Showing papers on "Vaginal delivery published in 2014"

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term

Abstract: Background Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. Objectives To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol). Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009) and bibliographies of relevant papers. We updated this search on 24 February 2012 and added the results to the awaiting classification section. Selection criteria Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods. Data collection and analysis We assessed studies and extracted data independently. Main results Sixty-three (10,441 women) have been included. Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18.1% versus 98.9%, risk ratio (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, two trials, 384 women). The risk of the cervix remaining unfavourable or unchanged was reduced (21.6% versus 40.3%, RR 0.46, 95% CI 0.35 to 0.62, five trials, 467 women); and the risk of oxytocin augmentation reduced (35.1% versus 43.8%, RR 0.83, 95% CI 0.73 to 0.94, 12 trials, 1321 women) when PGE2 was compared to placebo. There was no evidence of a difference between caesarean section rates, although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.4% versus 0.49%, RR 4.14, 95% CI 1.93 to 8.90, 14 trials, 1259 women). PGE2 tablet, gel and pessary appear to be as efficacious as each other and the use of sustained release PGE2 inserts appear to be associated with a reduction in instrumental vaginal delivery rates (9.9 % versus 19.5%, RR 0.51, 95% CI 0.35 to 0.76, NNT 10 (6.7 to 24.0), five trials, 661 women) when compared to vaginal PGE2 gel or tablet. Authors' conclusions PGE2 increases successful vaginal delivery rates in 24 hours and cervical favourability with no increase in operative delivery rates. Sustained release vaginal PGE2 is superior to vaginal PGE2 gel with respect to some outcomes studied. Further research is needed to assess the best vehicle for delivering vaginal prostaglandins and this should, where possible, include some examination of the cost-analysis. [Note: The 10 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

Risk factors of birth asphyxia

Abstract: Birth asphyxia is an insult to the fetus or newborn due to failure to breath or breathing poorly, leads to decrease oxygen perfusion to various organs. According to WHO, 4 million neonatal deaths occurred each year due to birth asphyxia. Our goal was to evaluate antepartum, intrapartum, and fetal risk factors of birth asphyxia. It was a Retrospective Case control study, conducted at Neonatal Intensive Care Unit of pediatric ward (I, II, III) and in Gynecology wards (I, II, III) of Civil Hospital Karachi, Dow University of Health Sciences. Study was conducted from January 2011-November 2012. Neonates diagnosed with birth asphyxia were considered as “cases” while neonates born either with normal vaginal delivery or by cesarean section having no abnormality were considered as “control”. Demographics of both the mother and neonate were noted and Questions regarding possible risk factors were asked from mother. Ethical issues were confirmed from Institutional review board of Civil Hospital Karachi, Dow University of Health Sciences. All data was entered and analyzed through SPSS 19. Out of total 240 neonates, 123 were “cases” and 117 were “control”. Mean maternal age in “case” group was 24.22 ± 3.38 while maternal age of control group was 24.30 ± 4.04. Significant antepartum risk factors were maternal age of 20–25 (OR 0.30 CI 95% 0.07-1.21), booking status (OR 0.20 CI 95% 0.11-0.37), pre-eclampsia (OR 0.94 CI 95% 0.90-0.98) and primigravidity (OR 2.64 CI 95% 1.56-4.46). Significant Intrapartum risk factors were breech presentation (OR 2.96 CI 95% 1.25-7.02), home delivery (OR 16.16 CI 95% 3.74-69.75) and maternal fever (OR 10.01 CI95% 3.78-26.52). Significant Fetal risk factors were resuscitation of child (OR 23 CI 95% 31.27-1720.74), pre-term babies(OR 0.34 CI 95% 0.19-0.58), fetal distress (OR 0.01 CI 95% 0.00-0.11) and baby weight (OR 0.13 CI 95% 0.05-0.32). Measures should be taken to prevent neonatal mortality with great emphasis on skilled attendance at birth and appropriate care of preterm and low birth weight neonates.

Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop

Abstract: With more than one third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. The available information on maternal and fetal factors, labor management and induction, and nonmedical factors leading to the first cesarean delivery was reviewed as well as the implications of the first cesarean delivery on future reproductive health. Key points were identified to assist with reduction in cesarean delivery rates including that labor induction should be performed primarily for medical indication; if done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress. The diagnosis of "failed induction" should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged. When discussing the first cesarean delivery with a patient, counseling should include its effect on future reproductive health.

Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study.

Abstract: Objective.The aim of this study was to evaluate the effect of the increased cesarean rate for term breech presentation on neonatal outcome. We also investigated whether the clinical case selection for vaginal delivery applied by Dutch obstetricians led to an optimization of neonatal outcome, or whether there is still room for improvement in terms of perinatal outcome.Design.Retrospective cohort.Setting.The Netherlands.Population.Singleton term breech deliveries from 37 +0 to 41 +6 weeks, excluding fetuses with congenital malformations or antenatal death.Method.We used data from the Dutch national perinatal registry from 1999 up to 2007.Main outcome measures.Perinatal mortality and morbidity.Results.We studied 58 320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3v odds ratio 0.51 (95% confidence interval 0.28‐0.93)], whereas it remained stable in the planned vaginal birth group [1.7v odds ratio 0.96 (95% confidence interval 0.52‐1.76)]. The number of cesareans done to prevent one perinatal death was 338.Conclusions.Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies. Abbreviations:CI, confidence interval; OR, odds ratio; PRN, Netherlands Perinatal Registry; RR, relative risk.

The Role of Labor Pain and Overall Birth Experience in the Development of Posttraumatic Stress Symptoms: A Longitudinal Cohort Study

Abstract: Background: The aim of this prospective study was to investigate the role oflabor pain and overall birth experience in the development of posttraumatic stress symptomsin a comprehensive framework. Methods: The study sample (N = 1893) comprised womenwith a vaginal delivery and was drawn from the Akershus Birth Cohort, which targeted allwomen scheduled to give birth at Akershus University Hospital in Norway. Questionnaireswere given at three different stages: from pregnancy weeks 17 to 32, from the maternityward, and from 8 weeks postpartum. Data were also obtained from the hospital’s birthrecord. Using structural equation modeling, a prospective mediation model was tested.Results: Posttraumatic stress symptoms were significantly related to both labor pain(r = 0.23) and overall birth experience (r = 0.39). A substantial portion (33%) of the effectof labor pain on posttraumatic stress symptoms was mediated by the overall birth experience.Conclusions: Although the results of this study showed that both labor pain and overallbirth experience played a role in the development of posttraumatic stress symptoms afterchildbirth, overall birth experience appeared to be the central factor. The women’s birthexperience was not only related to posttraumatic stress symptoms directly but also mediateda substantial portion of the effect of labor pain on posttraumatic stress symptoms. Futurework should address which areas of birth experience confer protective effects on women toimprove clinical care. (BIRTH 41:1 March 2014)Key words: labor pain, longitudinal cohort study, overall birth experience, posttraumaticstress symptoms after childbirthUp to one-third of all women view their labor anddelivery as traumatic (1,2). An estimated 2–6 percentof women experience the full constellation of symp-toms of posttraumatic stress disorder (PTSD) relating tochildbirth and qualify for a clinical PTSD diagnosis(3). Prevalence has typically been measured within the

Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth

Abstract: The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.

The influence of women’s preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study

Abstract: This study aimed to examine whether a mismatch between a woman’s preferred and actual mode of delivery increases the risk of post-traumatic stress symptoms after childbirth. The study sample consisted of 1,700 women scheduled to give birth between 2009 and 2010 at Akershus University Hospital, Norway. Questionnaire data from pregnancy weeks 17 and 32 and from 8 weeks postpartum were used along with data obtained from hospital birth records. Post-traumatic stress symptoms were measured with the Impact of Event Scale. Based on the women’s preferred and actual mode of delivery, four groups were established: Match 1 (no preference for cesarean section, no elective cesarean section, N = 1,493); Match 2 (preference for cesarean section, elective cesarean section, N = 53); Mismatch 1 (no preference for cesarean section, elective cesarean section, N = 42); and Mismatch 2 (preference for cesarean section, no elective cesarean section, N = 112). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were conducted to examine whether the level of post-traumatic stress symptoms differed significantly among these four groups. Examining differences for all four groups, ANOVA yielded significant overall group differences (F = 11.96, p < 0.001). However, Bonferroni post-hoc tests found significantly higher levels of post-traumatic stress symptoms only in Mismatch 2 compared to Match 1. This difference could be partly explained by a number of risk factors, particularly psychological risk factors such as fear of childbirth, depression, and anxiety. The results suggest increased post-traumatic stress symptoms in women who preferred delivery by cesarean section but delivered vaginally compared to women who both preferred vaginal delivery and delivered vaginally. In psychologically vulnerable women, such mismatch may threaten their physical integrity and, in turn, result in post-traumatic stress symptoms. These women, who often fear childbirth, may prefer a cesarean section even though vaginal delivery is usually the best option in the absence of medical indications. To avoid potential trauma, fear of childbirth and maternal requests for a cesarean section should be taken seriously and responded to adequately.

