PULMONARY HEART DISEASE—A Panel Discussion

Abruptio placentae, in its severe form, causes the most hazardous type of third trimester bleeding. The severe grade may be accompanied by systemic effects, some of which are potentially lethal. A knowledge of these, as well as a system of grading the severity in terms of maternal risk, is essential to an understanding of therapy. Cases should be graded in severity from I to III on the basis of clinical factors. A delay in delivery, in Grade III, may result in an increased incidence of serious maternal complications. In Grade II, immediate cesarean section has reduced the fetal mortality rate.In managing Grade III premature separation of the placenta, the following steps should be carried out: (1) Laboratory study, including blood cross-matching and determination of plasma fibrinogen; (2) vaginal examination to confirm the diagnosis and to rupture of the membranes; (3) indicated therapy of systemic effects with fresh whole blood and fibrinogen, before considering any operative delivery; (4) election of a mode of delivery which will terminate the pregnancy in less than about six hours after onset of separation; this will frequently be cesarean section; (5) careful attention to postpartum care to avoid shock and renal failure.In Grade II, the same principles of therapy obtain. If the fetal heart tones are present, however, and vaginal delivery is not imminent, immediate cesarean section is justified. Complete conservatism, with vaginal delivery, is recommended in Grade I.     

AN EVALUATION OF CESAREAN SECTION

The risks of cesarean section have been reduced in step with the increase in safety of all major surgical procedures.In a series of 13,153 deliveries, 1,265 (9.6 per cent) were by cesarean section. There were three obstetrical maternal deaths in 11,888 cases in which delivery was by the vaginal route—0.025 per cent. In the series of 1,265 deliveries by cesarean section there was one death attributable to the operation—0.08 per cent.The total uncorrected fetal loss following cesarean section was 3.8 per cent. This compares favorably with fetal loss of 3.2 per cent in the vaginal delivery group in this series, and with fetal loss rates reported from large obstetrical centers.Anesthesia by spinal injection is the method of choice in cesarean section. There were no maternal deaths or accidents attributable to spinal anesthetic, and in no case was it felt that fetal death was attributable to it.The incidence of maternal morbidity in the cesarean section group following spinal anesthesia was 15.8 per cent—less than half the incidence of morbidity following inhalation anesthesia.     

重度妊娠期肝内胆汁淤积症对母婴结局影响的临床分析

目的：分析重度妊娠期肝内胆汁淤积症（intrahepatic cholestasis of pregnancy,ICP）对母婴结局的影响,以提高对ICP的认识与治疗水平。方法：选择ICP产妇58例,根据ICP分度标准分为轻度组（n=26例）和重度组（n=32例）,比较两组产妇的母婴结局。结果：与轻度组相比,重度组产妇剖宫产率、产后出血与平均产后出血量显著升高或增加,阴道分娩率显著降低,组间比较差异均具有统计学意义（P〈0.05）;重度组新生儿早产、胎儿窘迫、羊水污染和新生儿窒息的发生率均显著上升,新生儿平均出生体重显著降低,组间比较差异均具有统计学意义（P〈0.05）。结论：ICP对产妇及新生儿均有不良影响,对ICP严重程度进行划分,有利于临床处理。对于重度ICP产妇,应尽早采取剖宫产分娩的方式终止妊娠。     

南京某大型医院剖宫产及其影响因素的初步分析

目的:分析某医院剖宫产的现状,初步探讨其影响因素及控制策略。方法:整理分析了南京某大型医院2009年共1411名入院产妇的病历资料,按分娩方式分为自然分娩组(经阴道分娩)和剖宫产组,比较两组产妇的一般信息、身体状况、产时情况等,采用多因素Logistic回归分析了剖宫产的影响因素。结果:该医院2009年度剖宫产产妇为608人,占总产妇的43.09%。剖宫产产妇的年龄和体重明显高于自然分娩产妇(P0.01),既往身体状况相对较差。入院时多无产兆、宫口未开,且产妇宫高、腹围、胎心率明显较高(P0.05或P0.01)。B超检查也显示,羊水异常(过多或过少)、巨大儿、胎位不正(主要为臀位)以及脐带绕颈的比例也明显高于自然分娩产妇(P0.05或P0.01)。多因素Logistic回归分析显示,产妇高龄(35岁)、入院产兆、胎位不正、产妇腹围过大、胎儿窘迫及新生儿超重等皆为剖宫产的独立影响因素。此外发现19.24%的剖宫产产妇无临床指征(即社会因素)。结论:该医院剖宫产的比例不低,要根据影响因素合理选择剖宫产,尤其要有效控制无指征的剖宫产选择,降低剖宫产率。     

