Safe prevention of the primary cesarean delivery Caughey, Aaron B., MD, PhD; Cahill, Alison G., MD, MSCI; Guise, Jeanne-Marie, MD, MPH ...
American journal of obstetrics and gynecology,
03/2014, Letnik:
210, Številka:
3
Journal Article
Recenzirano
Odprti dostop
In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid ...increase in cesarean birth rates from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.
Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine.
...Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013).
All published and unpublished randomised controlled trials comparing continuous support during labour with usual care.
We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.
Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.
Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.
Objectives
To investigate the mental status of pregnant women and to determine their obstetric decisions during the COVID‐19 outbreak.
Design
Cross‐sectional study.
Setting
Two cities in China––Wuhan ...(epicentre) and Chongqing (a less affected city).
Population
A total of 1947 pregnant women.
Methods
We collected demographic, pregnancy and epidemic information from our pregnant subjects, along with their attitudes towards COVID‐19 (using a self‐constructed five‐point scale). The Self‐Rating Anxiety Scale (SAS) was used to assess anxiety status. Obstetric decision‐making was also evaluated. The differences between cities in all of the above factors were compared and the factors that influenced anxiety levels were identified by multivariable analysis.
Main outcome measures
Anxiety status and its influencing factors. Obstetric decision‐making.
Results
Differences were observed between cities in some background characteristics and women's attitudes towards COVID‐19 in Wuhan were more extreme. More women in Wuhan felt anxious (24.5 versus 10.4%). Factors that influenced anxiety also included household income, subjective symptom and attitudes. Overall, obstetric decisions also revealed city‐based differences; these decisions mainly concerned hospital preference, time of prenatal care or delivery, mode of delivery and infant feeding.
Conclusions
The outbreak aggravated prenatal anxiety and the associated factors could be targets for psychological care. In parallel, key obstetric decision‐making changed, emphasising the need for pertinent professional advice. Special support is essential for pregnant mothers during epidemics.
Tweetable
The COVID‐19 outbreak increased pregnant women's anxiety and affected their decision‐making.
Tweetable
The COVID‐19 outbreak increased pregnant women's anxiety and affected their decision‐making.
This article includes Author Insights, a video available at https://vimeo.com/rcog/authorinsights16381
In 2011, one in three women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid ...increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.
As a quality marker and a tool for benchmarking between units, a visual analogue scale (VAS) (ranging from 1 to 10) to estimate woman's satisfaction with childbirth was introduced in 2014. This study ...aimed to assess how obstetric interventions and complications affected women's satisfaction with childbirth.
A retrospective cohort study including 16,775 women with an available VAS score who gave birth between January 2016 and December 2017. VAS score, maternal and obstetric characteristics were obtained from electronic medical records and crude and adjusted odds ratios (aOR) were calculated.
The total prevalence of dissatisfaction with childbirth (VAS 1-3) was 5.7%. The main risk factors for dissatisfaction with childbirth were emergency cesarean section, aOR 3.98 95% confidence interval (CI) 3.27-4.86, postpartum hemorrhage ≥2000 ml, aOR 1.85 95%CI 1.24-2.76 and Apgar score < 7 at five minutes, aOR 2.95 95%CI 1.95-4.47. The amount of postpartum hemorrhage showed a dose-response relation to dissatisfaction with childbirth. Moreover, labor induction, instrumental vaginal delivery, and obstetric anal sphincter injury were significantly associated with women's dissatisfaction with childbirth. A total number of 4429/21204 (21%) women giving birth during the study period had missing values on VAS. A comparison of characteristics between women with and without a recorded VAS score was performed. There were statistically significant differences in maternal age and maternal BMI between the study population and excluded women due to missing values on VAS. Moreover, 64% of the women excluded were multiparas, compared to 59% in the study population.
Obstetric interventions and complications, including emergency cesareans section and postpartum hemorrhage, were significantly related to dissatisfaction with childbirth. Such events are common and awareness of these associations might lead to a more individualized care of women during and after childbirth.
The caesarean section (c-section) rate in Canada is 27.1%, well above the 5-15% of deliveries suggested by the World Health Organization in 2009. Emergency and planned c-sections may adversely affect ...breastfeeding initiation, milk supply and infant breastfeeding receptivity compared to vaginal deliveries. Our study examined mode of delivery and breastfeeding initiation, duration, and difficulties reported by mothers at 4 months postpartum.
