Search

Competing Interests: The authors declare that they have no conflicts of interest.

The aim of this systemic review and meta-analysis was to examine the differences in caesarean section rates across European regions and at a country level by utilizing the Robson classification system. The study has compared caesarean rates across European regions using the Robson classification to identify the drivers of caesarean section use. This review shows significant variations in caesarean section rates across European regions, ranging from 16.9 % in Northern Europe to 43.6 % in Southern Europe. There was a higher contribution of previous CS (Robson Group 5), ranging from 51.2 to 95.0 % of CS in this group to overall rates, particularly in Southern Europe (95.0 %), raises concerns about the "domino effect" of primary caesareans. This finding emphasises the critical importance of strategies to reduce primary CS rates., Background: Caesarean section (CS) rates exhibit considerable global variation, reflecting diverse medical practices, cultural attitudes, and healthcare policies. While some regions maintain relatively low rates, others report significantly higher incidences of the procedure. Analysing these differences is crucial for understanding and developing targeted healthcare strategies and ensuring optimal maternal and neonatal outcomes. This review examines differences in CS rates in Europe according to the Robson 10 group classification., Methods: We identified articles between January 2000 to June 2023 using MEDLINE/PubMed, CINAHL, EMBASE, Global Index Medicus, Web of Science and Cochrane library. There was no restriction on patient population, except for birth in a country of the European region. We excluded all studies that were conference proceedings and studies reported in a language other than English and Swedish., Findings: The search generated a total of 1024 studies, out of which 44 were included, encompassing 6,641,615 births. The majority were from Northern (38 %) and Western Europe (33.5 %). CS rates varied markedly across Europe, ranging from 16.9 % in Northern region to 43.6 % in Southern Europe. The highest contribution to CS rates came from Robson Group 5 (previous CS), with contributions ranging from 51.2 % in Northern to 95.0 % in Southern Europe. The mode of birth for Robson Group 6 (nulliparous, breech) was predominately by CS (88.8 % in Northern to 92.5 % in Central-Eastern Europe)., Interpretation: CS rates continue to vary widely across Europe, with the highest rates in Southern and the lowest in Northern Europe. Previous CS and breech presentation were prominent drivers of CS rates. Region-specific strategies are needed to address these diverse factors to minimise accelerating CS rates across Europe., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: To develop and internally validate a model predicting successful trial of labour among pregnant women with previous caesarean scar., Design: Cohort study., Setting: Tertiary care and teaching hospital., Participants: All pregnant women with one previous caesarean delivery, presenting with singleton pregnancies in cephalic presentation at a gestation age of 37 weeks or more between 2018 and 2022., Main Outcome Measures: A stepwise multivariable logistic regression, followed by bootstrapping, was used to develop and validate the model. Success was defined as vaginal birth after caesarean section (VBAC) without complications for the mother and baby., Result: Out of 4515 cases of TOLAC, 39.8 % had a successful trial of labour. Maternal age (OR = 0.950, 95 %CI: 0.927-0.974), previous baby weight (OR = 1.000, 95 %CI: 1.000-1.001), indication of previous caesarean section such as breech presentation (OR = 0.453, 95 %CI: 0.315-0.652), failed induction (OR = 0.346, 95 %CI: 0.267-0.447), BISHOP score (OR = 1.725, 95 %Cl: 1.673-1.774) and induction of labour (OR = 0.587, 95 %CI: 0.466-0.741) were the strongest predictors of successful TOLAC. DEVI-CS model showed good discrimination with an area under the curve (AUC) of 0.928(95 %CI: 0.921-0.936) and good agreement between predicted and observed probabilities. Decision curve analysis showed a net benefit between 5 % and 90 % between the predicted thresholds., Conclusion: The new DEVI-CS prediction model, based on easily captured clinical variables, can quantify the chances of a successful trial of labour after a previous caesarean section. It could aid in shared decision-making regarding the mode of delivery among women with planning the trial of labour after caesarean section., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: To describe the experiences of partners accompanying pregnant women during a caesarean section and to identify factors which influence the experiences., Methods: It is a prospective, single-center, observational study which included all partners of women who underwent a planned or an unplanned caesarean section in a maternity hospital during a two months period (1st November 2020 - 1st January 2021). The outcome was evaluated by a standardized questionnaire: the first-time father questionnaire (FTFQ) (1). Univariate and multivariate analyses were carried out to evaluate the factors associated with the results of the FTFQ., Results: A total of 100 partners were included in the study. Partners were generally satisfied with their attendance at the caesarean section, with 91 % claiming a good experience of it and expressed a willingness to repeat the experience. The partners were satisfied with the support provided by the medical team and with their accompaniment (79 %). Most partners were reassured and guided by health professionals when necessary (61 %). Nevertheless, partner anxiety was common (50 %) throughout the procedure. Only one factor was significantly associated with a decreased partner satisfaction: transfer of the newborn to the intensive care or neonatology unit (p = 0.04)., Conclusion: Almost all partners were satisfied to be in the operating room for a cesarean section regardless of the type of caesarean (planned and unplanned). Partner satisfaction should be considered by maternity staff as a relevant factor in their decision to accept or refuse the partner's presence in the operating room during the cesarean section., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Masson SAS.)

This study examined the effectiveness of music storytelling communication intervention in promoting the acceptance of caesarean section (CS) among families in rural areas. The families were randomly assigned to control groups, music storytelling and non-music storytelling. The result showed that although the families reported a negative perception of CS at baseline and rejected it as a delivery option, this changed significantly after the intervention. Comparatively, families in music storytelling scored higher regarding positive perceptions and acceptance of CS than those in non-music storytelling. The difference between the control and treatment groups was sustained during follow-up assessment after six months. However, a relapse of 5.0 was observed for the non-music storytelling regarding their perception and 5.5 regarding their acceptance of CS. For the music storytelling, the relapse was 2.1 for perception and 2.9 for acceptance. This means that music storytelling also led to a low relapse when compared with non-music storytelling communication intervention., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Emergency caesarean section is associated with maternal and foetal complications, potentially exacerbated by general anaesthesia use., Objective: To determine whether labour epidural analgesia use affects caesarean section incidence., Study Design: This retrospective single-centre cohort study involved women in labour (n = 11,792) between 1 January 2015 and 31 December 2021. The primary outcome was caesarean section incidence, determined from electronic medical records; secondary outcome was caesarean section incidence change over time., Results: Of 5849 deliveries from 1 August 2018, when round-the-clock labour epidural analgesia became available, until 31 December 2021, 1,433 (24.5 %) involved labour epidural analgesia. Of these, 203 (14.2 %) involved unintended caesarean section, less than that in the non-labour epidural analgesia group (22.2 %) (hazard ratio: 0.47; 95 % confidence interval [CI]: 0.41-0.55, p < 0.001). Sensitivity analysis, assuming 50 % of non-labour epidural analgesia cases should have had used labour epidural analgesia, yielded a hazard ratio of 0.65 (95 %CI: 0.57-0.75, p < 0.001). Propensity-score matching adjusted for possible confounders. Temporal changes in caesarean section incidence were analysed between 1 August 2018 and 31 October 2021. This passage of time explained the reduction in values for the difference-in-differences analysis by 20.5 % (95 %CI: 5.5-35.6, p = 0.007). Interrupted time series analysis revealed caesarean section incidence increased with time after round-the-clock labour epidural analgesia became available in the non-labour epidural analgesia group (p = 0.01)., Conclusions: Round-the-clock labour epidural analgesia use is associated with decreased caesarean section incidence, partly due to optimisation of eligibility criteria. Labour epidural analgesia use should be expanded to aid vaginal delivery and improve maternal well-being., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier B.V.)

