Caesarean Section Frequency among Immigrants,Second- and Third-Generation Women,and Non-Immigrants: Prospective Study in Berlin/Germany

ObjectiveThe frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants.MethodsA standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers’ antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status.ResultsThe caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants.ConclusionUnlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history.     

Long-term outcome by method of delivery of fetuses in breech presentation at term: population based follow up.

OBJECTIVE--To compare the long-term outcome of infants delivered in breech presentation at term by intended mode of delivery. DESIGN--A population based comparison of outcomes up to school age. Data obtained from maternity, health visitor, and school medical records and handicap register. SETTING--Grampian region 1981-90. SUBJECTS--1645 infants delivered alive at term after breech presentation. MAIN OUTCOME MEASURES--Handicap, developmental delay, neurological deficit, psychiatric referral. RESULTS--Elective caesarean section was performed in 590 (35.9%) cases. The remainder (1055; 64.1%) were intended vaginal deliveries. Handicap or other health problem was recorded in 269 (19.4%) of 1387 infants for whom records were available. Proportions of elective caesarean sections and intended vaginal deliveries in this group were 37.2% (100 cases) and 62.8% (169) respectively, almost the same as in the total cohort. There were no significant differences between elective caesarean section and planned vaginal delivery in terms of severe handicap or any other outcome measure. Case records were obtained for 23 of 27 infants with severe handicap. 11 (47.8%) were delivered by elective caesarean section. Of these, three had undiagnosed congenital abnormalities and seven were unexplained. Of the 12 (52.2%) planned vaginal deliveries, in only one was handicap possibly attributable to delivery and four cases were unavoidable even if elective caesarean section had been planned. CONCLUSION--In selected cases of breech presentation at term planned vaginal delivery with caesarean section if necessary remains as safe as elective caesarean section in terms of long term handicap. It was not possible to determine whether particular babies would have fared better had they been delivered by elective caesarean section.     

Succinylcholine use in adult anesthesia - A multinational questionnaire survey

There are no definitive evidence based standards regarding use of succinylcholine (SCh) for anesthesia induction. However, there is a global trend toward eliminating SCh not only in elective, but also in emergency surgery in adults. The aim of the study was to survey the use of SCh in adult elective and emergency anesthesia practice in several European countries and the United States by questionnaire. One hundred and seventy anesthesiologists out of 201 possible, from six institutions in five countries (Croatia, Bosnia and Herzegovina, Hungary, United Kingdom, and the United States) anonymously completed the questionnaire about their use of SCh. The questionnaire was structured to assess the respondents': frequency of use of SCh in adult surgery (elective and emergency), reasons for use or rejection of SCh, positive and negative attributes of SCh, and observed side effects in their practice. Differences in use were tested using X2-test when appropriate. There was a significant difference in the use of SCh between countries for elective surgery with the lower use in UK and Hungary (chi2=45.8, p <0.001). One hundred and seventeen (69%) use it regularly. In emergency surgery 165 (97%) anesthesiologists use it without any significant difference among countries (chi2=2.13, p<0.711). The top indications for SCh use were anticipated difficult intubation/ventilation (74%), caesarean section (54%), and obesity and/or hiatus hernia (49%). The top reasons against SCh use were adequate substitutes (87%), fear of arrhythmias (45%), and anaphylaxis (19%). The most desirable reported drug features were: rapid onset (88%), short duration (64%), and effective relaxation (61%). Forty-six per cent of the surveyed anesthesiologists stated they had never experienced a complication with its use. The most frequently reported side effects were myalgias (47%), bradycardias (42%), and prolonged blockade (39%). Allergic reactions were reported by 13%, and asystole by 12% of physicians. From our survey it is possible to conclude that succinylcholine is still regularly used, at least by surveyed anesthesiologists in Europe and USA, in adult anesthesia practice, especially in elective surgery for which it may be least suited. This reflects the discrepancies between the international guidelines for the use of SCh and the clinical practice of many anesthesiologists in different countries. The regional differences in SCh usage may be considered through anesthesia cultures and practice variations depending on country.     

