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.     

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     

Outcomes of Induction of Labour in Women with Previous Caesarean Delivery: A Retrospective Cohort Study Using a Population Database

Background

There is evidence that induction of labour (IOL) around term reduces perinatal mortality and caesarean delivery rates when compared to expectant management of pregnancy (allowing the pregnancy to continue to await spontaneous labour or definitive indication for delivery). However, it is not clear whether IOL in women with a previous caesarean section confers the same benefits. The aim of this study was to describe outcomes of IOL at 39–41 weeks in women with one previous caesarean delivery and to compare outcomes of IOL or planned caesarean delivery to those of expectant management.

Methods and Findings

We performed a population-based retrospective cohort study of singleton births greater than 39 weeks gestation, in women with one previous caesarean delivery, in Scotland, UK 1981–2007 (n = 46,176). Outcomes included mode of delivery, perinatal mortality, neonatal unit admission, postpartum hemorrhage and uterine rupture. 40.1% (2,969/7,401) of women who underwent IOL 39–41 weeks were ultimately delivered by caesarean. When compared to expectant management IOL was associated with lower odds of caesarean delivery (adjusted odds ratio [AOR] after IOL at 39 weeks of 0.81 [95% CI 0.71–0.91]). There was no significant effect on the odds of perinatal mortality but greater odds of neonatal unit admission (AOR after IOL at 39 weeks of 1.29 [95% CI 1.08–1.55]). In contrast, when compared with expectant management, elective repeat caesarean delivery was associated with lower perinatal mortality (AOR after planned caesarean at 39 weeks of 0.23 [95% CI 0.07–0.75]) and, depending on gestation, the same or lower neonatal unit admission (AOR after planned caesarean at 39 weeks of 0.98 [0.90–1.07] at 40 weeks of 1.08 [0.94–1.23] and at 41 weeks of 0.77 [0.60–1.00]).

Conclusions

A more liberal policy of IOL in women with previous caesarean delivery may reduce repeat caesarean delivery, but increases the risks of neonatal complications.     

Caesarean Section: Could Different Transverse Abdominal Incision Techniques Influence Postpartum Pain and Subsequent Quality of Life? A Systematic Review

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon’s experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: “acute pain”, “chronic pain”, “Pfannenstiel incision”, “Misgav-Ladach”, “Joel Cohen incision”, in combination with “Caesarean Section”, “abdominal incision”, “numbness”, “neuropathic pain” and “nerve entrapment”. Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required.     

Birth order,gestational age,and risk of delivery related perinatal death in twins: retrospective cohort study

ObjectiveTo determine whether twins born second are at increased risk of perinatal death because of complications during labour and delivery.DesignRetrospective cohort study.SettingScotland, 1992 and 1997.ParticipantsAll twin births at or after 24 weeks'' gestation, excluding twin pairs in which either twin died before labour or delivery or died during or after labour and delivery because of congenital abnormality, non-immune hydrops, or twin to twin transfusion syndrome.ResultsOverall, delivery related perinatal deaths were recorded for 23 first twins only and 23 second twins only of 1438 twin pairs born before 36 weeks (preterm) by means other than planned caesarean section (P>0.99). No deaths of first twins and nine deaths of second twins (P=0.004) were recorded among the 2436 twin pairs born at or after 36 weeks (term). Discordance between first and second twins differed significantly in preterm and term births (P=0.007). Seven of nine deaths of second twins at term were due to anoxia during the birth (2.9 (95% confidence interval 1.2 to 5.9) per 1000); five of these deaths were associated with mechanical problems with the second delivery following vaginal delivery of the first twin. No deaths were recorded among 454 second twins delivered at term by planned caesarean section.ConclusionsSecond twins born at term are at higher risk than first twins of death due to complications of delivery. Previous studies may not have shown an increased risk because of inadequate categorisation of deaths, lack of statistical power, inappropriate analyses, and pooling of data about preterm births and term births.

What is already known on this topic

It is difficult to assess the wellbeing of second twins during labourDeliveries of second twins are at increased risk of mechanical problems, such as cord prolapse and malpresentation, after vaginal delivery of first twinsIncreased risks of perinatal death in second twins have not been shown, but the methods of these studies were flawed

What this study adds

Second twins delivered at term are at increased risk of delivery related perinatal deathsIntrapartum anoxia caused 75% of these deaths in second twins, and most of these resulted from mechanical problems after vaginal delivery of first twinsPlanned caesarean section of twins at term may prevent perinatal deaths     

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.     

