Preferred and actual delivery mode after a cesarean in London, UK

OBJECTIVE: To determine the delivery mode preferred by pregnant women with 1 previous cesarean delivery and to investigate the relationship between preferred and actual mode of delivery. METHOD: We reviewed the records of 215 women who were delivered in a London hospital with a history of 1 cesarean delivery. Women who planned an elective repeat cesarean section (ERCS) were compared with those who planned a vaginal birth after cesarean (VBAC). RESULTS: Although 55.3% chose VBAC overall, only 37.8% of those who chose it were delivered by it, whereas 94.8% of those who chose ERCS were delivered by ERCS. Nonwhite women were more likely to choose VBAC than white women (odds ratio, 3.5; 95% confidence interval, 1.9-6.1) but less likely to be deliver by it (odds ratio, 0.31; 95% confidence interval, 0.14-0.68). CONCLUSION: In this study, VBAC was the method of delivery preferred by most women. Nonwhite women were more likely to choose VBAC over ERCS but less likely to be delivered by VBAC.     

Delivery route preferences of urban women of low socioeconomic status

Objective

To identify the main determinants of mode of delivery preference among urban dwelling women of lower socioeconomic status (SES).

Methods

Over a 12-month period, a self-completion 36-item questionnaire was administered to a convenience sample of 308 women within the first 3 postpartum days. Non-parametric tests were used for analysis.

Results

Study participants were mostly African American (> 85%), single mothers (> 75%), and unemployed (≥ 55%). Among the women, 85.7% had vaginal delivery (VD) and 14.3% had cesarean delivery (CD). Women who preferred CD (10%) were more likely to be concerned about a vaginal tear/episiotomy during VD, forceps, and a "big" baby compared with women who preferred VD, for whom “pushing the baby out myself” and “fear of cesarean” were the most important factors. In the final model of 7 factors, the 3 main factors found to positively impact maternal preference for CD were a vaginal cut during VD (P < 0.001), higher mean BMI (P = 0.001), and cesarean as the most recent delivery type (P < 0.001). The total explained variance by this model was 46%.

Conclusions

Short-term complications of a VD, higher BMI, and a previous cesarean delivery are the most significant factors that impact the preferences of women of lower SES for future mode of delivery.     

阴道分娩和剖宫产对女性盆底功能的影响

盆底功能障碍性疾病(PFD)是临床症状表现为盆腔器官脱垂、尿失禁和粪失禁等症状的疾病,妊娠和分娩是产后PFD发生的主要因素.既往研究表明,产后PFD的发生与阴道分娩相关,而剖宫产可预防产后PFD的发生,但是阴道分娩和剖宫产对PFD发生的风险尚存争议.文章分析不同分娩方式对产后盆腔器官脱垂、尿失禁和粪失禁的影响,探讨分娩...     

Unsuccessful trial of labor in women with and without previous cesarean delivery

Objective.?To compare maternal and neonatal outcomes after unsuccessful labor in women with and those without prior cesarean delivery.

Methods.?This was a retrospective cohort study of all women in labor delivered by cesarean section (CS) from November 2004 through December 2006. The study population was dichotomized by previous CS and compared for various maternal and neonatal outcomes. Student t-test, χ² and Fisher exact tests were used for analysis.

Results.?There was a significantly higher rate of symptomatic uterine rupture [3/100 (3%) vs. 0/449 (0%), p?=?0.006], asymptomatic uterine scar dehiscence [6/100 (6%) vs. 0/449 (0%), p?=?0.0001], and bladder injury [2/100 (2%) vs. 0/100 (0%), p?=?0.001], among women with prior cesarean delivery compared to those without. The rate of respiratory distress syndrome [(6/100) (6%) vs. 10/449 (2.2%), p?=?0.05] and meconium aspiration [4/100 (4%) vs. 2/449 (0.4%), p?=?0.01] was also significantly higher among neonates of women with prior cesarean delivery. However, the rate of endomyometritis [3/100 (3%) vs. 50/449 (11.1%), p?=?0.009] and febrile morbidity [17/100 (17%) vs. 144/449 (32.1%), p =?0.003] was significantly lower among women with prior cesarean delivery compared to those without prior cesarean birth.

Conclusions.?Compared to laboring women without previous cesarean delivery, women with previous cesarean delivery have increased maternal and neonatal morbidity. Febrile morbidity was, however, lower among women with previous cesarean delivery. These differential findings should further inform our perinatal counseling of women contemplating trial of labor after a previous cesarean delivery.     

