Obstetrician gender and the likelihood of performing a maternal request for a cesarean delivery

OBJECTIVE: To examine the relationship between obstetrician gender and the likelihood of maternal request for cesarean section (CS) within different healthcare institutions (medical centers, regional hospitals, district hospitals, and obstetric and gynecology clinics). STUDY DESIGN: Five years of population-based data from Taiwan covering 857,920 singleton deliveries without a clinical indication for a CS were subjected to a multiple logistic regression to examine the association between obstetrician gender and the likelihood of maternal request for a CS. RESULTS: After adjusting for physician and institutional characteristics, it was found that male obstetricians were more likely to perform a requested CS than female obstetricians in district hospitals (OR=1.53) and clinics (OR=2.26), while obstetrician gender had no discernible associations with the likelihood of a CS upon maternal request in medical centers and regional hospitals. CONCLUSIONS: While obstetrician gender had the greatest association with delivery mode decisions in the lowest obstetric care units, those associations were diluted in higher-level healthcare institutions.     

Maternal age and the likelihood of a maternal request for cesarean delivery: a 5-year population-based study

OBJECTIVE: The purpose of this study was to examine associations between maternal age and maternal request cesarean deliveries. STUDY DESIGN: Five-year population-based data from Taiwan (1997-2001) that covered 904,657 singleton deliveries without a clinical indication for cesarean delivery that were judged by the attending physician were subjected to multiple logistic regression, year-wise, to examine the association of maternal age with request cesarean delivery, adjusted for health care institutional characteristics. RESULTS: Request cesarean delivery rates steadily increased over the study period within each age group, disproportionately so among the 34+ age group. Women aged < 25 years were less likely than women aged 25 to 34 years (reference group) to request a cesarean delivery (odds ratio range, 0.67-0.88) and women aged 34+ were more likely than the reference group to have a request cesarean delivery (odds ratio range, 1.96-2.01), adjusted for health care institutional characteristics. CONCLUSION: Population-based data confirms the expectancy that request cesarean delivery propensity increases with maternal age.     

Women's attitudes regarding mode of delivery and cesarean delivery on maternal request

Objective.?To explore women's attitudes and beliefs regarding cesarean delivery and cesarean delivery on maternal request (CDMR).

Study design.?Anonymous questionnaires assessing patient demographics, knowledge, and attitudes about CDMR were distributed at the time of routine mid-trimester ultrasound appointment.

Results.?Eight hundred thirty three out of 3929 (21.2%) potential participants completed the questionnaire. About 81.7% of participants indicated that they believed that vaginal delivery was a safer alternative for the mother and 72.8% believed that it was safer for the fetus. While only 6.1% of women thought that CDMR was ‘a good idea’, most believed that women should have the right to choose their mode of delivery and that the option should be offered to everyone (85.9% and 79.6%, respectively). Socioeconomic and demographic variables did not significantly influence the participants' responses.

Conclusion.?Majority of women believe that vaginal delivery is safer for the mother and baby and would prefer to have a vaginal delivery if given the option.     

Women's opinions and experiences with induction of labor and cesarean delivery on request in south eastern Nigeria

Objective

To assess the opinions and experiences of women regarding induction of labor and cesarean delivery on request in south eastern Nigeria.

Method

Women were interviewed using questionnaires on their awareness of their right to request labor induction and/or a cesarean delivery, and of their experience and opinion of the procedures.

Results

Of the 15.1% of the respondents who knew they could request a cesarean delivery, 2.4% had requested one; and of the 56.3% who knew they could request labor induction, 6.9% had requested one. Only 5.3% and 11.3% of the respondents who would chose the former or the latter procedure, respectively, said that they would insist on receiving it. Fear of their physicians' negative attitude regarding the procedures, and/or abandonment of care, ranked highest among their reasons for not insisting.

Conclusion

In south eastern Nigeria few women are aware of their right to a cesarean delivery on request and the rate of refusal to perform such deliveries is high among physicians; more women are aware of their right to receive induction of labor on request and the acceptance rate is higher among physicians; and most women are unwilling to insist that their physician respect their choice.     

Urbanization and the likelihood of a cesarean section

Objective

This study examines the association between the likelihood of cesarean section (CS) and the degree of urbanization in Taiwan, exploring possible explanations for the difference.

Study design

The database used in this study was the Taiwan 2004 National Health Insurance Research Database. A total of 200,207 singleton deliveries fulfilled our criteria and were included in our study. The urbanization level of cities/towns where parturients resided at the time of delivery was stratified into seven categories. A multilevel logistic regression model was applied to examine the relative likelihood of CS by urbanization level after adjusting for parturient, physician and hospital characteristics.

