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.     

Prediction of successful trial of labor after cesarean – the benefit of prior vaginal delivery

Objective: To determine predictive factors for vaginal birth after cesarean section (VBAC).

Methods: A retrospective cohort study of all women with singleton pregnancies and a prior single low transverse cesarean section (CS) who attempted vaginal delivery in a tertiary hospital (2010–2014). Pregnancy outcome of women with VBAC was compared to those who failed vaginal delivery. Sub-analysis for women with no prior vaginal deliveries was performed. Pregnancies with non-cephalic presentation, estimated fetal weight?>4000 g and any contraindications for vaginal delivery were excluded.

Results: Of the 40 714 deliveries, 1767 women met inclusion criteria. Among them 1563 (88.5%) had a VBAC and 204 (11.5%) failed. There was no significant difference between the groups regarding maternal age, comorbidities and pregnancy complications. Predictors for VBAC were (odds ratio, 95% confidence interval) interval from prior CS (1.13, 1.04–1.22, p=0.004), previous VBAC (2.77, 1.60–4.78, p?<?0.001), prior vaginal delivery prior to the CS (3.05, 1.73–5.39, p?<?0.001) and induction of labor (0.62, 0.40–0.97, p?=?0.03). For women with no prior vaginal birth, only birthweight was associated with VBAC (0.99, 0.99–1.00, p?=?0.02).

Conclusion: While different variables may influence the rate of VBAC, the predictive ability of VBAC for women with no previous vaginal deliveries remains poor.     

Quality of normal delivery care in Côte d'Ivoire

The aim of this study was to assess the quality of normal delivery care in C?te d'Ivoire. A total of 229 women were included in a cross-sectional study conducted in four urban maternity wards between 2002 and 2003. Observation checklists and exit-interviews were used to examine various dimensions of care. The results showed that the overall quality of care was poor, despite most women giving birth with a professional midwife. A vaginal examination was performed systematically at admission but blood pressure was measured in less than half of the women. The partograph was completed during labour in only 5% of cases. Episiotomy and uterine revision rates were high at 24% and 32%, respectively. There was a lack of universal hygiene precautions and women received little support during labour. Our results question the quality of labour, delivery and postpartum care by skilled attendants in C?te d'Ivoire.     

Is a cause of postpartum hemorrhage of using of tocolytic agents in preterm delivery?

Objective: Tocolytic agents are used to inhibit uterine contraction in preterm. The authors undertook this study to determine whether using of tocolytic agents before delivery is associated with increase postpartum hemorrhage in preterm delivered women.

Method: 296 singleton pregnancies delivered preterm from 24?+?1 to 37?+?0 weeks gestation were retrospectively reviewed. Hemoglobin (HB) and hematocrit (HCT) levels were checked before and after delivery to access postpartum blood loss. Multivariate logistic regression analysis was performed to determine whether delivery within the half-lives of tocolytic agents was associated with decreased HB and HCT levels.

Results: After adjusting for maternal age, parity, gestational age at delivery, birth weight, delivery method, and induction of labor, postpartum HB and HCT levels of those delivered within half-lives of tocolytic agents were found to be significantly diminished (HB: OR 3.306, 1.308–8.356 95% CI, p?=?0.011; HCT: OR 2.692, 1.077–6.726 95% CI, p?=?0.034). In addition, blood transfusion rates were elevated for deliveries made within the half-lives of tocolytic agents, (p?=?0.006).

Conclusions: Delivery within half-lives of tocolytic agents was found to be associated with low HB and HCT levels after delivery and higher blood transfusion rates in preterm delivered women.     

How well do midwives estimate the date of delivery?

