Falling caesarean section rate and improving intra-partum outcomes: a prospective cohort study.

OBJECTIVE: To evaluate caesarean section (CS) rates and moderate to severe hypoxaemic ischaemic encephalopathy (HIE) rates with other core intra-partum outcomes following reconfiguration of maternity services in Cardiff, South Wales, UK. DESIGN: Cohort study of births from 2006 to 2015. SETTINGS: A University tertiary referral centre for foetal and maternal medicine with 6000 births/year, University Hospital of Wales, United Kingdom. METHOD: Data relating to births from 1 January 2006 to 31 December 2015 were extracted from the computerized maternity database on a yearly basis. Case notes of all mothers and babies for the same duration were hand searched for documentation of HIE. HIE data was also collected prospectively by neonatologist (SC) and obstetrician (PA). MAIN OUTCOME MEASURES: Incidence of caesarean section births, babies with moderate to severe HIE, instrumental vaginal births, obstetric anal sphincter injuries (OASIS) associated with instrumental delivery, and major post-partum haemorrhage (MPPH) of 2500 mL or more. RESULTS: During this 10-year period, a downward trend in emergency CS rate was seen from 15.6% in 2006 to 10.5% in 2015, reducing total CS rate from 25.5% in 2006 to 21.2% in 2015. A downward trend in the incidence of moderate and severe HIE was seen over the same period. There was an increase in operative vaginal births (OVB) from 12.8% to 15%. The rate of spontaneous vaginal births (SVB) remained stable. The incidence of OASIS remained constant and MPPH rate has fallen. CONCLUSIONS: Following amalgamation of two medium sized obstetric units and the opening of a Midwifery Led Unit (MLU), core intrapartum outcomes have improved. Contributing factors are the introduction of regular multidisciplinary training with enhanced team working, compulsory education for obstetricians and midwives on cardiotocograph (CTG) interpretation, increased consultant presence on delivery suite, robust risk management systems and broad multidisciplinary agreement on clinical guidelines promoting vaginal birth.

Obstetric interventions, trends, and drivers of change: A 20-year population-based study from Iceland.

BACKGROUND: Population data on obstetric interventions is often limited to cesarean delivery. We aimed to provide a more comprehensive overview of trends in use of several common obstetric interventions over the past 2 decades. METHODS: The study was based on nationwide data from the Icelandic Medical Birth Register. Incidence of labor induction, epidural analgesia, cesarean, and instrumental delivery was calculated for all births in 1995-2014. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for several maternal and pregnancy-related characteristics. Analyses were stratified by women's parity and diagnosis of diabetes or hypertensive disorder. RESULTS: During the study period, there were 81 389 intended vaginal births and 5544 elective cesarean deliveries. Among both primiparous and multiparous women, we observed a marked increase across time for labor induction (RR 1.78 [CI 1.67-1.91] and RR 1.83 [CI 1.73-1.93], respectively) and epidural analgesia (RR 1.40 [CI 1.36-1.45] and RR 1.74 [CI 1.66-1.83], respectively). A similar trend of smaller magnitude was observed among women with hypertensive disorders but no time trend was observed among women with diabetes. Incidence of cesarean and instrumental delivery remained stable across time. DISCUSSION: The use of labor induction and epidural analgesia increased considerably over time, while the cesarean delivery rate remained low and stable. Increases in labor induction and epidural analgesia were most pronounced for women without a diagnosis of diabetes or hypertensive disorder and were not explained by maternal characteristics such as advanced age.

Trends in operative vaginal delivery, 2005-2013: a population-based study.

