3. [Neonatal outcome after cesarean section]. [Review] [Polish] Kornacka MK. Kufel K. Ginekologia Polska. 82(8):612-7, 2011 Aug.

[English Abstract. Journal Article. Review] UI: 21957607 Cesarean section is the most commonly performed procedure all over the world. Both American and European data reveal constant and steady increase of pregnancies resolved by a cesarean section. The reasons include: growing number of medical indications or requests of the pregnant women. Regardless of the fact that elective cesarean section decreases the risk of intrauterine hypoxia, meconium aspiration and injury during labor it remains a significant risk factor for respiratory failure in the course of transient tachypnea of the newborn, infant respiratory distress syndrome and pulmonary hypertension, both for term and late preterm infants. As a consequence, the infant requires a prolonged stay in the intensive care unit, together with advanced and often expensive medical procedures such as mechanical (often high-frequency) ventilation, nitric oxide therapy and extracorporeal membrane oxygenation. The American Association of Obstetricians and Gynecologists and the European Association of Perinatal Medicine recommend for a cesarean section due to medical indications to be performed after 39 weeks gestation, preferably after uterine contractions started, and elective cesarean section, particularly if there are indications to finish the pregnancy before 39 weeks gestation, after lung maturity has been assessed (in other case steroids ought to be administered prenatally to mature the lung muscles). That includes also cases of elective cesarean sections performed due to previous cesarean sections, which are the most frequent reasons for repeating procedure. The recommendations also restrict the indications for cesarean section in case of significant prematurity what in turn is connected with more restricted 1

indications for resuscitation of extremely premature infants and babies with extremely low birth weight. Status MEDLINE Authors Full Name Kornacka, Maria Katarzyna. Kufel, Katarzyna. Institution Klinik Neonatologii i Intensywnej Terapii Noworodka Warszawskiego Uniwersytetu Medycznego w Warszawie, Polska. mariak@szpitalkarowa.pl Date Created 20110930 Year of Publication 2011 4. [Analysis of the indications for the caesarean section delivery for very low birthweight neonates (< 1500 g) delivered in I department gynecology and obstetrics, Medical University in Lodz in 2006-2010]. [Polish] Brzozowska M. Kowalska-Koprek U. Kus E. Berner-Trabska M. Karowicz-Bilinska A. Ginekologia Polska. 82(8):592-7, 2011 Aug. [English Abstract. Journal Article] UI: 21957603 UNLABELLED: Despite better care pregnant women receive nowadays, preterm birth and prematurity remain to be the reason of many complications and high mortality of neonates.

OBJECTIVE: The goal was to analyze the indications for cesarean sections delivery for very low birthweight (<1500 g) newborns delivered in the I Department Gynecology and Obstetrics, Medical University in Lodz. MATERIAL: The data from 560 preterm caesarean sections were analyzed. Detailed analysis referring to 120 cesarean sections resulting in deliveries of very low birthweight neonates was performed. Maternal age, parity neonatal weight and gestational age were assessed. The authors also assessed the number of cesarean sections performed for extremely low birthweight newborns, in particularly years and the rate of the indications in the groups of gestational age. RESULTS: The greatest number of the cesarean sections was done between 26-35 years of age of the patients (68,4%) in 28-32 weeks of gestation (53,3%). The rate of cesarean section performed for very low birthweight neonates was 2,3% of preterm caesarean sections. Fetal growth restriction (IUGR) and the symptoms of intrauterine hypoxia were the indications for cesarean sections in 33,4%, multiple pregnancy in 17,5%, abnormal fetal presentation in 15,8%, intrauterine infection in 13,3% and placental abruption in 11,7% of cases. The rate of the other indications was 11,7% of cases. Conclusions: In our material the most frequent indication for the cesarean section for very low birthweight neonates was fetal growth restriction with the symptoms of intrauterine hypoxia.

Status MEDLINE Authors Full Name

Brzozowska, Maria. Kowalska-Koprek, Urszula. Kus, Ewa. Berner-Trabska, Marlena. Karowicz-Bilinska, Agata. Institution Klinika Patologii Ciazy, I Katedra Ginekologii i Poloznictwa UM w Lodzi, Polska. koala.mb@gazeta.pl Date Created 20110930 Year of Publication 2011 9. Effect of prior cesarean delivery on neonatal outcomes. Abenhaim HA. Benjamin A. Journal of Perinatal Medicine. 39(3):241-4, 2011 May. [Journal Article] UI: 21426242 AIMS: To examine the effect of a prior cesarean delivery on neonatal outcomes. METHODS: We conducted a retrospective cohort study on all women with a prior livebirth who delivered at the Royal Victoria Hospital between 2001 and 2006. We defined our exposure as a positive history for cesarean delivery and used unconditional logistic regression analysis to estimate the adjusted effect of a previous cesarean delivery on adverse neonatal outcomes. RESULTS: A total of 18,673 births took place of which 9708 were in women with a prior livebirth (77.0% with no previous cesarean delivery and 23.0% with a previous cesarean delivery). As compared to newborns delivered by

mothers with no prior cesarean delivery, increasing number of prior cesarean deliveries was associated with an increasing risk of preterm birth [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.09-1.39]; respiratory distress syndrome (OR 3.54, 95% CI 2.02-5.91); and admission to the neonatal intensive care unit (OR 1.41, 95% CI 1.25-1.60). These findings were predominantly due to differences in gestational age and mode of delivery. CONCLUSION: Having a prior cesarean delivery is associated with an increased risk of adverse neonatal outcomes. Adverse neonatal outcomes in subsequent pregnancies is additional evidence to suggest that unless specifically indicated, cesarean delivery should be avoided.

