Cesarean birth: how to reduce the rate

The cesarean section rate, which approached 25%, has stabilized and started a modest decline. A stated United States national goal by the year 2000 is a rate of 15%. Suggested rates are 12% for primary and 3% for repeat cesarean sections. The major indications for cesarean section are prior cesarean delivery (8%), dystocia (7%), breech presentation (4%), fetal distress (2% to 3%), and others. The major areas of reduction must occur in the categories of prior cesarean delivery and dystocia. An expanded use of trial of labor and vaginal birth after a prior cesarean section will produce further reductions. Countries in Europe achieve > 50% vaginal birth after a prior cesarean section compared with 25% in the United States. A heightened awareness must occur regarding the decision to perform the first cesarean section. The residual impact, a scarred uterus, affects 12% to 14% of women seen for delivery. Even if 50% achieve a vaginal birth after a prior cesarean section, the national goals are unachievable. The obstetrician must consciously consider the impact of "once a cesarean, always a scar."     

Assignment1 of human putative tumor suppressor genes ST13 (alias SNC6) and ST14 (alias SNC19) to human chromosome bands 22q13 and 11q24-->q25 by in situ hybridization

OBJECTIVE: Our aim was to describe the indications of repeat caesarean delivery and to determine modifiable practice patterns that might lead to fewer repeat caesarean deliveries. METHOD: Hospital records of all women with previous caesarean sections who delivered between 15 April, 1994-31 December, 1994 at the Princess Badeea Teaching Hospital in North Jordan were reviewed. Three groups were identified: 1) elective repeat caesarean 2) vaginal birth after caesarean 3) failed vaginal birth after caesarean. RESULTS: In this study there were 388 patients. Of these, 208 had a repeat caesarean delivery for the following reasons: failed vaginal birth after caesarean (39, 10.1%) and repeat elective caesarean section (169, 43.5%). The remaining (180, 46.4%) patients had a vaginal birth after caesarean. CONCLUSIONS: Our vaginal birth rate after one previous caesarean section was 82.2%. If this rate can be maintained in patients with 2 or 3 previous caesarean deliveries, we can reduce repeat caesarean rates by at least 14% by allowing more patients with 2 or even 3 previous caesarean deliveries to have a trial of labour under appropriate conditions and also proper management of dystocia.     

Prenatal diagnosis of congenital toxoplasmosis transmitted by an immunocompetent woman infected before conception. Reims Toxoplasmosis Group

OBJECTIVE: To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery. DESIGN: Retrospective follow up study. SETTING: Medical Centre Leeuwarden, The Netherlands. PARTICIPANTS: All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 19861998. METHODS: Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour. RESULTS: Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour. CONCLUSIONS: In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.     

Elective delivery of infants with macrosomia in diabetic women: reduced shoulder dystocia versus increased cesarean deliveries

OBJECTIVE: We sought to test the hypothesis that elective delivery of infants diagnosed with macrosomia by ultrasonographic studies in diabetic women will significantly reduce the rate of shoulder dystocia without significantly increasing cesarean section rate. STUDY DESIGN: In a prospective study diabetic women with ultrasonographic estimated fetal weight > or = 4250 gm underwent elective cesarean section; women with estimated fetal weight > or = 90th percentile but < 4250 gm underwent induction of labor. Maternal and neonatal outcomes were analyzed and compared for the periods before and after initiation of the protocol. RESULTS: A total of 2604 diabetic patients were included in this study. The rate of shoulder dystocia was significantly lower after instituting the protocol (2.4% vs 1.1%, odds ratio 2.2). The cesarean section rate increased significantly between the two periods (21.7% vs 25.1%, p < 0.04). Ultrasonography correctly identified the presence or absence of macrosomia in 87% of patients. Only 10.6% of diabetic patients at term required intervention under the protocol (6.8% labor induction, 3.8% elective cesarean section). The rate of shoulder dystocia was 7.4% in macrosomic infants delivered vaginally. CONCLUSION: An ultrasonographically estimated weight threshold as an indication for elective delivery in diabetic women reduces the rate of shoulder dystocia without a clinically meaningful increase in cesarean section rate. This practice, in conjunction with an intensified management approach to diabetes, improves the outcome of these high-risk women and their infants.     

