.26), maternal age over 35 years (OR 2.42, 95% CI 1.66-3.58), parity of three or greater (OR 2.30, 95% CI 1.26-4.18), previous manual placental removal (OR 12.5, 95% CI 1.17-133.0), previous myomectomy (OR 14.0, 95% CI 1.31-149.3), and twin pregnancy (OR 6.30, 95% CI 1.73-23.0) were all risk factors for peripartum hysterectomy. The risk associated with previous cesarean delivery was higher with increasing numbers of previous cesarean deliveries (OR 2.14 with one previous delivery [95% CI 1.37-3.33], 18.6 with two or more [95% CI 7.67-45.4]). Women undergoing a first cesarean delivery in the current pregnancy were also at increased risk (OR 7.13, 95% CI 3.71-13.7). CONCLUSION: Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity greater than 3. LEVEL OF EVIDENCE: II.     

New mothers’ feelings of disappointment and failure after cesarean delivery

Background

Childbirth is an important life event and how women feel in retrospect about their first childbirth may have long‐term effects on the mother, child, and family. In this study, we investigated the association between mode of delivery at first childbirth and birth experience, using a new scale developed specifically to measure women's affective response.

Methods

This was a prospective cohort study of 3006 women who were interviewed during pregnancy and 1‐month postpartum. The First Baby Study Birth Experience Scale was used to measure the association between mode of delivery and women's postpartum feelings about their childbirth, taking into account relevant confounders, including maternal age, race, education, pregnancy intendedness, depression, social support, and maternal and newborn complications by way of linear and logistic regression models.

Results

Women who had unplanned cesarean delivery had the least positive feelings overall about their first childbirth, in comparison to those whose deliveries were spontaneous vaginal (P < .001), instrumental vaginal (P = .001), and planned cesarean (P < .001). In addition, those who delivered by unplanned cesarean were more likely to feel disappointed (adjusted odds ratio [OR] 6.21 [95% confidence interval (CI) 4.62‐8.35]) and like a failure (adjusted OR 5.09 [95% CI 3.65‐7.09]) in comparison to women who had spontaneous vaginal delivery; and less likely to feel extremely or quite a bit proud of themselves (adjusted OR 2.70 [95% CI 2.20‐3.30]).

Conclusions

Delivering by unplanned cesarean delivery adversely affects how women feel about their first childbirth in retrospect, and their self‐esteem.     

Sleep disturbances during pregnancy are associated with cesarean delivery and preterm birth

Objective: The purpose of this study was to examine the associations of sleep disturbances during pregnancy with cesarean delivery and preterm birth.

Methods: In this prospective study, 688 healthy women with singleton pregnancy were selected from three hospitals in Chengdu, China 2013–2014. Self-report questionnaires, including the sleep quantity and quality as well as exercise habits in a recent month were administered at 12–16, 24–28, and 32–36 weeks’ gestation. Data on type of delivery, gestational age, and the neonates’ weight were recorded after delivery. After controlling the potential confounders, a serial of multi-factor logistic regression models were performed to evaluate whether sleep quality and quantity were associated with cesarean delivery and preterm birth.

Results: There were 382 (55.5%) women who had cesarean deliveries and 32 (4.7%) who delivered preterm. Women with poor sleep quality during the first (OR: 1.87, 95% CI [1.02–3.43]), second (5.19 [2.25–11.97]), and third trimester (1.82 [1.18–2.80]) were at high risk of cesarean delivery. Women with poor sleep quality during the second (5.35 [2.10–13.63]) and third trimester (3.01 [1.26–7.19]) as well as short sleep time (<7?h) during the third trimester (4.67 [1.24–17.50]) were at high risk of preterm birth.

Conclusions: Sleep disturbances are associated with an increased risk of cesarean delivery and preterm birth throughout pregnancy. Obstetric care providers should advise women with childbearing age to practice healthy sleep hygiene measures.     

Pregnancy outcomes in liver transplant patients,a population-based study

Objective: To determine the incidence of pregnancy in liver transplant (LT) patients in a large population-based cohort and to determine the maternal and fetal risks associated with these pregnancies.

Methods: We conducted an age-matched cohort study using the US Healthcare and Utilization project–Nationwide Inpatient Sample from 2003–2011. We used unconditional logistic regression, adjusted for baseline characteristics, to estimate the likelihood of common obstetric complications in the LT group compared with age-matched nontransplant patients.

Results: There were 7?288?712 deliveries and an estimated incidence of 2.1 LTs/100?000 deliveries over the nine-year study period. LT patients had higher rates of maternal complications including hypertensive disorders (OR 6.5, 95% CI: 4.4–9.5), gestational diabetes (OR 1.9, 95% CI: 1.0–3.5), anemia (OR 3.2, 95% CI: 2.1–4.9), thrombocytopenia (OR 27.5, 95% CI: 12.7–59.8) and genitourinary tract infections (OR 4.2, 95% CI: 1.8–9.8). Deliveries among women with LT had higher risks of cesarean section (OR 2.9, 95% CI: 2.0–4.1), postpartum hemorrhage (OR 3.2, 95% CI: 1.7–6.2) and blood transfusion (OR 18.7, 95% CI: 8.5–41.0). Fetal complications in LT patients included preterm delivery (OR 4.7, 95% CI: 3.2–7.0), intrauterine growth restriction (OR 4.1, 95% CI: 2.1–7.7) and congenital anomalies (OR 6.0, 95% CI: 1.1–32.0).

Conclusion: Although pregnancies in LT recipients are feasible, they are associated with a high rate of maternal and fetal morbidities. Close antenatal surveillance is recommended.