疤痕子宫妊娠妇女经产道分娩的可行性、安全性和相关危险因素分析

目的:探讨疤痕子宫妊娠妇女经产道分娩的可行性、安全性和相关危险因素。方法:选择疤痕子宫妊娠妇女120例,根据分娩方式的不同分为剖宫产组(80例)与自然分娩组(40例),观察再次剖宫产的原因与两组的预后情况。结果:再次剖宫产的指征主要为疤痕子宫(患者拒绝试产)、产程异常、胎儿窘迫、前置胎盘等。自然分娩组的产时出血量明显少于剖宫产组(P0.05),产后出血与产后感染发生率也均明显低于剖宫产组(P0.05)。两组的5分钟Apgar评分对比差异无统计学意义,但自然分娩组新生儿黄疸与新生儿湿肺发生情况明显低于剖宫产组(P0.05)。自然分娩组的分娩满意度为97.50%,剖宫产组为83.75%,自然分娩组明显高于剖宫产组(P0.05)。结论:疤痕子宫妊娠妇女经产道分娩可行性好,能减少对于产妇与新生儿的影响,安全性佳,但也要根据产妇的实际情况进行具体选择。     

南京某大型医院剖宫产及其影响因素的初步分析

目的：分析某医院剖宫产的现状,初步探讨其影响因素及控制策略。方法：整理分析了南京某大型医院2009年共1411名入院产妇的病历资料,按分娩方式分为自然分娩组（经阴道分娩）和剖宫产组,比较两组产妇的一般信息、身体状况、产时情况等,采用多因素Logistic回归分析了剖宫产的影响因素。结果：该医院2009年度剖宫产产妇为608人,占总产妇的43．09％。剖宫产产妇的年龄和体重明显高于自然分娩产妇（P〈0．01）,既往身体状况相对较差。入院时多无产兆、宫口未开,且产妇宫高、腹围、胎心率明显较高（P〈0．05或P〈0．01）。B超检查也显示,羊水异常（过多或过少）、巨大儿、胎位不正（主要为臀位）以及脐带绕颈的比例也明显高于自然分娩产妇（P〈0．05或P〈0．01）。多因素Logistic回归分析显示,产妇高龄（〉35岁）、入院产兆、胎位不正、产妇腹围过大、胎儿窘迫及新生儿超重等皆为剖宫产的独立影响因素。此外发现19．24％的剖宫产产妇无临床指征（即社会因素）。结论：该医院剖宫产的比例不低,要根据影响因素合理选择剖宫产,尤其要有效控制无指征的剖宫产选择,降低剖宫产率。     

Spontaneous oxidative DNA damage in bovine retained and nonretained placental membranes

Retention of fetal membranes (RFM) is believed to be associated with conditions of oxidative stress. In this study, 8-hydroxy-2'-deoxyguanosine (8-OH-dG) was used for the determination of spontaneous oxidative DNA lesions in maternal and fetal parts of bovine retained and nonretained placentas. Placental specimens were collected directly after spontaneous delivery or during cesarean section from cows divided into 6 groups: (A) cesarean section before term without RFM, (B) with RFM, (C) cesarean section at term without RFM, (D) with RFM, (E) spontaneous delivery at term without RFM and (F) with RFM. Isolated DNA was hydrolyzed and analyzed by HPLC; native nucleosides were monitored at 254 nm and 8-OH-dG by electrochemical detection. No significant differences in 8-OH-dG levels between retained and nonretained placental tissues were found in all samples from preterm groups (mean concentrations between 13 and 42 micromol/mol deoxyguanosine (dG)). In the term cesarean section group with RFM a significant increase in 8-OH-dG concentration in DNA from maternal (8-fold) and fetal (18-fold) membranes were detected when compared to the respective nonretained tissues. Also, in the term spontaneous delivery groups maternal nonretained placental tissues showed increased levels of 8-OH-dG in comparison to the respective tissues of the retained placenta group. In placental tissues oxidative DNA lesions appear to be controlled by responsive mechanisms which, possibly following exhaustion, give rise to increased 8-OH-dG levels.     