Status MEDLINE Authors Full Name Abenhaim, Haim A. Benjamin, Alice. Institution Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. haim.abenhaim@gmail.com Comments Comment in: J Perinat Med. 2011 Sep;39(5):615; PMID: 21767222 Date Created 20110510 Year of Publication 2011

16. [Descriptive analysis of maternal and neonatal characteristics in the maternity of the Dona Estefania Hospital between 2005 and 2008]. [Portuguese] Ventura MT. Gomes Mdo C. Acta Medica Portuguesa. 23(5):793-802, 2010 Sep-Oct. [English Abstract. Journal Article] UI: 21144318 Between 2005 and 2008 there were 8413 newborns at the maternity of the Hospital Dona Estefania (HDE), comprising about 8% of the total number of newborns in Portugal in the same period. Fetal mortality (0,20%) met the goal of the Portuguese National Health Plan (NHP) and was at the lowest levels reported in the European Union. The percentage of preterm deliveries (8,1%) and caesareans (31,9%), however, are still above the goals established by the NHP, respectively, 4,9% and 24,8%. In newborns, the odds ratio of a low Apgar index at five minutes was 1,35 for each 100 g of birth weight less and 1,33 for each gestational week less. Average maternal age was 30,4 years old, with 3,8% being adolescents. About 22% were foreign mothers, a number well above the Portuguese national average of 9%. The percentage of preterm births and caesareans were lower among Chinese mothers and quite variable among nationalities. Weight at birth was found to correlate significantly with gestational age, type of pregnancy (twins/singleton), foetus gender, maternal parity and age at delivery. On average, when everything else remained constant, one additional gestational week translated into more 176 g; a twin newborn was, on average, 381 g lighter than a singleton, and a female newborn was,

on average, 48 g lighter than a male. We present percentile tables of weight at birth by sex and gestational age (36-41 weeks) for newborns at the HDE. Status MEDLINE Authors Full Name Ventura, Maria Teresa. Gomes, Manuel do Carmo. Institution Servico Ginecologia/Obstetricia, Hospital Dona Estefania, Lisboa. Date Created 20101214 Year of Publication 2010 18. The effect of time intervals on neonatal outcome in elective cesarean delivery at term under regional anesthesia. Maayan-Metzger A. Schushan-Eisen I. Todris L. Etchin A. Kuint J. International Journal of Gynaecology & Obstetrics. 111(3):224-8, 2010 Dec.

[Journal Article] UI: 20855070 OBJECTIVES: To measure 3 intervals of time-induction of regional anesthesia to delivery (I-D), initial skin incision to delivery (S-D), and uterine incision to delivery (U-D)-in elective cesareans and to evaluate the impact of the duration of these 3 components on short-term neonatal outcome.

METHODS: We reviewed retrospective data on the duration of the components from the computerized database of the obstetrics operation room at the Sheba Medical Center, Tel Aviv, Israel, and from the medical records of term neonates. RESULTS: Sufficient data were available in 933 cases. The parameters associated with longer time to delivery at any stage were epidural rather than spinal anesthesia, maternal diabetes, previous cesarean delivery, antihypertensive treatment, higher birth weight (3456 g and 3285 g for U-D interval longer than 2 minutes and U-D interval up to 2 minutes, respectively; P=0.02), and male fetus. The duration of the I-D, S-D, and U-D intervals had no significant impact on any of the measured neonatal parameters. CONCLUSION: With regard to neonatal wellbeing, obstetricians have a relatively large safety margin in the time taken for inducing regional anesthesia and making the first and uterine incisions. Copyright Copyright 2010 Elsevier B.V. All rights reserved.

Status MEDLINE Authors Full Name Maayan-Metzger, Ayala. Schushan-Eisen, Irit. Todris, Liat. Etchin, Abba. Kuint, Jacob. Institution Department of Neonatology, Edmond and Lili Safra Children's Hospital, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University,

Tel Aviv, Israel. maayan@post.tau.ac.il Date Created 20101105 Year of Publication 2010 20. Effect of the interval between onset of sustained fetal bradycardia and cesarean delivery on long-term neonatal neurologic prognosis. Kamoshita E. Amano K. Kanai Y. Mochizuki J. Ikeda Y. Kikuchi S. Tani A. Shoda T. Okutomi T. Nowatari M. Unno N. International Journal of Gynaecology & Obstetrics. 111(1):23-7, 2010 Oct. [Journal Article. Research Support, Non-U.S. Gov't] UI: 20688328 OBJECTIVE: To examine the effect of the interval between onset of sustained fetal bradycardia and cesarean delivery on long-term neonatal neurologic prognosis. METHOD: A retrospective observational case-series performed with patients who had sudden-onset and sustained (<100 beats per minute) fetal bradycardia during labor. Fetal heart rate was monitored closely until cesarean delivery. The effect of the interval between the onset of bradycardia and delivery on neonatal neurologic prognosis was examined. RESULTS: Among 2267 deliveries in 2002-2003 at Kitasato University Hospital, 19 pregnancies met the inclusion criteria. Episodes of fetal bradycardia were due to umbilical cord prolapse (n=5), placental abruption (n=4), uterine rupture (n=3), maternal respiratory failure (n=1), and other causes (n=6). Mean onset of fetal bradycardia to delivery interval

(BDI) was 20.5+/-8.9 minutes. Mean decision-to-cesarean delivery interval was 11.4+/-3.9 minutes. BDI was negatively correlated with umbilical arterial pH at delivery. There were 3 postnatal deaths. Neurologic assessment at the age of 2 years revealed that 15 of 16 children were neurologically normal. When the BDI was less than 25 minutes, all term pregnancies led to normal neonatal neurologic development. CONCLUSION: In the event of sustained intrapartum fetal bradycardia, delivery by emergency cesarean within 25 minutes improved long-term neonatal neurologic outcome. Copyright Copyright 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Status MEDLINE Authors Full Name Kamoshita, Emi. Amano, Kan. Kanai, Yuji. Mochizuki, Junko. Ikeda, Yasuhiro. Kikuchi, Shinzo. Tani, Akihiro. Shoda, Takashi. Okutomi, Toshiyuki. Nowatari, Masahiko. Unno, Nobuya. Institution Department of Obstetrics and Gynecology, Kitasato University, School of Medicine, Sagamihara City, Kanagawa, Japan. unno@med.kitasato-u.ac.jp Date Created 20100910 Year of Publication 2010

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29. Neonatal outcomes and operative vaginal delivery versus cesarean delivery. Contag SA. Clifton RG. Bloom SL. Spong CY. Varner MW. Rouse DJ. Ramin SM. Caritis SN. Peaceman AM. Sorokin Y. Sciscione A. Carpenter MW. Mercer BM. Thorp JM Jr. Malone FD. Iams JD. American Journal of Perinatology. 27(6):493-9, 2010 Jun. [Comparative Study. Journal Article. Research Support, N.I.H., Extramural]