High‐dose versus low‐dose oxytocin infusion regimens for induction of labour at term

Abstract: Background When women require induction of labour, oxytocin is the most common agent used, delivered by an intravenous infusion titrated to uterine contraction strength and frequency. There is debate over the optimum dose regimen and how it impacts on maternal and fetal outcomes, particularly induction to birth interval, mode of birth, and rates of hyperstimulation. Current induction of labour regimens include both high- and low-dose regimens and are delivered by either continuous or pulsed infusions, with both linear and non-linear incremental increases in oxytocin dose. Whilst low-dose protocols bring on contractions safely, their potentially slow induction to birth interval may increase the chance of fetal infection and chorioamnionitis. Conversely, high-dose protocols may cause undue uterine hyperstimulation and fetal distress. Objectives To determine the effectiveness and safety of high- versus low-dose oxytocin for induction of labour at term Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 August 2014) and the reference lists of relevant papers. Selection criteria Randomised controlled trials and quasi-randomised controlled trials that compared oxytocin protocol for induction of labour for women at term, where high-dose oxytocin is at least 100 mU oxytocin in the first 40 minutes, with increments delivering at least 600 mU in the first two hours, compared with low-dose oxytocin, defined as less than 100 mU oxytocin in the first 40 minutes, and increments delivering less than 600 mU total in the first two hours. Data collection and analysis Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. Main results We have included nine trials, involving 2391 women and their babies in this review. Trials were at a moderate to high risk of bias overall. Results of primary outcomes revealed no significant differences in rates of vaginal delivery not achieved within 24 hours (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.78 to 1.14, two trials, 1339 women) or caesarean section (RR 0.96, 95% CI 0.81 to 1.14, eight trials, 2023 women). There was no difference in serious maternal morbidity or death (RR 1.24, 95% CI 0.55 to 2.82, one trial, 523 women), and no difference in serious neonatal morbidity or perinatal death (RR 0.84, 95% CI 0.23 to 3.12, one trial, 781 infants). Finally, no trials reported on the number of women who had uterine hyperstimulation with fetal heart rate changes. Results of secondary outcomes revealed no difference between time from induction to delivery (mean difference (MD) -0.90 hours, 95% CI -2.28 to +0.49 hours; five studies), uterine rupture (RR 3.10, 95% CI 0.50 to 19.33; three trials), epidural analgesia (RR 1.03, 95% CI 0.89 to 1.18; two trials), instrumental birth (RR 1.22, 95% CI 0.88 to 1.66; three trials), Apgar less than seven at five minutes (RR 1.25, 95% CI 0.77 to 2.01, five trials), perinatal death (RR 0.84, 95% CI 0.23 to 3.12; two trials), postpartum haemorrhage (RR 1.08, 95% CI 0.87 to 1.34; five trials), or endometritis (RR 1.35, 95% CI 0.53 to 3.43; three trials). Removal of high bias studies reveals a significant reduction of induction to delivery interval (MD -1.94 hours, 95% CI -0.99 to -2.89 hours, 489 women). A significant increase in hyperstimulation without specifying fetal heart rate changes was found in the high-dose group (RR 1.86, 95% CI 1.55 to 2.25). No other secondary outcomes were reported: unchanged/unfavourable cervix after 12 to 24 hours, meconium-stained liquor, neonatal intensive care unit admission, neonatal encephalopathy, disability in childhood, other maternal side-effects (nausea, vomiting, diarrhoea), maternal antibiotic use, maternal satisfaction, neonatal infection and neonatal antibiotic use. Authors' conclusions The findings of our review do not provide evidence that high-dose oxytocin increases either vaginal delivery within 24 hours or the caesarean section rate. There is no significant decrease in induction to delivery time at meta-analysis but these results may be confounded by poor quality trials. High-dose oxytocin was shown to increase the rate of uterine hyperstimulation but the effects of this are not clear. The conclusions here are specific to the definitions used in this review. Further trials evaluating the effects of high-dose regimens of oxytocin for induction of labour should consider all important maternal and infant outcomes.