Purpose: To propose an obstetric management model for patients with congenital bladder exstrophy (BE) and multiple previous surgeries, recognizing the unique anatomical variations of each patient and emphasizing the importance of personalized treatment approaches., Methods: We present the obstetric management and delivery of a 32-year-old pregnant woman with congenital BE, focusing on antenatal anatomical assessment, accurate delivery planning and key surgical steps during an elective caesarean section. Additionally, we conduct a comprehensive review of the current literature to enhance understanding of the reproductive implications associated with this exceptionally rare condition., Results: Following urological magnetic resonance imaging and intraoperative ultrasound, a successful neobladder-saving caesarean section was performed at 37 weeks, resulting in the delivery of a healthy infant with no maternal complications., Conclusion: Obstetric management in women with congenital BE presents unique challenges due to its significant impact on urinary and reproductive functions. Careful delivery planning and antenatal anatomical assessment are crucial for optimizing both maternal and fetal outcomes. A personalized, multidisciplinary approach can help minimize potential complications., Competing Interests: Declarations. Conflict of interest: No relevant conflict of interest to declare. Consent to publish: The patient gave written consent for publication of this study in the journal website, scientific literature websites (such as Pubmed, Sciencedirect, Scoput, etc.) and other applicable sites., (© 2025. The Author(s).)

Objective: Caesarean section (CS) rates in Sri Lanka have escalated significantly, with projections indicating that over half of all births may involve CS by 2025. To address this rise and mitigate maternal morbidity, it is essential that CS procedures are medically justified. This study evaluates RobsApp®, a novel smartphone application designed to collect high-quality prospective data on CS rates based on the Robson classification., Methods: The study utilized RobsApp® for data collection in the Professorial Unit of De Soysa Hospital for Women (DSHW), Sri Lanka. Data were collected prospectively from 1,712 deliveries between April and October 2019. The analysis focused on CS rates across different Robson categories and the quality of the collected data, comparing them with previous data obtained using traditional methods., Results: The overall CS rate was 33.0%, with Robson category 5a accounting for most cases. Emergency CS constituted 49.6% of all procedures, with cardiotocograph (CTG) abnormalities being the leading indication. The quality of the data collected through RobsApp® met the standards recommended by the Robson guidance, as evidenced by the study's ability to accurately categorize deliveries and assess CS rates., Conclusions: RobsApp® has proven to be an effective tool for prospective data collection, aligning well with Robson guidelines and facilitating high-quality data gathering. The study reveals a rising trend in CS rates at DSHW, particularly for reasons beyond previous CS. The inclusion of demographic data and birth weight analysis in future studies will enhance comparisons and insights into reducing CS rates., Ethics: Ethical approval was obtained from the Ethical Review Committee, Faculty of Medicine, University of Colombo (Ref - EC-19-024) which waived the need for individual consent. Study adhered to the Helsinki Declaration., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Ethical Review Committee of the Faculty of Medicine, University of Colombo on 21/03/2019 (Ref – EC-19–024), which waived the need for individual consent. This is not a clinical trial. The study involved examining patient records before they were archived, without any patient-identifiable details. The study adhered to the Helsinki Declaration standards. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objectives: To study the effect of implementing a Trial of Labour After Caesarean (TOLAC) delivery bundle with respect to decreasing caesarean delivery rates across five hospitals., Design: Prospective quality improvement study., Setting: Five Canadian hospital sites participated, two academic centres and three community hospitals, with annual delivery rates ranging from 2500 to 7500 per site., Participants: All obstetrical patients with a singleton gestation in cephalic presentation and only one previous caesarean delivery were included., Interventions: A TOLAC bundle was introduced at each hospital site, consisting of three main interventions: (1) education for healthcare providers, (2) a TOLAC discussion sheet and (3) patient educational tools., Primary and Secondary Outcome Measures: The primary outcome was the caesarean delivery rate in eligible patients. Secondary outcomes included rates of trial of labour after caesarean delivery, vaginal birth after caesarean delivery and induction of labour. Balance measures included rates of uterine rupture and neonatal intensive care unit admission. Process measures included attendance at educational rounds, elements of the interventions identified in chart review and view counts for educational videos., Results: The baseline caesarean delivery rate was 77% (1730 out of 2244 eligible patients). Following the introduction of the bundle, the caesarean delivery rate decreased to 71% (1497 out of 2097 eligible patients; 6% decrease, p<0.001). A significant increase in induction rate was noted from 5% preintervention to 9% postintervention (p<0.001). There was no increase in the uterine rupture or neonatal intensive care admission rates., Conclusion: This TOLAC bundle can decrease caesarean delivery rates without negatively impacting uterine rupture or neonatal intensive care admission rates. The interventions can be easily adapted for use in different hospitals and practice environments., Competing Interests: Competing interests: This study received funding from the North York General Hospital Exploration Fund and the Sinai Health Systems Quality Improvement Project Competition Grant. EM and EMS have been board members of the Canadian Society for the Advancement of Gynecologic Excellence. EMS is a member of the Simulation Working Group Board and the Ontario Annual Meeting Committee Board for the Society of Obstetricians and Gynecologists of Canada. EM has received grant funding unrelated to this project from the St. Michael's Hospital Innovation Grant, St. Michael's Hospital Foundation Angel's Den Grant and the University of Toronto PGME Medical Humanities Grant. EMS has received grant funding unrelated to this project from the St. Michael’s Hospital Foundation Rapid COVID Fun, Mount Sinai Hospital AFP Innovation Grant, St. Michael’s Hospital AFP Innovation Grant and the University of Toronto Merit Award. EMS has received funding from the Bayer Embassador Program. AO has received grant funding unrelated to this project from the University of Toronto PGME Medical Humanities Grant. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: To explore the variation and quality of the outcomes reported using descriptive analysis and interactive network visualisation of CS outcomes of comparative studies conducted in low-and middle-income settings., Study Design: Systematic review of comparative studies to reduce caesarean section complications in low- and middle-income countries and outcome assessment using the modified Harman questionnaire, assessing for the presence of a clear primary outcome, an explanation of how the outcomes were analysed and a description of the methods used to enhance the quality of these measures., Results: 102 comparative studies were included. Studies of interventions to improve maternal and perinatal outcomes after caesarean section reported 466 outcomes with 15 % of these outcomes appearing only once across the outcomes reviewed (n = 73). The most common outcome categories reported were maternal death, disability and bleeding. Psychological and injury outcomes were less commonly reported. The overall quality of outcome reporting varied between studies but was particularly low for reporting on methods to improve outcome measures. Very few outcomes scored a maximum of three points when assessed according to the modified Harman score, with only 15 of the primary outcomes (16 %) achieving 3 points and 40 of the secondary outcomes (11 %) achieving 3 points. The median quality of reporting was 2 (range 0, 3) for all outcomes, for a maximum score of 3. Quality of outcome reporting was associated with the type of outcome (primary or secondary), the region in which the study was conducted in, and journal characteristics such as impact factor and journal type., Conclusions: There was wide variability in both the outcomes reported and the frequency in which they were reported. Overall, very few primary and secondary outcomes achieved the maximum score of three on the modified Harman score, highlighting the need for a core outcome set for caesarean section intervention trials to improve the consistency and synergy of future research outcome definition, measurement and synthesis., Trial Registration: The protocol was registered (PROSPERO CRD42022353939)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier B.V.)

Vasa previa is a condition where unprotected fetal vessels, neither by placenta nor umbilical cord, lie within the membranes over the internal cervical ostium and beneath the presenting part of the fetus. Due to this condition, the membranous vessels pose a higher risk of being compressed or ruptures and could lead to fetal demise, exsanguination, or even fetal death. In this case report, we reported a case of a 36-year-old woman, G3P2A0, at term gestation and oblique lie. Early prenatal diagnosis using transvaginal ultrasound could increase the survival rate of the fetus if followed by sufficient management after diagnosis. Caesarean birth is the safest mode of delivery even before the clinical signs or onset of labor occur., Competing Interests: The authors report no conflicts of interest in this work., (© 2025 Nathania et al.)