Cesarean section: medical benefits and costs

Cesarean section rates have risen dramatically in the U.S. over the past 20 years. Although infant mortality has declined during the same period, there is little evidence that more frequent cesarean surgery is the cause. Cesareans save lives or benefit health in certain circumstances, but the incidence of those indications has not increased. Cesarean section also has risks, the most significant for the infant being iatrogenic prematurity or respiratory disease. Maternal mortality is 2-4 times higher and morbidity is 5-10 times higher after a cesarean compared to vaginal birth. The four indications responsible for most of the rise in cesarean rates--previous cesarean, dystocia, breech presentation, and fetal distress--are those conferring the least clear-cut benefit. Demographically, women who are most likely to experience pregnancy complications, low birth weight births, or infant mortality are least likely to have a cesarean. Social, economic, and other factors seem to have a greater influence on the decision to perform a cesarean than does expected medical benefit. The development of neonatal intensive care, expanded access to prenatal care, and greater availability of abortion and family planning have contributed more to falling infant mortality. It has been estimated that approximately half the cesareans currently performed in the U.S. are medically unnecessary, resulting in considerable avoidable maternal mortality and morbidity, and a cost of over $1 billion each year.     

Changes in indications for cesarean delivery: United States, 1985 and 1994

OBJECTIVES: The percentages of cesarean deliveries attributable to specific indications (breech, dystocia, fetal distress, and elective repeat cesarean) were computed for 1985 and 1994. METHODS: Data were derived from the 1985 and 1994 National Hospital Discharge Surveys. RESULTS: Dystocia was the leading indication for cesarean delivery in both years. In comparison with 1985, cesareans performed in 1994 that were attributable to dystocia and breech presentation increased, those attributable to fetal distress did not change significantly, and elective repeat cesareans declined. CONCLUSIONS: Studying indications for cesareans can be useful for hospitals, clinicians, and researchers in determining strategies to lower primary and repeat cesarean rates.     

Stress, endocrine, and immune system; stress induces the onset of autoimmune diseases

Previous studies of birth certificates have not fully evaluated how accurately they identify delivery methods that have a historical component, such as repeat cesarean and vaginal birth after previous cesarean (VBAC). The authors used linked Georgia birth certificates for first and second deliveries to examine the accuracy of four reported delivery methods in the second pregnancy: vaginal (without previous cesarean), VBAC, primary cesarean, and repeat cesarean, as well as an indicator of a previous cesarean. From the immediate birth certificates, the delivery method for each of the two births was classified as vaginal (V) or cesarean section (CS), which produced possible sequences of V-V, CS-V, V-CS, and CS-CS. The delivery method for the second births to 106,049 women from 1989 through 1992 was reviewed, taking into account the historical information from the linked certificates regarding the first births. Only 42.0% of women with a CS-V sequence were correctly designated on the second birth certificate as a VBAC; 79.3% of women with a V- CS sequence were correctly designated as primary cesarean. From 1980 through 1988, birth certificates contained a check box indicating a previous cesarean (but no VBAC box). During this period, only 75.5% of 25,491 women with a previous cesarean were so designated on the birth certificate. These findings suggest that cross-sectional vital records data substantially underestimate VBAC and primary cesarean rates.     

Vaginal birth after cesarean section in twin gestation

OBJECTIVE: We report a 10-year experience with vaginal birth after cesarean section in women with twins. STUDY DESIGN: Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences. RESULTS: Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality. CONCLUSIONS: In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.     