Results

There was an upward trend in the CS rate with advancing urbanization level; the CS rates for urbanization level 1 (most urbanized) through 7 (least urbanized) were 33.7, 32.3, 30.4, 30.2 29.7, 29.5, and 28.6%, respectively. Compared with participants living at the highest urbanization level, the adjusted odds of a CS were 0.91 (95% CI = 0.85–0.98, p = 0.014), 0.84 (95% CI = 0.78–0.91, p < 0.001), 0.83 (95% CI = 0.68–0.88, p < 0.001), 0.79 (95% CI = 0.72–0.86, p < 0.001), and 0.70 (95% CI = 0.62–0.80, p < 0.001) times, respectively, for those living in cities/towns ranked from the third highest to the lowest levels of urbanization.

Conclusions

We conclude that higher urbanization levels were associated with higher odds of CS. Highly urbanized communities could therefore be targeted for policy intervention aimed at reducing the unnecessary CS rate.     

Emergent primary cesarean delivery and maternal operative morbidity

Background: It is unknown how variations in surgical entry time in primary cesarean delivery (CD) may affect operative outcomes and maternal morbidity.

Objective: Determine whether performing a primary CD in labor emergently (“stat”) is associated with adverse maternal outcomes.

Study design: Retrospective cohort study of patients who underwent primary CD at The Mount Sinai Hospital during the years of 2011–2016. Women with a singleton pregnancy and without a prior uterine scar attempting a trial of labor were included. An emergent CD was defined as a skin-to-uterine incision (I-U) time of ≤3 minutes. Subjects were dichotomized into those with an I-U time of ≤3 minutes or ≥5 minutes.

Results: 1722 patients underwent primary CD and met eligibility criteria. 72 patients with an I-U time of 4 minutes were removed from the analysis. 196 patients (11.9%) had an I-U time ≤3 minutes and 1454 patients (88.1%) had an I-U time ≥5 minutes. There were no differences in any outcomes between groups. The likelihood of transfusion, hysterectomy, or admission to the intensive care unit (ICU) was 1.5% in the emergent group and 1.0% in the control group (p?=?.334). Postpartum length of stay was also similar between the groups (3.3 versus 3.2 days, p?=?.259). When 384 patients with I-U times >10 minutes were excluded, surgical outcomes remained similar between groups. Among the subgroup of patients who reached the second stage of labor, surgical outcomes were also similar between groups.

Conclusions: Emergent primary CD is not associated with increased maternal morbidity.     

Maternal request cesarean versus planned spontaneous vaginal delivery: maternal morbidity and short term outcomes

Since no randomized trial evaluates maternal morbidity from planned cesarean versus planned vaginal delivery, the issue must be addressed indirectly from retrospective cohort studies of vertex fetuses by actual or planned delivery route, and retrospective or randomized studies of breech fetuses by planned delivery route. The available data, although limited, suggest that term planned cesarean and planned vaginal delivery have similarly low rates of absolute and relative short-term maternal morbidity. Endometritis and cystitis are more frequent with cesarean, whereas hemorrhage is more frequent with planned vaginal delivery. Much of the morbidity of planned vaginal delivery is the morbidity of unplanned cesarean in labor and operative vaginal delivery, particularly forceps. Thus, the relative risk of short-term maternal morbidity of planned cesarean versus planned vaginal delivery will depend on the proportion of women in each group ultimately delivering in the planned manner and the frequency with which delivery occurs by an alternative unplanned method.     

Comparing grades of urgency for classification of cesarean delivery

Objective

To evaluate the agreement between the traditional binary system and a new system for classifying urgency of cesarean delivery among obstetricians in The Netherlands and Belgium.

Methods

A total of 212 obstetricians were requested to grade a list of 18 obstetric scenarios using 3 classification systems: traditional binary classification; a new classification using 4 grades of urgency without additional interpretation; and the new classification with additional interpretation. Agreement was assessed by weighted kappa.

Results

Seventy-nine obstetricians responded (The Netherlands 62.2%, Belgium 9.9%). There was substantial agreement among them for all 3 classification systems (κ = 0.71, traditional classification; κ = 0.70, new classification; κ = 0.67, new classification with additional interpretation).

Conclusion

The traditional binary system and the new classification of cesarean delivery based on 4 grades of urgency, with and without additional interpretation, have similar but relatively low interobserver agreement. We suggest that the new classification should be used, but future studies are necessary to evaluate the effect of this implementation.     

A predictive model for cesarean section in low risk pregnancies.