Sonographic prediction of vaginal delivery in prolonged labor: a two-center study

Abstract: Objective To investigate whether head-perineum distance (HPD) measured by transperineal ultrasound is predictive of vaginal delivery and time remaining in labor in nulliparous women with prolonged first stage of labor and to compare the predictive value with that of angle of progression (AoP). Methods This was a prospective observational study at Stavanger University Hospital, Norway and Addenbrooke's Hospital, Cambridge, UK from January 2012 to April 2013, of nulliparous women with singleton pregnancies with cephalic presentation at term with prolonged first stage of labor. We used transperineal ultrasound to measure HPD (shortest distance between the outer bony limit of the fetal skull and the perineum) and AoP (angle between a line through the long axis of the symphysis and the tangent to the fetal head) and transabdominal ultrasound to classify fetal head position. The main outcomes were vaginal delivery and time remaining in labor. Results Of 150 women enrolled, 39 underwent delivery by Cesarean section. The area under the receiver-operating characteristics curve for the prediction of vaginal delivery was 81% (95% CI, 73-89%) using HPD as the test variable and 72% (95% CI, 63-82%) using AoP. HPD was 40 mm in the other 66 (44%) women, of whom 34 (52%; 95% CI, 40-63%) delivered vaginally. AoP was >= 110 degrees in 84 of the 145 (58%) in whom this was available and, of these, 74 (88%; 95% CI, 79-93%) delivered vaginally. AoP was = 110 degrees (OR, 3.11; 95% CI, 1.01-9.56), non-occiput posterior position (OR, 3.36; 95% CI, 1.24-9.12) and spontaneous onset of labor (OR, 4.44; 95% CI, 1.42-13.89) were independent predictors for vaginal delivery. Both ultrasound methods were predictive for the time remaining in labor. Conclusion Transperineal ultrasound measurement of HPD and AoP provide important information about the likelihood of vaginal delivery and the time remaining in labor in nulliparous women with prolonged labor. Copyright (C) 2013 ISUOG. Published by John Wiley & Sons Ltd. (Less)

Successful induction of labor: prediction by preinduction cervical length, angle of progression and cervical elastography

Abstract: Objective To examine the potential value of preinduction cervical length, cervical elastography and angle of progression (AOP) in prediction of successful vaginal delivery and induction-to-delivery interval. Methods This was a prospective study in 99 women with singleton pregnancy undergoing preinduction ultrasound assessment at 35–42 weeks' gestation. Cervical length, elastographic score at the internal os and AOP were determined. Regression analysis was used to assess the relationship between cervical length and both AOP and elastographic score. Logistic regression analysis was used to determine which of the maternal characteristics (cervical length, AOP, elastographic score) were significant predictors of vaginal delivery and induction-to-delivery interval. Results Vaginal delivery occurred in 66 (66.7%) cases and Cesarean delivery was performed in 33 (33.3%) cases. There were significant correlations between cervical length and both AOP (r = − 0.319) and elastographic score (r = 0.368). Significant independent prediction of vaginal delivery and induction-to-delivery interval was provided by nulliparity and cervical length, with no additional significant contribution from electrographic score or AOP. Conclusions In women undergoing induction of labor, AOP and elastographic score at the internal os are unlikely to be useful in prediction of vaginal delivery and induction-to-delivery interval. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries - American Journal of Obstetrics and Gynecology - Vol. 206, 5 - ISBN: 0002-9378 - p.404.e1-404.e5

Abstract: We advocate the use of a mediolateral episiotomy in all operative vaginal deliveries to reduce the incidence of obstetrical anal sphincter injuries.