UI: 20099218 We compared outcomes for neonates with forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. This is a secondary analysis of a randomized trial in laboring, low-risk, nulliparous women at >or=36 weeks' gestation. Neonatal outcomes after use of forceps, vacuum, and cesarean were compared among women in the second stage of labor at station +1 or below (thirds scale) for failure of descent or nonreassuring fetal status. Nine hundred ninety women were included in this analysis: 549 (55%) with an indication for delivery of failure of descent and 441 (45%) for a nonreassuring fetal status. Umbilical cord gases were available for 87% of neonates. We found no differences in the base excess (P = 0.35 and 0.78 for failure of descent and nonreassuring fetal status) or frequencies of pH below 7.0 (P = 0.73 and 0.34 for failure of descent and nonreassuring fetal status) among the three delivery methods. Birth outcomes and umbilical cord blood gas values were similar for those neonates with a forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. The occurrence of significant fetal acidemia

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was not different among the three delivery methods regardless of the indication. Thieme Medical Publishers. Status MEDLINE Authors Full Name Contag, Stephen A. Clifton, Rebecca G. Bloom, Steven L. Spong, Catherine Y. Varner, Michael W. Rouse, Dwight J. Ramin, Susan M. Caritis, Steve N. Peaceman, Alan M. Sorokin, Yoram. Sciscione, Anthony. Carpenter, Marshall W. Mercer, Brian M. Thorp, John M Jr. Malone, Fergal D. Iams, Jay D. Institution Department of Obstetrics and Gynecology at Wake Forest University, Winston-Salem, North Carolina, USA. scontag@lifebridgehealth.org Date Created 20100525 Year of Publication 2010 34. Outcomes after internal versus external tocodynamometry for monitoring labor.[Erratum appears in N Engl J Med. 2010 May 13;362(19):1849] Bakker JJ. Verhoeven CJ. Janssen PF. van Lith JM. van Oudgaarden ED. Bloemenkamp KW. Papatsonis DN. Mol BW. van der Post JA. New England Journal of Medicine. 362(4):306-13, 2010 Jan 28. [Comparative Study. Journal Article. Multicenter Study. Randomized Controlled Trial] UI: 20107216 BACKGROUND: It has been hypothesized that internal tocodynamometry, as

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compared with external monitoring, may provide a more accurate assessment of contractions and thus improve the ability to adjust the dose of oxytocin effectively, resulting in fewer operative deliveries and less fetal distress. However, few data are available to test this hypothesis. METHODS: We performed a randomized, controlled trial in six hospitals in The Netherlands to compare internal tocodynamometry with external monitoring of uterine activity in women for whom induced or augmented labor was required. The primary outcome was the rate of operative deliveries, including both cesarean sections and instrumented vaginal deliveries. Secondary outcomes included the use of antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes (defined as any of the following: an Apgar score at 5 minutes of less than 7, umbilical-artery pH of less than 7.05, and neonatal hospital stay of longer than 48 hours). RESULTS: We randomly assigned 1456 women to either internal tocodynamometry (734) or external monitoring (722). The operative-delivery rate was 31.3% in the internal-tocodynamometry group and 29.6% in the external-monitoring group (relative risk with internal monitoring, 1.1; 95% confidence interval [CI], 0.91 to 1.2). Secondary outcomes did not differ significantly between the two groups. The rate of adverse neonatal outcomes was 14.3% with internal monitoring and 15.0% with external monitoring (relative risk, 0.95; 95% CI, 0.74 to 1.2). No serious adverse events associated with use of the intrauterine pressure catheter were reported. CONCLUSIONS: Internal tocodynamometry during induced or augmented labor,

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as compared with external monitoring, did not significantly reduce the rate of operative deliveries or of adverse neonatal outcomes. (Current Controlled Trials number, ISRCTN13667534; Netherlands Trial number, NTR285.) 2010 Massachusetts Medical Society

Status MEDLINE Authors Full Name Bakker, Jannet J H. Verhoeven, Corine J M. Janssen, Petra F. van Lith, Jan M. van Oudgaarden, Elisabeth D. Bloemenkamp, Kitty W M. Papatsonis, Dimitri N M. Mol, Ben Willem J. van der Post, Joris A M. Institution Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands. j.j.bakker@amc.uva.nl Comments Comment in: N Engl J Med. 2010 May 13;362(19):1842; author reply 1842-3; PMID: 20463346 Date Created 20100128 Year of Publication 2010 38. Pregnancy and perinatal outcome in women with hyperthyroidism. Pillar N. Levy A. Holcberg G. Sheiner E. International Journal of Gynaecology & Obstetrics. 108(1):61-4, 2010 Jan. [Journal Article]

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UI: 19766207 OBJECTIVE: To investigate pregnancy outcome for patients with treated hyperthyroidism. METHODS: A population-based study was performed comparing all singleton pregnancies of women with and women without hyperthyroidism at the Soroka University Medical Center, Be'er-Sheva, Israel, between January 1988 and January 2007. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders. RESULTS: During the study period, there were 185636 singleton deliveries in the medical center. Of these, 189 (0.1%) were from women with hyperthyroidism. Using multivariate analysis with backward elimination, the following risk factors were significantly associated with hyperthyroidism: placental abruption; cesarean delivery; and advanced maternal age. No significant differences regarding perinatal outcome were noted between the groups. Women with hyperthyroidism had significantly higher rates of cesarean delivery than did women without hyperthyroidism (20.1% vs 13.1%; P<0.004), even after controlling for confounders. CONCLUSIONS: Treated hyperthyroidism was not associated with adverse perinatal outcome. However, hyperthyroidism was found to be an independent risk factor for cesarean delivery.

Status MEDLINE Authors Full Name Pillar, Nir. Levy, Amalia. Holcberg, Gershon. Sheiner, Eyal.

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Institution Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er-Sheva, Israel. Date Created 20091216 Year of Publication 2010 40. [Effect of general anesthesia used in cesarean section on maternal-neonatal outcome of pregnancy complicated with severe thrombocytopenia]. [Chinese] Wei J. Liu GL. Liang MY. Wang SM. Chung-Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics & Gynecology]. 44(9):665-8, 2009 Sep. [English Abstract. Journal Article. Randomized Controlled Trial] UI: 20079177 OBJECTIVE: To investigate the effect of general anesthesia on pregnancy women with thrombocytopenia and neonate during cesarean section (CS). METHODS: Sixty-five singleton pregnant women with low platelet count (< 50 x 10(9)/L) and gestation>35 weeks were allocated into general anesthesia group (35 cases) and local anesthesia group (30 cases) randomly. The time from skin incision to fetal delivery, the oxyhemoglobin saturation (SO2) before and after anesthesia, the blood loss during operation, Apgar scores at 1 min, birth weight,umbilical cord blood gas analysis were recorded. RESULTS: The mean time from anesthesia induction to fetal delivery was (9.7 +/- 3.5) minutes in general anesthesia group. The time from skin

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incision to fetal delivery in general anesthesia group [(7.7 +/- 2.5) minutes] was shorter than that in local anesthesia group [(12.5 +/- 3.0) minutes, P < 0.01], while the operation time had no significant differences. There were no significant difference for the value of SO2 before and after general anesthesia or local anesthesia (P > 0.05). There was no significant difference for the blood loss [(471 +/- 245) ml vs. (452 +/- 213) ml, P > 0.05], Apgar scores at 1 minute, birth weight and umbilical cord blood gas analysis between the two groups (P > 0.05). There had two infants with blue asphyxia in local anesthesia group while no infant with asphyxia in general anesthesia group. CONCLUSION: General anesthesia is safe to pregnant women with thrombocytopenia during CS.

Status MEDLINE Authors Full Name Wei, Jun. Liu, Guo-li. Liang, Mei-ying. Wang, Shan-mi. Institution Department of Obstetrics, Peking University People's Hospital, Beijing 100044, China. Date Created 20100118 Year of Publication 2009 45. Adverse neonatal outcomes associated with trial of labor after

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previous cesarean delivery in an inner-city hospital in Lagos, Nigeria. Olusanya BO. Solanke OA. International Journal of Gynaecology & Obstetrics. 107(2):135-9, 2009 Nov.

[Journal Article] UI: 19647823 OBJECTIVE: To identify delivery methods and associated adverse neonatal outcomes after previous cesarean delivery. METHODS: A retrospective cross-sectional study in an inner-city maternity hospital in Lagos, Nigeria, in which outcomes associated with delivery methods were determined by multinomial logistic regression. RESULTS: Of 435 eligible singleton deliveries, 171 (39.3%) occurred via elective cesarean, 249 (57.2%) via emergency cesarean, and 15 (3.4%) after successful trial of labor. Emergency cesarean delivery was associated with low 1-minute Apgar scores compared with successful trial of labor. It was also associated with low 5-minute Apgar scores compared with elective cesarean delivery, in addition to hyperbilirubinemia and admission to the special care baby unit. Successful trial of labor was less likely to be associated with low 1-minute Apgar scores than was elective cesarean delivery. The delivery methods were not associated with risk of sensorineural hearing loss. CONCLUSION: Trial of labor is common in this tertiary hospital among women with previous cesarean delivery and is associated with high failure rates and adverse neonatal outcomes with potential developmental risks.

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Status MEDLINE Authors Full Name Olusanya, Bolajoko O. Solanke, Olumuyiwa A. Institution Maternal and Child Health Unit, Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria. boolusanya@aol.com Date Created 20091006 Year of Publication 2009 43. Pregnancy outcomes of repeat cesarean section in Peking Union Medical College Hospital. Ma LK. Liu N. Bian XM. Teng LR. Qi H. Gong XM. Liu JT. Yang JQ. Chinese Medical Sciences Journal. 24(3):147-50, 2009 Sep. [Journal Article] UI: 19848314 OBJECTIVE: To evaluate the effect of elective repeat cesarean section on the maternal and neonatal outcomes. METHODS: A retrospective clinic- and hospital-based survey was designed for comparing the maternal and neonatal outcomes of elective repeat cesarean section [RCS group (one previous cesarean section) and MRCS group (two or more previous cesarean sections)] and primary cesarean section (FCS group) at Peking Union Medical College Hospital from January 1998 to

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December 2007. RESULTS: The incidence of repeat cesarean section increased from 1.26% to 7.32%. The mean gestational age at delivery in RCS group (38.1+/-1.8 weeks) and MRCS group (37.3+/-2.5 weeks) were significantly shorter than that in FCS group (38.9+/-2.1 weeks, all P<0.01). The incidence of complication was 33.8% and 33.3% in RCS group and MRCS group respectively, and was significantly higher than that in FCS group (7.9%, P<0.05). Dense adhesion (13.5% vs. 0.4%, OR=7.156, 95% CI: 1.7-30.7, P<0.01) and uterine rupture (1.0% vs. 0, P<0.05) were commoner in RCS group compared with FCS group. Neonatal morbidity was similar among three groups (P>0.05). CONCLUSIONS: Repeat cesarean section is associated with more complicated surgery technique and increased frequency of maternal morbidity. However, the incidence of neonatal morbidity is similar to primary cesarean section.

Status MEDLINE Authors Full Name Ma, Liang-Kun. Liu, Na. Bian, Xu-Ming. Teng, Li-Rong. Qi, Hong. Gong, Xiao-Ming. Liu, Jun-Tao. Yang, Jian-Qiu. Institution Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China. Date Created

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20091023 Year of Publication 2009 89. Maternal and neonatal outcome after cesarean section: the impact of anesthesia. Gori F. Pasqualucci A. Corradetti F. Milli M. Peduto VA. Journal of Maternal-Fetal & Neonatal Medicine. 20(1):53-7, 2007 Jan. [Journal Article] UI: 17437200 BACKGROUND: Among the anesthetic technologies used, regional anesthesia is becoming the most common in cesarean section (CS) deliveries. Aim. This retrospective survey examined the variables taken into account when selecting the anesthetic technique to be used, and how this choice affects the outcome for the mother and the newborn. METHODS: One thousand eight hundred and seventy elective and emergency CS were evaluated for anesthetic technique used, indications, and maternal and neonatal outcome. RESULTS: Of the 611 elective CS (32.6%), 206 (33.8%) were performed under general anesthesia and 405 (66.2%) under regional anesthesia. Of the 1259 emergency CS performed (67.4%), 525 (41.9%) were under general anesthesia and 734 (58.1%) under regional anesthesia. Conditions associated with a newborn 1-minute Apgar score of <7 were general anesthesia and multiple pregnancy (p<0.01); a 5-minute Apgar score of <7 was only associated with multiple pregnancy. The most important factor for very low Apgar scores was the presence of fetal malformations. Whatever the chosen technique,

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neither maternal deaths directly or indirectly due to the anesthesia nor major maternal and perinatal complications were found. CONCLUSIONS: This survey confirms the preference for regional anesthesia during elective cesarean sections and for general anesthesia in emergency situations. Moreover, newborn outcome was found not to be influenced either by the technique used or by the character of the procedure.

