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Discover the most talked about and latest scientific content & concepts.

Concept: Breech birth

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To determine if “early rupture of membranes” (early ROM) during induction of labor is associated with an increased risk of cesarean section in term nulliparas.

Concepts: Childbirth, Obstetrics, Epidural, Caesarean section, Breech birth, Labor induction, Ventouse, Pre-eclampsia

170

Caesarean section incidence is steadily rising worldwide; the major contributor to this rise is pregnancies with previous caesarean section. Hence, it is important to scrutinise carefully the indication of primary caesarean sections. Preterm births, breech presentation and twin pregnancies together complicate 12-18% of all births. The role of caesarean section in these pregnancies is controversial and lacks good evidence-based guidelines. Policy on mode of delivery in these three important obstetric groups is bound to influence overall primary caesarean section rates. In this chapter, we review the evidence on the place of caesarean delivery in these three important groups.

Concepts: Childbirth, Obstetrics, Caesarean section, Breech birth, Ventouse, Pre-eclampsia

169

BACKGROUND: British women are increasingly delaying childbirth. The proportion giving birth over the age of 35 rose from 12% in 1996 to 20% in 2006. Women over this age are at a higher risk of perinatal death, and antepartum stillbirth accounts for 61% of all such deaths. Women over 40 years old have a similar stillbirth risk at 39 weeks as women who are between 25 and 29 years old have at 41 weeks.Many obstetricians respond to this by suggesting labour induction at term to forestall some of the risk. In a national survey of obstetricians 37% already induce women aged 40–44 years. A substantial minority of parents support such a policy, but others do not on the grounds that it might increase the risk of Caesarean section. However trials of induction in other high-risk scenarios have not shown any increase in Caesarean sections, rather the reverse. If induction for women over 35 did not increase Caesareans, or even reduced them, it would plausibly improve perinatal outcome and be an acceptable intervention. We therefore plan to perform a trial to test the effect of such an induction policy on Caesarean section rates.This trial is funded by the NHS Research for Patient Benefit (RfPB) Programme. DESIGN: The 35/39 trial is a multi-centre, prospective, randomised controlled trial. It is being run in twenty UK centres and we aim to recruit 630 nulliparous women (315 per group) aged over 35 years of age, over two years. Women will be randomly allocated to one of two groups:Induction of labour between 390/7 and 396/7 weeks gestation.Expectant management i.e. awaiting spontaneous onset of labour unless a situation develops necessitating either induction of labour or Caesarean Section.The primary purpose of this trial is to establish what effect a policy of induction of labour at 39 weeks for nulliparous women of advanced maternal age has on the rate of Caesarean section deliveries. The secondary aim is to act as a pilot study for a trial to answer the question, does induction of labour in this group of women improve perinatal outcomes? Randomisation will occur at 360/7 – 396/7 weeks gestation via a computerised randomisation programme at the Clinical Trials Unit, Nottingham University Hospitals NHS Trust. There will be no blinding to treatment allocation. DISCUSSION: The 35/39 trial is powered to detect an effect of induction of labour on the risk of caesarean section, it is underpowered to determine whether it improves perinatal outcome. The current study will also act as a pilot for a larger study to address this question.Trial registration: ISRCTN11517275.

Concepts: Childbirth, Randomized controlled trial, Obstetrics, Oxytocin, Caesarean section, Breech birth, Labor induction, Pre-eclampsia

83

Escalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization’s Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset.

Concepts: AIDS, Childbirth, Africa, Sub-Saharan Africa, Obstetrics, Epidural, Caesarean section, Breech birth

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The call for women-centred approaches to reduce labour interventions, particularly primary caesarean section, has renewed interest in a better understanding of natural labour progression.

Concepts: Childbirth, Obstetrics, Hysterectomy, Epidural, Caesarean section, Breech birth, Ventouse, Fetal distress

46

Until the 20th century, home was where most births took place. By the second half of that century, hospital birth had become the norm in most Western countries. With this change came the “medicalization” of birth, as hospitals introduced interventions to reduce the risks inherent to childbirth that could not be performed in the home setting. Many of these interventions were beneficial, even lifesaving, for the mother or baby, but some, often judged in retrospect, seemed unnecessary. The occasional performance of a cesarean delivery for a fetus thought to have hypoxemia and acidosis followed by the delivery of an entirely . . .

Concepts: Pregnancy, Childbirth, Infant, Obstetrics, 20th century, Epidural, Caesarean section, Breech birth

36

Recently, we presented the cliff-edge model to explain the evolutionary persistence of relatively high incidences of fetopelvic disproportion (FPD) in human childbirth. According to this model, the regular application of Caesarean sections since the mid-20th century has triggered an evolutionary increase of fetal size relative to the dimensions of the maternal birth canal, which, in turn, has inflated incidences of FPD. While this prediction is difficult to test in epidemiological data on Caesarean sections, the model also implies that women born by Caesarean because of FPD are more likely to develop FPD in their own childbirth compared with women born vaginally. Multigenerational epidemiological studies indeed evidence such an intergenerational predisposition to surgical delivery. When confined to anatomical indications, these studies report risks for Caesarean up to twice as high for women born by Caesarean compared with women born vaginally. These findings provide independent support for our model, which we show here predicts that the risk of FPD for mothers born by Caesarean because of FPD is 2.8 times the risk for mothers born vaginally. The congruence between these data and our prediction lends support to the cliff-edge model of obstetric selection and its underlying assumptions, despite the genetic and anatomical idealizations involved.

Concepts: Childbirth, Epidemiology, Biology, Obstetrics, Epidural, Caesarean section, Breech birth, Ventouse

28

: Shoulder dystocia is one of the most terrifying of obstetric emergencies. In this secondary analysis of two qualitative studies, the experiences of shoulder dystocia are compared and contrasted from two perspectives: the mothers and the labor and delivery nurses.

Concepts: Pregnancy, Childbirth, Obstetrics, Caesarean section, Breech birth, Midwifery, Shoulder dystocia

28

In 17th century France, the practice of obstetrics passed from female midwives to medical men called accoucheurs. François Mauriceau, a prominent French obstetrician of the 17th century urged the need of an organised obstetrical education, emphasising anatomy. He invented the semi-recumbent or ‘French’ birthing position, the ‘tire-tête’ forceps, the ‘Mauriceau manoeuvre’ in breech delivery, and provided one of the first epidemiological analyses in obstetrics contributing enormously to the development of this specialty. His best-seller, Traité des maladies des femmes grosses revolutionised the practice of obstetrics.

Concepts: Medicine, Childbirth, Obstetrics, Caesarean section, Breech birth, Midwifery, Childbirth and obstetrics in antiquity, 17th century

28

The aim of this study was to describe the distribution of indications for vacuum extraction (VE) and emergency cesarean section (EMCS) from 1999 to 2010. Furthermore, we investigated the association of induction of labor and epidural analgesia (EA) on the risk of operative delivery.

Concepts: Childbirth, Obstetrics, Epidural, Caesarean section, Breech birth, Labor induction, Ventouse, Pre-eclampsia