The All Our Babies study is a prospective pregnancy cohort in Calgary, Alberta, that began in 2008. Participants completed questionnaires at <25 and 34-36 weeks gestation and approximately 4 months postpartum. Demographic, mental health, lifestyle, and health services data were obtained. Women giving birth to singleton infants were included (n = 3021). Breastfeeding rates and difficulties according to mode of birth (vaginal, planned c-section and emergency c-section) were compared using cross-tabulations and chi-square tests. A multivariable logistic regression model was created to examine the association between mode of birth on breastfeeding duration to 12 weeks postpartum.
More women who delivered by planned c-section had no intention to breastfeed or did not initiate breastfeeding (7.4% and 4.3% respectively), when compared to women with vaginal births (3.4% and 1.8%, respectively) and emergency c-section (2.7% and 2.5%, respectively). Women who delivered by emergency c-section were found to have a higher proportion of breastfeeding difficulties (41%), and used more resources before (67%) and after (58%) leaving the hospital, when compared to vaginal delivery (29%, 40%, and 52%, respectively) or planned c-sections (33%, 49%, and 41%, respectively). Women who delivered with a planned c-section were more likely (OR = 1.61; 95% CI: 1.14, 2.26; p = 0.014) to discontinue breastfeeding before 12 weeks postpartum compared to those who delivered vaginally, controlling for income, education, parity, preterm birth, maternal physical and mental health, ethnicity and breastfeeding difficulties.
We found that when controlling for socio-demographic and labor and delivery characteristics, planned c-section is associated with early breastfeeding cessation. Anticipatory guidance around breastfeeding could be provided to women considering a planned c-section. As well, additional supportive care could be made available to lactating women with emergency c-sections, within the first 24 hours post birth and throughout the early postpartum period.
Historically, women have been attended and supported by other women during labour. However, in recent decades in hospitals worldwide, continuous support during labour has become the exception rather ...than the routine. Concerns about the consequent dehumanization of women's birth experiences have led to calls for a return to continuous support by women for women during labour.
Primary: to assess the effects, on mothers and their babies, of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour; (2) whether the caregiver is a member of the staff of the institution; and (3) whether the continuous support begins early or later in labour.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007).
All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.
We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. All authors participated in evaluation of methodological quality. One author and a research assistant independently extracted the data. We sought additional information from the trial authors. We used relative risk for categorical data and weighted mean difference for continuous data to present the results.
Sixteen trials involving 13,391 women met inclusion criteria and provided usable outcome data. Primary comparison: women who had continuous intrapartum support were likely to have a slightly shorter labour, were more likely to have a spontaneous vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences. Subgroup analyses: in general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour and in settings in which epidural analgesia was not routinely available.
All women should have support throughout labour and birth.
Respectful and dignified healthcare is a fundamental right for every woman. However, many women seeking childbirth services, especially those in low-income countries such as Pakistan, are mistreated ...by their birth attendants. The aim of this epidemiological study was to estimate the prevalence of mistreatment and types of mistreatment among women giving birth in facility- and home-based settings in Pakistan in order to address the lack of empirical evidence on this topic. The study also examined the association between demographics (socio-demographic, reproductive history and empowerment status) and mistreatment, both in general and according to birth setting (whether home- or facility-based).
In phase one, we identified 24 mistreatment indicators through an extensive literature review. We then pre-tested these indicators and classified them into seven behavioural types. During phase two, the survey was conducted (April-May 2013) in 14 districts across Pakistan. A total of 1,334 women who had given birth at home or in a healthcare facility over the past 12 months were interviewed. Linear regression analysis was employed for the full data set, and for facility- and home-based births separately, using Stata version 14.1.
There were no significant differences in manifestations of mistreatment between facility- and home-based childbirths. Approximately 97% of women reported experiencing at least one disrespectful and abusive behaviour. Experiences of mistreatment by type were as follows: non-consented care (81%); right to information (72%); non-confidential care (69%); verbal abuse (35%); abandonment of care (32%); discriminatory care (15%); and physical abuse (15%). In overall analysis, experience of mistreatment was lower among women who were unemployed (β = -1.17, 95% CI -1.81, -0.53); and higher among less empowered women (β = 0.11, 95% CI 0.06, 0.16); and those assisted by a traditional birth attendant as opposed to a general physician (β = 0.94, 95% CI 0.13, 1.75). Sub-group analyses for home-based births identified the same significant associations with mistreatment, with ethnicity included. In facility-based births, there was a significant relationship between women's employment and empowerment status and mistreatment. Women with prior education on birth preparedness were less likely to experience mistreatment compared to those who had received no previous birth preparedness education.
In order to promote care that is woman-centred and provided in a respectful and culturally appropriate manner, service providers should be cognisant of the current situation and ensure provision of quality antenatal care. At the community level, women should seek antenatal care for improved birth preparedness, while at the interpersonal level strategies should be devised to leverage women's ability to participate in key household decisions.
PDF