Status MEDLINE Authors Full Name Gori, F. Pasqualucci, A. Corradetti, F. Milli, M. Peduto, V A. Institution Department of Clinical and Experimental Medicine, Section of Anaesthesiology, Analgesia and Intensive Care, University of Perugia School of Medicine, Perugia, Italy. bobo.gori@libero.it Date Created 20070417 Year of Publication 2007

90. Comparison of effects of rapid colloid loading before and after spinal anesthesia on maternal hemodynamics and neonatal outcomes in cesarean section. Nishikawa K. Yokoyama N. Saito S. Goto F. Journal of Clinical Monitoring & Computing. 21(2):125-9, 2007 Apr.

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[Comparative Study. Journal Article. Randomized Controlled Trial. Research Support, Non-U.S. Gov't] UI: 17265094 BACKGROUND: The effects of colloid loading after spinal anesthesia on hemodynamics in parturients during cesarean section have not been fully understood. This study tested the hypothesis that colloid loading after spinal blockade can reduce hypotension compared with preloading, and affect neonatal outcomes. METHODS: A prospective, randomized, double-blinded study was performed in 54 healthy parturients (ASA I or II) undergoing elective cesarean section. Patients were randomly allocated into one of three groups to receive rapid infusion of 6% hydroxyethylstarch (HES) (70 kDa/0.5) before spinal anesthesia (15 ml x kg(-1), HES preload group, n = 18), or rapid infusion of HES after induction of spinal anesthesia (15 ml x kg(-1), HES coload group, n = 18), or no rapid infusion (control, n = 18). The incidence of hypotension, and the amount of ephedrine used to treat hypotension was compared. Neonatal outcomes were also assessed by pH, base excess, lactate concentration, and Apgar scores. RESULTS: The incidence of hypotension was significantly lower in HES preload and HES coload groups than control group (P < 0.01). Although systolic blood pressure decreased after spinal blockade in all groups, the lowest SBP after spinal blockade until delivery was significantly higher in fluid loading groups than control (P < 0.001). Similarly, total dose of ephedrine to treat hypotension was lower in fluid loading groups (P < 0.001). Umbilical cord pH, umbilical lactate concentration, and the

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incidence of neonates with Apgar score <7 were similar. CONCLUSION: Colloid loading after induction of spinal anesthesia was similarly effective in reducing hypo- tension compared with preloading in cesarean section.

Status MEDLINE Authors Full Name Nishikawa, Koichi. Yokoyama, Naho. Saito, Shigeru. Goto, Fumio. Institution Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi City 371-8511, Japan. nishikaw@med.gunma-u.ac.jp Date Created 20070413 Year of Publication 102. Central fetal monitoring: effect on perinatal outcomes and cesarean section rate. Withiam-Leitch M. Shelton J. Fleming E. Birth. 33(4):284-8, 2006 Dec. [Journal Article. Research Support, Non-U.S. Gov't] UI: 17150066 BACKGROUND: In a trend similar to continuous electronic fetal monitoring, many hospitals are incorporating central fetal monitoring into labor and delivery suites. The objective of this study was to investigate whether

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the use of central fetal monitoring had an effect on neonatal outcomes or cesarean section rate. METHODS: This retrospective study involved patient data from deliveries occurring at Women and Children's Hospital of Buffalo, Buffalo, New York, between the years 2000 and 2003. In the period from January 1, 2000, to December 31, 2001, central fetal monitoring was available, whereas in the period from February 1, 2002, to December 31, 2003, it was unavailable. Data on deliveries at Women and Children's Hospital of Buffalo were obtained using the Western New York Perinatal Data System, which is an electronic data set based on birth certificate information. The method of delivery, admission to the neonatal intensive care unit, and 5-minute Apgar scores less than 7 were compared for deliveries occurring with and without the use of central fetal monitoring. These outcomes were further subdivided into full-term and preterm deliveries. RESULTS: Three thousand five hundred and twelve deliveries used central monitoring and 3,007 deliveries did not. For full-term deliveries, in the years with central fetal monitoring compared with the years without it, no differences in the cesarean section rate (13.4 vs 14.5%, not significant [NS]), the admission rate in neonatal intensive care unit (3.3 vs 3.3%, NS), or the incidence of Apgar score less than 7 (0.6 vs 0.5%, NS) were observed. For preterm deliveries, comparing the years with central fetal monitoring with the years without, no differences in the cesarean section rate (21.3 vs 21.3%, NS), the admission rate in neonatal intensive care unit (17.7 vs 20.1%, NS), or the incidence of Apgar score less than 7 (7.0 vs 6.5%, NS) were observed. Analyses pooling all deliveries also failed to

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show any differences in any of the parameters. CONCLUSIONS: No statistically significant difference was demonstrated in the rates of cesarean section, admission to the neonatal intensive care unit, or incidence of Apgar scores of less than 7 associated with the use of central fetal monitoring. Therefore, we could not identify any benefit to the use of central fetal heart rate monitoring.

Status MEDLINE Authors Full Name Withiam-Leitch, Matthew. Shelton, James. Fleming, Emily. Institution Division of General Obstetrics and Gynecology, University at Buffalo, Women and Children's Hospital of Buffalo, Buffalo, New York 14222, USA. Date Created 20061207 Year of Publication 2006

103. Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Kolas T. Saugstad OD. Daltveit AK. Nilsen ST. Oian P. American Journal of Obstetrics & Gynecology. 195(6):1538-43, 2006 Dec. [Comparative Study. Journal Article. Research Support, Non-U.S. Gov't] UI: 16846577

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OBJECTIVE: The purpose of this study was to examine neonatal outcomes among women with a planned cesarean and a planned vaginal delivery at term. STUDY DESIGN: This prospective survey was conducted on 18,653 singleton deliveries that represent 24 maternity units during a 6-month period. The data were retrieved from the Medical Birth Registry of Norway and analyzed according to intended mode of delivery. RESULTS: Compared with planned vaginal deliveries, planned cesarean delivery increased transfer rates to the neonatal intensive care unit from 5.2% to 9.8% (P < .001). The risk for pulmonary disorders (transient tachypnea of the newborn infant and respiratory distress syndrome) rose from 0.8% to 1.6% (P = .01). There were no significant differences in the risks for low Apgar score and neurologic symptoms. CONCLUSION: A planned cesarean delivery doubled both the rate of transfer to the neonatal intensive care unit and the risk for pulmonary disorders, compared with a planned vaginal delivery.