OBJECTIVE: The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery. DESIGN: Retrospective cohort. SETTING: Population-based study of US birth records. POPULATION: US births from 2005 to 2013. METHODS: This study evaluated forceps and vacuum extraction during vaginal delivery in live-born, non-anomalous singleton gestations from ≥ 36 to < 42 weeks of gestation. The primary outcomes were vacuum, forceps and overall operative delivery. Obstetric, medical and demographic characteristics associated with operative vaginal delivery were analysed. Multivariable logistic regression models were developed to determine factors associated with forceps/vacuum use. RESULTS: A total of 22 598 971 vaginal deliveries between 2005 and 2013 were included in the analysis. In all, 1 083 318 (4.8%) were vacuum-assisted and 237 792 (1.1%) were by forceps. Both vacuum and forceps deliveries decreased over the study period; vacuum deliveries decreased from 5.8% in 2005 to 4.1% in 2013, and forceps deliveries decreased from 1.4% to 0.9% during the same period. The adjusted odds ratio for forceps delivery was 0.70 (95% CI 0.69-0.72) in 2013 with 2005 as a reference. For vacuum delivery the odds ratio was 0.68 (95% CI 0.67-0.69) comparing the same years. CONCLUSION: Forceps and vacuum deliveries decreased during the study period. Low rates of operative delivery pose a challenge for resident education and may limit the degree to which women have access to alternatives to caesarean delivery. Initiatives that allow future generations of obstetricians to develop expertise in performing operative deliveries in the setting of decreased volume are an urgent resident education priority. TWEETABLE ABSTRACT: Forceps and vacuum delivery decreased significantly in the USA from 2005 to 2013.

Nulliparous Women in the Second Stage of Labor: Changes in Delivery Outcomes Between Two Cohorts From 2000 and 2011.

OBJECTIVE: To evaluate changes over the past decade in the mode of delivery and second-stage duration in nulliparous women. METHODS: We conducted a retrospective cohort study at a single institution of nulliparous women reaching complete cervical dilation with singleton gestations 36 weeks or greater from January 1, 2011, to December 31, 2012, and compared these with a prior cohort prospectively collected from July 28, 2000, to February 28, 2003. We excluded pregnancies with prenatally diagnosed fetal anomalies. The primary outcome was cesarean delivery. Secondary outcomes included second-stage duration, rates of operative vaginal delivery (forceps and vacuum collectively), and indications for cesarean delivery and operative vaginal delivery. RESULTS: There were 1,023 mother-neonate pairs in the prior cohort and 1,476 in the current cohort. In the prior and current cohorts, respectively, 2% compared with 6% underwent cesarean delivery, 21% compared with 10% underwent operative vaginal delivery, and 77% compared with 84% had spontaneous vaginal delivery (all P<.01). Compared with the prior cohort, the adjusted odds (OR) of cesarean delivery (compared with any vaginal birth) for current patients was 1.74 (95% confidence interval [CI] 1.04-2.91), and in a separate regression model, the adjusted OR of operative vaginal delivery (compared with spontaneous vaginal delivery or cesarean delivery) was 0.42 (95% CI 0.33-0.54). Median (25th, 75th percentile) second-stage duration significantly increased from 38 (20, 71) to 42 (22, 87) minutes (P<.01), but this difference was nullified after adjusting for confounders. CONCLUSION: Comparing cohorts from 2000 and 2011, although the second-stage duration has not changed appreciably, nulliparous women in the second stage of labor at our institution are twice as likely to undergo cesarean delivery and half as likely to undergo operative vaginal delivery. LEVEL OF EVIDENCE: II.

Lowered national cesarean section rates after a concerted action.

OBJECTIVE: To evaluate national cesarean section (CS) rates and other obstetric indicators after a concerted action to reduce CS rates was undertaken in Portugal from 2010 onwards. This action was based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding. DESIGN: Retrospective observational population-based study. SETTING: Portugal. POPULATION: Births occurring in Portugal between 2000 and 2014. METHODS: Governmental sources were used to obtain data on national CS, perinatal and maternal mortality rates. Rates of instrumental vaginal delivery, vaginal birth after cesarean (VBAC), hypoxia-related complications and perineal lacerations were retrieved for state-owned hospitals. MAIN OUTCOME MEASURES: CS, perinatal and maternal mortality, instrumental vaginal delivery, VBAC, hypoxia-related complications and perineal lacerations. RESULTS: After a continuous rise between 2000 and 2009, national CS rates declined significantly over the following 5 years (36.6% vs. 33.1%, time trend p ≤ 0.001). Perinatal mortality maintained a downward trend during this period, while maternal mortality remained unchanged. Rates of instrumental vaginal delivery, VBAC and perineal lacerations increased, while the incidence of hypoxia-related complications decreased. CONCLUSIONS: A concerted action based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding, was followed by a significant reduction in national CS rates, as well as an improvement in most related obstetric indicators. There may be an association between the reported intervention and the observed changes.