Women's Choice of Positions during Labour: Return to the Past or a Modern Way to Give Birth? A Cohort Study in Italy

Abstract: Background. Childbirth medicalization has reduced the parturient's opportunity to labour and deliver in a spontaneous position, constricting her to assume the recumbent one. The aim of the study was to compare recumbent and alternative positions in terms of labour process, type of delivery, neonatal wellbeing, and intrapartum fetal head rotation. Methods. We conducted an observational cohort study on women at pregnancy term. Primiparous women with physiological pregnancies and single cephalic fetuses were eligible for the study. We considered data about maternal-general characteristics, labour process, type of delivery, and neonatal wellbeing at birth. Patients were divided into two groups: Group-A if they spent more than 50% of labour in a recumbent position and Group-B when in alternative ones. Results. 225 women were recruited (69 in Group-A and 156 in Group-B). We found significant differences between the groups in terms of labour length, Numeric Rating Scale score and analgesia request rate, type of delivery, need of episiotomy, and fetal occiput rotation. No differences were found in terms of neonatal outcomes. Conclusion. Alternative maternal positioning may positively influence labour process reducing maternal pain, operative vaginal delivery, caesarean section, and episiotomy rate. Women should be encouraged to move and deliver in the most comfortable position.

Impact of mode of delivery on the birth experience in first-time mothers: a qualitative study.

Abstract: The birth of a first child is an important event in a woman’s life Delivery psychological impacts vary depending on whether delivery has been positively or negatively experienced Delivery experience determinants have been identified but the understanding of their expression according to the mode of delivery is poorly documented The purpose of the study was to determine important elements associated with women’s first delivery experience according to the mode of delivery: vaginal or caesarean section Qualitative approach using thematic content analysis of in-depth interviews conducted between 4 and 6 weeks’ postpartum, in 24 primiparous women who delivered at Geneva University Hospital in 2012 Perceived control, emotions, and the first moments with the newborn are important elements for the experience of childbirth Depending on the mode of delivery these are perceived differently, with a negative connotation in the case of caesarean section Other elements influencing the delivery experience were identified among all participants, irrespective of the mode of delivery They included representations, as well as the relationship with caregivers and the father in the delivery room, privacy, unexpected sensory experiences, and ownership of the maternal role Women’s and health professionals’ representations sometimes led to a hierarchy based on the mode of delivery and use of analgesia The mode of delivery directly impacts on certain key delivery experience determinants as perceived control, emotions, and the first moments with the newborn The ability/inability of the woman to imagine a second pregnancy is a good indicator of the birth experience Certain health professional gestures or attitudes can promote a positive delivery experience We recommend to better prepare women during prenatal classes for the eventuality of a caesarean section delivery and to offer all women and, possibly, their partners, the opportunity to talk about the experience of childbirth during the postpartum period The results of this study suggest that further research is required on the social representations of women and health professionals regarding the existence of a hierarchy associated with the mode of delivery

Caesarean delivery, caesarean delivery on maternal request and childhood overweight: a Chinese birth cohort study of 181 380 children.

Abstract: Summary What is already known about this subject Both rates of caesarean section and childhood overweight have been steadily increasing over the past decade in many parts of the world. Caesarean delivery on maternal request contributes remarkably to the rising trend of caesarean births. A few small-scale studies suggest that caesarean section may be associated with later overweight and obesity, whereas little is known about the impact of caesarean delivery on maternal request. What this study adds Caesarean section is associated with an increased risk of childhood overweight. Children born by caesarean delivery on maternal request are also more likely to be overweight. The strength of the caesarean-overweight association is modest. Objectives To assess the impact of caesarean delivery including non-medically indicated maternal request caesarean delivery on childhood overweight. Methods We conducted a prospective investigation of a Chinese birth cohort involving 181 380 children, who were born during 1993–1996 to mothers registered in a perinatal care surveillance system and whose weight and height were measured in 2000. Information on delivery mode and covariates was obtained from the surveillance system. Overweight was defined according to the International Obesity Task Force body mass index (BMI) cutoffs. Multivariable logistic regression was used to estimate adjusted odds ratios. Stratified analyses were done to test whether the association between caesarean section and overweight persisted across subgroups. Results The adjusted odds ratio of overweight for children born by caesarean compared with vaginal delivery was 1.13 [95% confidence interval {CI}: 1.08, 1.18]. The association persisted in subgroups stratified by gender, maternal education, maternal BMI, weight gain during pregnancy and child birthweight (all P values for interaction test ≥0.30). The adjusted odds ratio of overweight for children born by non-medically indicated caesarean delivery compared with vaginal delivery was 1.18 (95% CI: 1.00, 1.41). Conclusion Caesarean delivery including non-medically indicated maternal request caesarean delivery compared with vaginal delivery modestly increases childhood overweight risk.