Status MEDLINE Authors Full Name Kolas, Toril. Saugstad, Ola D. Daltveit, Anne K. Nilsen, Stein T. Oian, Pal. Institution Department of Obstetrics and Gynecology, Innlandet Hospital Trust, Lillehammer, Norway. toril.kolas@sykehuset-innlandet.no

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Comments Comment in: Am J Obstet Gynecol. 2007 Aug;197(2):217; author reply 217; PMID: 17689658 Date Created 20061129 Year of Publication 2006

104. Obstetric and neonatal outcomes in women who live in an urban resettlement area of Delhi, India: a cohort study. Chhabra P. Sharma AK. Tupil KA. Journal of Obstetrics & Gynaecology Research. 32(6):567-73, 2006 Dec. [Journal Article] UI: 17100818 AIM: To study the pregnancy outcome, namely mode and place of delivery, attendant at birth and perinatal mortality in an urban resettlement area of Delhi, India, and to determine factors that affect the outcome. METHODS: All the pregnant women (n = 909) in the area were enrolled and followed until 7 days after delivery. We calculated the crude and adjusted odds ratios for predictors of pregnancy related obstetric and neonatal outcomes, using logistic regression analysis. RESULTS: A total of 884 (97.3%) women could be followed up. Approximately two-thirds of deliveries took place at home. Primigravida, more educated mothers and mothers with non-cephalic presentation or complications were more likely to deliver in a health facility (P < 0.05). Most deliveries

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(97%) were vaginal, 2.5% were cesarean and 0.5% forceps deliveries. Primigravida mothers, mothers with short stature, mothers with non-cephalic presentation or complications had cesarean and forceps delivery more often (P < 0.05). A perinatal mortality rate of 74.5 per 1000 live births was observed. Presentation of the fetus and complications in the mother remained important factors. CONCLUSION: The majority of deliveries in the under-privileged sections in urban Delhi take place at home and the perinatal mortality remains high.

Status MEDLINE Authors Full Name Chhabra, Pragti. Sharma, Arun Kumar. Tupil, Kannan Anjur. Institution Department of Community Medicine, University College of Medical Sciences and GTB Hospital, Delhi, India. pragschhabra@yahoo.co.in Date Created 20061114 Year of Publication 2006

105. The impact of abnormal autoimmune function on reproduction: maternal and fetal consequences. Gleicher N. Weiner R. Vietzke M. Journal of Autoimmunity. 27(3):161-5, 2006 Nov.

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[Journal Article] UI: 17029731 The impact of abnormal autoimmune function on reproductive success has remained a highly controversial issue. This is, at least partially, due to the relative lack of demographic data from women with established autoimmune diseases. We, therefore, investigated 163 women with proven autoimmune diseases and 73 controls in a demographic study of reproductive success and impact of abnormal autoimmunity on pregnancy and offspring. Women with autoimmune diseases experienced fewer pregnancies overall (p=0.04) and fewer pregnancy losses (p=0.05). Offspring from women with autoimmune diseases demonstrated a significantly increased prevalence of confirmed autoimmune diseases (p=0.04; OR 3.759; 95%CL 1.04-1.27), which increased further if suspected, but not yet confirmed, cases were added (p=0.001; OR 8.592; 95%CL 1.05-55.0). Women with autoimmune diseases exhibited a trend towards lower cesarean section delivery during their own birth and a significantly increased prevalence of disease in vaginally delivered offspring (p=0.014; OR 6.041; 95%CL 1.32-38.22). Autoimmune diseases impair female fecundity even before the diseases become clinically overt. Offspring are at increased risk to develop autoimmune diseases, though they may differ from those of their mothers. This risk appears to correlate with mode of delivery and may be the consequence of varying cell traffic dynamics with vaginal and cesarean section deliveries. Status MEDLINE

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Authors Full Name Gleicher, Norbert. Weiner, Rebecca. Vietzke, Mary. Institution Centers for Human Reproduction (CHR), New York, NY 10021, USA. ngleicher@thechr.com Date Created 20061113 Year of Publication 2006 2007 113. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America.[Erratum appears in Lancet. 2006 Aug 12;368(9535):580] Villar J. Valladares E. Wojdyla D. Zavaleta N. Carroli G. Velazco A. Shah A. Campodonico L. Bataglia V. Faundes A. Langer A. Narvaez A. Donner A. Romero M. Reynoso S. de Padua KS. Giordano D. Kublickas M. Acosta A. WHO 2005 global survey on maternal and perinatal health research group. Lancet. 367(9525):1819-29, 2006 Jun 3. [Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, Non-P.H.S.] UI: 16753484 BACKGROUND: Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS: For the 2005 WHO global survey on maternal and perinatal health,

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we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS: We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Status MEDLINE Authors Full Name Villar, Jose. Valladares, Eliette. Wojdyla, Daniel. Zavaleta, Nelly.

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Carroli, Guillermo. Velazco, Alejandro. Shah, Archana. Campodonico, Liana. Bataglia, Vicente. Faundes, Anibal. Langer, Ana. Narvaez, Alberto. Donner, Allan. Romero, Mariana. Reynoso, Sofia. de Padua, Karla Simonia. Giordano, Daniel. Kublickas, Marius. Acosta, Arnaldo. WHO 2005 global survey on maternal and perinatal health research group. Institution UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, 1211 Geneva 27, Switzerland. villarj@who.int Comments Comment in: Lancet. 2006 Jun 3;367(9525):1796-7; PMID: 16753467 Date Created 20060606 Year of Publication 2006 136. The incidence of large fetomaternal hemorrhage and the Kleihauer-Betke test. Salim R. Ben-Shlomo I. Nachum Z. Mader R. Shalev E. Obstetrics & Gynecology. 105(5 Pt 1):1039-44, 2005 May. [Comparative Study. Journal Article] UI: 15863542 OBJECTIVE: To assess the frequency of large fetomaternal hemorrhage and to estimate its incidence in cesarean compared with vaginal deliveries. METHODS: In this prospective cohort study, the study group was composed of 313 women who underwent cesarean delivery. Control subjects were 253 women

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who delivered vaginally and were matched for age, parity, ethnic origin, and gestational age. Ninety-six pregnant women at term, but before delivery (prelabor group), were also included to determine whether delivery itself is the cause of fetomaternal hemorrhage. Fetomaternal hemorrhage was measured by using the Kleihauer-Betke test. RESULTS: Twenty women (6.4%) in the study group and 17 (6.7%) in the control group had a large fetomaternal hemorrhage (Kleihauer-Betke test > 0.4%). Five women (5.2%) in the prelabor group had a large fetomaternal hemorrhage. The differences were not significant. A large fetomaternal hemorrhage occurred in 14 of 146 (9.6%) women who underwent emergency cesarean, compared with 6 of 167 (3.5%) who delivered by elective cesarean (P = .04). In deliveries complicated by oligohydramnios, cord around the neck, or low birth weight, a higher rate of large fetomaternal hemorrhage was seen. CONCLUSION: Our results indicate a rate of large fetomaternal hemorrhage that is substantially higher than previously reported, with no difference between vaginal and cesarean deliveries. This may reflect inaccuracies with the current method used to estimate the degree of fetomaternal hemorrhage.

