'NEEDLESS' BIRTH INDUCTION FEARS , Emma Wilkinson, Health Reporter
Concerns have been raised about pregnant women being induced "unnecessarily", after a Scottish audit of 17,000 births. In more than a quarter of cases, researchers could not find a medical or other explanation for the procedure. The Aberdeen University team said in the Journal of Public Health that rates of obstetric intervention were rising. Experts warned that more studies were needed to assess whether inductions are being done without good reason. In the UK, the commonest method of induction is the use of a gel containing prostaglandins to bring on contractions and start the labour process. Medical reasons for induction include being over 41 weeks pregnant, waters breaking but no onset of labour, or planned timing of labour because of complications. The procedure is associated with an increased likelihood of further medical interventions, such as caesarean section.Rates of induction are rising in the UK - particularly in Scotland - but there does not seem to be a single explanation for the figures, the researchers said. Using data in the Aberdeen Maternity and Neonatal databank on births between 1999 and 2003, they identified that 5,700 or 32% of pregnant women had been induced. Reasons for induction included the standard medical reasons as well as social factors such as living a long way from the hospital. But 28% of cases remained unexplained.
"I did expect to find a proportion that could not be explained because as good as the database is I'm sure there are characteristics that are just not collected, but we were slightly surprised that it was as high as it was," said study leader Tracy Humphrey, consultant midwife at Grampian NHS Board. "It raises the question that there may be some unnecessary interventions and we are planning further studies." She added: "The main debate about unnecessary interventions has focused on caesareans and we have forgotten about the other interventions that go on." Mary Newburn, head of policy research at the National Childbirth Trust, said that if a significant number of inductions were being done without cause, it was a serious problem which must be addressed. "Further research is needed to identify the circumstances of induced labour where there are not good clinical reasons." She added that induced labour tends to be more painful and more difficult for women to manage without strong drugs. "If women are asking for induction because they are tired at the end of pregnancy, they may need more support, and encouragement to rest as much as possible, so that they can wait a bit longer."
Patrick O' Brien, a consultant at University College London Hospitals and a spokesperson for the Royal College of Obstetricians and Gynaecologists, said the finding was interesting but it may be that reasons for induction were not properly recorded in the database. "But it is important that there is a good reason for inducing labour when it happens," he added. "More research needs to be done."
Sue Macdonald, spokeswoman for the Royal College of Midwives, said it was important that women knew why induction was being done. "We are very interested in trying to support normal birth and ensuring an intervention is done only when it's absolutely necessary."
(Story from BBC News - http://news.bbc.co.uk/2/hi/health/7833058.stm, published 18 January, 2009)
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VAGINAL/CAESAREAN COMBO DELIVERY OF TWINS ,
Newswise
Doctors need not go straight to Caesarean section when delivering twins, but can start with vaginal delivery of the first twin in many cases, researchers have found in a study led by UT Southwestern Medical Center. Should the second-born twin turn out to require a Caesarean section, there is a slightly higher risk of infection for the baby and the mother, but that is easily treated and the risk of more serious complications for the second twin is not increased, the researchers found. “It keeps the options open for women and providers who are motivated for vaginal delivery,” said Dr. James Alexander, associate professor of obstetrics and gynecology at UT Southwestern and lead author of the two-year study, which appears in the October issue of the journal Obstetrics and Gynecology.
Although such “combined” delivery is relatively rare, there have been no large-scale studies to gauge how the mothers and babies fared after the procedure, Dr. Alexander said.
The UT Southwestern researchers are members of the Maternal-Fetal Medicine Units Network, a subset of the National Institutes of Health that comprises 14 university-based clinical centers and a data coordinating center. They compared deliveries of 1,028 women at 13 network locations from 1999 to 2000, using data collected from a registry of information maintained by the group. This made the study the largest to address the question of combined-delivery safety, Dr. Alexander said. All of the women in the study went through a period of labor. Ultimately, 849 had Caesarean sections of both twins, while 179 had a combined delivery of the first twin vaginally and the second by Caesarean section, usually because of a nonreassuring fetal heart rate or a poor position for delivery. Four percent of women who had combined delivery developed chorioamnionitis, an infection involving the uterus, while 13 percent developed endometritis, an infection of the lining of the uterus. In contrast, 6 percent of the women who had Caesarean section of both twins developed chorioamnionitis, while 9 percent developed endometritis.
Dr. Alexander said the differences in infection rates were not statistically significant after accounting for the mothers’ ages, length of pregnancy and characteristics of the labor, such as whether labor was induced or an antibiotic was used, and the time from onset of labor to delivery. There were roughly equal rates of injury, seizures, low Apgar scores and other factors to the babies in both types of deliveries, showing that overall health was the same. The difference in rates of serious infection was not statistically significant, although the second-born twins from a combined delivery showed a slightly higher rate (9 percent versus 5 percent) than sets of twins being delivered by Caesarean section.
Dr. Kenneth Leveno, professor of obstetrics and gynecology at UT Southwestern, was also involved in the study. Researchers from the University of Alabama at Birmingham, Ohio State University, George Washington University Biostatistics Center, the National Institute of Child Health and Human Development (NICHHD), University of Utah, University of Chicago, University of Pittsburgh, Wake Forest University School of Medicine, Thomas Jefferson University, Wayne State University, University of Cincinnati, University of Miami, University of Tennessee, UT Health Science Center at San Antonio and Vanderbilt University also participated.
The study was funded by the National Institutes of Health. Visit http://www.utsouthwestern.org/obgyn to learn more about gynecology and obstetrics clinical services at UT Southwestern. Dr. James Alexander - http://www.utsouthwestern.edu/findfac/professional/0,2356,10101,00.html
(Source - UT Southwestern Medical Center, http://www.newswise.com/articles/view/545874/, released Wednesday 29 October 2008)
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VAGINAL BIRTH AFTER CAESAREAN - CLINICAL RISK FACTORS ASSOCIATED WITH ADVERSE OUTCOMES,
Kimberly D. Gregory, MD, MPH; Lisa M. Korst, MD, PhD; Moshe Fridman,
PhD; Ida Shihady, MPH; Paula Broussard, RN; Arlene Fink, PhD; Linda
Burnes Bolton, RN, DrPH
Objective - The objective of the study was to identify vaginal birth
after cesarean (VBAC) success rates and maternal and neonatal
complication rates for selected antenatal conditions.
Study Design - This was a population-based cohort study using
administrative discharge data for women delivering in California
hospitals during 2002.
Results - Among 41,450 women, 29.72% (12,320 of 41,450) had
maternal, fetal, or placental conditions complicating pregnancy.
Attempted VBAC rates and VBAC success rates varied widely by these
clinical condition, ranging from 10% to 73%. The VBAC success rate
for low-risk women (no conditions) was 73.76% vs 50.31% for highrisk
women (at least 1 condition), P .0001. Absolute rates of maternal
and neonatal complications were low (less than 1-2%), and the rate
of adverse events was higher in the high-risk clinical group as
compared with the low-risk clinical group.
Conclusion - Variation in rates of VBAC success and childbirth
morbidities can be partially attributed to clinical factors
complicating pregnancy. Women without such conditions show improved
VBAC success and fewer maternal and neonatal complications.
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TIMING OF ELECTIVE REPEAT CAESAREAN DELIVERY AT TERM AND NEONATAL OUTCOMES, by Tita et al,
New England Journal of Medicine, 2009, 360:111-20.
Background - Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes.
Methods - We studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU).
Results - Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.
Conclusions - Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes