Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

BACKGROUND: The issues related to safety of induction of labour in women with previous caesarean section remain controversial. The main adverse outcome fuelling this debate is a "small" risk of uterine rupture that is potentially devastating for both the mother and the fetus. OBJECTIVE: To estimate the risk of uterine rupture or dehiscence in women who require induction of labour with previous caesarean sections. DESIGN: Five year retrospective review of computerised hospital records and case note review of index cases. SETTING: Large inner city teaching hospital. POPULATION: Two hundred and five women who had their labour induced with history of one lower segment caesarean section. METHODS: This study was conducted at Liverpool Women's Hospital, a tertiary referral centre, with approximately 6000 births per annum. We searched the hospital's computerised records of deliveries from June 1997 to June 2002 and reviewed all indications and outcomes of induction of labour in women with one previous caesarean section. Women with singleton pregnancy and cephalic presentation were then divided into three groups: those with one previous caesarean section and no previous vaginal deliveries, those whose last delivery was a caesarean section but had delivered vaginally before and those whose last delivery was by vaginal route, but had had one caesarean section in the past. MAIN OUTCOME MEASURES: Uterine rupture or dehiscence, adverse neonatal outcome. RESULTS: Two hundred and five women were included. There were four cases of uterine rupture and one dehiscence (2.4%, 95% CI 0.8-5.6%). Two babies were profoundly acidotic at birth, but all five neonates were healthy when discharged from hospital with no long term morbidity. All five cases occurred in the group of women with no previous vaginal deliveries. The intrauterine pressure catheter recordings had contributed to the diagnosis of uterine rupture/dehiscence in three out of five cases. CONCLUSION: In women with previous caesarean section and no vaginal deliveries, induction of labour carries a relatively high risk of uterine rupture/dehiscence despite all precautions, including intrauterine pressure monitoring.     

Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation to maternal body mass index

Objective

To assess whether non-elective caesarean section due to obstructed labour and/or ineffective uterine contractility was associated with maternal body mass index (BMI).

Study design

The prospective dataset from the Swedish Medical Birth Registry consisted of 233,887 nulliparous women with a spontaneous onset of labour categorized in six classes of pre-pregnancy BMI, who delivered in Sweden between, January 1, 1999 and December 31, 2005. The mode of delivery was classified as either vaginal or by caesarean section. The caesarean section was classified as either elective or non-elective. Adjusted risks for non-elective caesarean section due to ineffective uterine contractility, or obstructed labour or fetal distress were determined using Mantel–Haenszel technique.

Results

The risk of a non-elective caesarean section due to obstructed labour was not significantly associated with maternal BMI. However, ineffective uterine contractility was significantly associated with maternal BMI and the risk of non-elective caesarean delivery due to labour arrest disorders increased with increasing BMI, reaching a 4-fold increased risk among the morbidly obese women. The risk of non-elective caesarean section due to fetal distress also increased significantly with increasing maternal BMI.

Conclusions

It appears that ineffective labour could be a factor leading to the increased risk of non-elective caesarean section among obese and morbidly obese women. These findings challenge obstetricians to learn more about how to manage oxytocin infusions during labour in relation to maternal BMI.     

Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section

OBJECTIVE: Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. DESIGN: Cohort study. SETTING: University Hospital. POPULATION: All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n = 1011). METHODS: Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. MAIN OUTCOME MEASURE: Incidence of uterine rupture. RESULTS: Uterine rupture occurred in 0.3% in the previous caesarean section--induction group versus 0.3% in the previous caesarean section--spontaneous labour group (P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. CONCLUSION: Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.     

Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services

Obesity represents a rapidly emerging epidemic amongst pregnant women. Our study looks at the impact of morbid obesity on pregnant singleton nulliparous women in comparison with normal body mass index women. We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. We also found no significant difference in length of hospital stay, postnatal complications and neonatal morbidity.     

Elective induction of labour increases caesarean section rate in low risk multiparous women

The aim of this study was to compare the risk of secondary caesarean section in induced versus spontaneous labour in the second delivery of low risk women who had a vaginal delivery in their first pregnancy. The data were retrospective cohort from an existing regional database, comparing term (between 37 and 42 gestational weeks) second deliveries in cephalic position in women who had previously given vaginal birth. Diabetes, hypertension and multiple pregnancy were excluded as were those with a birth weight less than 2500 g or more than 4500 g. The difference was not significant when induction was performed after 41 weeks. The results showed a total number of 29693 deliveries were included, 21243 in spontaneous labour and 8450 after induction of labour. In the spontaneous group 312 (1.5%) underwent secondary caesarean section, as compared to 237 (2.8%) in the induced group, p < 0.001, OR 1.93 (95% confidence interval 1.63-2.29). It was concluded that elective induction of labour in low risk women who have previously given vaginal birth is associated with an almost doubled rate of secondary caesarean section if performed before 41 weeks.     

Breech delivery and epidural analgesia.

OBJECTIVE: To examine the effect of epidural analgesia on the progress and outcome of spontaneous labour in women with a singleton breech presentation at term (greater than or equal to 37 weeks). DESIGN: A retrospective study. SETTING: Data Bank, Aberdeen Maternity Hospital. SUBJECTS: 643 women (273 primiparae and 370 multiparae) with a singleton breech presentation and spontaneous onset of labour at term. OUTCOME MEASURES: Duration of labour; augmentation of labour with oxytocin infusion; caesarean section rates. RESULTS: Epidural analgesia was associated with a significantly increased need for augmentation of labour with oxytocin infusion (P less than 0.001) and longer duration of labour (P less than 0.001), irrespective of parity. Comparing women who had epidural analgesia with those who did not, there was no significant difference in caesarean section rates in the first stage of labour in primiparae (odds ratio 1.79; 95% CI 0.88-3.63) or multiparae (odds ratio 0.97; 95% CI 0.48-1.96). Epidural analgesia was associated with a significantly increased likelihood of caesarean section in the second stage of labour, both in primiparae (odds ratio 5.43; 95% CI 2.46-11.95) and multiparae (odds ratio 5.37; 95% CI 2.07-13.87). The increased likelihood of caesarean section in the second stage in primiparae with epidurals was independent of the extent of cervical dilatation (less than 3 cm or greater than or equal to 3 cm) on admission. However, in multiparae with epidurals, the difference in second stage caesarean section rate was significant only when initial cervical dilatation was less than 3 cm (odds ratio 3.65; 95% CI 1.14-11.65). CONCLUSION: Epidural analgesia was associated with longer duration of labour, increased need for augmentation of labour with oxytocin infusion and a significantly higher caesarean section rate in the second stage of labour.     

Caesarean delivery at full cervical dilatation versus caesarean delivery in the first stage of labour: comparison of maternal and perinatal morbidity

OBJECTIVE: To compare perinatal and maternal morbidity associated with caesarean sections performed in the first with that performed in the second stages of labour. PATIENTS AND METHODS: Comparative analyses between nulliparous women with singleton term pregnancies who had a caesarean section in the first stage of labour and those who had a second stage caesarean section were completed using standard statistical methods. A subgroup analysis, according to indication for caesarean section, was also performed. RESULTS: Of 627 women, 81% had caesarean delivery in the first stage and 19% had caesarean delivery in the second stage of labour. Women undergoing caesarean delivery at full cervical dilatation were 1.9 times more likely to have an augmented labour (95% CI 1.2-3.4, P < 0.001) and 2.8 times more likely to have epidural anaesthesia in labour (95% CI 1.5-5.2, P < 0.001) than those in the first stage. Compared with caesarean delivery in the first stage of labour, women undergoing caesarean delivery at full cervical dilatation were 4.6 times more likely to have composite intraoperative complications (95% CI 2.7-7.9, P < 0.001), 3.1 times more likely to have blood loss greater than 1,000 ml (95% CI 1.3-7.4, P = 0.01), and 2.9 times more likely to have a blood transfusion (95% CI 1.5-5.6, P < 0.001). The risk of neonatal morbidity was higher in first stage caesareans when they were performed for presumed fetal compromise (66.3 vs. 26.3%, P = 0.002), and lower when they were performed for failure to progress (18.4 vs. 42%, P = 0.02). CONCLUSION: Caesarean section in the second stage of labour is associated with a higher risk of maternal but not perinatal morbidity.     