Objective: The incidence of caesarean sections (CSs) has increased significantly in recent years, especially in developed countries. This study aimed to identify the factors that most influence the length of hospital stay (LOS) after a CS, using data from 9,900 women who underwent CS at the "Federico II" University Hospital of Naples between 2014 and 2021., Methods: Various artificial intelligence models were employed to analyze the relationships between the LOS and a set of independent variables, including maternal and foetal characteristics. The analysis focused on identifying the model with the best predictive performance and specific comorbidities impacting LOS., Results: A multiple linear regression model determined the highest R-value (0.815), indicating a strong correlation between the identified variables and LOS. Significant predictors of LOS included abnormal foetuses, cardiovascular disease, respiratory disorders, hypertension, haemorrhage, multiple births, preeclampsia, previous delivery complications, surgical complications, and preoperative LOS. In terms of classification models, the decision tree yielded the highest accuracy (75%)., Conclusions: The study concluded that certain comorbidities, such as cardiovascular disease and preeclampsia, significantly impact LOS following a CS. These findings can assist hospital management in optimizing resource allocation and reducing costs by focusing on the most influential factors., Competing Interests: Declarations. Ethics approval and consent to participate: In compliance with the Declaration of Helsinki and with the Italian Legislative Decree 211/2003, Implementation of the 2001/20/CE directive, since no patients/children were involved in the study, the signed informed consent form and ethical approval are not mandatory for these types of studies. Furthermore, in compliance with the regulations of the Italian National Institute of Health, our study is not reported among those needing assessment by the Ethical Committee of the Italian National Institute of Health. Consent for publication: Not applicable. Consent to participate: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Caesarean section is a common surgical procedure, accounting for almost a third of all surgical procedures in low- middle-income countries. Enhanced recovery after Caesarean section (ERAC) programmes are rarely implemented in resource-limited settings. This study evaluated a tailored enhanced recovery programme's impact on quality of recovery after elective Caesarean section in a Johannesburg public hospital., Methods: This was a prospective, observational, before-after cohort study. Fifty-two patients (aged ≥18 yr) undergoing elective Caesarean section were analysed, comprising a pre-ERAC cohort ( n =25), analysed from 8 to 22 April 2024 and a post-ERAC cohort ( n =27), analysed from 3 to13 June 2024. The primary outcome was postpartum recovery measured by the Obstetric Quality of Recovery-10 score., Results: There was a significant improvement in Obstetric Quality of Recovery-10 scores post-ERAC, with a difference in medians of 9 between cohorts (95% confidence interval: 6-14; P <0.001). There was also a significant reduction in opioid consumption with a median decrease of 10 mg oral morphine equivalent in the post-ERAC cohort in the first 24 h after operation (95% confidence interval: -26 to 6; P <0.001). Time to urinary catheter removal, time to first oral intake, time to first mobilisation, and preoperative fasting for liquids all showed significant improvement in the post-ERAC cohort. There was no difference in length of stay and other secondary outcomes., Conclusion: This study demonstrates that ERAC implementation in a resource-limited setting is feasible and can enhance maternal recovery after elective Caesarean section. These findings highlight the potential for ERAC programs to significantly improve patient-centred outcomes in low-middle income countries., Competing Interests: This research was conducted as partial fulfilment of a Master of Medicine degree in Anaesthesia., (© 2024 The Author(s).)

Background: In Sri Lanka, there is some evidence that the likelihood of breastfeeding initiation varies by exposure to Baby-Friendly Hospital Initiative [BFHI]-compliant care and mode of birth. Globally, there is some evidence that exposure to mother-baby skin-to-skin contact (BFHI Step 4) is lower in caesarean section births. Therefore, we aimed to determine how breastfeeding initiation varies by mode of birth in Sri Lanka, and the extent to which women's exposure to BFHI practices explains any associations found., Methods: A cross-sectional survey was conducted with women with a live baby across four government hospitals in Sri Lanka. Quantitative data were collected through participant interviews and extraction from medical records. Associations between BFHI practices, breastfeeding initiation, mode of birth, and women's characteristics were assessed using binary logistic regression analysis applied in mediation and moderated mediation models., Results: Women who received care compliant with Steps 4 and 6 of BFHI, regardless of their mode of birth, were more likely to initiate breastfeeding within the first hour after birth. BFHI Step 4 partially and completely mediated the effect of planned caesarean section and emergency caesarean section, respectively, on breastfeeding initiation within one hour of birth. Further, exposure to BFHI Step 6 partially mediated the effect of emergency caesarean section on breastfeeding initiation within one hour of birth. Women's age, pre-pregnancy BMI, parity status, and ethnic group significantly influenced the relationship between planned or emergency caesarean section, exposure to Step 4 or Step 6 of BFHI, and breastfeeding initiation within one hour of birth. Specifically, being primiparous strengthened the likelihood that having a planned caesarean section decreased women's exposure to BFHI Step 4; and having a pre-pregnancy BMI of 23-27.49 kg/m 2 weakened the likelihood that planned caesarean section decreased exposure to BFHI Step 4., Conclusions: Improving compliance with mother-baby skin-to-skin contact (BFHI Step 4) and no supplementation (BFHI Step 6) is critical for Sri Lankan health services to support all women to establish breastfeeding initiation within one hour of birth, as these practices attenuate the negative effect of caesarean section on breastfeeding initiation., Competing Interests: Declarations. Ethics approval and consent to participate: This study was conducted in accordance with the National Statement on Ethical Conduct in Human Research in Australia and the Code of Conduct on Health Research in Sri Lanka. Ethics approval to conduct this study in selected hospitals was obtained from the University Human Research Ethics Committee [UHREC] of Queensland University of Technology (Approval number – 2000001001) on the 28th of February 2021, Ethics Review Committee of Faculty of Health-Care Sciences, Eastern University, Sri Lanka (Approval number – E/2021/05) on the 3rd of August 2021, and the Ethics Review Committee of Department of Health Services, North-Western province, Sri Lanka (Approval number – ERC/NWP/2021/11) on the 7th of December 2021. This study conforms to the provisions of the 1995 Declaration of Helsinki (as revised in Edinburgh in 2000). Informed consent: was obtained from participants before conducting the face-to-face interview and collecting data from their medical records. Consent for publication: Not Applicable. Submission declaration: This manuscript has not been published anywhere else previously. Only a smaller portion of methods such as study setting, participants, and data collection, and some information on participants’ characteristics have been reported in another manuscript which is under review with another journal. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: While strategies aimed at preventing urological injuries complicating hysterectomy for gynaecological indications and placenta accreta surgery have been proposed, a comprehensive model for pregnancy-related hysterectomy (PRH) is lacking. The aim of this study was to investigate risk factors for urological complications of obstetric hysterectomy, and to propose strategies to improve the quality of care., Methods: This retrospective study of patients undergoing PRH was conducted in an academic centre between 2009 and 2022. Surgical lesions of the urinary tract were defined by the need for direct repair or subsequent additional urological interventions. Univariate and multivariate analyses were performed to identify determinants of urological injuries., Results: Among 141 patients undergoing obstetric hysterectomy, 25 (17.7 %) experienced urological injuries (22 bladder lesions, three lesions of the bladder and ureter). Bladder injuries were repaired intraoperatively, while ureteral lesions were diagnosed 2-5 weeks after surgery. After adjustment for confounding variables, the number of previous caesarean deliveries (p = 0.006) and intraoperative estimated blood loss (p = 0.002) were independently associated with urological complications., Conclusion: The burden of urological complications during obstetric hysterectomy is high. Subtotal hysterectomy can be considered in selected cases to reduce the risk of ureteral injury, while postoperative ultrasonographic screening of the urinary tract and analysis of serum markers may facilitate early detection of undiagnosed ureteral complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Objective: To establish whether digital foetal scalp stimulation (dFSS) performs better than foetal blood sampling (FBS) in terms of reducing the rate of caesarean section (CS) in labour, without adversely affecting perinatal outcomes., Design: A multicentre parallel-group randomised controlled trial., Setting: Maternity centres in Ireland., Population: The study aimed to randomise 2500 nulliparous women who required a second-line test of foetal well-being in labour due to abnormal cardiotocography (CTG)., Methods: Participants were randomly allocated to dFSS or FBS in a 1:1 ratio. Analysis was according to the published protocol and included a meta-analysis of the pilot study data and trial data., Main Outcome Measures: The primary outcome was CS., Results: Due to lower-than-expected randomisations, the trial concluded early. Of 534 consented participants, 124 had a second-line test of foetal well-being in labour and 43 (34.7%) were randomised; 20 to dFSS and 23 to FBS. The rate of CS was 40.0% (8/20) in the dFSS group and 47.8% (11/23) in the FBS group (absolute difference 7.8%; OR 0.73, 95% CI 0.22-2.44). The rate of CS was lower in the dFSS group when the trial data were included in a meta-analysis with the pilot data (n = 50), although the confidence limits were wide (OR 0.41, 95% CI 0.17-0.96). There was no significant difference in rates of adverse perinatal and maternal outcomes. Of the nonrandomised participants who received a second-line test, 65% (53/81) received dFSS., Conclusions: The small sample size limits the ability to conclude whether dFSS performs better as a second-line test of foetal well-being in labour than FBS. A clinician preference for dFSS was apparent, even though robust evidence is lacking., Trial Registration: This trial was prospectively registered on ClinicalTrials.gov on the 31st of March 2022., Clinicaltrials: gov Identifier: NCT05306756 (Access at https://clinicaltrials.gov/study/NCT05306756?cond=fetal%20blood%20sampling&rank=3)., (© 2025 John Wiley & Sons Ltd.)