At What Price? A Cost-Effectiveness Analysis Comparing Trial of Labour after Previous Caesarean versus Elective Repeat Caesarean Delivery

Background

Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.

Methods

Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both “bottom-up” and “top-down” costing estimations.

Results

Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€1,835.06 versus €4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.

Conclusions

Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.     

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.     

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.     

Differing Prevalence and Diversity of Bacterial Species in Fetal Membranes from Very Preterm and Term Labor

Background

Intrauterine infection may play a role in preterm delivery due to spontaneous preterm labor (PTL) and preterm prolonged rupture of membranes (PPROM). Because bacteria previously associated with preterm delivery are often difficult to culture, a molecular biology approach was used to identify bacterial DNA in placenta and fetal membranes.

Methodology/Principal findings

We used broad-range 16S rDNA PCR and species-specific, real-time assays to amplify bacterial DNA from fetal membranes and placenta. 74 women were recruited to the following groups: PPROM <32 weeks (n = 26; 11 caesarean); PTL with intact membranes <32 weeks (n = 19; all vaginal birth); indicated preterm delivery <32 weeks (n = 8; all caesarean); term (n = 21; 11 caesarean). 50% (5/10) of term vaginal deliveries were positive for bacterial DNA. However, little spread was observed through tissues and species diversity was restricted. Minimal bacteria were detected in term elective section or indicated preterm deliveries. Bacterial prevalence was significantly increased in samples from PTL with intact membranes [89% (17/19) versus 50% (5/10) in term vaginal delivery p = 0.03] and PPROM (CS) [55% (6/11) versus 0% (0/11) in term elective CS, p = 0.01]. In addition, bacterial spread and diversity was greater in the preterm groups with 68% (13/19) PTL group having 3 or more positive samples and over 60% (12/19) showing two or more bacterial species (versus 20% (2/10) in term vaginal deliveries). Blood monocytes from women with PTL with intact membranes and PPROM who were 16S bacterial positive showed greater level of immune paresis (p = 0.03). A positive PCR result was associated with histological chorioamnionitis in preterm deliveries.

Conclusion/Significance

Bacteria are found in both preterm and term fetal membranes. A greater spread and diversity of bacterial species were found in tissues of women who had very preterm births. It is unclear to what extent the greater bacterial prevalence observed in all vaginal delivery groups reflects bacterial contamination or colonization of membranes during labor. Bacteria positive preterm tissues are associated with histological chorioamnionitis and a pronounced maternal immune paresis.     

Mothers' experiences of induction

Mothers of a random sample of 2182 legitimate live births were interviewed about their experiences of pregnancy, labour, and delivery. Of these, 24% reported that their labours were induced, and data about this from a subsample of mothers tallied with information obtained through the doctors in charge in 88% of cases. All but 3% of the mothers who were induced perceived some medical reason for the induction. The proportion of inductions in the 24 study areas ranged from 6% to 39%. A relatively small proportion of labours in “teaching” hospitals, small hospitals with less than 100 beds, and GP maternity hospitals were induced, but a comparatively high proportion of private patients had an induction. There was no clear association between induction and the mother''s age or parity. Despite being given more pain relief, those who were induced reported similar intensities of pain during the first and second stages of labour to those whose labour started spontaneously; they also reported that they had “bad pains” for a similar period. The period they had contractions was shorter for the induced than for those starting spontaneously, and the intensity of pain at delivery was rated somewhat less by those who were induced.There was no difference between induced babies and others in the proportion who were held by their mothers immediately after their birth. Two-fifths of the mothers who were induced would have liked more information about induction; and a similar proportion said they had not discussed induction with a doctor, midwife, or nurse during their pregnancy. Only 17% of the mothers who had an induction said they would prefer to be induced if they had another baby. This contrasts with 63% of those who had epidural analgesia who would opt for the same procedure next time, while 83% of those who had had a baby in hospital, and 91% of those having had a home birth, would want their next baby in the same type of place.     

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.     