The relationship between obesity and surgical site infections in women undergoing caesarean sections: An integrative review

Objectiveto provide a critical evaluation of published research on the relationship between obesity and surgical site infection (SSI) in obese women undergoing caesarean section.Methodan integrative literature review was conducted using five databases (CINAHL, PUBMED, Cochrane, and EBSCO host) for 2002–2012. Inclusion criteria were: (1) wound infection as an outcome measure for obstetric/maternal complications; (2) obesity assessed as an independent risk factor for wound infection in women undergoing caesarean section; (3) research undertaken in the past 10 years; and (4) full text articles available in English with abstract. A two point assessment score was used to evaluate the included studies in relation to representativeness of sample; accuracy of measures in data collection; and appropriateness of analytic techniques; (5) Databases where accessed including PubMed and MedLine. an intergrative literature review was conducted using four databases.Findingsthirteen research-based papers met the inclusion criteria, and the selected papers used various designs and methods. Five out of 13 studies scored highly in all three quality domains. All 13 studies supported a relationship between obesity and SSI and caesarean section was more common in obese women.Conclusionobesity is a global priority health concern affecting all ages and as demonstrated in this review, can result in serious postoperative complications for child bearing women undergoing caesarean section such as SSI. Further research is required into wound management practices of the obese women following caesarean section as this is an area currently lacking high quality research.Implications for practicecommunity midwives are well positioned to implement wound assessments in this cohort of women post-discharge, when SSI is often detected.     

Trial of labour after two or three previous caesarean sections

OBJECTIVE: To investigate the safety of a trial of labour (TOL) after two or three previous caesarean sections. STUDY DESIGN: Retrospective analysis of medical records of women with a history of more than one previous caesarean section who gave birth during a 10-year period (1988-1997) in two large university hospitals in The Netherlands. RESULTS: Women numbering 30,132 gave birth with a hospital caesarean birth rate of 14.8%. There were 246 women with a history of more than one previous caesarean section: 187 (76%) delivered by elective repeat caesarean section (ERCS); 59 (24%) had a trial of labour, of whom 49 (83%) had a vaginal birth. Three uterine ruptures occurred after previous lower segment caesarean sections without maternal or perinatal mortality related to the uterine rupture; only one rupture was during a trial of labour. In the study group there was no maternal mortality. Maternal morbidity did not differ between women with an elective repeat caesarean or a failed trial of labour. Perinatal mortality was not related to the mode of delivery. CONCLUSION: Elective repeat caesarean section is not the only answer to a woman with two or three previous caesarean sections. A trial of labour can be a safe option for a selected group of women.     

Indications of caesarean section in overweight and obese versus normal-weight pregnant women: a retrospective cohort study

Purpose: The aim of this study was to test the hypothesis that indications of c-section in overweight or obese pregnant women are different from those with normal-weight.

Methods: Retrospective cohort study at University Hospital of Puerto Real (Cádiz-Spain). We compared frequency distribution of c-section indications in overweight and obese versus normal-weight. The risk of c-section by different indications was calculated as relative risk.

Results: A total of 4685 births were included in the study. There are significant differences in the frequency distribution of caesarean indications among normal weight and overweight or obese women. In overweight, we found an increased risk of c-section due to previous c-section (RR: 1.73; confidence interval [CI] 95% 1.24–2.42), obstructed/non-progressive labour (RR: 1.34; CI 95% 1.03–1.75), failed induction of labour (RR: 2.38; CI 95% 1.30–4.34) and foetal distress (RR: 1.73; CI 95% 1.21–2.49). This risk was even higher in obese women: previous c-section (RR: 3.25; CI 95% 2.24–4.71), obstructed/non-progressive labour (RR: 2; CI 95% 1.45–2.77), failed induction (RR: 2.52; CI 95% 1.15–5.51) and foetal distress (RR: 2.35; CI 95% 1.51–3.65).