Psychosocial factors and mode of delivery

Childbirth is a substantial physical and emotional endeavor. Because emergency Cesarean and instrumental vaginal delivery impose a greater mortality and physical and emotional morbidity on both the mother and the infant than normal vaginal delivery, it is important to identify factors that are associated with the risk of operative delivery. In previous investigations, some associations have been found, but the effect of psychosocial factors is not clear. In this study we examined several factors which could be associated with the risk for instrumental and surgical delivery. In addition to biomedical factors we included psychosocial factors such as depressive symptoms, quality of the relationship of the woman with her partner, personality, lifestyle and educational level. We assessed 354 healthy nulliparous pregnant women with a child in vertex presentation and spontaneous onset of term labor using validated questionnaires. We found that social support from the woman's partner in pregnancy, lack of depressive symptoms and specific personality traits are not protective against instrumentally assisted vaginal delivery or emergency Cesarean section. Predictive factors for operative delivery after spontaneous onset of labor are higher fetal weight, non-occiput anterior presentation and advanced gestational age, and foremost fetal distress during parturition.     

Mode of delivery for breech presentation in grandmultiparous women.

OBJECTIVES: To compare maternal and neonatal outcomes of planned vaginal delivery vs. elective cesarean delivery for breech presentation at term. METHODS: Retrospective study of term breech deliveries from January 1997 through December 2000. A group of 128 women for whom vaginal delivery was planned was compared with a group of 122 women who had an elective cesarean delivery with regard to neonatal mortality and morbidity (birth trauma, birth asphyxia, hyperbilirubinemia, and duration of stay in the neonatal intensive care unit) and maternal morbidity (infections, hemorrhage, hysterectomy, deep venous thrombosis, and pulmonary embolism). RESULTS: There was no difference in neonatal mortality and morbidity between the two groups (13.0% vs. 9.4%). There were fewer maternal complications in the planned vaginal group than in the elective cesarean group (5.5% vs. 18%; P<0.01). In the planned vaginal delivery group 70% of multiparas and 85% of grandmultiparas were delivered vaginally compared with 50% of nulliparas. CONCLUSIONS: In breech presentations at term vaginal delivery can be achieved in 85% of grandmultiparas without significant neonatal morbidity. Elective cesarean section is associated with increased maternal morbidity compared with planned vaginal delivery.     

阴道助产对剖宫产术后阴道分娩母婴结局的影响

目的探讨阴道助产对于剖宫产术后再次妊娠阴道分娩母婴结局的影响。 方法回顾性分析2014年1月1日至2018年12月31日广东省妇幼保健院收治的剖宫产术后再次妊娠阴道分娩的567例产妇的临床资料,将成功阴道分娩者纳入顺产组475例,将阴道分娩过程中接受助产手术者纳入助产组92例(产钳助产59例、胎头吸引助产33例),比较两组母婴结局和并发症情况,以及不同助产方式母婴结局和并发症情况。 结果(1)助产组高龄产妇29例(31.52%),顺产组89例(18.74%),两组相比差异有统计学意义(χ²＝7.64,P<0.001);助产组住院时间(2.80±0.73)d,顺产组(2.04±0.24)d,差异有统计学意义(t＝-18.13,P<0.001)。(2)助产组产后出血量(316.16±483.67)ml,产后出血率5.43%,顺产组产后出血量(201.38±144.43)ml,产后出血率1.26%,差异有统计学意义(t＝-4.29,P<0.001; χ²＝7.05,P＝0.008);两组其他分娩并发症及新生儿并发症发生率均无统计学差异(P>0.05)。(3)两种助产方式之间相比,产钳组出胎时间(10.36±1.75)min,胎吸引产组出胎时间(12.12±2.36)min,差异有统计学意义(t＝-4.09,P<0.001)。产钳组住院时间为(2.95±0.71)d,胎吸引产组为(2.55±0.71)d,差异有统计学意义(t＝2.63,P＝0.010);两种助产方式分娩并发症及新生儿并发症发生率无统计学差异(P>0.05)。 结论阴道助产可能会增加剖宫产术后再次妊娠阴道试产产妇产后出血的风险,但未增加新生儿并发症的发生风险,产程中应根据母胎情况选择恰当的助产方式。     

Neurodevelopmental outcome of twins at two years of age according to the planned mode of delivery

Objectives: To determine neurodevelopment at two years in twins.

