[Perinatal mortality after previous cesarean section]. / Perinatale kindliche Todesfälle bei Kaiserschnitt in der mütterlichen Anamnese.

BACKGROUND: Perinatal neonatal mortality is increased where there is a maternal history of cesarean section (0.45 vs. 0.31 % in deliveries after previous vaginal delivery). In this study we have analyzed the causes of the perinatal deaths. PATIENTS AND METHODS: The increased risk was found by analyzing the database of the Swiss Working Group of Obstetric and Gynecological Institutions with its 29 046 deliveries with a history of previous cesarean section between 1983 and 1996. In this time period 130 perinatal neonatal deaths in deliveries after previous cesarean were recorded. RESULTS: The cause of death could be established in 124 cases. In the 42 term deliveries the causes of death were the following: malformations 20, uterine rupture 5, placental abruption 5, respiratory distress syndrome 5, and other causes 7. In the 82 preterm deliveries: prematurity caused by premature contractions/rupture of membranes 38, malformations 12, chorioamnionitis 12, placental abruption 9, severe growth retardation 4, complications of placenta praevia 2, uterine rupture 1, other causes 4. DISCUSSION: Preterm deliveries are more frequent (in births) after a previous c/s (7.75 vs. 5.55 % in multiparous mothers without previous cesarean) - not because of a higher frequency of preterm labor or premature rupture of membranes, but because of placental abruption, chorioamnionitis, placental insufficiency and severe growth retardation. Although some of the neonatal deaths are linked to the previous cesarean delivery, perinatal death after previous cesarean is a very rare event. A recommendation to routinely perform a repeat cesarean instead of a trial of labor seems not appropriate.

Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions.

OBJECTIVE: To examine the risks of vaginal delivery after previous cesarean and to find criteria to help decide whether a trial of labor or an elective repeat cesarean should be preferred. METHODS: We evaluated 29,046 deliveries after previous cesarean registered in a pooled database of 457,825 deliveries used to assess quality control in gynecology and obstetrics departments in Switzerland. RESULTS: Among the 17,613 trial-of-labor cases logged (attempt rate 60.64%), the success rate was 73.73% (65.56% after inducing labor and 75.06% after the spontaneous onset of labor). The following complications were significantly more frequent in the previous-cesarean group: maternal febrile episodes (relative risk [RR] 2.77; 95% confidence interval [CI] 2.52, 3.05), thromboembolic events (RR 2.81; CI 2.23, 3.55), bleeding due to placenta previa during pregnancy (RR 2.06; CI 1.70, 2.49), uterine rupture (92 cases; RR 42.18; CI 31.09, 57.24), and perinatal mortality (118 cases, including six associated with uterine rupture; RR 1.33; CI 1.10, 1.62). The postcesarean group also showed a 0.28% rate of peripartum hysterectomy (81 cases; RR 6.07; CI 4.71, 7.83). There was one maternal death in the group, compared with 14 maternal deaths in the group without previous cesarean (no statistical significance). The risk of uterine rupture for patients with previous cesareans was elevated in the trial-of-labor group compared with the group without trial of labor (RR 2.07; CI 1.29, 3.30), but all other maternal risks, including peripartum hysterectomy (RR 0.36; CI 0.23, 0.56), were lower. When comparing the women having a trial of labor, the 70 with uterine rupture more often had induced labor (24.29% compared with 13.92% in the nonrupture group; P = .013), had epidural anesthesia (24.29% compared with 8.44%; P < .001), had an abnormal fetal heart rate tracing (32.86% compared with 8.53%; P < .001), and had failure to progress (21.43% compared with 7.98%; P = .001). CONCLUSION: A history of cesarean delivery significantly elevates the risks for mother and child in future deliveries. Nonetheless, a trial of labor after previous cesarean is safe. Induction of labor, epidural anesthesia, failure to progress, and abnormal fetal heart rate pattern are all associated with failure of a trial of labor and uterine rupture.

Elective mutism: an analysis of 100 cases.

OBJECTIVE: An extended series of 100 children with elective mutism (EM) was clinically analyzed. METHOD: The total sample included two subgroups of clinically referred children at different locations and a subgroup of nonreferred children with EM. The study was based on comprehensive item sheets and, in the nonreferred sample only, the Child Behavior Checklist. RESULTS: EM is a rare disorder in the referred child psychiatric samples. It typically starts at preschool age, is more common in girls, and is seen in all social strata. A background of migration and early developmental risk factors is also quite common. Premorbid speech and language disorders play a role in one third of the clientele, and three quarters of children with EM had behavioral abnormalities during infancy and preschool age. School and unfamiliar people create the social context in which children with EM most frequently do not speak. Shyness and internalizing behavior problems are the most common personality features in EM, and comorbid diagnoses are quite frequent. CONCLUSION: This large series of affected children has identified the most typical features of EM and thereby extends the limited knowledge of this rare disorder of childhood.