The Impact of Cesarean Section on Offspring Overweight and Obesity: A Systematic Review and Meta-analysis

Abstract: Concerns have arisen regarding the long-term impacts of cesarean section (CS) on the health of offspring. One mechanism linking CS with later diseases is the hygiene hypothesis, based on the concept of different bacteria present in the newborns depending on mode of delivery. This early-life difference in bacteria acquisition could have lasting effects on offspring gut microbiota composition and related disorders. This review and meta-analysis were performed to determine whether an association exists between CS and overweight/obesity in offspring and to evaluate the strength of the possible association. Relevant articles and abstracts were obtained from searches of PubMed, EMBASE, and Web of Science databases through June 2012. Studies were cohort or case-control investigations that examined the association of CS compared with vaginal delivery with overweight/obesity in childhood (3–8 years), adolescence (9–18 years), or adulthood (>19 years). Statistical heterogeneity across estimates was assessed by I2 statistics; values of 25%, 50%, and 75% indicated low, medium, and high heterogeneity, respectively. The primary analysis was to estimate the overall pooled OR for offspring delivered by CS versus vaginal delivery and specific pooled ORs for children, adolescents, and adults. Two-sided P Eight of an initial 2454 studies met the inclusion criteria along with 1 unpublished study, for a total of 7 cohort and 2 case-control studies. Overall, 10 childhood, 2 adolescence, and 3 adulthood estimates were included in the meta-analysis. The pooled OR of overweight/obesity for offspring delivered by CS compared with those born vaginally was 1.33 (95% CI, 1.19–1.48), with moderate to high heterogeneity (I2 = 63%) across the 15 estimates. Pooled ORs of overweight and obesity were 1.22 (95% CI, 0.99–1.50; I2 = 64%) and 1.37 (95% CI, 1.21–2.56; I2 = 45%; P for interaction = 0.33), respectively. The pooled OR for childhood overweight/obesity was 1.32 (95% CI, 1.15–1.51; I2 = 66%) across the 10 estimates. The pooled OR of overweight was 1.22 (95% CI, 0.99–1.50; I2 = 64%), and that for obesity was 1.40 (95% CI, 1.17–1.67; I2 = 50%; P for interaction = 0.31). The pooled ORs for adolescence and adult obesity were 1.24 (95% CI, 1.00–1.54; I2 = 0%) and 1.50 (95% CI, 1.02–2.20; I2 = 74%), respectively. The pooled ORs for male and female offspring did not differ significantly. Compared with vaginal delivery, CS was associated with a 33% increased risk of later overweight and obesity in offspring. The underlying mechanism of this association is unclear, although the hygiene hypothesis is one possible mechanism. Future studies should examine the causal relationship between CS and obesity, particularly in adolescents and adults, and whether these associations have a common pathway with other health outcomes in offspring born by CS.

Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor

Abstract: Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed.

Can the risk of obstetric anal sphincter injuries (OASIs) be predicted using a risk-scoring system?