Changes of nitric oxide, carbon monoxide and oxidative stress in term infants at birth

The higher risk of respiratory problem in infants delivered by elective caesarean section in comparison with vaginally born infants may be favoured by lower level of nitric oxide (NO) and carbon monoxide (CO) and higher oxidative stress in infants born by caesarean section. We studied healthy term infants born by vaginal delivery or by elective caesarean section. Nitric oxide, CO, guanosine 3-5 cyclic monophosphate, total hydroperoxide and advanced oxidation protein products (AOPP) were measured at birth and 48-72 h of life. Nitric oxide, CO and cGMP were lower at birth and at 48-72 h of life in infants born by elective caesarean delivery. Total hydroperoxide and AOPP levels were similar in the two groups and increased from birth to 48-72 h of life. In conclusion, nitric oxide and CO concentrations were higher in term infants vaginally born than in infants born by elective caesarean section and decreased from birth to 48-72 h of life. The mode of delivery did not affect the oxidative stress which increases from birth to 48-72 h of life.     

Changes of nitric oxide,carbon monoxide and oxidative stress in term infants at birth

The higher risk of respiratory problem in infants delivered by elective caesarean section in comparison with vaginally born infants may be favoured by lower level of nitric oxide (NO) and carbon monoxide (CO) and higher oxidative stress in infants born by caesarean section. We studied healthy term infants born by vaginal delivery or by elective caesarean section. Nitric oxide, CO, guanosine 3–5 cyclic monophosphate, total hydroperoxide and advanced oxidation protein products (AOPP) were measured at birth and 48–72 h of life. Nitric oxide, CO and cGMP were lower at birth and at 48–72 h of life in infants born by elective caesarean delivery. Total hydroperoxide and AOPP levels were similar in the two groups and increased from birth to 48–72 h of life. In conclusion, nitric oxide and CO concentrations were higher in term infants vaginally born than in infants born by elective caesarean section and decreased from birth to 48–72 h of life. The mode of delivery did not affect the oxidative stress which increases from birth to 48–72 h of life.     

Outcome of breech delivery at term.

OBJECTIVE--To compare neonatal mortality and morbidity in term infants presenting by the breech and delivered vaginally or by caesarean section. DESIGN--Population based comparison of outcomes. Data derived from the St Mary''s maternity information system. SETTING--North West Thames Regional Health Authority, 1988-90. SUBJECTS--3447 singleton fetuses presenting by the breech at term. MAIN OUTCOME MEASURES--Intrapartum and neonatal mortality, low Apgar scores, intubation at birth, and admission to special care baby units. RESULTS--After the exclusion of babies with congenital anomalies the incidence of intrapartum and neonatal death associated with vaginal birth was 8/961 (0.83%) compared with 1/2486 (0.03%) in babies born by caesarean section (relative risk 20, 95% confidence interval 2.5 to 163). The numbers of low Apgar scores and neonatal intubation were doubled in babies born vaginally or by emergency caesarean section compared with those delivered by elective operation. CONCLUSIONS--The good neonatal outcome associated with elective caesarean delivery of the term breech fetus may influence the decision of women and their obstetricians about mode of delivery.     

Optimal Timing of Delivery among Low-Risk Women with Prior Caesarean Section: A Secondary Analysis of the WHO Multicountry Survey on Maternal and Newborn Health

Objective

To investigate optimal timing of elective repeat caesarean section among low-risk pregnant women with prior caesarean section in a multicountry sample from largely low- and middle-income countries.

Design

Secondary analysis of a cross-sectional study.

Setting

Twenty-nine countries from the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

29,647 women with prior caesarean section and no pregnancy complications in their current pregnancy who delivered a term singleton (live birth and stillbirth) at gestational age 37–41 weeks by pre-labour caesarean section, intra-partum caesarean section, or vaginal birth following spontaneous onset of labour.