Epidural analgesia and operative delivery: a ten-year population-based cohort study in The Netherlands.

OBJECTIVE: To describe trends in the use of epidural analgesia (EA) and to evaluate the association of EA with operative deliveries. STUDY DESIGN: In this population-based, retrospective cohort study, women with an intention to deliver vaginally of a term, cephalic, singleton between 2000 and 2009 (n=1378458) were included. Main outcome measures were labor EA rates, unplanned caesarean section (CS), and instrumental vaginal delivery (IVD) including deliveries by either vacuum or forceps. Data were obtained from the Perinatal Registry of The Netherlands and logistic regression analyses were used. RESULTS: Among nulliparous, EA use almost tripled over the 10-year span (from 7.7% to 21.9%), while rates of CS and IVD did not change much (+2.8% and -3.3%, respectively). Among multiparous, EA use increased from 2.4% to 6.8%, while rates of CS and IVD changed slightly (+0.8% and -0.7%, respectively). Multivariable analysis showed a positive association of EA with CS, which weakened in ten years, from an adjusted OR of 2.35 (95% CI, 2.18 to 2.54) to 1.69 (95% CI, 1.60 to 1.79; p<0.001) in nulliparous, and from an adjusted OR of 3.17 (95% CI, 2.79 to 3.61) to 2.56 (95% CI, 2.34 to 2.81; p<0.001) in multiparous women. A weak inverse association between EA and IVD was found among nulliparous (adjusted OR, 0.76; 95% CI, 0.75 to 0.78), and a positive one among multiparous women (adjusted OR, 2.08; 95% CI, 2.00 to 2.16). Both associations grew slightly weaker over time. CONCLUSIONS: A near triplication of EA use in The Netherlands in ten years was accompanied by relatively stable rates of operative deliveries. The association between EA and operative delivery became weaker. This supports the idea that EA is not an important causal factor of operative deliveries.

[Trends in vaginal assisted deliveries in the Moravian-Silesian region between the years 2002-2011]. / Trendy operacních vaginálních porodu v Moravskoslezském regionu v letech 2002-2011.

OBJECTIVE: To analyze trends in vaginal assisted deliveries between 2002-2011 in the Moravian-Silesian region, Czech Republic. DESIGN: Retrospective analysis. SETTING: Obstetric facilities in the Moravian-Silesian region, Czech Republic. METHODS: Analysis of data on vaginal assisted deliveries in the obstetric facilities in the Moravian-Silesian region, Czech Republic, between the years 2002-2011. RESULTS: During the analyzed period the use of vacuum extraction rose from 0.11% to 2.44% of all deliveries and the use of forceps declined from 1.54% to 0.24% of all deliveries. The overall frequency of vaginal assisted deliveries increased from 1.65% to 2.87%. The frequency of caesarean section increased from 16% to 24.5%. CONCLUSION: A fundamental change in the trends of vaginal assisted deliveries occurred in the Moravian-Silesian region between 2002 to 2011. There was a significant reduction in the use of forceps and the rise in the use of vacuum extraction with an overall increase in vaginal assisted deliveries. In comparison with the results of the rest of the Czech Republic, the trends in the Moravian-Silesian region are more pronounced. During the analysed period a significant rise of the cesarean section deliveries occurred.

Mothers' level of education and childbirth interventions: A population-based study in Flanders, Northern Belgium.

BACKGROUND: Interventions to influence the time and way to be born have been a global concern for decades. Yet, limited information is available on what drives these interventions and their variation in frequency among countries, institutions, and practitioners. The objective of this study was to examine to what extent first-time mothers' educational achievement contributes to the frequency of childbirth interventions. METHODS: Childbirth interventions, including induction of labor, cesarean section, instrumental delivery, and epidural analgesia, registered by the Flemish Study Center for Perinatal Epidemiology for Belgian-born nulliparous women from 1999 to 2006, were linked to the level of maternal education, recorded by the Belgian civil birth registration. Education was divided into four levels based on the highest diploma attained and adjusted for marital and occupational status. RESULTS: Frequencies of all interventions were inversely related to the level of maternal education. The effect remained after adjustment for birth year, maternal age, marital status, occupation, infant birthweight, gestational age, assisted conception, and type of hospital. Effect sizes between highest and lowest levels of education were relatively small for operative (31% vs 36%) and instrumental vaginal birth (20.7% vs 22.3%) compared with "initiated delivery" (defined as labor induction and prelabor cesarean section; 30.2% vs 40.3%) and epidural analgesia (66.8% vs 78.0%). The educational gradient in initiated delivery occurred at all gestational ages, contributing to lower gestational age and lower birthweight of term infants with decreasing levels of education. CONCLUSIONS: In an affluent society with universal and equitable access to maternity care, the more educated women are, the more likely they are to have a spontaneous labor and spontaneous birth without intervention. (BIRTH 38:3 September 2011).

Novos aspectos da vácuo-extração fetal / New aspects of vaccum-extracted deliveries

Apresentamos um dispositivo descartável de manejo simples (Mityvac - Prism Healthcare, San Antonio, Texas) que, embora pouco difundido, já está disponível em alguns hospitais brasileiros e é devidamente licenciado pela Agência Nacional de Vigilância Sanitária (ANVISA). Sua aceitação na Inglaterra e Estados Unidos tem sido grande nos últimos 10 anos. Os principais tempos e cuidados no manuseio do equipamento são expostos

Trends in obstetric interventions in the Dutch obstetrical care system in the period 1993-2002.

OBJECTIVE: To determine trends in induction of labour-, instrumental vaginal delivery- and caesarean section rates in the Netherlands in the period 1993-2002. STUDY DESIGN: Data derived from The Netherlands Perinatal Registry and Statistics Netherlands were used to calculate annual rates for induction of labour, instrumental vaginal delivery and caesarean section. Regarding caesarean section, rates were also calculated for different subgroups with respect to parity, presentation of the fetus, gestational age and multiple pregnancies. In the subgroup of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation instrumental delivery rates were compared for women with induced labours and women in spontaneous labour. RESULTS: The overall CS rate rose from 8.1 to 13.6%. Proportionally the rise was greatest for breech presentation (+37.7%), multiple gestations (+12.7%) and women delivering between 24 and 28 weeks (+9.5%). However, in absolute numbers the rise was most impressive in the group of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation. Rate of induction of labour and instrumental vaginal delivery remained constant (approximately 15% respectively 10% of all deliveries). In nulliparous term women with singletons in vertex presentation the CS rate increased with 8.0% to a rate of 20.7% when labour was induced versus an increase of 3.4% to a rate of 7.5% in spontaneous labour. CONCLUSION: In absolute numbers the rise in CS was most extensive in the group of women with a singleton fetus in vertex presentation between 37 and 42 weeks of gestation. Induction of labour rates and instrumental vaginal delivery rates remained constant during the past decade.

Trends in labour and birth interventions among low-risk women in New South Wales.