Status MEDLINE Authors Full Name Salim, Raed. Ben-Shlomo, Izhar. Nachum, Zohar. Mader, Rivka. Shalev, Eliezer.

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Institution Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel. Comments Comment in: Obstet Gynecol. 2006 Jan;107(1):206-7; author reply 207; PMID: 16394063, Comment in: Obstet Gynecol. 2005 Sep;106(3):642-3; author reply 643; PMID: 16135606 Date Created 20050502 Year of Publication 2005 152. Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital. Loebel G. Zelop CM. Egan JF. Wax J. Journal of Maternal-Fetal & Neonatal Medicine. 15(4):243-6, 2004 Apr. [Comparative Study. Journal Article] UI: 15280132 OBJECTIVE: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar. STUDY DESIGN: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother-neonate

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dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother-neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery. RESULTS: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p < 0.05). Mother-neonatal dyads with a failed trial of labor sustained the greatest risk of complications. CONCLUSION: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.

Status MEDLINE Authors Full Name Loebel, G. Zelop, C M. Egan, J F X. Wax, J. Institution Department of Obstetrics and Gynecology, St Francis Hospital and Medical

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Center, Hartford, Connecticut 06001, USA. Date Created 20040728 Year of Publication 2004 169. Neonatal outcome after trial of labor compared with elective repeat cesarean section. Fisler RE. Cohen A. Ringer SA. Lieberman E. Birth. 30(2):83-8, 2003 Jun. [Comparative Study. Journal Article] UI: 12752164 BACKGROUND: Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a trial of labor after cesarean. METHODS: All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a trial of labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the trial of labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). RESULTS: Infants delivered after a trial of labor had increased rates of

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sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p < 0.001); and mild bruising (8.0% vs 1.5%, p = 0.008). Within the trial of labor group, infants of mothers who received epidural analgesia were more likely to have received diagnostic tests and therapeutic interventions including sepsis evaluation (29.6% vs 6.0%, p = 0.001) and antibiotic treatment (13.9% vs 4.8%, p = 0.03) than within the no-epidural analgesia group. CONCLUSIONS: Infants born to mothers after a trial of labor are twice as likely to undergo diagnostic tests and therapeutic interventions than infants born after an elective repeat cesarean section, but the increase occurred only in the subgroup of infants whose mothers received epidural analgesia for pain relief during labor. The higher rate of intervention could relate to the well-documented increase in intrapartum fever that occurs with epidural use.

Status MEDLINE Authors Full Name Fisler, Rita E. Cohen, Amy. Ringer, Steven A. Lieberman, Ellice. Institution Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. Date Created 20030519

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Year of Publication 2003 181. Obstetrical intervention rates and maternal and neonatal outcomes of women with gestational hypertension. Gofton EN. Capewell V. Natale R. Gratton RJ. American Journal of Obstetrics & Gynecology. 185(4):798-803, 2001 Oct. [Comparative Study. Journal Article] UI: 11641654 OBJECTIVE: The purpose of this study was to determine the obstetrical intervention rates and maternal and neonatal outcomes of women with gestational hypertension. STUDY DESIGN: Induction and operative delivery rates and indices of maternal and neonatal morbidity were determined in women (37-41 completed weeks) with gestational hypertension (n = 979), preeclampsia (n = 165), chronic hypertension (n = 187), and control subjects (n = 11,434) in a retrospective review of St. Joseph's Health Care Perinatal Database from November 1, 1995, to October 31, 1999. Data were analyzed by chi-square test, analysis of variance, Dunnett's t -test, and pairwise chi-square tests with Bonferroni correction. RESULTS: The induction and cesarean delivery rates in gestational hypertension were similar to preeclampsia and chronic hypertension groups and almost double of control subjects. The length of labor and postpartum stays and the incidence of operative vaginal delivery, postpartum hemorrhage, and neonatal intensive care involvement were greater in the gestational hypertension group than in the control subjects.

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CONCLUSION: Women with gestational hypertension had obstetrical intervention rates much higher than control subjects and similar to those with preeclampsia and chronic hypertension.

Status MEDLINE Authors Full Name Gofton, E N. Capewell, V. Natale, R. Gratton, R J. Institution Department of Obstetrics and Gynecology, St. Joseph's Health Care, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada. Date Created 20011019 Year of Publication 2001 10. Maternal and neonatal effects of single-dose epidural anesthesia with lidocaine and morphine for cesarean delivery. Niruthisard S. Somboonviboon W. Thaithumyanon P. Mahutchawaroj N. Chaiyakul A. Journal of the Medical Association of Thailand. 81(2):103-9, 1998 Feb. [Clinical Trial. Journal Article. Research Support, Non-U.S. Gov't] UI: 9529839 Two per cent lidocaine (18-20 ml) with epinephrine 1:200,000 plus 4 mg of morphine was given as a single epidural injection over 3 minutes for

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elective cesarean section in 60 healthy mothers at term. It provided effective, safe and adequate analgesia in the postoperative period. There was no evidence of neonatal depression related to the epidural morphine as judged by Apgar scores at 1 and 5 minutes and umbilical venous pH at birth. Maternal and umbilical venous levels of morphine were measured and found to be low at birth. However, this study was done only in healthy mothers not in labor and having a term fetus. We do not recommend using this technique in complicated obstetric patients. Status MEDLINE Authors Full Name Niruthisard, S. Somboonviboon, W. Thaithumyanon, P. Mahutchawaroj, N. Chaiyakul, A. Institution Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. Date Created 19980423 Year of Publication 1998
Pregnancy outcomes

For this study, we considered pregnancy complications or high risk pregnancy (hypertensive disorder of pregnancy or gestational diabetes), method of delivery, gestation or preterm birth (normal, premature), birth weight (measured in grams) and placental weight (measured in grams) as pregnancy outcomes. Hypertensive disorders in pregnancy (HDP) were diagnosed at birth by a consultant obstetrician and defined as a diastolic BP over 90 mmHg on at least two occasions beyond 20 weeks gestation associated with proteinuria and/or excessive fluid retention (defined as generalized oedema including the face and

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hands and excessive weight gain) [29]. For the purpose of this study, all delivery methods were grouped into three categories: normal delivery, caesarean delivery and others (forceps, ventouse, assisted breech and combined methods). Preterm birth was defined as normal if gestation was more than 36 weeks and premature if gestation was 21 to 36 weeks. Birth weight, placental weight and methods of delivery were obtained from the obstetric records.