Methods

We compared the rate of short-term adverse maternal and newborn outcomes following pre-labour caesarean section at a given gestational age, to those following ongoing pregnancies beyond that gestational age.

Main Outcome Measures

Severe maternal outcomes, neonatal morbidity, and intra-hospital early neonatal mortality.

Results

Odds of neonatal morbidity and intra-hospital early neonatal mortality were 0.48 (95% confidence interval [CI] 0.39–0.60) and 0.31 (95% CI 0.16–0.58) times lower for ongoing pregnancies compared to pre-labour caesarean section at 37 weeks. We did not find any significant change in the risk of severe maternal outcomes between pre-labour caesarean section at a given gestational age and ongoing pregnancies beyond that gestational age.

Conclusions

Elective repeat caesarean section at 37 weeks had higher risk of neonatal morbidity and mortality compared to ongoing pregnancy, however risks at later gestational ages did not differ between groups.     

Reducing the incidence of infection after caesarean section: implications of prophylaxis with antibiotics for hospital resources.

OBJECTIVES--To estimate the cost effectiveness of giving prophylactic antibiotics routinely to reduce the incidence of wound infection after caesarean section. DESIGN--Estimation of cost effectiveness was based, firstly, on a retrospective overview of 58 controlled trials and, secondly, on evidence about costs derived from data and observations of practice. SETTING--Trials included in the overview were from obstetric units in several different countries, including the United Kingdom. The costing study was based on data referring to the John Radcliffe Maternity Hospital, Oxford. SUBJECTS--A total of 7777 women were included in the 58 controlled trials comparing the effects of giving routine prophylactic antibiotics at caesarean section with either treatment with a placebo or no treatment. Cost estimates were based on data on 486 women who had caesarean sections between January and September 1987. MAIN OUTCOME MEASURE--Cost effectiveness of prophylaxis with antibiotics. RESULTS--The odds of wound infection are likely to be reduced by between about 50 and 70% by giving antibiotics routinely at caesarean section. Forty one (8.4%) women who had caesarean section were coded by the Oxford obstetric data system as having developed wound infection. The additional average cost of hospital postnatal care for women with wound infection (compared with women who had had caesarean section and no wound infection) was estimated to be 716 pounds; introducing routine prophylaxis with antibiotics would reduce average costs of postnatal care by between 1300 pounds and 3900/100 pounds caesarean sections (at 1988 prices), depending on the cost of the antibiotic used and its effectiveness. CONCLUSIONS--The results suggest that giving antibiotics routinely at caesarean section will not only reduce rates of infection after caesarean section but also reduce costs.     

Association of Maternal Vitamin D Status with Glucose Tolerance and Caesarean Section in a Multi-Ethnic Asian Cohort: The Growing Up in Singapore Towards Healthy Outcomes Study

Objective

Epidemiological studies relating maternal 25-hydroxyvitamin D (25OHD) with gestational diabetes mellitus (GDM) and mode of delivery have shown controversial results. We examined if maternal 25OHD status was associated with plasma glucose concentrations, risks of GDM and caesarean section in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study.

Methods

Plasma 25OHD concentrations, fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations were measured in 940 women from a Singapore mother-offspring cohort study at 26–28 weeks’ gestation. 25OHD inadequacy and adequacy were defined based on concentrations of 25OHD ≤75nmol/l and >75nmol/l respectively. Mode of delivery was obtained from hospital records. Multiple linear regression was performed to examine the association between 25OHD status and glucose concentrations, while multiple logistic regression was performed to examine the association of 25OHD status with risks of GDM and caesarean section.

Results

In total, 388 (41.3%) women had 25OHD inadequacy. Of these, 131 (33.8%), 155 (39.9%) and 102 (26.3%) were Chinese, Malay and Indian respectively. After adjustment for confounders, maternal 25OHD inadequacy was associated with higher FG concentrations (β = 0.08mmol/l, 95% Confidence Interval (CI) = 0.01, 0.14), but not 2HPPG concentrations and risk of GDM. A trend between 25OHD inadequacy and higher likelihood of emergency caesarean section (Odds Ratio (OR) = 1.39, 95% CI = 0.95, 2.05) was observed. On stratification by ethnicity, the association with higher FG concentrations was significant in Malay women (β = 0.19mmol/l, 95% CI = 0.04, 0.33), while risk of emergency caesarean section was greater in Chinese (OR = 1.90, 95% CI = 1.06, 3.43) and Indian women (OR = 2.41, 95% CI = 1.01, 5.73).

Conclusions

25OHD inadequacy is prevalent in pregnant Singaporean women, particularly among the Malay and Indian women. This is associated with higher FG concentrations in Malay women, and increased risk of emergency caesarean section in Chinese and Indian women.     

Estimation of human fetal-placental unit metabolic rate by application of the Bohr principle

The Bohr Principle via continuous indirect calorimetry was used to estimate human fetal-placental unit metabolic rate in 12 normal women undergoing elective caesarean section under continuous lumbar epidural anaesthesia. Maternal oxygen consumption decreased after umbilical cord clamping and after placental removal. Fetal-placental unit oxygen consumption was 10.7 +/- 1.3 ml/min per kg (mean +/- SEM). Fetal oxygen consumption was 6.8 +/- 1.4 ml/min per kg. Placental oxygen consumption was 37 +/- 12 ml/min per kg. Fetal-placental unit carbon dioxide production was 9.2 +/- 1.2 ml/min per kg. These mean values agree favourably with measurements of uterine and fetal metabolism from other mammalian species. Maternal minute ventilation decreased with removal of the fetal-placental unit, and this decrease was found to be linearly related to the fetal-placental unit carbon dioxide production.     

Perinatal outcome analysis of twin pregnancies at the Department of Obstetrics and Gynecology Central Clinical Hospital of Ministry of Interior and Administration in Warsaw in the years 2005-2006

A group of 59 twin pregnant women who gave birth at the Department of Obstetrics and Gynecology Central Clinical Hospital of Ministry of Interior and Administration in Warsaw in the years 2005-2006. The patients have been divided into four groups: spontaneous twin pregnant women (n=16), twin pregnant women after in- vitro fertilization (IVF) (n=11), twin pregnant women after in-vitro fertilization with intracytoplasmic sperm injection (ICSI) (n=29) and twin pregnant women after ICSI and transfer of frozen embryos (n=3). In one case intrauterine death of one of twins in the 34th week of gestation has been noticed. The cause of the death was umbilical cord wrapped around his neck. The gestation was ended with cesarean section and Apgar score of the second twin was 8 in the fifth minute. In one case there was an urgent indication for a cesarean delivery of children with a very low birth weight (because of intrauterine infection, preterm labor in progress) and in three cases at least one of twins with a low birth weight. Among the group 19 women (32%) have given birth prematurely. The Apgar score in the first, third and fifth minute has been statistically significant and inversely proportional dependent only on the gestational age. There were no differences in birth weight among study groups regardless the way of conception. Only two spontaneous twin pregnant patients have had a vaginal labor. By the remaining 57 patients there has been an elective cesarean section in thirty five cases and there has been an urgent indication for cesarean section in twenty two cases.     

Delivery after caesarean section: review of 2176 consecutive cases.

A total of 2176 consecutive patients who had had one previous caesarean section were studied retrospectively. A repeat elective caesarean section was performed in 395 (18.2%). Labour started spontaneously in 1363 patients, 301 of whom were given oxytocin to accelerate inert labour, and was induced by amniotomy and infusion of oxytocin in 418 women; 1618 of these 1781 patients (90.8%) delivered vaginally. Patients who had had a previous vaginal delivery were more likely to deliver vaginally again. Those women in whom the initial caesarean section had been performed during labour before the cervix was 4 cm dilated were less likely to deliver vaginally than those who had progressed further in labour or those who had had an elective caesarean section. Similarly, those who received oxytocin to stimulate inert labour were more likely to require a repeat caesarean section than those who did not. The uterine scar ruptured in only eight (0.45%) of the 1781 patients allowed into labour. The risk of rupture of the scar was not increased by the use of oxytocin alone either to induce or to accelerate labour. The combination of oxytocin to accelerate labour and epidural analgesia to provide pain relief, however, was associated with an increased incidence of scar rupture. Labour may be safely allowed in women who have had a previous caesarean section, most of whom will deliver vaginally. Induction of labour does not increase the risk of either a repeat caesarean section or rupture of a uterine scar.     

Which deliveries require paediatricians in attendance?

The mode of delivery and one minute Apgar score were taken from the neonatal records of 2086 full term infants born at one obstetric unit over 12 months. There were 1554 spontaneous vaginal vertex deliveries, 26 vaginal breech deliveries, and 506 operative or instrumental deliveries. The obstetric records of the operative deliveries were reviewed to determine whether fetal distress had been an indication for intervention, and the obstetric records of the spontaneous vaginal vertex deliveries were also reviewed for fetal distress detected antenatally. When fetal distress was present antenatally in spontaneous vaginal vertex deliveries the frequency of a one minute Apgar score below 7 was 10.2%. In operative and instrumental deliveries where fetal distress was the indication for intervention the frequency of one a minute Apgar score below 7 was 15.6% after non-rotational forceps delivery, 13.9% after rotational forceps delivery, and 45.8% after caesarean section. In the absence of fetal distress the frequency of an Apgar score below 7 was 2.4% after spontaneous deliveries, 7.1% after non-rotational forceps delivery, 13.2% after caesarean section, and 18.4% after rotational forceps delivery. The presence of fetal distress considerably increased the frequency of an Apgar score below 7 in each category except rotational forceps deliveries. Paediatric services to an obstetric unit may be organised rationally in the light of local staffing conditions with the help of these findings.     

急诊危重孕产妇5分钟紧急剖宫产的临床效果及新生儿不良结局的危险因素分析

摘要 目的：探讨急诊危重孕产妇5分钟紧急剖宫产的临床效果,并分析新生儿不良结局的危险因素。方法：回顾性分析2018年1月~2022年6月在河北省儿童医院妇产科收治的急诊危重孕产妇139例的临床资料。根据急诊剖宫产流程分为对照组（n=68,常规紧急剖宫产流程下进行手术）及观察组（n=71,5分钟紧急剖宫产）。观察两组孕产妇的手术情况、手术反应时间、孕产妇并发症、新生儿不良结局发生率。采用多因素Logistic回归模型分析新生儿不良结局的危险因素。结果：两组住院时间、术中出血量、术中输血情况组间对比,未见统计学差异（P>0.05）。与对照组相比,观察组进手术室至手术开始时间、决定手术至胎儿娩出的时间间隔（DDI）、决定手术至进手术室时间、手术开始至胎儿娩出时间均更短,新生儿不良结局发生率、并发症发生率更低（P<0.05）。根据新生儿不良结局将孕产妇分为不良组（n=38）、良好组（n=101）。单因素分析结果显示：新生儿不良结局与受教育程度、新生儿体重、孕周、剖宫产类型、DDI、妊娠合并症、采用辅助生殖技术有关（P<0.05）。多因素Logistic回归分析结果显示,受教育程度为小学及其以下、新生儿体重偏低、剖宫产类型为I类剖宫产、孕周偏短、DDI偏长均是新生儿不良结局的危险因素（P<0.05）。结论：急诊危重孕产妇5分钟紧急剖宫产可缩短各项手术反应时间,降低孕产妇并发症和新生儿不良结局发生率。此外,新生儿不良结局的发生与受教育程度、新生儿体重、剖宫产类型、孕周、DDI等因素有关。     

A History of Abuse and Operative Delivery – Results from a European Multi-Country Cohort Study

Objective

The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult.

