Inducing labour in older women having their first baby does not increase the chance of caesarean delivery

Planning to artificially start labour for older women, pregnant with their first child, in the 39th week of pregnancy does not affect the chance of having a caesarean delivery | NIHR Signal


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Older women having a first baby have a higher risk of stillbirth and other complications than younger mothers and inducing labour at or before the due date is thought to reduce this risk. However, there have been fears that inducing labour may raise the risk of a caesarean delivery.

This study found that women aged 35 or over having their first child and who were induced at 39 weeks had no higher risk of a caesarean (32%) than women who had standard wait-and-see care (33%) with intervention if necessary.

It’s important to note that this study did not investigate whether women whose labour was induced had a lower risk of stillbirth. A large trial is in progress to investigate this issue. In the meantime, the findings may reassure some women aged over 35 that labour induction may carry no more risk of having a caesarean than spontaneous labour.

Read the full overview here

Choice of Anesthesia for Cesarean Delivery

Neuraxial anesthesia use in cesarean deliveries (CDs) has been rising since the 1980s, whereas general anesthesia (GA) use has been declining | Anesthesia & Analgesia

In this brief report we analyzed recent obstetric anesthesia practice patterns using National Anesthesiology Clinical Outcomes Registry data. Approximately 218,285 CD cases were identified between 2010 and 2015. GA was used in 5.8% of all CDs and 14.6% of emergent CDs. Higher rates of GA use were observed in CDs performed in university hospitals, after hours and on weekends, and on patients who were American Society of Anesthesiologists class III or higher and 18 years of age or younger.

Full reference: Juang, J. et al. (2017) Choice of Anesthesia for Cesarean Delivery: An Analysis of the National Anesthesia Clinical Outcomes Registry. Anesthesia & Analgesia. 124 (6) pp. 1914–1917

Azithromycin Prophylaxis for Cesarean Delivery

Rothaus, C. The New England Journal of Medicine. Published online: September 29th 2016

Cesarean delivery is the most common major surgical procedure and is associated with a rate of surgical-site infection (including endometritis and wound infection) that is 5 to 10 times the rate for vaginal delivery. Tita et al. assessed whether the addition of azithromycin to standard antibiotic prophylaxis before skin incision would reduce the incidence of infection after cesarean section among women who were undergoing nonelective cesarean delivery during labor or after membrane rupture. In this new Original Article involving women who received standard antibiotic prophylaxis for nonelective cesarean section, the risk of infection after surgery was lower with the addition of azithromycin than with placebo.

Clinical Pearl

• How does pregnancy-associated infection rank as a cause of maternal death in the United States?

Globally, pregnancy-associated infection is a major cause of maternal death and is the fourth most common cause in the United States.

Clinical Pearl

• How often do postoperative infections occur after nonelective cesarean delivery?

Despite routine use of antibiotic prophylaxis (commonly, a cephalosporin given before skin incision), infection after cesarean section remains an important concern, particularly among women who undergo nonelective procedures (i.e., unscheduled cesarean section during labor, after membrane rupture, or for maternal or fetal emergencies). As many as 60 to 70% of all cesarean deliveries are nonelective; postoperative infections occur in up to 12% of women undergoing nonelective cesarean delivery with standard preincision prophylaxis.#

Read the full Now@NEJM Blog post here

Read the original research article here

Maternal vitamin D deficiency and fetal distress/birth asphyxia: a population-based nested case–control study

Lindqvist, P.G. et al. BMJ Open. Published online: 22 September 2016


Objective: Vitamin D deficiency causes not only skeletal problems but also muscle weakness, including heart muscle. If the fetal heart is also affected, it might be more susceptible to fetal distress and birth asphyxia. In this pilot study, we hypothesised that low maternal vitamin D levels are over-represented in pregnancies with fetal distress/birth asphyxia.

Design and setting: A population-based nested case–control study.

Patients: Banked sera of 2496 women from the 12th week of pregnancy.

Outcome measures: Vitamin D levels were analysed using a direct competitive chemiluminescence immunoassay. Vitamin D levels in early gestation in women delivered by emergency caesarean section due to suspected fetal distress were compared to those in controls. Birth asphyxia was defined as Apgar <7 at 5 min and/or umbilical cord pH≤7.15.

Results: Vitamin D levels were significantly lower in mothers delivered by emergency caesarean section due to suspected fetal distress (n=53, 43.6±18 nmol/L) compared to controls (n=120, 48.6±19 nmol/L, p=0.04). Birth asphyxia was more common in women with vitamin D deficiency (n=95) in early pregnancy (OR 2.4, 95% CI 1.1 to 5.7).

Conclusions: Low vitamin D levels in early pregnancy may be associated with emergency caesarean section due to suspected fetal distress and birth asphyxia. If our findings are supported by further studies, preferably on severe birth asphyxia, vitamin D supplementation/sun exposure in pregnancy may lower the risk of subsequent birth asphyxia.

Read the article here

Induction of Labor and Cesarean Delivery

Grobman, W. A. New England Journal of Medicine 2016; 374:880-881. Published online: March 3, 2016

At the heart of obstetrical care is a seemingly simple calculus: when are the benefits of delivery greater than the benefits of continued pregnancy? However, making this determination is anything but straightforward, given the potentially conflicting needs of the mother and the needs of her offspring, which must both be taken into account to maximize maternal and perinatal health.

In the absence of maternal or fetal complications, current consensus favors the consideration of delivery between 41 weeks 0 days and 42 weeks 0 days of gestation. In addition, for these women, delivery is recommended after 42 weeks 0 days and no later than 42 weeks 6 days of gestation, given the increase in perinatal morbidity and mortality at these gestational ages.1 Thus, induction before 41 weeks 0 days of gestation in the absence of complications is considered not to be medically indicated.

One consideration that traditionally has tipped the balance toward continuing pregnancy is the concern that labor induction may increase the risk of cesarean delivery, particularly among nulliparous women. This belief is based on the findings of multiple observational studies in which outcomes in women who underwent induction were compared with those of women who had spontaneous labor.2 However, spontaneous labor is not a clinical “strategy,” and thus it is not the appropriate comparison.

Read the full editorial here



“Vaginal seeding” of infants born by caesarean section

Cunningham, A. et al. BMJ 2016;352:i227

How should health professionals engage with this increasingly popular but unproved practice?

The microbiota is the community of microbes that colonises our bodies, outnumbering our own cells 10 to 1. This complex microbial community varies from one part of the body to another, and from one person to another. Characteristic differences in the microbiota are associated with various diseases. As a result interest has surged in the potential for manipulating the microbiota to promote health and treat disease.

The term “vaginal seeding” describes the use of a gauze swab to transfer maternal vaginal fluid, and hence vaginal microbiota, on to an infant born by caesarean section. The composition of the early microbiota of infants is heavily influenced by mode of delivery. In infants born by caesarean section the microbiota resembles that of maternal skin, whereas in vaginally born infants it resembles that of the maternal vagina.

These early differences in the microbiota have been suggested to determine susceptibility to an increasing number of common non-communicable diseases. In theory, vaginal seeding might restore the microbiota of infants born by caesarean section to a more “natural” state and decrease the risk of disease. The potential benefits of vaginal seeding have recently been reported in the press and, as a result, demand has increased among women attending our hospitals. Demand has outstripped both professional awareness and professional guidance on this practice.

Read the full editorial here