Caesarean section on request: a survey in The Netherlands

OBJECTIVE: To determine the opinion of Dutch gynaecologists and registrars on caesarean section (CS) on request. STUDY DESIGN: Anonymous postal survey. METHODS: A structured survey was send to all 900 gynaecologists and registrars in The Netherlands. They were asked to what extent they were willing to accept a request for an elective caesarean section, without evident medical reason. The survey contained eight simulated cases in which the reason for this request differed (obstetrical history and course of the present pregnancy). In two cases, there was no medical indication at all to perform a caesarean section; and in a third case caesarean section was due to excessive maternal weight relatively contraindicated. RESULTS: The response rate was 65%. Willingness to perform an elective caesarean section ranged from 17 to 81% between the cases. Main reasons to perform a caesarean section were: (a). autonomy; (b). an unfavourable course of delivery in the absence of motivation for a natural childbirth; (c). litigation. The main reasons to refuse a request for a caesarean section were: (a). higher maternal morbidity and mortality; (b). no indication for caesarean section. A logistic regression analysis on personal characteristics showed that an experienced doctor is more willing to perform an elective caesarean section then a consultant or registrar with limited experience. The sex of the doctor was of no influence and the same held for the University at which they had been trained. Furthermore, it seems that doctors are more willing to accept the request if it is based upon unfounded, but understandable fear. CONCLUSION: In The Netherlands, a woman can always find a gynaecologist willing to perform a caesarean section for non medical reasons. This willingness increases with the age of the doctor. There is a need for guidelines when handling these cases.     

Analysis of indications for a repeat Caesarean section

The aim of the study is to establish the indications for a Resectio Caesarean (RS) and to compare them with those of the first Caesarean section (CS). The Study is retrospective and covers the period from 1.1.2000 to 31.XII.2000. For this period were accomplished 3646 deliveries, 894 (24.52%) of them with S. C. The RS were 182 (20.04%) of all CS. The number and the rate of each indication is calculate on the base of the sum of the first and the second indication from all CS. The first two indications reflect well the real reason for each CS. The results show that the average age of women with RS is grater 2 years and 7 months than those with first CS. The RS are elective in 80.7% of cases and is done at 38.4 +/- 1.4 w.g. The average weight of the newborns from RS is non significantly less with 31 g than this from first CS. The indication "status post CS" is not well defined as it is used in 98.3% of RS. The indication is accepted mostly as a relative one because is added in cases with enough reasonable other obstetric indications. The analysis of the indications of RS shows That 60% of them are justifiable 40% are undertaken on the bases of unconvincing complex indication, but which don't differ from those at first CS.     

孕期宫颈长度在前置胎盘紧急剖宫产中的预测价值

目的:评估孕期宫颈长度(CL)能否作为前置胎盘紧急剖宫产(CS)的一个预测指标。方法:回顾分析2010年1月至2014年11月于我院妇产科就诊的93例前置胎盘孕妇的临床资料,阴道多普勒超声测量患者不同妊娠期的CL,分别记为CL1(孕19~23周)、CL2(孕24~28周)、CL3(孕29~31周)和CL4(孕32~34周)。31例因阴道大出血行紧急CS,62例行择期CS。比较两组患者的临床资料、CL变化及临床结局,并分析前置胎盘患者发生紧急CS的危险因素及CL变化对紧急CS的预测价值。结果:两组的CL均随妊娠期进展而逐渐缩短,孕29~31周时两组的CL比较,差异无统计学意义;孕32周后紧急CS组的CL突然明显缩短,择期CS组仍持续缓慢缩短。多因素Logistic回归分析显示,入院时阴道出血(OR=34.710,95%CI为5.239~229.973)和CL变化(OR=3.522,95%CI为1.210~10.253)是紧急CS的危险因素。ROC曲线显示,CL变化可作为紧急CS的预测指标(AUC=0.74,P0.05),最佳cut-off值为6.0mm。结论:入院时阴道出血和CL变化是前置胎盘紧急CS的独立预测因子,前置胎盘孕妇妊娠中期至晚期CL变化超过6mm有较高风险行紧急CS。妊娠中期或晚期单次的CL缩短并不能预测紧急CS。     

An investigation of women's involvement in the decision to deliver by caesarean section