Design

The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations.

Results

Among 3308 primiparous women, sexual abuse as an adult (≥18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28–3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24–11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46–11.3). Neither physical abuse (in adulthood or childhood <18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05–2.19).

Conclusion

Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS.     

Caesarean Section in Peru: Analysis of Trends Using the Robson Classification System

Introduction

Cesarean section rates continue to increase worldwide while the reasons appear to be multiple, complex and, in many cases, country specific. Over the last decades, several classification systems for caesarean section have been created and proposed to monitor and compare caesarean section rates in a standardized, reliable, consistent and action-oriented manner with the aim to understand the drivers and contributors of this trend. The aims of the present study were to conduct an analysis in the three Peruvian geographical regions to assess levels and trends of delivery by caesarean section using the Robson classification for caesarean section, identify the groups of women with highest caesarean section rates and assess variation of maternal and perinatal outcomes according to caesarean section levels in each group over time.

Material and Methods

Data from 549,681 pregnant women included in the Peruvian Perinatal Information System database from 43 maternal facilities in three Peruvian geographical regions from 2000 and 2010 were studied. The data were analyzed using the Robson classification and women were studied in the ten groups in the classification. Cochran-Armitage test was used to evaluate time trends in the rates of caesarean section rates and; logistic regression was used to evaluate risk for each classification.

Results

The caesarean section rate was 27% and a yearly increase in the overall caesarean section rates from 2000 to 2010 from 23.5% to 30% (time trend p<0.001) was observed. Robson groups 1, 3 (nulliparous and multiparas, respectively, with a single cephalic term pregnancy in spontaneous labour), 5 (multiparas with a previous uterine scar with a single, cephalic, term pregnancy) and 7 (multiparas with a single breech pregnancy with or without previous scars) showed an increase in the caesarean section rates over time. Robson groups 1 and 3 were significantly associated with stillbirths (OR 1.43, CI95% 1.17–1.72; OR 3.53, CI95% 2.95–4.2) and maternal mortality (OR 3.39, CI95% 1.59–7.22; OR 8.05, CI95% 3.34–19.41).

Discussion

The caesarean section rates increased in the last years as result of increased CS in groups with spontaneous labor and in-group of multiparas with a scarred uterus. Women included in groups 1 y 3 were associated to maternal perinatal complications. Women with previous cesarean section constitute the most important determinant of overall cesarean section rates. The use of Robson classification becomes an useful tool for monitoring cesarean section in low human development index countries.     

Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-Control Study

Background

Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.

Methods and Findings

A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16–7.85) and <12 months since their last caesarean delivery (aOR 3.12, 95% CI 1.62–6.02). A higher risk of rupture with labour induction and oxytocin use was apparent (aOR 3.92, 95% CI 1.00–15.33). Two women with uterine rupture died (case fatality 1.3%, 95% CI 0.2–4.5%). There were 18 perinatal deaths associated with uterine rupture among 145 infants (perinatal mortality 124 per 1,000 total births, 95% CI 75–189).

Conclusions

Although uterine rupture is associated with significant mortality and morbidity, even amongst women with a previous caesarean section planning a vaginal delivery, it is a rare occurrence. For women with a previous caesarean section, risk of uterine rupture increases with number of previous caesarean deliveries, a short interval since the last caesarean section, and labour induction and/or augmentation. These factors should be considered when counselling and managing the labour of women with a previous caesarean section. Please see later in the article for the Editors'' Summary     

Prevalence and determinants of caesarean section in Jamaica.

The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14-49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4.1%. Repeat caesarean sections accounted for 1.3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals.     

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery.Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health.Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided dataParticipants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage).Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics.Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective.Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.     

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

ObjectivesTo explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.DesignQualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.SettingSantiago, Chile.ParticipantsQualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.ResultsPrivate health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.ConclusionsPolicies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.