Conclusions: The risk of caesarean section due to previous caesarean section, obstructed/non-progressive labour, failed induction of labour or foetal distress is greater in overweight and obese than in normal-weight. This increase in risk also increases progressively as maternal BMI increases.     

Grossesse des patientes obèses : quels risques faut-il craindre ?

OBJECTIVE: To evaluate the deleterious effects of maternal obesity on obstetrical complications and neonatal outcomes. PATIENTS AND METHODS: Historical cohort study including all patients delivered in our maternity between 1st January 2002 and 31st December 2004. Intra uterine death and fetal loss before 22 weeks were excluded. Women were categorized by the Body Mass Index: less than 25, between 25 and 30, and more than 30. Maternal data, obstetrical complications, labor and its complications, and neonatal outcomes were studied. RESULTS: During these 3 years, 23.5% (1336/5686) of patients were overweight and 7.5% (425/5686) were obese. Obstetrical pathologies (gestational diabetes mellitus, hypertension, preeclampsia and fetal macrosomia) and labour induction were more significantly frequent in obese patients (P < 0.01). We noted twice more caesarean sections during labour in obese patients. The rate of artificial placental delivery was significantly higher in obese patients (P < 0.01). Obese patients with prior caesarean sections had a rate of vaginal delivery significantly lower than non obese patients with prior C-sections (23.6 vs 43.8%; P < 0.01). Mean children birth weight was significantly higher in obese patients (3305 vs 3181 g; P < 0.01) with no impact on Apgar score. DISCUSSION AND CONCLUSION: Our study confirms that obesity is responsible for major obstetrical complications, for what should no doubt be considered as high risk pregnancies. Our practices must take these complications into account by ensuring an adapted and early management in order to improve maternal and neonatal issues.     

Induction of labour with previous caesarean delivery: where do we stand?

PURPOSE OF REVIEW: This paper reviews the literature to elucidate the international stance on induction of labour in women with previous caesarean section. RECENT FINDINGS: There is no evidence to suggest that current induction methods are less effective in women with previous caesarean section. It would, therefore, seem logical to use the same regimens as for women with intact uteri, including prostaglandins, particularly in women with unfavourable cervices. The clinical decision making and counselling, however, will always focus on safety, not effectiveness. There is no question that induction of labour is associated with higher risk of uterine rupture, but quantifying this risk remains elusive. SUMMARY: For the present, we will continue our practice, based on the sources of the best evidence available. Improvements in obstetric care have not only reduced the risks associated with uterine rupture but also risks associated with caesarean section. Therefore, both elective caesarean section and induction of labour, with or without prostaglandins, are reasonable choices for women who need induction with previous caesarean section. The efforts to better quantify the benefits/risks of various policies and regimens should continue, but should be complemented with qualitative studies to obtain crucial insight into the demands and challenges confronting women and clinicians to identify factors influencing their decision-making or their preferences.     

Term breech singletons and caesarean section: A population study, Australia 1991–2005

Objective: To describe the method of birth of term breech singletons in Australia.
Design, setting and participants:  A retrospective population-based study of women who gave birth to term breech singletons in Australia between 1 January 1991 and 31 December 2005 using data from the National Perinatal Data Collection.
Main outcome measures:  Caesarean section, vaginal breech birth.
Results:  Method of birth changed for term breech singletons from 1991 (vaginal breech birth 23.1% versus caesarean (no labour 55.6%, labour 21.2%)) to 2005 (vaginal breech birth 3.7% versus caesarean (no labour 76.6%, labour 19.7%)). Overall, the population attributable risk percentage of term breech singletons for all caesarean sections declined from 10.2% in 1991 to 6.9% in 2005.
Conclusion:  Planned caesarean section is the standard method of birth for term breech singletons in Australia. Active measures including external cephalic version should be supported to reduce the rate of caesarean section where clinically indicated. Retention of a skilled clinical workforce is essential in the provision of the latter and to assist the minority of women having vaginal breech births. Breech presentation is not a major factor in the overall rise in caesarean section experienced by Australia since 1996.     