OBJECTIVE: to compare expected date of delivery (EDD) and gestational age (GA) obtained by midwives with those calculated using the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI) recommended formula. DESIGN: retrospective study of obstetric records and prospective study of clinical cases examined by multiple midwives. SETTING: postnatal wards, Maternity Unit, Plymouth, Devon, UK. PARTICIPANTS: two studies were performed.The first was a retrospective analysis of 115 sets of obstetric records. The second, a prospective study which included five clinical cases and 19 qualified midwives whose experience ranged from six months to 25 years. FINDINGS: in the retrospective study, 68 (59%) of the 115 obstetric case notes had sufficient information to apply the CESDI formula. The midwives'calculated EDD was interpreted to a GA and 35 (52.5%) agreed to within three days of the GA derived from the CESDI formula EDD. In the prospective study, the midwives' calculation of EDD was in good agreement with the CESDI formula in cases where last menstrual period (LMP) was known and menstrual cycle was 28 days with 17 (90%) of the 19 midwives providing the EDD to within three days of the CESDI formula. In the clinical case where LMP was known but menstrual cycle length was 33 days only two (10%) of the 19 calculated the EDD within three days of the CESDI formula. KEY CONCLUSIONS: when LMP is known and the cycle length is 28 days, midwives produce results consistent with the CESDI formula. However, when the menstrual cycle differs from 28 days or LMP is unknown, inaccurate or ambiguous and obstetric ultrasound scan (USS) information is used to calculate the EDD, the midwives show varying degrees of departure from the CESDI formula. Further, we found that the midwives tended to produce underestimates when calculating GA from EDD. This bias occurs across the range of gestations covered, including early gestations when such biases may have more important medical implications. IMPLICATIONS FOR PRACTICE: midwives' calculation of EDD and estimation of GA showed both random and systematic errors; in some cases, the errors were so large that they may have important medical consequences. If the CESDI-recommended formula for calculating EDD were used there would be improved accuracy and reliability of EDD and the calculation of GA.     

Impact of amniotic fluid “sludge” on the risk of preterm delivery

Objective: To evaluate the impact of amniotic fluid “sludge” (AFS) on the risk of preterm delivery and to describe the effect of antibiotic treatment in that situation.

Methods: Case–control study including singleton pregnancies with or without AFS, between 15–32 weeks of gestation. Factors associated with preterm delivery before 32 weeks, 34 weeks and 37 weeks were evaluated with univariate and multivariate logistic regression. Since all women with AFS in this study were treated with antibiotics, a historical comparison was performed with similar patients with AFS found before 2007 and not treated with antibiotics.

Results: AFS was observed in 90/1220 patients (7.4%). AFS was associated with shorter cervical length, greater body mass index, cervical cerclage and preterm birth before 28 weeks. However, after adjustment, AFS did not remain associated with preterm delivery before 32 or 34 weeks. The historical comparison suggested that azithromycin could significantly reduce the risk of preterm delivery before 34 weeks (odds ratio: 0.2; 95% CI: 0.04–0.92).

Conclusions: AFS, treated with azithromycin, was associated with a higher risk of prematurity, but not independently after adjustment for cervical length and second trimester vaginal bleeding. Further studies need to evaluate the effect of antibiotics in pregnancies with AFS.     

Vaginal delivery for fetuses at risk of alloimmune thrombocytopenia?

OBJECTIVES: To evaluate the safety of vaginal delivery in pregnancies with fetal and neonatal alloimmune thrombocytopenia (FNAIT). DESIGN: Prospective data collection. SETTING: Leiden University Medical Centre, the national centre for management of severe red cell and platelet alloimmunisation. POPULATION: Thirty-two pregnancies with FNAIT, with a sibling with thrombocytopenia but without an intracranial haemorrhage (ICH). METHODS: The mode of delivery, platelet count in cord blood and neonatal outcome were analysed. All women received weekly intravenous immunoglobulin from 32 to 38 weeks of gestation. Head ultrasound scan was performed in all neonates. MAIN OUTCOME MEASURES: Signs of ICH or other bleeding in the neonates. RESULTS: Twenty-three women delivered vaginally. Nine caesarean sections were performed, all for obstetric reasons. Median platelet count at birth was 142 x 10(9)/l (range, 4-252 x 10(9)/l), with severe thrombocytopenia (<50 x10(9)/l) in four neonates, of which three were born vaginally. None of the neonates showed signs of ICH or other bleeding. CONCLUSIONS: In pregnancies with FNAIT and a thrombocytopenic sibling without ICH, vaginal delivery was not associated with neonatal intracranial bleeding. These initial results support our noninvasive management of these pregnancies with FNAIT.     

Does mode of delivery affect neonate oxidative stress in parturition? Review of literature

Purpose

The production of reactive oxygen substances plays an important regulatory role in many physiologic reproductive processes. Excessive production may lead to oxidative stress (OS), and bring about pregnancy disorders. Growing evidence indicates that OS plays a major role in the pathophysiology of complications such as early pregnancy loss, placental insufficiency, preeclampsia, fetal growth restriction, and neonatal complications. Whether parturition induces oxidative stress is in dispute. In this review, we elaborate the influence of mode of delivery (vaginal delivery or cesarean delivery) on oxidative stress of neonates.