Objective To assess the degree and nature of women's involvement in the decision to deliver by caesarean section, and women's satisfaction with this involvement.
Design Observational study.
Setting The maternity unit in a large teaching hospital.
Sample One hundred and sixty-six women undergoing caesarean section.
Methods Interviews with the women on the third or fourth day postpartum, questionnaires sent to the women at 6 weeks and at 12 weeks postpartum, and extraction of information from the women's medical records.
Main outcome measures Women's knowledge, satisfaction, and involvement in making the decision concerning their caesarean section.
Results The majority of the women were satisfied with the information they received during pregnancy on caesarean section and with their involvement in making the decision, but the proportions were significantly higher for elective than emergency sections. For 7% of the women, maternal preference for caesarean section was a direct factor in making the decision. Just over half of the 166 women reported that they were not debriefed on the reasons for their caesarean section before their discharge from hospital. Almost a third of the women undergoing emergency caesarean section expressed negative feelings towards their delivery, compared with 13% of those undergoing elective caesarean sections.
Conclusion Women are not a homogeneous group in terms of their requirements for information, nor their desire to be involved in the decision on mode of delivery. Health professionals need to be responsive to this variability and to agree on standards for communicating with women during pregnancy about the possibility of operative delivery and for debriefing women after caesarean section. sarean section, and women's satisfaction with this involvement.     

Pre-term delivery by Caesarean section 'en caul': a case series.

Twenty-four pre-term infants (24-32 weeks) were delivered by Caesarean section 'en caul', i.e. with the membranes left intact until the whole pregnancy sac had been delivered. Seventeen survived to discharge from hospital (29% mortality, 26% after exclusion of lethal congenital abnormality). Three babies had a cord haemoglobin below 15 g/dl at delivery and 11 required blood transfusion. None had any other recognisable cause for the anaemia. Although en caul delivery has obvious theoretical advantages, the danger of causing fetal blood loss is real and should be evaluated in a randomised controlled trial before widespread application.     

The distribution of arachidonic acid in plasma and tissues of patients near term undergoing elective or emergency Caesarean section

The distribution of arachidonic acid in both the free and the bound state was measured in the maternal circulation, the fetal circulation and tissues within the pregnant uterus in 16 patients undergoing Caesarean section. Half of the patients had an elective Caesarean section and half had a Caesarean section during labour. No differences in arachidonic acid concentrations were found between the maternal or fetal circulations in women having elective Caesarean section and those having a Caesarean section in labour. The total and bound values of arachidonic acid in myometrium were higher in patients undergoing Caesarean section in labour. There was also an increased amount of arachidonic acid when expressed as an arachidonic acid/palmitic acid ratio between the fetal circulation and the maternal circulation, suggesting an active transport mechanism for arachidonic acid across the placenta. Levels of free arachidonic acid were in microgram quantities in both plasma and tissues, suggesting that the availability of free arachidonic acid was not the limiting factor in prostaglandin production.     

An investigation of women's involvement in the decision to deliver by caesarean section.

OBJECTIVE: To assess the degree and nature of women's involvement in the decision to deliver by caesarean section, and women's satisfaction with this involvement. DESIGN: Observational study. SETTING: The maternity unit in a large teaching hospital. SAMPLE: One hundred and sixty-six women undergoing caesarean section. METHODS: Interviews with the women on the third or fourth day postpartum, questionnaires sent to the women at 6 weeks and at 12 weeks postpartum, and extraction of information from the women's medical records. MAIN OUTCOME MEASURES: Women's knowledge, satisfaction, and involvement in making the decision concerning their caesarean section. RESULTS: The majority of the women were satisfied with the information they received during pregnancy on caesarean section and with their involvement in making the decision, but the proportions were significantly higher for elective than emergency sections. For 7% of the women, maternal preference for caesarean section was a direct factor in making the decision. Just over half of the 166 women reported that they were not debriefed on the reasons for their caesarean section before their discharge from hospital. Almost a third of the women undergoing emergency caesarean section expressed negative feelings towards their delivery, compared with 13% of those undergoing elective caesarean sections. CONCLUSION: Women are not a homogeneous group in terms of their requirements for information, nor their desire to be involved in the decision on mode of delivery. Health professionals need to be responsive to this variability and to agree on standards for communicating with women during pregnancy about the possibility of operative delivery and for debriefing women after caesarean section.     

Tuberculous tubo-ovarian abscess as a distant complication of Caesarean section

A 37-year-old patient, two mounts after the third caesarean sections, was rehospitalised due to severe lower abdomen pains and fever. She had been treated with antibiotics several times with no apparent result. Laparotomy was performed and the tubo-ovarian abscess was resected. The histological diagnosis was--adnexal tuberculosis. The postoperative period was febrile with prolonged inguinal lymphatic nodes reaction. She was constantly treated with broad-spectrum antibiotics and left hospital after 30 postoperative days. The disease was probably the result of symptomless lung tuberculosis, she had suffered from in the past.     