SummaryIron-deficiency anaemia (IDA) is a global health problem. The impact of IDA on outcomes in obstetric patients who undergo caesarean section (CS) is unknown. We assessed the feasibility of conducting a large study to investigate perioperative anaemia and outcomes after CS. With ethics approval and trial registration, 60 obstetric patients (30 planned CS, 30 emergency CS) were included. Feasibility categories were willingness to participate in a study, to undergo additional blood tests (haemoglobin, ferritin), to have weight measured and to undertake quality of recovery (QoR) questionnaires. Of eligible people approached, 100% agreed to participate and 100% would participate in a future study. Ninety percent (95% confidence interval (CI) 82.4% to 97.6%) and 83% (95% CI 73.9% to 92.7%) agreed to additional tests in hospital and after discharge, respectively. Ninety-eight per cent (95% CI 95.1% to 100%) consented to being weighed, and 100% completed QoR questionnaires. Preoperatively, 8.5% (95% CI 1.4% to 15.6%) of participants were anaemic. Postoperative haemoglobin was measured in only 22 (36.7%, 95% CI 24.5% to 48.9%) participants, and 40.9% (95% CI 20.4% to 61.5%) were anaemic, suggesting at least a quadrupling of the proportion of anaemic patients from pre- to postoperatively. Ferritin was not measured postoperatively in any participant. The prevalence of participants discharged with IDA was unquantifiable. Postoperative IDA in obstetric patients is likely to be a serious problem that is currently unrecognised. Our data suggest that a definitive study to determine associations between maternal anaemia and perioperative outcomes after CS surgery is feasible.

Aim: The aim was to investigate feeding type at discharge; exclusively breastfeeding (EBF), mixed breastfeeding (MBF), and formula milk feeding (FMF), factors associated with feeding type, and changes in weight-for-age z-score (ΔWAZ) in infants admitted to Danish neonatal units., Methods: Using data from the Danish National Quality Database for Births and the Danish Newborn Quality Database, we included 8639 mother-infant dyads admitted ≥5 days between February 2019 and December 2021. We used logistic regression to investigate associations between maternal and infant factors and feeding type, and descriptive statistics to describe ΔWAZ and feeding type at discharge., Results: Of all infants 59.1% were EBF, 16.9% MBF and 24.0% FMF at discharge. Gestational age <37 weeks, caesarean section, multiple births, small for gestational age, weeks at hospital, ≥6 h before skin-to-skin contact, and few weeks at hospital were associated with failure to EBF at discharge. Median (min-max) ΔWAZ in EBF, MBF and FMF infants was -0.44 (-4.78 to 4.88), -0.43 (-3.47 to 4.42) and -0.39 (-3.54 to 4.03), respectively. ΔWAZ was higher in EBF compared to FMF infants, p-value 0.01, but no significant difference in ΔWAZ between MBF and FMF infants, p-value 0.06., Conclusion: Danish newborn infants demonstrated satisfactory growth during admission to the neonatal unit, independent of feeding type at discharge. Rates of exclusively breastfeeding need improvement., (© 2025 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Postoperative pain is one of the most common problems after caesarean section (CS). Pain reduction and effective mobilisation after CS positively affect maternal and infant health., Aim: This study aimed to determine the effects of acupressure applied to women after CS on pain intensity and first mobilisation distance., Methods: The sample of this prospective, two-armed (1:1), double-blind randomised controlled clinical trial consisted of 64 women undergoing CS (32 acupressure and 32 placebo acupressure group). The data were analysed using descriptive statistics, chi-square test, independent-groups t-test, Mann-Whitney U test, repeated-measures two-way analysis of variance (ANOVA) and simple main-effects analysis., Results: Findings showed statistically significant group effects (F = 19.32, p<.001), time effects (F = 27.67, p<.001), and group- and time-interaction effects (F = 26.60, p<.001) on postoperative pain after CS. In the acupressure group, the VAS scores were lower at 1 min, 2 h and 4 h after the intervention compared to before the intervention (p<.001; p<.001; p=.001, respectively). In the placebo group, the VAS score at 1 min after the application decreased, increasing at 2 h and 4 h, but these changes were not significant (p>.05). The first mobilisation distance of the acupressure group was significantly longer than that of the placebo group (p<.001)., Conclusion: Acupressure applied to the SP6, P6 and LI4 points was an effective nursing intervention for pain control and mobilisation after CS. Considering the significant impact of pain after CS on maternal and infant health, nurses should include acupressure, which is easy to apply, cost-effective, and efficacious, in postpartum care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The World Health Organisation has suggested antenatal education be integrated within standard antenatal care. However, evidence for the impact of antenatal education varies. This systematic review and meta-analysis evaluated randomised controlled trial evidence regarding the influence of antenatal education on labour and birth outcomes., Methods: Electronic databases (CINAHL, PubMed, Embase and Scopus) were searched for randomised controlled trials published between 2011 and 2023. Primary outcomes were mode of birth, epidural analgesia use, and induction of labour. Subgroup analysis by type of education (general education, specific technique, birth plan use) was performed. Three authors reviewed studies and extracted data. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Meta-analysis was performed using RevMan., Results: Seventeen studies (n=7260 participants) were included, most (n=10) had low risk of bias. Antenatal education was associated with decreased rates of planned caesarean sections (Relative Risk (RR) 0.87; 95 % confidence interval (CI), 0.83-0.92, I 2 =0 %), but not unplanned caesareans (RR 0.99; 95 % CI, 0.88-1.12, I 2 =0 %),as well as increased vaginal births (RR 1.14; 95 % CI 1.07-1.21, I 2 =79 %) and increased spontaneous onset of labour (n=10 studies, RR, 1.07; 95 % CI, 1.01-1.14, I 2 =0 %). Epidural analgesia use (RR, 0.88; 95 % CI, 0.88-1.00, I 2 =78 %) was not significantly affected. General education and birth plan care interventions were found to be more effective than specific technique care., Conclusion: Antenatal education programs studied improve some labour and birth outcomes, although with substantial heterogeneity regarding mode of birth and epidural analgesia use findings. General education appeared more effective than specific technique education., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Isthmoceles are defects related to Caesarean section (CS) scars, known to cause secondary infertility and interfere with in-vitro fertilization in women who have had Caesarean deliveries. The etiologies are multifactorial. Isthmoceles, similar to dehiscent CS scars, can be potential sites for ectopic pregnancies and abnormal placentation. There are a few case reports of pregnancies occurring within isthmoceles. However, there is a lack of studies focusing on the histopathologic details of gestations occurring within isthmoceles. Our main aim is to address this gap by illustrating the different histopathologic patterns of products of conception and gestational trophoblastic lesions involving isthmoceles. We also aim to determine the potential clinical relevance of gestational isthmoceles. We have conducted a retrospective review study of isthmocele specimens obtained from hysteroscopic isthmoplasty and hysterectomies. We found 14 (7.4 %) isthmocele ectopic pregnancies. The involved pouches were large, wide-based, predominantly low-level endocervical mucosa-lined isthmoceles. Six patients (43 %) presented with placental site nodule and plaque, four patients (28 %) with incomplete abortus material, two patients with atypical placental nodules, one patient with an exaggerated placental site, and one patient with epithelioid trophoblastic tumor. The features were highlighted by special stains and accentuated by appropriate immunohistochemistry. Some small and focal placental site nodule gestational trophoblastic lesions were found to have been missed, overlooked or misinterpreted by the original pathologists. The presence of zonation layers, typified by a hemosiderotic inflammatory stromal band, was found to be a useful clue in order to perform deeper levels to uncover small hidden residual trophoblastic foci. The larger atypical placental site nodule and epithelioid trophoblastic cell tumor lesions were initially confused with cervical squamous cell carcinoma, which was excluded by trophoblast-specific immunomarkers. Large, wide-based, low-level endocervical mucosa-lined isthmoceles are more prone to harboring ectopic pregnancies. A history of previous scar pregnancies was found to be a risk factor for developing subsequent isthmocele ectopic pregnancies. Gestational isthmocele is a common phenomenon that exhibits a variety of histopathologic changes. Pathologists should be aware of these changes in resected isthmocele specimens in order to properly guide gynecologists in patient management and avoid potential diagnostic pitfalls., Competing Interests: Declaration of competing interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Cutaneous endometriosis is a rare manifestation of endometriosis, and few reports on its dermoscopic features have been published. In this case report, we present a 40-year-old female with cutaneous endometriosis arising in a caesarean scar, exhibiting unique and distinct dermoscopic features. The patient presented with a nodular, papillomatous growth in the right end of the scar, and dermoscopic examination revealed structureless red papillomatous projections, as well as nonpapillomatous areas with red dotted vessels surrounded by a white reticular network. A biopsy confirmed the diagnosis of endometriosis. To our knowledge, this is the first report of such dermoscopic features in cutaneous endometriosis arising in a caesarean scar. Our case report adds to the current limited knowledge of dermoscopic features of cutaneous endometriosis and may help in the diagnosis of this condition., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Kevin Yang and Karim Saleh.)