Abstract: Perineal trauma involving the anal sphincter is an important complication of vaginal delivery. Prediction of anal sphincter injuries may improve the prevention of anal sphincter injuries. Our aim was to construct a risk scoring model to assist in both prediction and prevention of Obstetric Anal Sphincter Injuries (OASIs). We carried out an analysis of factors involved with OASIs, and tested the constructed model on new patient data. Data on all vaginal deliveries over a 5 year period (2004–2008) was obtained from the electronic maternity record system of one institution in the UK. All risk factors were analysed using logistic regression analysis. Odds ratios for independent variables were then used to construct a risk scoring algorithm. This algorithm was then tested on subsequent vaginal deliveries from the same institution to predict the incidence of OASIs. Data on 16,920 births were analysed. OASIs occurred in 616 (3.6%) of all vaginal deliveries between 2004 and 2008. Significant (p < 0.05) variables that increased the risk of OASIs on multivariate analysis were: African-Caribbean descent, water immersion in labour, water birth, ventouse delivery, forceps delivery. The following variables remained independently significant in decreasing the risk of OASIs: South Asian descent, vaginal multiparity, current smoker, home delivery. The subsequent odds ratios were then used to construct a risk-scoring algorithm that was tested on a separate cohort of patients, showing a sensitivity of 52.7% and specificity of 71.1%. We have confirmed known risk factors previously associated with OASIs, namely parity, birth weight and use of instrumentation during delivery. We have also identified several previously unknown factors, namely smoking status, ethnicity and water immersion. This paper identifies a risk scoring system that fulfils the criteria of a reasonable predictor of the risk of OASIs. This supersedes current practice where no screening is implemented other than examination at the time of delivery by a single examiner. Further prospective studies are required to assess the clinical impact of this scoring system on the identification and prevention of third degree tears.

Epidural analgesia and severe perineal tears: a literature review and large cohort study

Abstract: Objective: Our objectives were to study the association between epidural analgesia and risk of severe perineal tears (SPT), and identify additional risk factors for SPT.Methods: We conducted a historical cohort study of women with term delivery between 2006 and 2011. Inclusion criteria were an uncomplicated singleton pregnancy, cephalic presentation and vaginal delivery. Multivariate logistic regression models were constructed to study the association between epidural analgesia and SPT, controlling for potential confounders. Additional models studied the association between prolonged second stage and instrumental labor and SPT.Results: During the study period, 61 308 eligible women gave birth, 31 631 (51.6%) of whom received epidural analgesia. SPT occurred in 0.3% of births. Deliveries with epidural had significantly higher rates of primiparity, induction and augmentation of labor, prolonged second stage of labor, instrumental births and midline episiotomies. The univariate analysis showed a sign...

Effect of mode of delivery on macronutrient content of breast milk

Abstract: Objective: To determine the effect of delivery type on macronutrient content of colostral milk.Materials and methods: The study was conducted at Zekai Tahir Burak Maternity Teaching Hospital. Colostral milk samples from term lactating mothers who gave birth by vaginal or cesarean delivery (CD) were obtained on the 2nd postpartum day. Milk protein, fat, carbohydrate (CHO) and energy levels were measured by using a mid-infrared human milk analyzer.Results: A total of 204 term lactating mothers were recruited to the study; 111 mothers gave birth by vaginal route and 93 mothers by CD. Protein levels were statistically lower in colostral milk of mothers after CD compared to mothers who delivered vaginally (median 2.4 (range 0.3–6.4) g/dl versus 3 (0.5–6.3) g/dl, respectively; p = 0.036). Colostral fat, CHO and energy levels were similar between groups. In linear regression analysis, CD and maternal age were independently associated with lower protein content in colostrum.Conclusion: Vaginal delivery is...

Third and fourth degree perineal tears – the risk of recurrence in subsequent pregnancy

Abstract: Objective: To assess the risk of recurrence of third- and fourth-degree perineal tears (34DPT) and to determine whether previous 34DPT is an independent risk factor for 34DPT in subsequent deliveries.Method: The study group included all women who had a vaginal delivery complicated by 34DPT (2000–2012, N = 356) and subsequently delivered again in the same medical center (N = 204). The rate of recurrence of 34DPT was compared with a control group of women who had a previous vaginal delivery not complicated by 34DPT (N = 58 581) and had a subsequent delivery in the same time period (N = 23 045).Results: Women in the past-34DPT group had a higher rate of CS (18.6% versus 10.1%, p < 0.001), fetal head in occiput-posterior position (POP; 2.5% versus 0.7%, p = 0.004) and mediolateral episiotomy (25.5% versus 19.4%, p = 0.03). Women in the past-34DPT group had a higher rate of 34DPT in the subsequent delivery (2.0% versus 0.3%, p < 0.001). The rate of recurrence of 34DPT was considerably higher among wome...