Vaginal delivery after previous caesarean section for failure of second stage of labour

Objective To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery.
Design Retrospective follow up study.
Setting Medical Centre Leeuwarden, The Netherlands.
Participants All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 1986–1998.
Methods Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour.
Results Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour.
Conclusions In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.     

The utility of clinical tests of eligibility for a trial of labour following a caesarean section: a decision analysis.

OBJECTIVE: There is evidence to suggest that women who have a failed trial of labour following caesarean section are at the highest risk of major morbid events, compared with those who have a successful trial of labour or elective repeat caesarean section. Attempts are being made to predict, either by radiological or ultrasonic measurements or clinical factors, who should attempt a trial of labour after a prior caesarean section and who should not, in the hopes of reducing the number of failed trials of labour with their associated morbidity. The goal of this study was to determine the necessary sensitivity and specificity for such a test to be clinically useful in this setting. METHODS: A decision analytic approach was used which compared two strategies for treating women with a prior caesarean section: trial of labour for all or application of a hypothetical test, the results of which would determine whether a woman would be offered a trial of labour. It was assumed that the goal of the strategies was to minimise the number of major maternal morbid events (hysterectomy, uterine rupture, operative injury) with an acceptable caesarean section rate. Probability estimates for these outcomes were obtained from the existing literature. We evaluated several combinations of sensitivity and specificity to determine the impact of these characteristics on the number of major complications and the number of caesarean sections, compared with the strategy of trial of labour for all women. The results are reported per 1000 women with a previous caesarean section. RESULTS: Under baseline assumptions, a clinical test for determining eligibility for a trial of labour must have both a sensitivity and specificity in excess of 75% to obtain a reasonable trade-off between reduction in morbidity and the total rate of caesarean sections. In women with a low empiric likelihood of a successful trial of labour, tests with lesser degrees of both sensitivity and specificity are reasonable. In women with a high empiric likelihood of a successful trial of labour, much higher sensitivities and specificities are required. CONCLUSIONS: In developing tests to determine to whom to offer a trial of labour, investigators and clinicians must realise that in most cases, a highly sensitive and specific test is needed, although this is dependent on the empiric likelihood of the success of a trial of labour.     

The influence of increasing BMI in nulliparous women on pregnancy outcome

Objective

The aim of the study was to demonstrate the influence of BMI in pregnancy on rates of adverse pregnancy outcome in overweight nulliparous women.

Study design

The study was a retrospective review of data from the local hospital database held at the Jessop Wing of the Royal Hallamshire Hospital in Sheffield. We reviewed all nulliparous women with recorded BMI at booking between January 2001 and November 2008 who delivered singleton babies. All the women were stratified into five groups (underweight, normal, overweight, obese, and morbidly obese). The different BMI range groups were compared with the group of women with a normal BMI (20-25). SPSS v15 was used for statistical analysis.

Results

The caesarean section rate rose from 18.2% in women of normal BMI to 40.6% in the morbidly obese women (RR 2.2 - CI 1.7-2.8). Morbidly obese women had three times that risk of macrosomia compared with normal BMI women (RR 3.1 - CI 2.1-4.8). The stillbirth rate was associated with increasing obesity with RR 16.7 (CI 4.9-56) for the morbidly obese women.

Conclusions

Increasing degrees of obesity are associated with increases in the incidence of caesarean section, fetal birth weight and adverse pregnancy outcomes. The increased risk shows an increment in a stepwise fashion among the different BMI groups.     

Risk factors for failed induction in nulliparous women

Objective: To identify risk factors for failed induction in nulliparous women. Material and methods: A retrospective cohort study of nulliparous women admitted for induction of labour (IOL). Identification of risk factors for failed IOL by comparing clinical characteristics of patients with a failed IOL defined as birth by caesarean section (LSCS) with those achieving vaginal birth. Results: During a 12 month episode, 400 nulliparous women had an IOL; of these 168 (42%) failed to deliver vaginally. Independent antenatal risk factors for failed IOL were higher maternal age (OR = 1.052 per additional year), being shorter (OR = 1.112 per cm less maternal height) and a lower cervical dilatation score (OR = 1.411 per lower cervical dilatation score). A longer active phase (OR = 1.004 per additional minute) was the only independent intrapartum risk factor for having a LSCS. Conclusions: Maternal age, height and cervical dilatation are independent antepartum risk factors, while duration of active phase is the single independent intrapartum risk factor for a failed IOL. Increased maternal BMI was less of a risk factor than anticipated with increased risk for failed IOL, as independent risk factor, more or less restricted to the morbidly obese women.     