不同类型妊娠高血压疾病对产妇妊娠结局的影响

目的:探讨不同类型妊娠高血压疾病(PIH)对产妇妊娠结局的影响。方法:选取2011年1月~2013年12月我妇产科院收治的妊娠期出现高血压症状的产妇106例为观察组,并选取同期正常孕产妇100例为对照组,根据诊断标准将观察组患者再分为PIH组(75例)、子痫前期组(21例)以及子痫组(10例),对比4组产妇的胎儿窘迫、胎盘早剥、早产、剖宫产、产后出血以及新生儿窒息的发生率。结果:观察组产妇的胎儿窘迫、胎盘早剥、早产、剖宫产、产后出血以及新生儿窒息的发生率明显高于对照组,差异有统计学意义(P0.05);妊娠期高血压组、子痫前期组、子痫组的胎儿窘迫、胎盘早剥、早产、剖宫产、产后出血以及新生儿窒息的发生率,依次升高,差别有统计学意义(P0.05)。结论:应正确认识到不同类型PIH对妊娠结局的影响以及其并发症的规律,做好预防措施,以减少不良妊娠结局的发生。     

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women''s clinical diagnoses.

Methods and Findings

Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

Conclusions

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors'' Summary     

Intrauterine transfusion with red cells and platelets.

Having direct access to the fetoplacental circulation by ultrasound-directed needle puncture has led to therapeutic interventions for fetal anemia and thrombocytopenia. Most cases of red cell alloimmunization associated with fetal anemia are caused by the antibody to the D red cell antigen. The intravascular transfusion of red cells to a hydropic fetus in such cases has notably improved survival. Nonimmune hydrops fetalis due to maternal parvovirus infection has also been treated successfully with the intravascular transfusion of red cells, whereas fetomaternal hemorrhage has not proved amenable to such therapy. Sensitization to the PLA-1 platelet antigen is the most common cause of fetal thrombocytopenia in maternal platelet alloimmunization. Fetal platelet transfusions have not proved to be a practical therapeutic modality for this disorder owing to the short half-life of the platelets. Platelets transfusions to the fetus just before delivery may avert the need for cesarean section in cases of severe thrombocytopenia.     

经会阴三维超声评价不同分娩方式初产妇肛门括约肌复合体和盆膈裂孔的临床应用价值

摘要 目的：探讨经会阴三维超声在不同分娩方式初产妇肛门括约肌复合体（ASC）和盆膈裂孔（PH）影响的评估价值。方法：选择2017年1月～2019年12月我院进行分娩的初产妇150例,按照分娩方式分成阴道分娩组71例,剖宫产组79例,比较两组基线资料。对所有受试者均实施经会阴三维超声检查,比较两组缩肛动作下肛门内括约肌（IAS）远端、中端及远端平面厚度,肛门外括约肌（EAS）远端平面及耻骨直肠肌（PRM）中端平面厚度,分娩前、产后6周、产后3个月PH左右径、PH前后径以及PH面积。结果：两组孕妇年龄、孕周及体质指数比较无差异（P＞0.05）,阴道分娩组IAS近端6点钟方向、12点钟方向平面厚度以及IAS中端、12点钟方向平面厚度均小于剖宫产组（P＜0.05）。阴道分娩组EAS远端12点钟方向平面厚度小于剖宫产组（P＜0.05）。阴道分娩组产后6周的PH左右径大于剖宫产组（P＜0.05）。阴道分娩组产后6周的PH前后径大于剖宫产组（P＜0.05）。阴道分娩组产后6周的pH面积大于剖宫产组（P＜0.05）。结论：经会阴三维超声可有效评估初产妇ASC和PH的影响情况,分娩会对初产妇ASC和PH产生影响,阴道分娩的初产妇产后存在明显的ASC厚度减小和PH增大现象。     

Molecular and immunological characterization of allergens from the entomopathogenic fungus Beauveria bassiana

Background

The mechanisms for the association between birth by cesarean section and atopy and asthma are largely unknown.