OBJECTIVE: To examine recent trends in obstetric intervention rates among women at low-risk of poor pregnancy outcome. DESIGN: Cross-sectional analytic study SETTING AND POPULATION: A population of 336,189 women categorised as low-risk of a poor pregnancy outcome who gave birth to a live singleton in NSW from 1 January 1990 to 31 December 1997. MAIN OUTCOME MEASURES: Obstetric intervention rates including oxytocin induction and augmentation of labour, epidural analgesia, instrumental births, caesarean section and episiotomy METHODS: Trends over time were assessed by fitting trend-lines to numbers of births or by trends in proportions. Unconditional logistic regression was used to assess the impact of epidural analgesia on instrumental birth over time. RESULTS: Rates of operative births did not rise despite increases in maternal age and use of epidural analgesia. Instrumental births declined over time from 26% to 22% among primiparas and 5% to 4% among multiparas. There was also a shift to vacuum extraction rather than forceps. Although instrumental birth was strongly associated with epidural analgesia, the strength of the association declined over the study period, for primiparas from an adjusted odds ratio of 7.2 to 5.2 and for multiparas from 13.2 to 10.3. CONCLUSIONS: Increased use of epidural analgesia for labour has been a feature of the management of birth at term during the 1990s. The decline in the strength of association between epidural analgesia and instrumental birth may reflect improved epidural techniques and management of epidural labour, and recognition of the adverse maternal outcomes associated with forceps and vacuum births.

[Trends in the frequency of obstetrical operations and perinatal mortality in the Czech Republic in comparison with other countries]. / Vývoj frekvence porodnických operací a perinatální úmrtnosti v Ceské republice v mezinárodním srovnání.

In an international epidemiological survey during a 10-year period the increase of obstetric operations was investigated in 11 countries with advanced perinatal care. Major differences were found as regards the frequency of Caesarean sections as well as vaginal operations (forceps and vacuum extraction). The mean effectiveness of the increase in the frequency of Caesarean sections on the reduction (evaluated by the mille drop of perinatal mortality rate is reduced when the frequency of Caesarean section) exceeds about 10%. Of all investigated countries only the Netherlands and the Czech Republic achieve a low perinatal mortality, while the frequency of Caesarean sections is low. The author discusses the reasons for the revealed differences between different countries.

Variation in caesarean and instrumental delivery rates in New Zealand hospitals.

A study of Caesarean section and instrumental delivery rates in the maternity hospitals in New Zealand delivering over 1,000 women per year was undertaken. The results at Middlemore Hospital were compared with those seen elsewhere. The Caesarean section rate at Middlemore Hospital in 1993 was significantly lower than the other large maternity hospitals in New Zealand. The Caesarean section rate at Middlemore from 1988 to 1993 has shown a significant downward trend which is different from the trends at other hospitals. The spontaneous vaginal delivery rates at Middlemore Hospital were higher than at other New Zealand hospitals between 1988 and 1993. We conclude that Middlemore Hospital has been successful in maintaining low interventional delivery rates by New Zealand and international standards--the Caesarean section rate remains below 10% and the spontaneous vaginal delivery rate approaches 85%. This is likely to be a consequence of a number of factors operating together but there is evidence to suggest that obstetric management policies at Middlemore do play a role in this.

Vaginal operative deliveries in Italy.

OBJECTIVE: To analyze the trends in vaginal operative deliveries in Italy. DESIGN: Analysis of information on all deliveries after the 28th week of gestation, routinely collected by the Italian Central Institute of Statistics using a standard form. SETTING: National data on all Italian deliveries in the period 1981-85. SUBJECTS: All deliveries occurred in Italy in the period. RESULTS: Forceps and vacuum delivery were reported in 1981 respectively in 0.9 and 2.1/100 deliveries. Similar percentages were observed during the whole considered quinquennium for vacuum extraction, but the forceps delivery rate decreased to 0.6/100 in 1985. Nulliparous women more frequently had an operative vaginal delivery: the rates of forceps and vacuum deliveries were respectively 1.1 and 3.7/100 in nulliparae and 0.3 and 1.0 in women reporting one or more previous births. There was a direct relationship between vacuum delivery rate and birth weight: vacuum deliveries were reported for respectively 0.9 and 2.3/100 infants weighing less than 2500 g and > or = 2500 g. Likewise, vaginal operative deliveries were more frequent in term or post-term births, and vacuum deliveries among singleton births than multiple ones (2.3 vs 1.7/100 deliveries). CONCLUSIONS: Operative vaginal delivery rates in Italy in the mid 1980's were lower than in most developed countries. The reasons for forceps and vacuum extraction were similar to other developed countries with regard to obstetric determinants, but some differences emerged for socio-demographic factors.