Placenta accreta spectrum (PAS) disorders pose significant challenges in the anaesthetic management of elective caesarean section. This article explores the anaesthetic considerations for patients with PAS focusing on the optimal techniques to ensure maternal safety and surgical success. The analysis examines the advantages and disadvantages of general anaesthesia, neuraxial anaesthesia, and combined techniques to inform considerations of anaesthetic management in this high-risk population.

Objectives: Modern obstetrics confronts a rise in caesarean sections (CS). Prevention of unnecessary primary CS is a global priority. Women face intense psychological and physiological challenges during childbirth. Fear and anxiety during labour reduce women's self-confidence and empowerment. Yoga is a body-mind practice that lowers maternal fear and anxiety and helps relax pelvic floor muscles during labour. The study examined whether yoga practice in pregnancy influences CS rate in primiparous singleton pregnant women, labour pain intensity and epidural analgesia requests at delivery ward admission., Methods: We conducted a single-blind, randomised, controlled clinical trial comparing yoga to standard obstetric care in pregnancy. A total of 214 participants were randomised, 106 in yoga and 108 in controls. Weekly 90-min yoga classes were led by a certified yoga teacher's supervision. Every pregnant woman in the interventional group completed 12 yoga sessions., Results: Yoga group had a lower total CS due to less frequent In-labour CS (p=0.004) and a higher rate of spontaneous vaginal birth (p=0.009). They experienced less pain intensity during labour (p<0.001), and there was no difference in epidural analgesia requests., Conclusions: Engaging in yoga during pregnancy reduces the rate of In-labour CS, decreases discomfort and encourages spontaneous vaginal birth in primiparous singleton pregnant women., (© 2024 the author(s), published by De Gruyter, Berlin/Boston.)

Background: The effect of caesarean section (CS) on breastfeeding initiation has been extensively studied, but its influence on exclusive breastfeeding practices remains inconclusive. Therefore, this study aims to investigate the impact of CS on exclusive breastfeeding using evidence from four countries in the Southeast Asian region., Methods: This cross-sectional study used secondary data obtained from the Demographic and Health Surveys (DHS) conducted between 2016 and 2022 in four countries within the Southeast Asian Region. We included information on the youngest children aged 0-5 months living with their mothers within the DHS datasets. The association between CS and exclusive breastfeeding was determined using a simple and multiple logistic regression models. Weight factors were taken into account in all analyses for the two-stage stratified cluster sampling design., Results: Among 3420 children, nearly half (49.1%, 95%CI: 47.0, 51.2) were exclusively breastfed. Children born by CS had lower odds of being exclusively breastfed, compared to children born vaginally (aOR = 0.68, 95%CI: 0.53, 0.88). Women who were married or living with a partner (aOR = 2.19, 95%CI: 1.33, 3.60), children born at a health facility (aOR = 1.31, 95%CI: 1.00, 1.71), and girl babies (aOR = 1.24, 95%CI: 1.05, 1.48) had higher odds of exclusive breastfeeding. Furthermore, residing in rural areas was associated with an increased likelihood of exclusive breastfeeding (aOR = 1.47, 95%CI: 1.20, 1.80). Maternal age, mother's education, parity, antenatal and postnatal care taken, and mass media exposure were not associated with exclusive breastfeeding., Conclusion: This study highlights a significant association between CS and reduced exclusive breastfeeding practices. The findings underscore the importance of providing adequate support and interventions to mothers who deliver by CS and their family members to ensure they can successfully achieve exclusive breastfeeding, particularly in a global context where CS rates are rising., Competing Interests: Declarations. Ethics approval and consent to participate: The DHS studies were conducted in compliance with ethical standards and obtained ethics approval from the local ethics committees. Respondents’ identities were kept confidential, and the dataset provided was already de-identified and fully anonymized. The study title was also registered at the DHS program website. The authorization letter to use the survey datasets has been granted by the DHS program officials. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Aims: To understand the perspectives and experiences of healthcare providers who have experience working with an enhanced recovery care after elective caesarean birth pathway with next-day discharge and home midwifery., Design: This study applies a qualitative study design with a pragmatic realist approach. The realist framework was used while also taking a post-positivist philosophy., Methods: The work was conducted in South Australia, Australia between May and October 2019. Twenty-three semi-structured interviews were completed with 5 doctors and 18 midwives who had occupational experience working with the pathway. Interviews were analysed using following the six-phase qualitative thematic analysis process outlined by Braun and Clarke. COREQ guidelines were followed., Results: Four main themes and 11 sub-themes were identified. Main themes identified were as follows: The pathway is more than just early discharge; experiences with the process; staff engagement with the pathway; and the impact of the pathway within the health system., Conclusion: Healthcare providers generally accepted the pathway and found enhanced recovery care to be a positive and beneficial model of care. Staff identified five main challenges with implementing the pathway: early discharge; eligible women's automatic inclusion on the pathway; engaging women; change for staff and organisational constraints and procedures. Elements that support integration include the following: education for women; reassurance and communication with women and families; prepared care and supports including home midwifery; staff education and communication of the evidence; clear guidelines and protocols; defined staff roles; enough clinical time and clinical flexibility., Impact: Knowledge from staff in this study would be useful for other health services to consider when looking to deliver similar models of care., Patient or Public Contribution: The health service and health providers were involved with the initiation and development of the research aims and design., (© 2024 John Wiley & Sons Ltd.)

In the field of obstetrics, cesarean sections have now become the most prominent procedure for the delivery of newborns. Cesarean sections may be handled with a variety of different anesthetic approaches, of which most focus seems to be on that of spinal forms, due to their rapid and effective action. Dosages of spinal anesthesia formulations differ depending on multiple variables, such as depth of anesthesia, level of analgesia, and desired duration of effects. Furthermore, length of stay in the hospital is also a crucial variable to take into account when using spinal anesthesia due to its implications for patient comfort, quality of care, and return to daily life. Hyperbaric bupivacaine is a mainstay agent in regard to cesarean section anesthesia, with the most commonly used dosages being 1.8 mL and 2.0 mL. This study aims to assess the difference in duration of stay in the post-anesthesia care unit between patients receiving 1.8 mL and 2.0 mL of 0.5% hyperbaric bupivacaine. Of the 306 patients who underwent elective cesarean sections, 63 patients received 2.0 mL of 0.5% hyperbaric bupivacaine and 243 patients received 1.8 mL of 0.5% hyperbaric bupivacaine., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. King Abdullah International Medical Research Center issued approval NRR24/098/10. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alkinani et al.)