Objective

To examine whether cesarean section results in neonatal secretion of cytokines that are associated with increased risk of atopy and/or asthma in childhood. To examine whether the association between mode of delivery and neonatal immune responses is explained by exposure to the maternal gut flora (a marker of the vaginal flora).

Methods

CBMCs were isolated from 37 neonates at delivery, and secretion of IL-13, IFN-γ, and IL-10 (at baseline and after stimulation with antigens [dust mite and cat dander allergens, phytohemagglutinin, and lipopolysaccharide]) was quantified by ELISA. Total and specific microbes were quantified in maternal stool. The relation between mode of delivery and cord blood cytokines was examined by linear regression. The relation between maternal stool microbes and cord blood cytokines was examined by Spearman's correlation coefficients.

Results

Cesarean section was associated with increased levels of IL-13 and IFN-γ. In multivariate analyses, cesarean section was associated with an increment of 79.4 pg/ml in secretion of IL-13 by CBMCs after stimulation with dust mite allergen (P < 0.001). Among children born by vaginal delivery, gram-positive anaerobes and total anaerobes in maternal stool were positively correlated with levels of IL-10, and gram-negative aerobic bacteria in maternal stool were negatively correlated with levels of IL-13 and IFN-γ.

Conclusion

Cesarean section is associated with increased levels of IL-13 and IFN-γ, perhaps because of lack of labor and/or reduced exposure to specific microbes (e.g., gram-positive anaerobes) at birth.     

Maternal and Perinatal Outcomes by Mode of Delivery in Senegal and Mali: A Cross-Sectional Epidemiological Survey

Objective

In the context of rapid changes regarding practices related to delivery in Africa, we assessed maternal and perinatal adverse outcomes associated with the mode of delivery in 41 referral hospitals of Mali and Senegal.

Study Design

Cross-sectional survey nested in a randomised cluster trial (1/10/2007–1/10/2008). The associations between intended mode of delivery and (i) in-hospital maternal mortality, (ii) maternal morbidity (transfusion or hysterectomy), (iii) stillbirth or neonatal death before Day 1 and (iv) neonatal death between 24 hours after birth and hospital discharge were examined. We excluded women with immediate life threatening maternal or fetal complication to avoid indication bias. The analyses were performed using hierarchical logistic mixed models with random intercept and were adjusted for women''s, newborn''s and hospitals'' characteristics.

Results

Among the 78,166 included women, 2.2% had a pre-labor cesarean section (CS) and 97.8% had a trial of labor. Among women with a trial of labor, 87.5% delivered vaginally and 12.5% had intrapartum CS. Pre-labor CS was associated with a marked reduction in the risk of stillbirth or neonatal death before Day 1 as compared with trial of labor (OR = 0.2 [0.16–0.36]), though we did not show that maternal mortality (OR = 0.3 [0.07–1.32]) and neonatal mortality after Day 1 (OR = 1.3 (0.66–2.72]) differed significantly between groups. Among women with trial of labor, intrapartum CS and operative vaginal delivery were associated with higher risks of maternal mortality and morbidity, and neonatal mortality after Day 1, as compared with spontaneous vaginal delivery.

Conclusions

In referral hospitals of Mali and Senegal, pre-labor CS is a safe procedure although intrapartum CS and operative vaginal delivery are associated with increased risks in mothers and infants. Further research is needed to determine what aspects of obstetric care contribute to a delay in the provision of intrapartum interventions so that practices may be made safer when they are needed.     