Hospital stay due to various hysterectomies, caesarean section and normal delivery in Turku University Central Hospital area from 1983 to 1992.

The optimal length of hospital stay in obstetrics and gynaecology has recently been much debated, as short hospitalisation times being commonly introduced as alternatives to conventional hospitalisations. The hospital stay for major gynaecological and obstetric surgery as well as normal delivery was studied in the hospitals working in area of the Turku University Central Hospital (population approximately 750,000). In the six studied hospitals the mean hospital stay for abdominal and vaginal hysterectomy decreased during the 1980s by one fifth. In 1992, the mean hospitalisation for hysterectomy varied from 7.4 to 8.3 and from 9.0 to 9.1 days, for abdominal and vaginal hysterectomy, respectively, and that of caesarean section from 8.1 to 8.6 days. The number of days in hospital required for normal delivery was 4.4-6.2 days. These figures are similar to the corresponding national average in Finland, but they also show that the discharge in our country occurs some 2 to 3 times later than what has recently been reported, e.g. from the U.S.A. Consequently, we find that there is a need for a prospective trial to find out how rational short hospitalisation is in the field of obstetrics and gynaecology in Finland.

[Obstetric-perinatal status 1990 in the Oder region (a contribution to the obstetric-perinatal care in East Brandenburg)]. / Zur geburtshilflich-perinatologischen Situation des Jahres 1990 in der Oder-Region (Ein Beitrag zum Stand der geburtshilflich-perinatologischen Betreuung in Ost-Brandenburg).

On the background of the first All-German-Perinatal-Study in 1992 the results in obstetrics and perinatology in the Oder-Region (east part of the State of Brandenbourg) in 1990 are described. In comparison to the results in a previous study (1985) we found a drastical decline in the number of births (newborns 1985: 10244; 1990: 7723); in addition to the changing in the reproduction- and health-care behaviour, too, we have noted a decreasing perinatal mortality from 7.5% in 1985 to 4.9% in 1990. The ameliorated monitoring-rate (cardiotocography-rate) of the fetus (1985: 71%, 1990: 88.4%) and the decreasing still-birth-rate may be the main cause of this phenomenon. Clinic-births were the most common deliveries, the house-birth was the great exception; only 0.2% of all deliveries occurred at home or otherwhere. Our data support that there is no difference, except the birth-rate, in relation to the situation in the "old" Federal Republic of Germany.

Patterns of use of obstetrical interventions in 12 countries.

Recent obstetrical practice trends in 12 countries were surveyed. There was a 3-fold difference in caesarean section rates and a 10-fold difference in instrumental vaginal delivery rates among countries. There was a net increase in the caesarean section rate of all countries over the study period and a net decrease in the instrumental vaginal delivery rate of some countries. There was a decrease in the caesarean section rate during the last year of observation in Australia, Denmark and Finland. In general, countries with high caesarean rates also had high instrumental vaginal delivery rates. There was no consistent relationship between use of caesarean section and use of instrumental vaginal delivery, although in several countries increasing use of caesarean section was accompanied by decreasing use of instrumental vaginal delivery. Oxytocin use rates were associated positively with instrumental delivery but not with caesarean section rates. While it was not possible to determine the proportions of women who received appropriate obstetrical care, we can infer that a significant proportion of interventions were unnecessary or only marginally beneficial. Continued increases in rates of obstetrical intervention are unlikely to result in improvements in birth outcome overall and may pose a risk to mothers and their newborns.