October 20th, 2006
A Canadian population-based cohort study has revealed that medical induction of labour increases the risk of amniotic-fluid embolism. The study was led by Dr. Michael Kramer, Canadian Institutes of Health Research (CIHR) Senior Investigator from McGill University, and will be published in the October 21st issue of The Lancet.
Amniotic-fluid embolism (AFE) is a rare, but serious and even fatal maternal complication of delivery. While its cause is unknown, it is one of the leading causes of maternal mortality in developed countries, accounting for seven of 44 direct maternal deaths in Canada in the period 1997-2000.
This population-based study examined the association of AFE and medical induction of labour in a cohort of three million hospital births in Canada, for the twelve fiscal years 1991-2002.
“AFE remains a rare occurrence,” said Dr. Michael Kramer, principal investigator of the study and Scientific Director of CIHR’s Institute of Human Development, Child and Youth Health. “Of the 180 cases of AFE we found, 24 or 13% were fatal. AFE arose almost twice as frequently in women who had medical induction of labour as in those who did not; fatal cases arose 31⁄2 times more frequently.”
“Dr. Kramer's research has resulted in a discovery that will benefit physicians who look after pregnant women as they will now be aware of this potential complication should they induce labour", said Dr. Joseph Shuster, Interim Scientific Director of the MUHC. "This is an example of how academic university teaching hospitals improve the quality of patient care.”
The research team also found several other factors to be associated with higher rates of AFE, including multiple pregnancy, older maternal age (35 years or older), caesarean or instrumental vaginal delivery, eclampsia (a serious complication of pregnancy characterised by convulsions), polyhydramnios (too much amniotic fluid), abnormal placental position or separation, and cervical laceration or uterine rupture.
“Our findings confirm the hypothesis that medical induction of labour is related to an increased risk of AFE,” added Dr. Kramer. “Although the absolute risk increase of AFE for women is very small (four or five total cases and one or two fatal cases per 100,000 women induced) and is unlikely to affect the decision to induce labour in the presence of compelling clinical indications, women and physicians should be aware of this risk if the decision is elective.”
Dr. Kramer worked with Drs. K.S. Joseph and Thomas F. Baskett at Dalhousie University as well as with Mr. Jocelyn Rouleau at the Public Health Agency of Canada (PHAC). The research was conducted for the Maternal Health Study Group of the Canadian Perinatal Surveillance System, a program under PHAC auspices.
Source: Canadian Institutes of Health Research
http://www.physorg.com/news80564831.html
Growing danger from post-birth bleeding
February 25th, 2009
Post-partum haemorrhage (PPH) immediately after giving birth is the largest threat to new mothers in high-income countries. An Australian study, featured in the open access journal BMC Pregnancy and Childbirth, shows that an increasing number of women suffered severe problems arising from blood loss after delivery.
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Christine Roberts from the University of Sydney and Royal North Shore Hospital led a team of researchers who studied the birth-hospital discharge records of the 500,603 women who had children in New South Wales during the study period. She said, "We identified 6242 women who suffered severe adverse outcomes, including 22 who died in hospital. Of the 6242, 67% had an obstetric haemorrhage (60% PPH)".
The consequences of adverse maternal outcomes can include infertility, psychological effects, disability and even death. According to Roberts, "Active management of the third stage of labour, delivery of the placenta, is effective in reducing PPH. Unfortunately, adherence to active third-stage management recommendations is poorly reported and/or suboptimal in Australia, and significant variations in policies and practice have been reported in Europe. Suboptimal adherence to active management guidelines could explain the rising PPH rates".
The authors found that between 1999 and 2004 the annual rate of adverse maternal outcomes increased by 20.9%. This increase occurred almost entirely among women who had a PPH. Although adverse outcomes also increased among women with conditions related to high blood pressure, over half these women also had a PPH. Roberts said, "Women with risk factors for PPH, such as a very low placenta or a previous PPH, should give birth in hospitals with facilities to manage severe haemorrhage."
The authors conclude, "We feel that all women should have access to active management of the third stage of labour and careful observation in the first two hours after delivery, as this may reduce the PPH rate and the potential for severe harm and death".
More information: Trends in adverse maternal outcomes during childbirth: a population-based study of severe maternal morbidity, Christine L Roberts, Jane B Ford, Charles S Algert, Jane C Bell, Judy M Simpson and Jonathan M Morris, BMC Pregnancy and Childbirth (in press), http://www.biomedcentral.com/bmcpregnancychildbirth/
Source: BioMed Central
http://www.physorg.com/news154767601.html
Patience during stalled labor can avoid many C-sections, study shows
November 1st, 2008
Pregnant women whose labor stalls while in the active phase of childbirth can reduce health risks to themselves and their infants by waiting out the delivery process for an extra two hours, according to a new study by researchers at the University of California, San Francisco.
By doing so, obstetricians could eliminate more than 130,000 cesarean deliveries – the more dangerous and expensive surgical approach – per year in the United States, the researchers conclude.
The study examined the health outcomes of 1,014 pregnancies that involved active-phase arrest – two or more hours without cervical dilation during active labor – and found that one-third of the women achieved a normal delivery without harm to themselves or their child, with the rest proceeding with a cesarean delivery.