Orifice-view aortography in patients with congenitally deformed aortic valves: determination of aortic valve area

Reports from the United States and around the world have marked a steadily rising cesarean section rate. Although the indications that account for the increase are generally agreed upon (previous cesarean section, dystocia, fetal distress, and malpresentation), the benefits derived from the liberalized use of cesarean section to deal with these diagnoses have not been carefully documented. In an attempt to determine if the cesarean section rate could be lowered with no adverse effect on neonatal outcome, 105,848 deliveries at Downstate-Kings County Hospital from 1961 through 1977 were reviewed. The 9727 cesarean sections performed were evaluated to determine the reasons for the increasing rates and the effect on perinatal outcome. It was concluded that by the use of fetal scalp blood sampling in cases of fetal distress, the use of internal pressure transducers in patients who fail to progress in labor, and allowing selected patients with previous sections to labor, the cesarean section rate might be substantially lowered. The maternal morbidity and mortality were also analyzed.     

Trial of labor in patients with a previous lower uterine vertical cesarean section

OBJECTIVE: Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section. STUDY DESIGN: A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS: Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted. CONCLUSION: A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.     

Aerobic and anaerobic microbiology of retroperitoneal abscesses

OBJECTIVE: This study examined the effects of order of previous modes of delivery on the rate of cesarean delivery and duration of a trial of labor among women with a history of 1 previous cesarean delivery and 1 previous vaginal delivery. STUDY DESIGN: The medical records of 4393 women at our institution who were seen June 1984-July 1996 for a trial of labor after a previous cesarean delivery were abstracted. The 800 women with a history of 1 previous cesarean and 1 previous vaginal delivery were included in this analysis. They were split into 2 groups by obstetric history: (1) 1 cesarean delivery followed by 1 vaginal delivery (vaginal last) and (2) 1 vaginal delivery followed by 1 cesarean delivery (cesarean last). Patient characteristics, durations of labor, and rates of cesarean delivery were compared with chi2 analysis, the Student t test, and the Wilcoxon rank sum test. Possible confounding variables were controlled for with multivariate logistic regression. RESULTS: The rates of cesarean delivery for the vaginal last and cesarean last groups were 7.2% and 14.7%, respectively (P = .002). The median durations of labor for the vaginal last and cesarean last groups were 5.6 and 7.0 hours, respectively (P = .01). The differences in cesarean rates and durations of labor were seen regardless of the indication for the previous cesarean delivery. CONCLUSIONS: Among women with 1 previous cesarean and 1 previous vaginal delivery, those whose most recent delivery was vaginal had a lower rate of cesarean delivery and shorter duration of labor than did those whose most recent delivery was cesarean.     

Maternal attitude and psychophysical adaptation of women undergoing primary and secondary cesarean section

BACKGROUND: The increase of cesarean sections, which is typical of the most industrialised countries, resulted in a higher rate of repeat cesarean sections. The previous CS is the main indication for cesarean delivery. The purpose of this study is to compare women who had a primary cesarean with women who had a repeat cesarean section in order to assess their different emotional reactions as well as their psychophysical consequences. METHODS: A questionnaire was administered to 36 patients who had a primary cesarean section and to 34 patients who had a repeat cesarean section, 6-12 months after birth. All these women were similar for age and gestational age of the birth. RESULTS: Results underline that patients are more disposed to accept the operation in repeat cesarean rather than in primary cesarean. Women who have a repeat cesarean section are more likely to accept this kind of delivery since the beginning, with positive effects on their postoperative course. Women who have a repeat cesarean section face more serenely not only prenatal but also post-natal period and show less serious psychophysical sequelae with respect to primary cesarean section because of their previous experience. CONCLUSIONS: As a result, an appropriate psychological support coupled with adequate information can reduce discomfort in cesarean patients.     

Common peripartum emergencies

Peripartum emergencies occur in patients with no known risk factors. When the well-being of the fetus is in question, the fetal heart rate pattern may offer etiologic clues. Repetitive late decelerations may signify uteroplacental insufficiency, and a sinusoidal pattern may indicate severe fetal distress. Repetitive variable decelerations suggesting umbilical cord compression may be relieved by amnioinfusion. Regardless of the etiology of the nonreassuring fetal heart pattern, measures to improve fetal oxygenation should be attempted while options for delivery are considered. Massive obstetric hemorrhage requires prompt action. Clinical signs, such as painless bleeding, uterine tenderness and nonreassuring fetal heart patterns, may help to differentiate causes of vaginal bleeding that may or may not require emergency cesarean delivery. The causes of postpartum hemorrhage include uterine atony, vaginal or cervical laceration, and retained placenta. The challenge of managing shoulder dystocia is to effect a rapid delivery while avoiding neonatal and maternal morbidity. The McRoberts maneuver has been shown to be the safest and most successful technique for relieving shoulder dystocia. Eclampsia responds best to magnesium sulfate, supportive care and supplemental hydralazine or labetalol as needed for severe hypertension.     