The harmful consequences of prelabour caesarean section on the baby

Interest in rising caesarean section (CS) rates, especially ‘non-medical’ planned prelabour CS (PLCS), has not usually focused on the potential detrimental effects on babies, especially as long-term health is harder to study. Shortening pregnancy and avoiding labour may affect fetal maturity. Babies who do not experience labour have significantly increased respiratory and other morbidities which may have profound effects on development, determining immediate and potentially life-long disease. As labour is usually beneficial, this must be factored into individual decisions. Consideration should be given to awaiting or inducing labour even in women with a high chance of CS or who are requesting this operation. Mothers must be fully informed of all the evidence before they can give valid consent and make decisions on their baby’s behalf. Although all modes of delivery carry potential risk of neonatal morbidity or mortality, avoiding labour may cause more long-term harm than good for children overall.     

The use of oxytocin after a previous Caesarean section — a review and report on a series

Summary We briefly present our experience with trial labour in the presence of a Caesarean section scar and review some of the literature on the management of such patients.     

Maternal height as a risk factor for Caesarean section due to failure to progress in labour

We examined for a regional sample of the New Zealand population, the relationship between maternal height and an increased risk of emergency Caesarean section due to arrested labour, to identify a height below which the risk of Caesarean section increases markedly and to quantify the risk of a Caesarean section for a range of maternal heights. The data of nulliparous singleton pregnancies over the period 1994-1998 was sorted into 2 study groups, one resulting in emergency Caesarean section for arrested labour and the other a group of women who had normal vaginal delivery requiring no intervention. The means and standard deviations of these 2 groups were found and 99% confidence intervals calculated. They were analysed for statistical difference and then a logistical regression calculation tried to identify a height at which the risk of a Caesarean section increased suddenly. There were 81 women in the Caesarean section group and 997 in the normal vaginal delivery group. Mean heights and confidence intervals were 161.0 cm (158.9-163.1) and 164.6 cm (164.0-165.2) respectively. There was a statistically significant difference between these means (p<0.001) but logistic regression analysis showed that risk of Caesarean section increased gradually with decreasing height, and even then did not reach more than 30% risk until a height of less than 140 cm. Low maternal height was associated with increased risk of Caesarean section due to labour arrest. Because the likelihood of having a normal vaginal delivery was still very good (>80 %) at modest degrees of short stature, this risk factor alone is unlikely to affect management. However the combination of other risk factors with maternal height may be of clinical use.     

急诊科医患的防范

目的:通过对患者及家属的有效管理,减少医患纠纷的发生。方法:分析和总结我科近年医患纠纷发生的原因,并采取针对性的制定防范管理方法。结果:经过加强培训,医护人员的法律意识、医患纠纷防范意识增强,显著减少了医患纠纷的发生。结论:医护人员通过学习,掌握正确的医护行为准则可以有效减少医疗纠纷的发生。     

Fertility outcomes of IVF/ICSI after Caesarean section: a cohort study

Research questionThe study objective was to evaluate the impact of a previous Caesarean section on fertility outcomes in women undergoing IVF/intracytoplasmic sperm injection (ICSI).DesignA retrospective cohort study was designed that included 1793 women undergoing IVF/ICSI who had had a previous delivery from January 2015 to December 2016. The primary outcome was live birth. Secondary outcomes were implantation, clinical pregnancy, miscarriage, ectopic pregnancy, multiple pregnancy and perinatal complications.ResultsOf the 1793 women included, 796 had had a previous Caesarean section and 997 a previous vaginal delivery. Propensity score matching in a 1:1 ratio resulted in 538 women per group. Compared with women with a previous vaginal delivery, women with a previous Caesarean section had a lower live birth rate (30.1% versus 38.1%, odds ratio [OR] 0.70, 95% confidence interval [CI] 0.54–0.90) and a higher miscarriage rate (25.9% versus 17.5%, OR 1.65, 95% CI 1.06–2.56). Among other secondary outcomes, implantation rates were 32.9% and 37.1% (OR 0.83, 95% CI 0.69–1.01), and clinical pregnancy rates were 42.4% and 46.8% (OR 0.84, 95% CI 0.66–1.06), in the Caesarean section group and vaginal delivery group, respectively. There were no statistically significant differences in terms of ectopic pregnancy, multiple pregnancy or perinatal outcomes between the groups. Further adjustment for confounders did not change the result of the primary outcome (OR 0.64, 95% CI 0.49–0.84).ConclusionsWomen undergoing IVF/ICSI who have had a previous Caesarean section have a lower live birth rate and a higher miscarriage rate than those with a previous vaginal delivery.