Methods: At two years of age, all twins ≥32 weeks, delivered in our center and not randomized in the Twin Birth Study, underwent a neurodevelopment screen using the Ages and Stages Questionnaire (ASQ). Children with ≥1 abnormal ASQ domain score were evaluated by a pediatrician. Results were documented according to a planned cesarean section (PCS) or a planned vaginal delivery (PVD).

Results: An ASQ was obtained from 185 children (67%). No significant differences in percentages of abnormal scores were found between the PCS group and the PVD group or between twins A and B. Pediatric assessment revealed three children with a neurodevelopmental delay. Five other children were already under pediatric or general practitioner care for other reasons. One child with a congenital anomaly was born by a PCS, two twins A and five twins B were born in the PVD group.

Conclusion: ASQ screening revealed no significant differences in abnormal neurodevelopment in twins at two years of age according to the mode of delivery. Pediatric assessment suggested an increased incidence for abnormal neurodevelopment in twins B born by PVD.     

Ultrasound examination at term for predicting the outcome of delivery in women with a previous cesarean section

Objective: To evaluate if ultrasound variables at term are associated with the mode of delivery in women with previous cesarean section (PCS).

Methods: This was a prospective study of singleton pregnant women who planned a trial of vaginal birth after cesarean delivery. Cervical length, posterior cervical angle, head–perineum distance, and estimated fetal weight were measured at 37–39 weeks of gestation.

Results: One hundred forty-four pregnancies were examined and vaginal delivery was achieved in 98 women (73%). Logistic regression analysis identified cervical length, head–perineum distance, age, previous vaginal delivery, previous cesarean for dystocia, and Bishop score as predictors of vaginal delivery. Combining ultrasound and clinical parameters, two models for risk scoring that differ in the variable Bishop score or cervical length were constructed. The AUC of these models was 0.867 and 0.855, respectively.

Conclusions: In women with a PCS, measurement of cervical length and head–perineum distance at term is associated with the mode of delivery. A combination of clinical and sonographic parameters at term can predict the likelihood of vaginal delivery.     

提高阴道分娩安全性有效降低剖宫产率

<正>剖宫产术是处理妊娠并发症和合并症、解决难产和围生儿宫内窒息的重要手段,在降低孕产妇和围生儿死亡率方面起到重要作用。20世纪70年代开始,胎儿电子监护和超声影像学的应用,围生医学的兴起,进一步扩大了剖宫产的指征,至80年代,剖宫产率上升到10%～15%。这一     

妊娠合并心脏病妊娠风险及分娩方式评估

妊娠合并心脏病是导致孕产妇死亡发生的重要原因之一,此类患者妊娠前及围产期的评估管理对降低孕产妇死亡率、改善母儿预后有重要作用。文章就目前国内外妊娠合并心脏病妊娠风险评估及分娩方式选择做一总结,为广大临床工作者对妊娠合并心脏的诊疗及管理提供参考。     

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study

Objective  To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section.
Main outcome measures  The evolution of decision making, women's participation in decision making, and factors affecting decision making.
Design and methods  A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective.
Setting  An antenatal unit in a large teaching hospital in Scotland and participants' homes.
Sample  Twenty-six women who had previously had a caesarean section for a nonrecurrent cause.
Results  Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section.
Conclusion  Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.     

Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy: a review of the data

Uterine rupture is an obstetrical emergency that can be catastrophic for the mother and fetus. Previous uterine surgery, including previous cesarean delivery or myomectomy, is an established risk factor, although the exact magnitude of the associated risk remains uncertain. We reviewed the literature related to uterine rupture after previous cesarean delivery with classical incision or myomectomy in an attempt to quantify outcomes associated with various management strategies. Although cesarean delivery with a classical incision is relatively uncommon (representing 0.3%-0.4% of deliveries), it presents a significant risk of rupture in subsequent pregnancies (1%-12% on the basis of published reports). Available data suggest that scheduled cesarean at 36-37 weeks optimizes both maternal and fetal outcomes in these cases. Patients with previous myomectomy are more frequently encountered in the obstetrical population. The risk of uterine rupture in subsequent pregnancies in these women is substantially lower than those with a history of previous classical incision (0.5%-0.7% on the basis of published reports). Although less common, given the potentially devastating consequences of uterine rupture, scheduled delivery at 38 weeks is suggested in those women requiring cesarean delivery. Despite the lack of well-controlled studies, preferred management strategies can be gleaned from previously published data to optimize maternal and fetal outcomes in women with these risk factors.