Methods

A review of old and recent literature was done. The studies were divided according to the impact of mode of delivery on oxidative stress in the newborn.

Results

There is a divergence in the oxidative stress production according to the mode of delivery.

Conclusions

In view of neonatal oxidative stress measures, no major difference was found between uncomplicated vaginal delivery and elective cesarean section.     

Biopsychosocial predictors of preterm labor and preterm delivery? Results of a prospective study

RESEARCH QUESTION: In addition to medical, job related, sociodemographic risk factors, and health related behavior, topics that traditionally have been less in the focus of attention in this context, such as biographic data, coping with stress, personality variables, pregnancy related attitudes, fears, and the social network were examined. PATIENTS AND METHODS: 589 women between 16(th) and 22(nd) week of pregnancy were examined using a questionnaire that was designed for the study. This resulted in 508 women pregnant with a single child, whose pregnancy and delivery were examined based on their medical records. Factor analysis and main component analysis with subsequent varimax rotation resulted in factors that were subject to a proof of reliability. Statistical analysis was based on logistic regression. RESULTS: 129 (27.7%) of women displayed signs/indices of an imminent preterm delivery, 29% (5.8%) of whom later actually had a preterm delivery before the end of the 37(th) week of pregnancy. Pregnant women who were in treatment for an imminent preterm delivery appear to have been subject to higher social stress as compared to those, who later later actually gave birth before completing the 37(th) week of pregnancy. Lack of a female network and lack of emotional understanding from the partner are correlated to both of these complications. Specifically, actual preterm delivery appears to be significantly influenced by partner relationship. Another significant predicting variable for imminent and actual preterm delivery appears to be a history of gynecological problems. A distinct risk factor for delivery before completion of the 37(th) week of pregnancy was a history of colpitis. In addition, pronounced anxieties in respect to the pregnancy, and low general anxiety were significant predicting variables for delivery before completion of the 37(th) week of pregnancy. CONCLUSIONS: Partner relationship, female networks, psychosomatic reactivity in terms of diseases/disorders of the reproductive organs, and anxieties appear to be worthwhile targets in the prevention of preterm delivery.     

The influence of planned kinds of delivery on pregnant women’s emotional state

Objective: To evaluate if labour induction and elective caesarean section could influence anxiety and depression in pregnant women. Methods: One hundred and sixteen consecutive pregnant women with uncomplicated singleton pregnancy at term, scheduled for these two obstetric procedures were enrolled. An anonymous questionnaire with two self-rating instruments STAI and HAM-A for anxiety and HAM-D for depression was administered. Results: Anxiety levels did not show significant differences while a light depressive mood was evidenced among pregnant women waiting for labour induction (p?=?0.01). Conclusions: An adequate psychological support could be considered a helpful tool for pregnant women scheduled for labour induction.     

Does a second delivery increase the risk of anal incontinence?

Objective To evaluate the prevalence of anal incontinence and anal sphincter defects after a first vaginal delivery and assess the effect of a second delivery.
Design Prospective cohort study using postal questionnaires assessing incontinence to flatus and stools at three and thirty months postnatally and anal endosonography at three months following delivery.
Setting Recruitment was from the antenatal clinic at the University Hospitals of Geneva, Switzerland.
Population One hundred women with a vaginal delivery of their first child.
Main outcome measures Prevalence of anal incontinence and anal sphincter defects.
Results Anal incontinence was reported by 16/92 (17%) of women at three months after delivery and by 11/77 (14%) at 30 months. At that time, 5/54 (9%) with no further delivery reported incontinence, compared with 6/23 (26%) of those who had had another delivery (RR 2.8, 95% CI 1.0-8.3). Anal sphincter defects were diagnosed by endosonography in 46/87 (53%) women and were associated with reported incontinence at both three months (RR 1.9; 95% CI 1.4-2.6) and 30 months (RR 1.9; 95% CI 1.3-2.8) after delivery. The prevalence of anal incontinence at 30 months was highest (5/13, 39%) among those in whom a sphincter defect was diagnosed by endosonography after their first delivery and with a second delivery.
Conclusion Anal incontinence after childbirth is associated with defects of the anal sphincter diagnosed by endosonography. Subsequent deliveries increase the risk of incontinence, particularly among women with a sphincter defect diagnosed after the first delivery.