Reattempting failed external cephalic version under epidural anesthesia

OBJECTIVES: We hypothesize that the success rate of external cephalic version may be increased by performing a repeat attempt with the patient under epidural anesthesia. STUDY DESIGN: One hundred eight women with term singleton pregnancies in breech presentation underwent attempted external version. When external version failed, we offered them the option of a later attempt under epidural anesthesia. All fetuses who remained in breech position were delivered by elective cesarean section. RESULTS: Fifty (60%) of the 83 attempted external versions performed without anesthesia were successful. Seventeen of the 33 women whose versions were unsuccessful underwent elective cesarean delivery, and 16 elected to undergo repeat version attempts under epidural. Nine (56%) of these 16 procedures were successful, and 7 of these 9 women were delivered vaginally. The overall success rate was 71%, similar to the success rate of versions attempted on 25 women under epidural anesthesia. CONCLUSIONS: When an attempted external version fails, a repeat attempt under epidural anesthesia will usually be successful, resulting in a lower cesarean delivery rate.     

Prevention of obstetrical damage to the perineum. Proposal for a fetal-pelvic index for the selection of parturients at risk

BACKGROUND: According to some authors, vaginal delivery always causes denervation of perineum and the greater the damage the longer the second labour phase (the so-called "delivering phase"). Therefore, it is necessary to reduce the number of too prolonged labours, but it is equally important to avoid an uncontrolled increase of cesarean sections. In order to achieve this objective, it is important to carry out a careful selection among laboring women and choose those most at risk for whom cesarean section is strongly recommended. On the basis of the data collected by the medical literature and in consideration of the pathogenetic role of the outlet dystocia, we have tried to identify a simple and effective prognostic index resulting from the different pelvimetric and ultrasonographic parameters. METHODS: In 72 full-term pregnant women, we have taken into account the ultrasonographic parameters expressing the fetal dimension (cephalic diameters, cephalic and abdominal circumferences, estimated fetal weight according to Haddlok), the outlet pelvic diameters (trans-ischial and coccygeal-pubic) and a fetal-pelvic index derived from these parameters. RESULTS: If taken individually, these parameters do not seem to have any direct connection with the length of the delivering phase, but the combination of the cephalic and external pelvimetric diameters has produced a significative statistical coefficient. CONCLUSIONS: On the basis of the data collected, it is suggested that a careful evaluation of external pelvimetric and cephalic parameters would be useful from the clinical point of view.     

Use of a logistic regression model at two levels in the analysis of medical practice variations: the prophylactic cesarean

We show the use of a hierarchical logistic model to study the variations of the prophylactic cesarean section rate between the maternity hospitals of the Rh?ne-Alpes region. These variations are analyzed according to the women characteristics at first level, and the maternity hospital characteristics at second level. We present the two-level hierarchical logistic model and the method of estimation of the fixed and random parameters. Then, we compare and discuss the results obtained with those of the usual logistic model. The usual logistic model underestimates the standard error of the regression parameters. In our example however, the results obtained with the hierarchical model do not modify the conclusions concerning the effect of the women characteristics. All the women characteristics increase significantly the probability for a woman to have a prophylactic cesarean section. Nevertheless, the hierarchical model reveals the effect of the maternity hospital characteristics and shows that the maternity hospitals which receive many "at risk" women tend to perform fewer prophylactic cesarean sections than the others, in women with the same characteristics. It permits to estimate the residual variance of second level linked to the unobserved characteristics of the maternity hospitals. It permits to show that the effect of the main characteristics of the women (previous cesarean section, dystocia, chronic fetal distress) vary between maternity hospitals.     