OBJECTIVE: A small number of women with low risk pregnancies undergo cesarean section. A model that can predict this risk and therefore identify these women will be of help in several hospitals where personnel and resources are limited. METHODS: The study consisted of 2 parts. All charts of women with low risk singleton pregnancies admitted to labor room over a 5-month period were analyzed. Adjusted odds ratios were calculated to find out relative importance of each risk factor and likelihood ratios were obtained. These were prospectively applied to 1010 consecutive low risk women and the post test probability calculated. Finally the actual incidence of cesarean section was compared with posttest probability derived from predictors. RESULTS: A combination of maternal age >24 years, primiparity and height <150 cm or a combination of any 2 of the 3 variables is significantly associated with increased cesarean section rate. Individually, primiparity, height <150 cm or age >24 years also significantly increased the chances of cesarean section. CONCLUSIONS: A predictive model consisting of maternal age, parity and height can be used to identify low risk pregnant women who are likely to require cesarean section.     

Maternal obesity and rate of cesarean delivery in Djibouti

Objective

To calculate the prevalence of maternal obesity and to determine the relation between obesity and cesarean delivery in an urban hospital in Djibouti.

Methods

In an observational cohort study, all women who had a live birth or stillbirth between October 2012 and November 2013 were considered for inclusion. Body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was calculated throughout pregnancy, and women with a BMI of at least 30.0 were deemed to be obese. Multivariate logistic regression analyses were used to evaluate the relation between cesarean and obesity.

Results

Overall, 100 (24.8%) of 404 women were obese before 14 weeks of pregnancy, as were 112 (25.2%) of 445 before 22 weeks, and 200 (43.2%) of 463 at delivery. Obesity before 22 weeks was associated with a 127% excess risk of cesarean delivery (adjusted odds ratio 2.27; 95% CI 1.07–4.82; P = 0.032). Similar trends were found when the analyses were limited to the subgroup of women without a previous cesarean delivery or primiparae.

Conclusion

Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables.     

Increased maternal morbidity after cesarean delivery before 28 weeks of gestation

To test the hypothesis that there is increased maternal morbidity associated with cesarean section at very early gestational ages compared to cesarean section at term, a case-control study was performed. Eighty consecutive cases of cesarean section before 28 weeks of gestation were chronologically matched to 80 controls with cesareans at term. Compared to term controls, preterm cases were more frequently complicated by postpartum endomyometritis (32% vs. 9%, P < 0.001) and blood transfusion (14% vs. 1%, P < 0.01), resulting in a significantly longer postpartum stay and longer duration of antibiotic use. One or more major complications occurred in 45% of preterm cases versus 14% of controls (P < 0.001); two major complications occurred in 11% of cases versus 1% of controls (P < 0.05). Some, but not all, of the higher risk for postpartum complications was attributable to pre-existing differences in risk factors for infection and hemorrhage between the two groups. We conclude that cesarean section before 28 weeks of gestation is associated with a high risk of postoperative complications and that patients should be counseled accordingly     

Patient satisfaction with the prenatal care provider and the risk of cesarean delivery

OBJECTIVES: This study was undertaken to assess the relationship between patient satisfaction with the prenatal care provider and a gravid woman's risk of cesarean delivery. STUDY DESIGN: Medical records of 586 consecutive deliveries in a single obstetrics department were reviewed. The delivery mode was correlated to the providers' overall patient satisfaction score as measured by an ongoing mail survey. Mann-Whitney U tests and 2-tailed t tests were used. RESULTS: On the basis of the prenatal provider, not the delivering physician, the cesarean section delivery rates fell into 3 groups: low rate, average rate, and high rate. There is a significant difference in both the cesarean delivery rate and the patient satisfaction survey scores between the prenatal providers in the high- and low-rate groups. CONCLUSION: Higher patient satisfaction scores is correlated with a lower cesarean delivery rate.     

Cesarean section for non-medical reasons.

Cesarean section without medical indication is cited as a factor in the increase in the rate of cesarean delivery in modern obstetric practice. Individual obstetricians often express strong views supporting or refuting the right of women to request operative delivery and their rights to decline or fulfill this request. Such strong opinions may be misplaced as the available evidence does not conclusively support either view-point.     