The findings appear in the November, 2008 issue of Obstetrics and Gynecology, the official journal of the American College of Obstetricians and Gynecologists (ACOG).
While ACOG already recommends waiting at least two hours with adequate contractions in the setting of no progress in active labor, it is routine practice in many clinical settings to proceed with a cesarean for "lack of progress" before those ACOG criteria have been met, according to Aaron Caughey, MD, PhD, an associate professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, and senior author on the paper.
"One third of all first-time cesareans are performed due to active-phase arrest during labor, which contributes to approximately 400,000 surgical births per year," said Caughey, who is affiliated with the UCSF National Center of Excellence in Women's Health. "In our study, we found that just by being patient, one third of those women could have avoided the more dangerous and costly surgical approach."
The cesarean delivery rate reached an all-time high in 2006 of 31.1 percent of all deliveries, according to the UCSF study. Arrest in the active phase of labor has been previously shown to raise the risk of cesarean delivery between four- and six-fold.
"Cesarean delivery is associated with significantly increased risk of maternal hemorrhage, requiring a blood transfusion, and postpartum infection," Caughey said. "After a cesarean, women also have a higher risk in future pregnancies of experiencing abnormal placental location, surgical complications, and uterine rupture."
The ten-year study identified all women who experienced what is known as active-phase arrest during their delivery at UCSF from 1991 to 2001. The study only included women with live, singleton deliveries who were delivered full-term.
The researchers examined maternal outcomes such as maternal infection, endomyometritis, postpartum hemorrhage and the need for blood transfusions. It also examined the infant's Apgar score, rates of infection and frequency of admission to the neonatal intensive care unit, among other health indicators.
The study found an increased risk of maternal health complications in the group that underwent cesarean deliveries, including postpartum hemorrhage, severe postpartum hemorrhage and infections such as chorioamnionitis and endomyometritis, but found no significant difference in the health outcomes of the infants.
It concluded that efforts to continue with a normal delivery can reduce the maternal risks associated with cesarean delivery, without a significant difference in the health risk to the infant.
"Given the extensive data on the risk of cesarean deliveries, both during the procedure and for later births, prevention of the first cesarean delivery should be given high priority," Caughey said.
Source: University of California - San Francisco
http://www.physorg.com/news144769920.html
Repeat C-section before 39 weeks raises risk of neonatal illness
January 7th, 2009
Women choosing repeat cesarean deliveries and having them at term but before completing 39 weeks gestation are up to two times more likely to have a baby with serious complications including respiratory distress resulting in mechanical ventilation and NICU admission.
UAB researchers, led by Alan T.N. Tita, M.D., Ph.D., assistant professor in the UAB Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, and colleagues reported in a study published January 8 in the New England Journal of Medicine that women who choose to have their babies delivered via repeat cesarean at 37 or 38 weeks without a medical or obstetric indication, risk serious complications for their child.
"The cesarean rate in the United States has risen dramatically, from 20.7 percent in 1996 to 31.1 percent in 2006. A major reason is the decline in attempted vaginal births after cesarean. Because elective cesareans can be scheduled to accommodate patient and physician convenience, there is a risk that they may be performed earlier than is appropriate." Tita said. "We knew from previous small studies that infants born before 39 weeks' gestation are at increased risk for respiratory distress. Because nearly 40 percent of the cesareans performed in the United States each year are repeat procedures, we undertook this large study to describe the timing of elective repeat cesareans and assess its relationship with the risk of various adverse neonatal outcomes."
Tita and colleagues studied 13,258 women who had elective repeat cesarean sections at the 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network from 1999 through 2002. They were selected from the Cesarean Section Registry of the network. The registry contains detailed, prospectively collected information on nearly 50,000 women with a prior cesarean who underwent either repeat cesarean delivery or a trial of labor at the 19 centers over the 4-year period. The 13,258 women studied were those who underwent an elective cesarean of a viable infant at 37 weeks gestation or later in the absence of labor or other obstetric or medical indications for early cesarean delivery (prior to 39 weeks).
The researchers looked at whether an infant who was delivered at 37 weeks later died or was diagnosed with a number of conditions, including respiratory distress syndrome and/or transient tachypnea of the newborn, newborn sepsis, seizures, necrotizing entercolitis, hypoxic ischemic encephalopathy, required ventilator support within 24 hours of birth, had umbilical cord arterial pH (a measure of oxygenation) below 7.0, an Apgar score at five minutes of three or below, was admitted to a neonatal intensive care unit or required prolonged hospitalization.
Of the 13,258 women who had elective repeat cesarean sections, as many as 35.8 percent were delivered before 39 weeks. Babies born at 37 weeks, were two times more likely to suffer with conditions common to babies born too soon, and at 38 weeks, they were one and a half times more likely.
Tita said these findings, along with other studies, underscore the importance of not delivering a baby before 39 weeks for the sake of convenience.
"Unfortunately, these early deliveries are associated with a preventable increase in neonatal morbidity and NICU admissions, which carry a high personal and economic cost. These findings support recommendations to delay elective delivery until 39 weeks gestation and should be helpful in counseling women on the necessity of waiting to deliver."
Source: University of Alabama at Birmingham
http://www.physorg.com/news150571274.html
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