胎盘早剥86 例的临床表征与病因分析

目的:分析胎盘早剥漏诊、误诊原因,提高早期确诊率,降低母儿并发症。方法:回顾性分析我院10年内胎盘早剥患者的临床资料,分析比较胎盘早剥漏诊与误诊原因。结果:过去十年内我院共检测出胎盘早剥86例,发生率为0.46%,该类孕妇临床表现主要为腰腹胀或腹痛、阴道流血、血性羊水。其中,急诊入院患者占(61.6%),有明确诱因39例,占45.3%,且以妊娠期高血压疾病、胎膜早破、外伤性因素为主。B超检出率62.8%。轻型胎盘早剥45例(52.3%),重型胎盘早剥41例(47.7%),出现症状到就诊及处理时间重型胎盘早剥均长于轻型胎盘组P<0.01。剖宫产分娩60例(69.8%),阴道分娩26例(30.2%)。结论:临床发病到临床处理时间是影响胎盘早剥轻重程度的重要因素;胎盘早剥临床表现易与早产、先兆临产或胎儿窘迫等混淆;后壁胎盘发生胎盘早剥时,超声容易漏诊。     

Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil

BackgroundCesarean delivery rates continue to increase worldwide and reached 57% in Brazil in 2014. Although the safety of this surgery has improved in the last decades, this trend is a concern because it carries potential risks to women’s health and may be a modifiable risk factor of maternal mortality. This paper aims to investigate the risk of postpartum maternal death directly associated with cesarean delivery in comparison to vaginal delivery in Brazil.MethodsThis was a population-based case—control study performed in eight Brazilian states. To control for indication bias, deaths due to antenatal morbidity were excluded. We included 73 cases of postpartum maternal deaths from 2009–2012. Controls were selected from the Birth in Brazil Study, a 2011 nationwide survey including 9,221 postpartum women. We examined the association of cesarean section and postpartum maternal death by multivariate logistic regression, adjusting for confounders.ResultsAfter controlling for indication bias and confounders, the risk of postpartum maternal death was almost three-fold higher with cesarean than vaginal delivery (OR 2.87, 95% CI 1.63–5.06), mainly due to deaths from postpartum hemorrhage and complications of anesthesia.ConclusionCesarean delivery is an independent risk factor of postpartum maternal death. Clinicians and patients should consider this fact in balancing the benefits and risks of the procedure.     

ITP in pregnancy and the newborn: introduction

Idiopathic thrombocytopenic purpura (ITP) occurs more commonly in young women and is one of the commonest immune mediated disorders in pregnancy. It may exist as an incidental finding in an otherwise healthy pregnant woman or may be associated with symptomatic reduction in the platelet count and varying degrees of clinical hemorrhage. The condition termed incidental thrombocytopenia of pregnancy is invariably associated with a platelet count of greater than 100 x 10(9)/L and a very low incidence of fetal thrombocytopenia. Symptomatic thrombocytopenia is more commonly associated with low platelet counts in the fetus (estimated between 20%-40%). It has recently been suggested that the incidence of fetal thrombocytopenia is substantially lower than this figure. The management of ITP in pregnancy is complicated by the fact that fetal thrombocytopenia is difficult to diagnose and carries substantial risks during the delivery process with rare cases of fetal hemorrhage occurring spontaneously in utero. Unfortunately there are no laboratory studies that can be performed precisely in the mother that may predict the occurrence of fetal thrombocytopenia. Maternal management is usually directed towards treatment of maternal symptoms. Maternal treatment or response to treatment is inconsistently associated with predictable changes in the fetal platelet count. Obstetric management is aimed at reducing the risks of life threatening fetal hemorrhage occurring at the time of delivery, and fetal management is directed towards the obtaining of fetal platelet samples in order to plan an appropriate strategy for obstetrical delivery. Fetal blood samples are obtained either by a scalp vein puncture at the time of delivery or earlier in gestation by the use of the newer technique termed percutaneous umbilical blood sampling. Fetuses with platelet counts of less then 50 x 10(9)/L are generally delivered by cesarean section whereas those with counts greater than 50 x 10(9)/L are allowed to proceed with vaginal delivery assuming no obstetrical contraindications exist. The use of IVIgG therapy during pregnancy has theoretical implications on improving platelet counts in the mother in situations of severe hemorrhage, however cannot be considered to be appropriate treatment for the prevention of fetal thrombocytopenia, since the exogenous transport of IVIgG across the placenta appears to be inconsistent and unpredictable.(ABSTRACT TRUNCATED AT 400 WORDS)     