Background: The rate of caesarean section in Iran has significantly increased. The main reason cited by Iranian mothers for it is labor pain and fear of it. However, the experience of pain during childbirth has different meanings for mothers in various conditions. Therefore, this study aims to examine the components from the mothers' perspective that helped them manage pain in labor. The findings of this article may help prevent unnecessary medical interventions., Methods: The current article is one component of a mixed-method study conducted in Iran. Its primary objective was to develop protocols for maternity unit design to enhance maternal satisfaction, promote husbands' involvement, and improve pain management. The current study focuses on examining contextual components that are effective in managing pain among 25 mothers selected through stratified purposive sampling. Data collection from mothers who gave birth in four large hospitals in Iran was carried out through unstructured in-depth interviews. The data were analyzed using interpretative phenomenological analysis., Findings: The data show that two major environmental factors affect mothers' perception of pain and their ability to control it: (1) Internal and (2) External environments. The main components of the internal factor are identified as "Personal beliefs", "Self-confidence and lack of fear", and the external environment includes three subfactors: "Spatial environment", "Social environment", and "Interactive environment". The overall meaning attributed to pain caused by these factors determines how mothers can cope with it., Conclusion: In this study, self-confidence and a positive mindset were significant factors in managing pain during labor among this group of mothers. Furthermore, each mother's perception of pain was shaped by a combination of physical, social, and interactive influences. The research identified the importance of support during labor according to mothers' individual, subjective needs, while improving the physical environment, with a view to reducing interventions and promoting positive experiences for mothers and husbands. Consequently, enhancing internal resources and the birthing environment during labor which involve identifying the optimal blend of physical, mental, and emotional strategies tailored to the specific needs of mothers, can be considered to a potential reduction in the perceived intensity of pain in future., Competing Interests: Declarations. Ethics approval and consent to participate: The Ethics Committee of Iran University of Science and Technology, Tehran, Iran approved the study protocol (Code: 2625391). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Objective: Women undergoing IVF who have had a previous c-section (CS) have a lower live birth rate than those with a previous vaginal delivery. However, the precise underlying mechanisms need clarification. Does a previous CS affect the pattern of uterine contractility?., Methods: Prospective evaluation in patients undergoing frozen blastocyst embryo transfer in medicated endometrial preparation cycles. Twenty patients were included in groups: A/nulliparous. B/previous vaginal delivery. C/ previous CS without a niche, whereas fifteen patients were recruited in group D (CS and a niche). Patients employed estradiol compounds and 800 mg vaginal progesterone. A 3D-scan was performed the transfer-day where uterine contractility/minute was recorded., Results: Baseline characteristics (age, BMI, smoking, endometrial thickness) were similar. Mean frequency of uterine contractions/minute was similar between groups (1.15, 1.01, 0.92, and 1.21 for groups A, B, C, and D, respectively). There was a slight increase in the number of contractions in patients with a sonographic niche versus controls, not reaching statistical significance (p=0.48). No differences were observed when comparing patients with a previous C-section (regardless of the presence of a niche) to those without a C-section, either nulliparous (p=0.78) or with a previous vaginal delivery (p=0.80). The frequency of uterine contractions was similar between patients who achieved a clinical pregnancy and those who did not (1.19 vs. 1.02 UC/min, p=0.219, respectively)., Conclusions: Our study found no significant difference in the frequency of uterine contractility between patients with or without a previous C-section or sonographic diagnosed niche. Further investigation is necessary to understand the physiological mechanisms affecting implantation in patients with isthmocele.

Background: A ten-group classification system of caesarean section was proposed by Michael Robson in 2001. It is helpful in comparing the rates of caesarean section between hospitals. The objective of this study was to determine the caesarean section rates to analyse trends of caesarean section and classify according to Robson's categories., Methods: This cross-sectional study was conducted from 2016 to 2022. A total of 3176 women who underwent caesarean section were grouped under Robson's ten-group classification system., Results: The most common group was Group 5 (All multiparous women with at least one previous uterine scar, with single cephalic pregnancy, ≥37 weeks gestation) followed by Group 2 (Nulliparous women, with single cephalic pregnancy, >37 weeks gestation who either had labour induced or were delivered by caesarean section before labour). Results were obtained for the specified period (from 2016 to 2022), and Group 5 contributes more to the total CS rates (45% in 2016, 46% in 2017, 46% in 2018, 57% in 2019, 49% in 2020, 52% in 2021, 54% in 2022), followed by Group 2 (20% in 2016, 17% in 2017, 18% in 2018, 19% in 2019, 26% in 2020, 24% in 2021, 24% in 2022)., Conclusion: Pregnant women with prior uterine scars contribute more to caesarean section rates according to Robson's categories. Hence, strategies must be implemented to lower the primary caesarean section rates., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Family Medicine and Primary Care.)

Abdominal wall endometriosis (AWE) is one of the rarest forms of endometriosis. Little is known about differences between umbilical AWE (U-AWE) and non-umbilical AWE (non-U-AWE) patients. This retrospective cohort study included patients treated for AWE at tertiary endometriosis centre between 2012 and 2020. Patients were divided into two groups - umbilical AWE and non-umbilical AWE.We identified 14 U-AWE and 45 non-U-AWE patients who mostly had lesions in caesarean section scar (38, 64.4%), rarely at other locations (7, 11.9%). Infertility rates for U-AWE patients and non-U-AWE patients were 57.1% and 17.8%, respectively. Concurrent or previous peritoneal endometriosis was noted in 85.7% of U-AWE and 24.4% of non-U- AWE patients. In addition, U-AWE patients and non-UAWE patients significantly differed in following: parity, number of previous caesarean sections, lesion size, prevalence of concurrent or previous deep infiltrating endometriosis, bleeding from abdominal wall, cyclic pain, continuous pain.Infertility and pelvic endometriosis were more prevalent in U-AWE patients. Our data suggests that U-AWE may be a specific marker for a patient highly prone to pelvic endometriosis and subsequent infertility. Findings suggests that clinician should consider comprehensive evaluation of U-AWE patients.

Background: Microbial colonisation in infants is initially dependent on the mother and is affected by the mode of delivery. Understanding these impacts is crucial as the early-life gut microbiota plays a vital role in immune development, metabolism, and overall health. Early-life infant gut microbiota is diverse among populations and geographic origins. However, in this context, only a few studies have explored the impact of the mode of delivery on the intestinal microbiome in children in Guangzhou, China. Therefore, this study aimed to investigate the influence of birth mode on the intestinal microbiota of healthy infants in Guangzhou, China., Methods: Faecal samples were collected once from 20 healthy full-term infants aged 1-6 months, delivered via either caesarean section (CS) or vaginal delivery (VD), post-enrolment. The intestinal microbiota were characterised using full-length 16S rRNA gene sequencing. Bacterial quantity and community composition were compared between the two groups., Results: No significant differences in gut bacterial diversity and richness were observed between the CS and VD groups. The Pseudomonadota phylum (44.15 ± 33.05% vs 15.62 ± 15.60%, p  = 0.028) and Enterobacteriaceae family (44.00 ± 33.11% vs 15.31 ± 15.47%, p  = 0.028) were more abundant in the CS group than in the VD group. The VD group exhibited a higher abundance of the Bacillota phylum (40.51 ± 32.77% vs 75.57 ± 27.83%, p  = 0.019)., Conclusions: The early stage of intestinal bacterial colonisation was altered in the CS group as compared with the VD group. Our findings provide evidence that CS has the potential to disrupt the maturation of intestinal microbial communities in infants by influencing the colonisation of specific microorganisms. Further comprehensive studies that consider geographical locations are necessary to elucidate the progression of microbiota in infants born via different delivery modes.