Trial and Failed Forceps in Obstetrics

Current literature dealing with trial and failed forceps is reviewed, and a representative case of each is presented. There is a place in modern obstetrics for trial forceps. “Failed forceps” is due to one or more of the following conditions: (1) cephalopelvic disproportion, (2) malposition of the head, (3) premature interference under conditions unfavourable for vaginal delivery, (4) incomplete dilatation of the cervix, and (5) constriction ring. A large caput succedaneum may occasion premature obstetrical interference. An adequate pelvic examination should be performed and/or lateral radiographs of the pelvis should be taken to prevent this mistake, i.e. attempted forceps extraction. There is no place in the management of failed forceps cases for version and extraction. It may be advisable to perform an elective Cesarean section following failed forceps, even with a dead fetus.     

Active management of labour: current knowledge and research issues.

OBJECTIVES--To review the evidence that the package of labour interventions collectively called "active management"--namely, strict diagnostic criteria for labour, early amniotomy, early use of oxytocin, and continuous professional support--reduce rates of caesarean sections and operative vaginal delivery in first labours. DESIGN--Review of observational data, supplemented by evidence from four separate overviews of relevant randomised trials previously published as part of the Cochrane Collaboration pregnancy and childbirth database. RESULTS--Observational data do not permit a clear conclusion. There have been no randomised trials of the total package of active management or of the use of strict diagnostic criteria alone, but trials of early amniotomy, early oxytocin, and these interventions combined do not suggest that these interventions are effective in reducing rates of caesarean sections or operative vaginal deliveries. In contrast, the provision of continuous professional support in labour seems to reduce both types of operative delivery, although the effect on caesarean sections is confined to those settings where non-professional companions are not normally present in labour. CONCLUSIONS--Delivery units should endeavour to provide continuous professional support in labour, but routine use of amniotomy and early oxytocin is not recommended.     

不同分娩方式对晚期早产儿肠道菌群的影响

目的 探讨不同分娩方式对晚期早产儿肠道菌群定植的影响。方法 以胎龄(周)为34~(0/7)～36~(6/7)的15例晚期早产儿为研究对象,根据分娩方式分为自然分娩组(n=8)和剖宫产组(n=7)。收集早产儿出生后3 d、7 d、14 d的粪便标本,应用高通量测序技术对细菌16S rRNA可变区中的V4区进行测序,分析肠道菌群多样性及组成结构。结果 (1)自然分娩组晚期早产儿粪便标本菌群多样性指数逐渐上升,剖宫产组的多样性指数较平稳,两组相比差异无统计学意义;(2)45份粪便标本中共检测出10个菌门,均以变形菌门、厚壁菌门、放线菌门和拟杆菌门为优势菌门,两组晚期早产儿生后变形菌门、拟杆菌门所占比例逐渐降低,厚壁菌门、放线菌门呈增多趋势。两组相比,剖宫产组7 d、14 d时拟杆菌门的相对丰度显著低于自然分娩组(Z=-2.896,P=0.004;Z=-2.120,P=0.040),变形菌门相对丰度仅在7 d时显著高于自然分娩组(Z=-2.190,P=0.030);(3)两组研究对象中,除自然分娩组14 d时以双歧杆菌属为优势菌属外,余下均以肠杆菌属为优势菌属。相比于自然分娩组,在7 d时剖宫产组拟杆菌属所占比例显著降低(Z=-2.806,P=0.005),肠杆菌属所占比例显著升高(Z=-2.199,P=0.030)。结论 剖宫产能显著影响婴儿早期肠道菌群的定植,降低肠道中早期拟杆菌的水平。     

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.     

Role of pelvimetry in active management of labour.

All cases referred for pelvimetry in 1970-1 and all breech presentations referred for pelvimetry in 1972-4 were reviewed. Indications for pelvimetry fell into four main categories: high head in the antenatal clinic (47-8%); high head in labour (13-9%); breech presentation (20-9%); and previous caesarean section (14-8%). In the first two categories pelvimetry rarely if ever influenced management, and it should not be performed routinely. In breech presentation and cases of caesarean section pelvimetry seemed to be of value, but in the latter group it should be performed puerperally to avoid the known radiation hazard to the fetus. A fairly close correlation between obstetric conjugate and pelvic capacity was shown, which suggested that a 3400-g baby might pass through a pelvis of obstetric conjugate of 10 cm as a cephalic trial of labour, but would need an obstetric conjugate of 11-7 cm for safe vaginal breech delivery.     

Kielland's forceps: role of antenatal factors in prediction of use.