The influence of obesity and diabetes on the risk of cesarean delivery

OBJECTIVE: To determine the influence of pregravid obesity and diabetes on cesarean delivery (CD) risk. STUDY DESIGN: Women with singleton pregnancies of 23 weeks or more estimated gestational age who were undergoing a trial of labor January 1997 through June 2001 were categorized by pregravid body mass index (underweight [<19.8 kg/m 2 ], normal [19.8-25 kg/m 2 ], overweight [25.1-30 kg/m2], obese [>30 kg/m2]). Diabetes (DM) was divided into categories of gestational, treated with diet modification (A1GDM) or insulin (A2GDM), and pregestational (PDM). Prior CDs were excluded. CD rates for each group were compared in univariate analyses stratified by estimated gestational age (term, preterm, total). Other variables examined included DM, macrosomia (birth weight 4500 g or more), induction, and parity. Multiple regression included significant variables to predict the influence of diabetes and obesity on CD risk. RESULTS: Records for 12,303 deliveries were evaluated (obese: 2828 [22.9%]; overweight: 2605 [21.2%]; A1GDM: 270 [2.2%]; A2GDM: 93 [0.8%]; PDM: 126 [1%]). Obese and overweight subjects had a higher risk for CD, compared with normal subjects (13.8% and 10.4% versus 7.7%, P < .0001 for each). Other CD risk factors were macrosomia (25% versus 9.4%), nulliparity (16.5% versus 4.7%), induction (17.4% versus 8.3%), diabetes (A1GDM: 16.7% versus 9.4%; A2GDM: 24.7% versus 9.5%; PDM: 34.9% versus 9.3%) and black race (10.7% versus 8.8%) ( P < .0001 for each). In multiple regression models including term deliveries, obesity and PDM were independent CD risk factors ([adjusted OR overweight: 1.5, P < .0001; adjusted OR PDM: 2.9, P = .01]; [adjusted OR obese: 2.4, P < .0001, PDM: 2.9, P = .0002]). CONCLUSION: Pregravid obesity and diabetes independently increase the risk for CD. Given the disparate prevalence of obesity and diabetes in the United States, body habitus has a significantly larger impact on CD risk.     

Population-based trends and correlates of maternal overweight and obesity, Utah 1991-2001

OBJECTIVE: This study aims to identify recent population-based trends in maternal overweight and obesity and adverse outcomes. STUDY DESIGN: Statewide retrospective cohort study of birth certificate data for live singleton births to women in Utah between 1991 and 2001. RESULTS: Prepregnancy overweight and obesity increased from 25.1% in 1991 to 35.2% in 2001, a 40.2% increase (prevalence ratio [PR] 1.40 [1.37-1.43]), whereas maternal obesity at delivery rose 36.2% from 28.7% to 39.1% (PR 1.36 [1.33-1.39]). The attributable fraction of cesarean delivery in overweight and obese women was 0.388 (0.369-0.407). Statewide, among all women having a cesarean delivery in 2001, 1 in 7 is attributable to overweight and obesity. CONCLUSION: This is the first state-wide analysis of maternal obesity trends demonstrating a significant increase in maternal overweight and obesity. Overweight and obese women are at increased risk of cesarean delivery, preeclampsia, eclampsia, dystocia, and macrosomia, risks that increase as the body mass index rises.     

Self-inflicted cesarean section with maternal and fetal survival.

An unusual case of self-inflicted cesarean section with maternal and child survival is presented. No similar event was found in an Internet literature search. Because of a lack of medical assistance and a history of fetal death in utero, a 40-year-old multiparous woman unable to deliver herself alone vaginally sliced her abdomen and uterus and delivered her child. She was transferred to a hospital where she underwent repair of the incisions and had to remain hospitalized. Mother and child survived the event. Unusual and extraordinary measures to preserve their offspring sometimes moves women to extreme decisions endangering their own lives. Social, educational, and health measures should be instituted all over the world, particularly in rural areas of developing countries, to avoid such extreme events.     

膀胱腹膜界线测量在膀胱翻转法剖宫产中的应用

目的　为腹膜外剖宫产提供基础研究数据,并为推广膀胱翻转法剖宫产提供临床应用资料。方法　测量１０７ 例剖宫产孕妇膀胱顶与反折腹膜缘的位置和体表投影。结果　膀胱顶至脐和至耻骨联合上缘中点间距分别为（１４ ．１ ±３ ．４）ｃｍ 和（６ ．８ ±１ ．４）ｃｍ ; 反折腹膜缘至脐和至耻骨联合上缘中点间距分别为（１５ ．８ ±３ ．９）ｃｍ 和（４ ．９ ±１ ．５）ｃｍ 。妊娠晚期膀胱顶的体表投影位于脐耻连线的中下１／３ 处,子宫膀胱反折腹膜缘体表投影位于脐耻连线的上３／４ 与下１／４ 交界处。膀胱翻转法腹膜外剖宫产从皮肤切开至胎儿娩出时间为（１４ ．６ ±６ ．３） 分钟,手术时间为（４５ ．５ ±９ ．３） 分钟,娩出最大胎儿５ ０５０ｇ ,无一例膀胱损伤。结论　膀胱腹膜界线体表投影的确定,可明显缩短手术时间;膀胱翻转法是腹膜外剖宫产减少副损伤的一种较理想的方法。