Introduction: In recent years, caesarean section (CS) rate has risen worldwide. Complications associated with CS scars have risen too, such as scar dehiscences and uterine ruptures. Uterine healing is a complex phenomenon still poorly understood. The aim of this study is to carry out a comparative histological analysis of healthy and scarred uterus., Material and Methods: Women who underwent hysterectomy for benign pathology were included prospectively and divided into two groups: previous CS (group 1) versus control (group 2). Hysterectomy specimen were analyzed histologically and immunohistochemically., Results: Sixty women were included: 30 women per group. In group 1, only 19 women could be analyzed. Median total thickness at the thinnest site of the scar is significantly thinner (4.34 mm; IQR [2.76-9.45]) than that of adjacent healthy isthmus (12.70 mm; IQR [10.45-14.95]) (p < 0.001). It is also thinner than in group 2 (13.45 mm; IQR [11.03-16.90]) (p < 0.001). Median myometrial thickness within the scar in group 1 was also thinner (1.14 mm; IQR [0.30-2.69]) than that of the adjacent healthy isthmus (8.90 mm; IQR [8.18-10.08]) (p < 0.001) and that in group 2 (10.00 mm; IQR [8.38-13.35]) (p < 0.001). There was a significant increase in fibrosis in the scar (55.01 %; IQR [35.71-63.46]) compared with adjacent tissue (17.41 %; IQR [15.08-24.78]) (p < 0.001) and with healthy uterus (33.91 %; IQR [18.93-46.53]) (p = 0.006)., Conclusion: In uterus with previous CS scar, total thickness of the wall and thickness of the myometrium are reduced and proportion of fibrosis is significantly increased. This study shows that the thickness of the wall remains reduced in scarred uterus, even very long after CS. Further studies are currently in progress to understand its pathophysiology within the uterus using animal models., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The trend of increasing caesarean section (CS) rates brings up questions related to subfertility. Research regarding the influence of CS on assisted reproduction techniques (ART) is conflicting. A potential mechanism behind CS-induced subfertility is intra uterine fluid resulting from a caesarean scar defect or niche. The vaginal microbiome has been repeatedly connected to negative ART outcomes, but it is unknown if the microbiome is changed in relation to a niche., Methods: This systematic review describes literature investigating the effect of a niche on live birth rates after assisted reproduction. Furthermore, studies investigating a difference in microbial composition in subfertile persons with a niche compared to no niche are evaluated. Pubmed, Embase and Web of Science were searched on March 2023 for comparative studies on both study questions. Inclusion criteria were i.e., English language, human-only studies, availability of the full article and presence of comparative pregnancy data on a niche. The quality of the included studies and their risk of bias were assessed using the Newcastle-Ottawa scale for cohort studies. The results were graphically displayed in a forest plot., Results: Six retrospective cohort studies could be included on fertility outcomes, with a total of 1083 persons with a niche and 3987 without a niche. The overall direction of effect shows a negative impact of a niche on the live birth rate (pooled aOR 0.58, 95% CI 0.48-0.69) with low-grade evidence. Three studies comparing the microbiome between persons with and without a CS could be identified., Conclusion: There is low-grade evidence to conclude that the presence of a niche reduces live birth rates when compared to persons without a niche. The theory that a caesarean has a negative impact on pregnancy outcomes because of dysbiosis promoted by the niche is interesting, but there is no sufficient literature about this.

Recent reviews into maternity safety in the United Kingdom (UK) have led to a paradigm shift in culture and policy around caesarean section (CS) rate monitoring. CS rates in the UK have risen considerably over the last few decades and, in this time, there has been national effort at the level of government to kerb such rises due to concerns about the associated morbidity, and the medicalisation of birth. However, recent findings from two landmark reviews raise concerns that the pursuit of low CS rates may have caused harm to patients in some instances, and this has led the UK government to recommend cessation of the use of total CS rates as performance metric for maternity services. Instead, it is proposed that such data be collected with use of the Robson classification. Ongoing appraisal of maternity safety will be required to evaluate the effect of these changes in future.

This study explored the reasons underlying pregnant women's reluctance to undergo cesarean sections in Togo, despite its importance in reducing maternal and neonatal mortality. A total of 397 pregnant women who expressed hesitancy toward cesarean sections were enrolled during routine prenatal care visits at the country's largest hospital. They completed a questionnaire comprising 72 statements addressing potential reasons for hesitancy toward cesarean sections. Their responses were analyzed using factor analysis, and the effects of participants' demographic characteristics on scores for each factor were assessed using ANOVA. A seven-factor structure of motives was found: Fear of Death (endorsed by 92% of the sample); Regaining Autonomy Quickly (87%); Financial Concerns (74%); Fear of Stigmatization (73%); Fear of Unsupportive Reactions from Spouses and Relatives (72%); Prevention Through Spiritual Interventions (70%); and Perceived Health Risks for the Mother and Baby (40%). Scores on these factors were related to participants' sociodemographic characteristics. Effectively addressing the low uptake of cesarean section requires a multifaceted approach rather than one focused on a single barrier. Our findings suggest critical points that could help develop tailored interventions to address the various obstacles to this life-saving care.

Wilms tumour (WT) is the fourth leading cause of cancer death in children. Elucidating modifiable risk factors is crucial in identifying venues for primary prevention of the disease. This study aimed to review literature and synthesize environmental risk factors for WT. We conducted a systematic review and meta-analysis of epidemiological studies using PubMed, Web of Science, and Embase databases. Studies were included if they were case-control or cohort studies of children under the age of 20 years at diagnosis and reported Relative Risks (RRs) with 95 % confidence intervals (CIs). Pooled effect sizes (ES) and 95 % CIs for risk factors associated with WT were estimated using random-effects models. We included 58 eligible studies from Asia, Europe, Latin and North America, and Oceania totalling approximately10000 cases of WT diagnosed between 1953 and 2019. We confirmed an association between high birthweight ((>4000 g) ES 1.54, CI 1.20-1.97) and WT. Similarly, consistent associations were suggested for Caesarean section (ES 1.23, CI 1.07-1.42), gestational age <37 weeks (ES 1.45, CI 1.21-1.74), and large-for-gestational age (ES 1.52, CI 1.09-2.12). Parental occupational exposure to pesticides during preconception / pregnancy also showed increased risks of WT (maternal ES 1.28, CI 1.02-1.60, paternal ES 1.48, CI 0.98-2.24). There were inverse associations for breastfeeding (ever breastfed = ES 0.71, CI 0.56-0.89; < 6 months ES 0.67, CI 0.49-0.91; and ≥6 months ES 0.75, CI 0.59-0.97), and maternal intake of vitamins (unspecified) and folic acid during pregnancy (ES 0.78, CI 0.69-0.89). Among factors showing no associations were low birthweight (<2500 g), small-for-gestational age, assisted reproductive technology, parental age, and smoking or alcohol consumption during preconception / pregnancy, paternal occupational extremely low frequency magnetic fields (ELF-MF) exposures, and maternal X-ray exposure during pregnancy. Our findings suggest that modifiable risk factors of WT are parental occupational exposure to pesticides, breastfeeding (beneficial), and intake of folic acid during preconception / pregnancy (beneficial), but all associations were rather modest in strength., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd.)

Acute promyelocytic leukemia (APML), a rare disease encountered during pregnancy, is associated with high mortality secondary to consumptive coagulopathy and fatal bleeding diathesis. It usually presents as a medical emergency and warrants prompt diagnosis and treatment to improve maternal survival. This case report details a 19-year-old female with new onset APML who presented for emergency cesarean section because of respiratory distress and suspected placental abruption. Antifibrinolytics, which are commonly utilized to treat postpartum hemorrhage, were contraindicated because the patient was receiving all transretinoic acid (ATRA) therapy for APML. This case adds insight into the disease and its management along with anesthesia considerations for patients undergoing emergent caesarean delivery in the setting of acute disseminated intravascular coagulation and ATRA therapy. It also highlights the importance of a multidisciplinary team approach to plan for treatment and timing of delivery that balances the risk of disease progression and fetal well-being. Such multidisciplinary care and proper planning helped in attaining the best possible outcomes for both mother and baby., Competing Interests: Name: Rachel M. Smith-Steinert, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author; she is the corresponding author for this article. Disclosures: None. Name: Benu Makkad, MD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None., (Copyright © 2024 by the American Association of Nurse Anesthesiology.)

