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Concept: Caesarean section

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The strikingly high incidence of obstructed labor due to the disproportion of fetal size and the mother’s pelvic dimensions has puzzled evolutionary scientists for decades. Here we propose that these high rates are a direct consequence of the distinct characteristics of human obstetric selection. Neonatal size relative to the birth-relevant maternal dimensions is highly variable and positively associated with reproductive success until it reaches a critical value, beyond which natural delivery becomes impossible. As a consequence, the symmetric phenotype distribution cannot match the highly asymmetric, cliff-edged fitness distribution well: The optimal phenotype distribution that maximizes population mean fitness entails a fraction of individuals falling beyond the “fitness edge” (i.e., those with fetopelvic disproportion). Using a simple mathematical model, we show that weak directional selection for a large neonate, a narrow pelvic canal, or both is sufficient to account for the considerable incidence of fetopelvic disproportion. Based on this model, we predict that the regular use of Caesarean sections throughout the last decades has led to an evolutionary increase of fetopelvic disproportion rates by 10 to 20%.

Concepts: Gene, Pregnancy, Childbirth, Natural selection, Evolution, Evolutionary biology, Caesarean section, Fitness

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BACKGROUND: Physical and psychological problems after childbirth are common, and may have a significant negative and long-term impact on women’s wellbeing and daily functioning. The method of birth may be a particularly important factor influencing women’s health and wellbeing following birth, however, population-wide evidence is limited. This study uses data from 5,332 women who responded to a national survey of women’s experiences of maternity care in England. We examined women’s postnatal wellbeing in the first three months after birth, and whether these varied by mode of birth. METHODS: This is a secondary analysis of survey data using a random sample of women selected from birth registration. We used multinomial logistic regression models to examine the association between women’s self-reported psychological symptoms, health problems and mode of birth. RESULTS: Women who had forceps-assisted vaginal births and unplanned caesarean section births reported the poorest health and wellbeing, while those of women who had unassisted vaginal births and planned caesarean section births were less affected by the birth process. Most women’s physical and emotional health appeared to improve with time, however, those who had a forceps-assisted vaginal birth were more likely to report ongoing posttraumatic-type symptoms several months after the birth. CONCLUSIONS: Mode of birth was associated with differences in outcomes at three months. By comparison to women who had unassisted vaginal births, the risk of reduced postnatal health and wellbeing was higher amongst the women who had forceps-assisted vaginal births but not amongst women who had ventouse-assisted vaginal births. This would suggest that it is important to differentiate the different types of instrumental birth in outcome studies. Of concern was the higher rate of posttraumatic-type symptoms among women who had forceps-assisted vaginal births relative to the other modes of birth. Women who have forceps-assisted births should be monitored carefully by health professionals in the postnatal period, and in the months after childbirth, when they could be offered the opportunity to discuss their labour and birth.

Concepts: Regression analysis, Logistic regression, Childbirth, Obstetrics, Multinomial logit, Vagina, Caesarean section, Unassisted childbirth

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BACKGROUND: Few studies have systematically addressed the role of epidural analgesia and caesarean delivery in predicting the post-partum disease activity in women with Multiple Sclerosis (MS)The objective of this study was to assess the impact of epidural analgesia (EA) and caesarean delivery (CD) on the risk of post-partum relapses and disability in women with MS. METHODS: In the context of an Italian prospective study on the safety of immunomodulators in pregnancy, we included pregnancies occurred between 2002 and 2008 in women with MS regularly followed-up in 21 Italian MS centers. Data were gathered through a standardized, semi-structured interview, dealing with pregnancy outcomes, breastfeeding, type of delivery (vaginal or caesarean) and EA. The risk of post-partum relapses and disability progression (1 point on the Expanded Disability Status Sclae, EDSS, point, confirmed after six months) was assessed through a logistic multivariate regression analysis. RESULTS: We collected data on 423 pregnancies in 415 women. Among these, 349 pregnancies resulted in full term deliveries, with a post-partum follow-up of at least one year (mean follow-up period 5.5+/-3.1 years). One hundred and fifty-five patients (44.4%) underwent CD and 65 (18.5%) EA. In the multivariate analysis neither CD, nor EA were associated with a higher risk of post-partum relapses. Post-partum relapses were related to a higher EDSS score at conception (OR=1.42; 95%CI 1.11-1.82; p=0.005), a higher number of relapses in the year before pregnancy (OR=1.62; 95%CI 1.15-2.29; p=0.006) and during pregnancy (OR=3.07; 95% CI 1.40-6.72; p=0.005). Likewise, CD and EA were not associated with disability progression on the EDSS after delivery. The only significant predictor of disability progression was the occurrence of relapses in the year after delivery (disability progression in the year after delivery: OR= 4.00; 95%CI 2.0-8.2; p<0.001; disability progression over the whole follow-up period: OR= 2.0; 95%CI 1.2-3.3; p=0.005). CONCLUSIONS: Our findings, show no correlation between EA, CD and postpartum relapses and disability. Therefore these procedures can safely be applied in MS patients. On the other hand, post-partum relapses are significantly associated with increased disability, which calls for the need of preventive therapies after delivery.