硬膜外麻醉无痛分娩、剖宫产和自然分娩对盆底组织功能的影响

摘要 目的：比较不同的分娩方法（自然分娩、无痛分娩、剖宫产）对产妇盆底组织功能的影响。方法：选择2019年10月～2020年11月在我院进行分娩的80例产妇,其中,自然分娩组15例,无痛分娩组26例、剖宫产组39例。记录自然分娩组和无痛分娩组第一、第二产程的疼痛程度和第一、第二产程所需时间,巨大儿、新生儿黄疸、低体重儿和新生儿窒息等母婴结局,Apgar评分、产时出血量和胎儿体重;且检查产妇的盆底肌力,记录自然分娩组、无痛分娩组、剖宫产组的尿失禁发生率。结果：无痛分娩组的第一、第二产程的视觉模拟评分法（Visual analog scales,VAS）评分和第一、第二产程所需时间明显低于自然分娩组(P<0.05);自然分娩组和无痛分娩组的巨大儿、新生儿黄疸、低体重儿和新生儿窒息率无明显差异(P>0.05);自然分娩组和无痛分娩组的Apgar评分、产时出血量和胎儿体重无明显差异(P>0.05);无痛分娩组的盆底肌力明显高于自然分娩组(P<0.05),剖宫产组的盆底肌力明显高于无痛分娩组(P<0.05);三组尿失禁的发生率对比差异无统计学意义(P>0.05)。结论：无痛分娩不但能减轻分娩疼痛程度,还能减轻对盆底组织功能的损伤,值得进行推广。     

The effect of delaying childbirth on primary cesarean section rates

Background

The relationship between population trends in delaying childbirth and rising rates of primary cesarean delivery is unclear. The aims of the present study were (1) to characterize the association between maternal age and the outcome of labor, (2) to determine the proportion of the increase in primary cesarean rates that could be attributed to changes in maternal age distribution, and (3) to determine whether the contractility of uterine smooth muscle (myometrium) varied with maternal age.

Methods and Findings

We utilized nationally collected data from Scotland, from 1980 to 2005, and modeled the risk of emergency cesarean section among women delivering a liveborn infant in a cephalic presentation at term. We also studied isolated myometrial strips obtained from 62 women attending for planned cesarean delivery in Cambridge, England, from 2005 to 2007. Among 583,843 eligible nulliparous women, there was a linear increase in the log odds of cesarean delivery with advancing maternal age from 16 y upwards, and this increase was unaffected by adjustment for a range of maternal characteristics (adjusted odds ratio for a 5-y increase 1.49, 95% confidence interval [CI] 1.48–1.51). Increasing maternal age was also associated with a longer duration of labor (0.49 h longer for a 5-y increase in age, 95% CI 0.46–0.51) and an increased risk of operative vaginal birth (adjusted odds ratio for a 5-y increase 1.49, 95% CI 1.48–1.50). Over the period from 1980 to 2005, the cesarean delivery rate among nulliparous women more than doubled and the proportion of women aged 30–34 y increased 3-fold, the proportion aged 35–39 y increased 7-fold, and the proportion aged ≥40 y increased 10-fold. Modeling indicated that if the age distribution had stayed the same over the period of study, 38% of the additional cesarean deliveries would have been avoided. Similar associations were observed in multiparous women. When studied in vitro, increasing maternal age was associated with reduced spontaneous activity and increased likelihood of multiphasic spontaneous myometrial contractions.

Conclusions

Delaying childbirth has significantly contributed to rising rates of intrapartum primary cesarean delivery. The association between increasing maternal age and the risk of intrapartum cesarean delivery is likely to have a biological basis.     

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.