Risk of uterine rupture following induction of labour in women with a previous caesarean section in a large UK teaching hospital.

To determine the outcome of induction of labour for women who had had previous caesarean sections, we identified all women who had induction of labour at the Leicester Royal Infirmary between January 1994 and September 2001. During the study period, there were 43,175 deliveries and 8761 inductions of labour (20.3%). Of these, 5047 (57.6%) were induced with prostaglandins and 138 women in this group had a previous caesarean section but eight were excluded from the analysis because of induction for early intrauterine death (five) and late terminations for fetal anomalies (three). The remaining 130 women formed the study group. Induction of labour resulted in spontaneous vaginal delivery in 50% of cases, with 11% requiring instrumental delivery and 39% had caesarean sections. There were no cases of uterine rupture in this series. We conclude that prostaglandins are safe for inducing labour in women with previous caesarean sections, but should be administered with caution.     

Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort

Objectives  To examine the associations between fear of childbirth and emergency caesarean section and between fear of childbirth and dystocia or protracted labour and fetal distress.
Design  Prospective cohort study.
Setting  Danish National Birth Cohort.
Population  A total of 25 297 healthy nulliparous women in spontaneous labour with a single fetus in cephalic presentation at term following an uncomplicated pregnancy.
Methods  Data were collected during 1997–2003 from computer-assisted telephone interviews twice in pregnancy linked with national health registers.
Main outcome measures  Risk for emergency caesarean section of women who feared childbirth; risk for dystocia/protracted labour or fetal distress of women who feared childbirth.
Results  Fear of childbirth in early (16 weeks, 6 ± 29 days) and late (31 weeks, 4 ± 21 days) pregnancy was associated with emergency caesarean section: OR, 1.23 (1.05–1.47) and 1.32 (1.13–1.55), respectively. When fear of childbirth was expressed at both interviews, the OR was 1.43 (1.13–1.80). Women who feared childbirth had an increased risk for dystocia or protracted labour (OR, 1.33; 1.15–1.54), but not for fetal distress (OR, 0.94; 0.72–1.23).
Conclusions  Fear of childbirth during pregnancy was associated with dystocia and emergency caesarean section but not with fetal distress.     

Mode of delivery in the early preterm infant (<28 weeks)

Elective caesarean section for women in labour with an immature baby might reduce the chances of fetal or neonatal death, but might also increase the risk of maternal morbidity. A review (updated in February 2004) of randomised trials comparing a policy of elective caesarean section versus expectant management with recourse to caesarean section produced six studies involving only 122 women. Differences in fetal outcome did not reach significance, but mothers undergoing elective caesarean section were more likely to have serious morbidity. Scientifically, the evidence remains inadequate. Clinically, the recommendation is that prematurity is not, in itself, an indication for caesarean section. In a survey from Israel, published in December 2004, of 2955 very low birthweight infants born at 24–34 weeks of gestation, the overall caesarean section rate was 51.7%, and the mortality rate among babies prior to discharge was lower after caesarean section (13.2 versus 21.8%). After adjustment using multiple logistic regression, caesarean section had no effect on survival except in a subgroup with amnionitis, and it was again concluded that caesarean section cannot be routinely recommended unless there are other indications. A decision model developed in the USA has compared costs and health outcomes of two options for managing labour at 24 weeks of gestation. The probabilities of both intact survival (16.8 versus 12.9%) and survival with major morbidity (39.2 versus 19.4%) are higher with willingness to perform caesarean section, but less aggressive management is the more cost-effective strategy. Large studies are few and recruitment to such studies is perceived as a major problem. For clinicians, the decision will be influenced by local circumstances.