Conclusions We found that pre-pregnancy obesity and excess weight gain during pregnancy were associated with greater odds of caesarean delivery and pregnancy complication, heavier birth and placenta weights. Excess GWG was associated with greater length of hospital stay independent of pre-pregnancy BMI, maternal life style, pregnancy complications and caesarean delivery. Inadequate GWG or pre-pregnancy underweight was associated with greater risk of preterm births. The relationship between prepregnancy obesity and increased length of hospital stay was fully mediated by pregnancy complications and caesarean delivery in this study population. Our results highlight the importance of routinely collecting accurate data on weight, height and weight gain throughout pregnancy, both to identify women at increased risk of health care requirements and so that other studies can replicate the results. In recent years, most high-income countries have seen a trend towards rapid discharge of mothers and babies after delivery in order to reduce the risk of hospital infection, improve rapid integration of the new-born into family life and provide a more efficient healthcare service. The main implication from this study is that, as well as causing adverse perinatal and longer term outcomes, excessive weight gain during pregnancy may also lead to adverse pregnancy outcomes and extended health care utilization in obstetric care. If our results are replicated in other cohorts, further research needs to determine the mechanisms linking these pathways of excess GWG to adverse pregnancy outcomes to longer hospital stay and identify means of supporting healthy weight gain in pregnancy.
Mamun et al. BMC Pregnancy and Childbirth 2011, 11:62 http://www.biomedcentral.com/1471-2393/11/62 Page 7 of 9

Neonatal outcomes after vaginal and caesarean breech delivery

Louis-Jacques van Bogaert, Asha Misra To the Editor: The safety of vaginal breech delivery is still a matter of debate. Definite evidence that caesarean breech delivery improves mortality and morbidity is lacking.1 The meta-analysis by Cheng and Hannah found a 3- to 4-fold significantly higher perinatal mortality rate (PNMR) and neonatal morbidity with planned vaginal delivery (VD) compared with planned caesarean section (CS).2 On the other hand, in a Dutch survey where 95% of 247 women with a term singleton breech were allowed to labour, 84% delivered

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vaginally and had a normal neonatal outcome. The feasibility of VD was determined by normal progress of labour in the first stage with no signs of fetal distress.3 Another Dutch survey compared the PNMR in breech presentation with that in vertex presentation in singleton pregnancies; it was concluded that breech presentation is not coincidental but a consequence of poor fetal quality.4 According to Cunningham et al., if hydrocephaly is excluded, the head is flexed, the biparietal diameter is less than 10 cm, a footling breech is ruled out, and the fetus is estimated to be of average weight, a VD can be anticipated.5 In developing world settings, and especially in rural conditions, a proper management plan before the onset of labour is often not achievable. The unpopularity of the prospect of a CS prompts women to delay admission to the labour ward until in established labour. In a series of 181 consecutive breech presentations, 64 (35.4%) had a VD, and 117 (64.6%) a CS. Table I lists the comparative maternal and fetal details. VD patients were older and of higher parity; the birth weights were lighter. The 1-minute Apgar score was significantly lower. The other parameters (5-minute Apgar score, fresh stillbirth rate, early neonatal mortality rate, and PNMR) were similar. The overall PNMR was 83 per 1 000, 2.5 times higher than that in the institution over the last 2 years. The aim of this survey was not to argue against CS for breech presentations when a VD is deemed unwarranted, either for feto-maternal reasons or lack of skills in breech VD. The purpose was to find out about neonates outcomes in conditions where planning is often impossible. In view of the high PNMR in both groups, it also supports the suggestion that breech presentation is a consequence of poor fetal quality.
References
1. de Leeuw JP. Breech presentation. Vaginal or abdominal delivery? MD thesis, Rijksuniversiteit Limburg, Maastricht, 1989. 2. Cheng M, Hannah M. Breech delivery at term. A critical review of the literature. Obstet Gynecol 1993; 82: 605-610. 3. Roumen FJME, Luyben AG. Safety of term vaginal breech delivery. Eur J Obstet Gynecol Reprod Biol 1991; 40: 171-176. 4. Schutte MF, van Hemel OJS, van den Berg C, van de Pol A. Perinatal mortality in breech presentation as compared to vertex presentation in singleton pregnancies: An analysis based on 57,819 computer-registered pregnancies in the Netherlands. Eur J Obstet Gynecol Reprod Biol 1985; 19: 391-399. 5. Cunningham FG, MacDonald PC, Gant NF, et al. Williams Obstetrics. 20th ed. London: Prentice Hall, 1997.

Saint Ritas Hospital, Glen Cowie, Limpopo Louis-Jacques van Bogaert, MD, MMed (O&G), MCOG (SA), MMed (Anat Path), MPhil, DPhil, PhD Asha Misra, MB ChB, Dipl Obstet Corresponding author: L-J van Bogaert (ljfvanbo@lantic.net)

Table I. Comparative features between vaginal and caesarean breech deliveries

Vaginal breech Caesarean breech N = 64 (35.4%) N = 117 (84.6%) t p Age (years) 29.8 7.1 27.1 7.0 2.4 0.01 Parity 2.4 2.0 1.3 1.6 4.0 < 0.0001 Birth weight (g) 2 760 748 3 107 503 3.7 0.0003 1-minute Apgar 7.2 2.3 7.9 1.5 2.5 0.016 5-minute Apgar 9.2 2.5 9.6 1.3 1.4 0.16 5-minute Apgar < 7 2 (3.3%) 3 (2.7%) 0.06* 0.80 Fresh stillbirth rate 4 (6.3%) 5 (4.3%) 0.34* 0.56 Early neonatal death 3 (5.0%) 3 (2.7%) 0.57* 0.45 PNMR (/1 000) 109 68 0.91* 0.34
* 2.

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