Pattern of cervical dilatation in previous lower segment caesarean section patients

The pattern of cervical dilatation during labour in 100 patients with previous lower segment caesarean section (LSCS) was determined in a prospective partographic study. Eighty-four subjects delivered successfully by vaginal route. The mean initial dilatation rate (IDR) and average dilatation rate (ADR) were 0.884 cm/hour and 1.255 cm/hour respectively. The mean IDR and ADR of the patients who delivered vaginally were 0.96 cm/hour and 1.41 cm/hour respectively, while of those who required repeat LSCS mean IDR was 0.44 cm/hour and mean ADR was 0.42 cm/hour. Hence ADR in cases who required repeat LSCS was significantly slower as compared to those who delivered vaginally (p < 0.01). Most (87.5%) of the cases who required repeat LSCS crossed the alert line as compared to 34.5% of patients who delivered vaginally. The mean admission delivery interval (ADI) was 9.45 +/- 4.29 hours in patients with no previous vaginal delivery and 8.02 +/- 4.83 hours in patients with previous vaginal delivery. The mean durations of 1st and 2nd stages of labour were 11.8 +/- 5.35 hours and 29.4 +/- 27.3 minutes respectively. It is concluded that partographic evaluation is an important aspect in management of labour of such patients.     

Comparison of stature growth curves in children and adolescents

During the period 1988-1966, 737 pregnancies, in which the infant birth weight was > or = 4000 grams were studied. During the same period there were 11,631 newborns, and 6.3% of them were infants with a birth weight > or = 4000 grams. Normal vaginal delivery occurred in 583 cases (79.1%), vacuum extraction in 24 cases (3.3%) and caesarean section in 130 cases (17.6%). Regarding the caesarean section, 38 (29.2%) of them were elective and 92 (70.8%) were done in different periods of the labour. In these macrosomic babies perinatal death never occurred, but different pathological neonatal outcomes were observed and the majority of these were clavicle abruptions (39 cases: 5.3%). Maternal morbidity observed in the 607 (82.4%) cases with vaginal delivery is characterized by: 60 cases (9.8%) of vaginal and perineal tears, 4 cases (0.6%) of cervical tears, and 2 cases (0.3%) of pubic symphysis traumatic diastasis. Shoulder dystocia is the most likely outcome in fetal macrosomic delivery; for this reason we considered the diagnostic and therapeutic management of this obstetrical complication. Because the normal outcome of neonatal births actually encourages the preference for normal vaginal delivery, we concluded that mothers with macrosomic fetuses can safely be managed expectantly unless there is a high maternal and fetal risk.     

Maintenance treatment of ulcerative proctitis with mesalazine suppositories: a double-blind placebo-controlled trial. The Italian IBD Study Group

OBJECTIVE: To examine the outcome of trial second labor after a first cesarean performed because of cephalopelvic disproportion, defined according to strict diagnostic criteria. METHODS: Obstetric details of nulliparous women delivering at 37 or more weeks' gestation by cesarean for cephalopelvic disproportion, between 1975 and 1990, were recorded prospectively. The diagnostic criteria for cephalopelvic disproportion were cervical dilation arrested after 5 cm, unresponsive to oxytocin augmentation, after active dilatation of 2 cm or more in 2 hours. Fetal malpresentations and malpositions were excluded. The outcome of next delivery in our hospital by each woman enrolled was then examined. RESULTS: Eighty-four of 42,793 women met the criteria for disproportion, and 40 with cephalic presentations delivered their next baby in our hospital. All 40 underwent a trial of labor and 27 (68%) delivered vaginally, comprising seven (47%) women with larger second and 20 (80%) with smaller second babies. Of 15 women previously delivered by cesarean at full dilatation, 11 (73%) delivered vaginally with no serious maternal or neonatal morbidity. CONCLUSION: The strictly defined diagnosis of nulliparous cephalopelvic disproportion should not constitute an automatic "recurrent" indication for elective cesarean delivery, because 68% of patients in our series had successful vaginal deliveries in their next pregnancies. This rate is similar to those reported after all nulliparous cesareans for dystocia.