The association between certain antenatal factors and the use of Kielland''s forceps was analysed retrospectively in liveborn singleton births that occurred at this hospital between January and December 1976. Factors significantly associated with the use of Kielland''s forceps were primiparity, short maternal stature, induction of labour, late engagement of the fetal head, low ratio of maternal height to fetal occipitofrontal head circumference, slow dilatation of the cervix in labour, and the use of epidural analgesia in labour. The findings support a contribution of cephalopelvic disproportion in the genesis of malposition, and when associated with slow dilatation of the cervix delivery should be expedited. Long-term follow-up studies are needed, however, before the role of caesarean section in reducing morbidity associated with malposition can be properly assessed.     

Postpartum Haemorrhage in Canada and France: A Population-Based Comparison

Objective

Maternal mortality ratio due to postpartum haemorrhage (PPH) is higher in France than in Canada. We explored this difference by comparing PPH features between these two countries.

Methods

Using data between 2004 and 2006, we compared the incidence, risk factors, causes and use of second-line treatments, of PPH between France (N = 6,660 PPH) and Canada (N = 9,838 PPH). We assessed factors associated with PPH through multivariate logistic models.

Results

PPH incidence, overall (4.8% (95% CI 4.7–4.9) in Canada and 4.5% (95% CI 4.4–4.7) in France), and after vaginal delivery (5.3% (95%CI 5.2–5.4) in Canada and 4.8 (95%CI 4.7–4.9) in France), were significantly higher in Canada than in France, but not after caesarean delivery. Women delivering without PPH were similar between the two populations, except for macrosomia (11% in Canada, 7% in France, p<0.001), caesarean delivery (27% in Canada, 18% in France, p<0.001), and episiotomy (17% in Canada, 34% in France, p<0.001). After vaginal delivery, factors strongly associated with PPH were multiple pregnancy, operative delivery and macrosomia in both populations, and episiotomy only in France (Odds Ratio 1.39 (95% CI 1.23–1.57)). The use of second-line treatments for PPH management was significantly more frequent in France than in Canada after both vaginal and caesarean delivery.

Conclusion

PPH incidence was not higher in France than in Canada and there was no substantial difference in PPH risk factors between the 2 countries. Greater use of second-line treatments in PPH management in France suggests a more frequent failure of first-line treatments and a higher rate of severe PPH, which may be involved in the higher maternal mortality ratio due to PPH.     

Differential expression of proteases in human gestational tissues before, during and after spontaneous-onset labour at term.

A number of tightly regulated proteolytic enzyme systems, including the plasminogen activation cascade and matrix metalloproteases, play integral roles in the remodelling of extracellular matrices during pregnancy and parturition. This study assessed these labour-associated changes in protease activity in human gestational tissues. Amnion, choriodecidua and placenta collected from women before (at caesarean section, not in labour), during (at caesarean section, in labour) and after (spontaneous-onset labour, normal vaginal delivery) labour were examined on gelatin-substrate SDS-PAGE zymography. All tissues displayed major 55 kDa plasminogen-dependent activity that was abolished by the serine protease inhibitors (10 mmol phenylmethyl-sulphonylfluoride l-1, 100 mmol epsilon aminocaproic acid l-1, 1 mmol Glu-Gly-Arg chloromethylketone l-1). The enzymic activity was identified as urokinase plasminogen activator on the basis of its co-migration with reference standard and western blot analysis, and did not vary with labour status. An additional protease with an apparent molecular mass of approximately 90 kDa was detected in all tissues. Densitometric measurement of these tissues showed a significant (P < 0.05) increase in this enzyme activity with labour onset. Heavy metal chelators (1 mmol 1.10 phenanthroline l-1 and 10 mmol EDTA l-1) selectively blocked the 90 kDa activity, consistent with the proposal that it is a metalloprotease. Co-migration with reference standard and western blot analysis confirmed the identity of this protease as the matrix metalloprotease 9 (MMP-9). Immunoreactive MMP-9 protein was also significantly (P < 0.05) increased during and after labour compared with before labour in all tissues examined. It is proposed that the upregulated expression of MMP-9 is involved in fetal membrane rupture and placental separation during and after labour onset, respectively. In conclusion, the regulated repertoire of protease activities expressed by human gestational tissues implies an important role for matrix-degrading enzymes during human parturition.