Concepts: Regression analysis, Childbirth, Obstetrics, Multiple sclerosis, Caesarean delivery on maternal request, Epidural, Caesarean section, Placenta accreta

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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

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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

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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

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BACKGROUND: Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali METHODS: We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007–10/01/2008). Data were collected regarding women’s characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model. RESULTS: Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]). CONCLUSIONS: We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

Concepts: Childbirth, Epidemiology, Risk, Obstetrics, Anesthesia, Caesarean section, Pre-eclampsia, Premature rupture of membranes

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We describe the case of a 29-year-old parturient who, after undergoing elective cesarean delivery, displayed symptoms of lower extremity weakness and sensory deficit. Her past medical history was significant for asymptomatic Arnold Chiari Type I malformation and asthma. She had received spinal anesthesia that failed to achieve an adequate surgical level requiring conversion to general anesthesia. After tracheal extubation, she exhibited bilateral leg weakness that did not resolve over the next 4-6h. An urgent magnetic resonance imaging scan revealed a normal spine with no evidence of hematoma. The lower extremity paresis persisted and a neurologist diagnosed psychogenic paresis, a type of conversion disorder. Interestingly, the patient’s postoperative leg paresis was not her first occurrence of neurological dysfunction after dural puncture. At 27weeks of gestation, she had similar lower extremity symptoms after a lumbar puncture, performed to exclude meningitis for severe headache symptoms. Psychogenic paresis is not commonly reported in the medical literature and we found no reports of psychogenic paresis after spinal anesthesia in a parturient or recurrent psychogenic paresis. We review the various risk factors, etiology, neurological signs and symptoms, types, therapy and future management of a patient with recurrent conversion disorder.

Concepts: Medicine, Childbirth, The Canon of Medicine, Neurology, Anesthesia, Epidural, Caesarean section, Arnold-Chiari malformation

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Objective To study the strength and validity of associations between adiposity and risk of any type of obstetric or gynaecological conditions.Design An umbrella review of meta-analyses.Data sources PubMed, Cochrane database of systematic reviews, manual screening of references for systematic reviews or meta-analyses of observational and interventional studies evaluating the association between adiposity and risk of any obstetrical or gynaecological outcome.Main outcomes Meta-analyses of cohort studies on associations between indices of adiposity and obstetric and gynaecological outcomes.Data synthesis Evidence from observational studies was graded into strong, highly suggestive, suggestive, or weak based on the significance of the random effects summary estimate and the largest study in the included meta-analysis, the number of cases, heterogeneity between studies, 95% prediction intervals, small study effects, excess significance bias, and sensitivity analysis with credibility ceilings. Interventional meta-analyses were assessed separately.Results 156 meta-analyses of observational studies were included, investigating associations between adiposity and risk of 84 obstetric or gynaecological outcomes. Of the 144 meta-analyses that included cohort studies, only 11 (8%) had strong evidence for eight outcomes: adiposity was associated with a higher risk of endometrial cancer, ovarian cancer, antenatal depression, total and emergency caesarean section, pre-eclampsia, fetal macrosomia, and low Apgar score. The summary effect estimates ranged from 1.21 (95% confidence interval 1.13 to 1.29) for an association between a 0.1 unit increase in waist to hip ratio and risk endometrial cancer up to 4.14 (3.61 to 4.75) for risk of pre-eclampsia for BMI >35 compared with <25. Only three out of these eight outcomes were also assessed in meta-analyses of trials evaluating weight loss interventions. These interventions significantly reduced the risk of caesarean section and pre-eclampsia, whereas there was no evidence of association with fetal macrosomia.Conclusions Although the associations between adiposity and obstetric and gynaecological outcomes have been extensively studied, only a minority were considered strong and without hints of bias.

Concepts: Pregnancy, Childbirth, Systematic review, Obstetrics, Hysterectomy, Caesarean section, Pre-eclampsia

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Background The addition of azithromycin to standard regimens for antibiotic prophylaxis before cesarean delivery may further reduce the rate of postoperative infection. We evaluated the benefits and safety of azithromycin-based extended-spectrum prophylaxis in women undergoing nonelective cesarean section. Methods In this trial conducted at 14 centers in the United States, we studied 2013 women who had a singleton pregnancy with a gestation of 24 weeks or more and who were undergoing cesarean delivery during labor or after membrane rupture. We randomly assigned 1019 to receive 500 mg of intravenous azithromycin and 994 to receive placebo. All the women were also scheduled to receive standard antibiotic prophylaxis. The primary outcome was a composite of endometritis, wound infection, or other infection occurring within 6 weeks. Results The primary outcome occurred in 62 women (6.1%) who received azithromycin and in 119 (12.0%) who received placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). There were significant differences between the azithromycin group and the placebo group in rates of endometritis (3.8% vs. 6.1%, P=0.02), wound infection (2.4% vs. 6.6%, P<0.001), and serious maternal adverse events (1.5% vs. 2.9%, P=0.03). There was no significant between-group difference in a secondary neonatal composite outcome that included neonatal death and serious neonatal complications (14.3% vs. 13.6%, P=0.63). Conclusions Among women undergoing nonelective cesarean delivery who were all receiving standard antibiotic prophylaxis, extended-spectrum prophylaxis with adjunctive azithromycin was more effective than placebo in reducing the risk of postoperative infection. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; C/SOAP ClinicalTrials.gov number, NCT01235546 .).

Concepts: Childbirth, Obstetrics, Caesarean section, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, Kennedy family, Ted Kennedy, Maria Shriver