Background: During the coronavirus disease (COVID-19) pandemic, caesarean section (CS) has been the preferred deliver method for pregnant women with COVID-19 in order to limit the use of hospital beds and prevent morbidity among healthcare workers., Methods: To evaluate delivery methods used during the COVID-19 pandemic as well as the rates of adverse events and healthcare worker morbidity associated with caesarean deliveries., Methods: We investigated maternal and neonatal backgrounds, delivery methods, indications and complication rates among pregnant women with COVID-19 from December 2020 to August 2022 in Mie Prefecture, Japan. The predominant mutation period was classified as the pre-Delta, Delta and Omicron epoch., Results: Of the 1291 pregnant women with COVID-19, 59 delivered; 23 had a vaginal delivery and 36 underwent CS. Thirteen underwent CS with no medical indications other than mild COVID-19, all during the Omicron epoch. Neonatal complications occurred significantly more often in CS than in vaginal delivery. COVID-19 in healthcare workers was not attributable to the delivery process., Conclusion: The number of CS with no medical indications and neonatal complications related to CS increased during the COVID-19 pandemic. Although this study included centres that performed vaginal deliveries during COVID-19, there were no cases of COVID-19 in healthcare workers. It is possible that the number of CS and neonatal complications could have been reduced by establishing a system for vaginal delivery in pregnant women with recent-onset COVID-19, given that there were no cases of COVID-19 among the healthcare workers included in the study.

Background: Post-caesarean surgical site infections (PCSSIs) significantly impact maternal morbidity, mortality, and healthcare costs in low- and middle-income countries, particularly in sub-Saharan Africa, where preventive measures are often inadequate. Despite this burden, data on PCSSIs in this context are limited. This study aimed to evaluate the incidence and factors associated with PCSSIs at Mubende Regional Referral Hospital., Methods: This prospective cohort study included 204 women who underwent caesarean sections from July to September 2023. Data was collected and participants were monitored for up to 28 days post-delivery to identify occurrences of surgical site infections (SSIs). Statistical analysis was conducted using STATA, with significance defined as a p-value of < 0.05., Results: Most participants (63.2%) were aged 18-35 years, with over 67% having a parity of ≤4. Preoperative antibiotics were administered to 77.5% of participants. Most surgeries (64.2%) lasted 1-2 hours, and the overall incidence of surgical site infections (SSIs) was 16.18%. Significant risk factors associated with more than a twofold increase in SSI risk included unstable referral status (aRR = 2.02), obstructed labor (aRR = 2.97), chorioamnionitis (aRR = 2.73), and prolonged premature rupture of membranes (PROM) (aRR = 2.05). Prolonged labor increased SSI risk by 1.37-fold (aRR = 1.37), while receipt of preoperative antibiotics was linked to a reduced SSI risk (aRR = 0.77)., Conclusion: The post-caesarean SSI rate at Mubende Regional Referral Hospital is notably high, with key risk factors including unstable referral status, obstructed labor, prolonged labor, chorioamnionitis, and prolonged premature rupture of membranes (PROM). Administering preoperative antibiotics 30 minutes to 1 hour prior to surgery is linked to a reduced risk of SSI., Competing Interests: The authors declare no competing interests., (© 2024 Omara et al.)

Background: Truncal blocks contribute to multimodal analgesia that enhances early recovery after caesarean delivery. The transversus abdominis plane (TAP) block is an established technique that offers somatic abdominal wall analgesia. The erector spinae plane (ESP) block is a fascial plane technique that may offer additional visceral analgesic effects. This study hypothesized that ESP block would offer superior analgesic efficacy to TAP block in women undergoing caesarean delivery under spinal anaesthesia., Methods: Sixty-six ASA physical status grade 1-3 (≥18 years) patients undergoing elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either bilateral ultrasound-guided TAP (N = 33) or ESP blocks at the T9 vertebral level (N = 35). The primary outcome measure was 24-hour cumulative morphine consumption. The secondary outcomes included time to first analgesic request, duration of block placement, numeric rating scale (NRS) pain scores at rest and movement, effect of pain on activities of daily living (ADLs) and care for the infant, patient analgesic satisfaction, frequency and severity of opioid-related side effects., Results: There was no statistically significant difference in mean (95% CI) 24-hour cumulative morphine consumption between groups: 32.0 (27.0 to 37.0) mg with TAP versus 27.0 (19.9 to 34.0) mg with ESP (p = 0.16). The mean (SD) duration of block placement was longer for ESP than for TAP blocks (10.7 (2.2) minutes versus 9.0 (2.5) minutes; p = 0.004). There were no significant differences in the other secondary outcomes., Conclusion: This study found similar postoperative opioid use and analgesic efficacy between ESP and TAP block after caesarean delivery performed under spinal anaesthesia., Trial Registration: South African National Clinical Trial Registry (DOH-27-102022-5278): https://sanctr.samrc.ac.za/TrialDisplay.aspx?TrialID=8100, Pan African Clinical Trials Registry (PACTR202301645957324): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24267., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Problem: Separating women and babies immediately after birth contributes to poor birth experience and reduced satisfaction., Background: A negative birth experience can impact a woman's transition to motherhood and emotional well-being beyond the newborn period. Separating women from their baby at birth is known to reduce birth satisfaction and is more likely to happen at caesarean section births., Question: What is the experience of women who are separated from their baby after caesarean section birth without medical necessity?, Methods: Unstructured, in-depth phenomenological interviews were conducted with fifteen women who had been separated from their well-baby at caesarean section birth. Data was analysed using a Modified van Kaam approach. A novel feminist phenomenological framework with two birthing theories was used to explore the experience of the participants., Findings: Four major themes emerged - Disconnection, Emotional Turmoil, Influence, and Insight. These demonstrated significant trauma that both the separation and perinatal care created., Discussion: The participants recognised their vulnerability and the lack of power and control they had over themselves and their baby, which was seemingly not acknowledged. Provider and hospital needs were valued above those of the women., Conclusion: Woman-centred care was not evident in the treatment of these women despite the attendance of a midwife at each birth. This research challenges midwives and other health care providers to support and advocate for those birthing by caesarean section to return power and control and support them to remain in close physical contact with their baby immediately after birth., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Noise reduction during surgical procedures leads to improved surgical performance and results. The caesarean birth (CB) is an exceptional operation and a life changing experience. Through the introduction of staff education and implementation of audiovisual feedback, we intended to reduce noise, and subsequently reduce surgical complications and increase the well-being of patients and staff., Methods: During Phase I, blinded baseline measurements of noise were conducted. Phase II started after staff education and structured questionnaires on subjective noise and stress were added, and in Phase III audiovisual feedback was introduced. Mean and peak noise levels over the time of the procedure were obtained in A-weighted decibels (dB(A)). Kruskal-Wallis H tests were performed to evaluate the impact of interventions on noise levels. Questionnaires were evaluated using descriptive statistics; stress-scores were compared using independent sample t-tests., Results: Ninety planned CBs were included. Median noise levels were 62.85 dB(A) at baseline. They decreased significantly to 60.60 dB(A) (Phase II) and 59.25 dB(A) (Phase III), respectively. This reduction of 3.6 dB(A) leads to a subjective noise reduction of around 20%. Significant differences for A-weighted and peak noise levels during actual surgery were found after combining staff education with audiovisual feedback. In Phase III, staff reported less stressful noise. Stress also decreased significantly in the patient group. Beeping machines and telephones were identified as the most stressful sources of noise., Conclusion: We show that noise reduction during CB is both necessary and possible. Diminished subjective perception of noise and stress are positive impacts of this intervention. Staff education and audiovisual feedback can help to provide a calm and lower stress environment for patients and staff during caesarean births., (© 2024 The Author(s). Birth published by Wiley Periodicals LLC.)

Objectives: Several anaesthetic protocols for caesarean section (c-section) have been described in dogs; however, anaesthesiological studies in cats undergoing c-section are lacking. The aim of this study was to assess the viability and outcome of kittens born from queens undergoing emergency c-section and receiving propofol or alfaxalone for anaesthetic induction and isoflurane for maintenance of general anaesthesia., Methods: All cats admitted to the Veterinary Teaching Hospital of the University of Bologna between January 2014 and December 2022 for dystocia that had undergone an emergency c-section were analysed in this retrospective study. The queens received propofol 2-6 mg/kg IV (group P) or alfaxalone 1-3 mg/kg IV (group A) administered slowly; general anaesthesia was maintained with isoflurane. Survival of all the kittens was evaluated at birth and after 24 h; in addition, heart rate, respiratory rate and mucous membrane colour were evaluated in the kittens at birth., Results: Of the 14 cats included in the study, eight received alfaxalone (group A) and six received propofol (group P) for induction of the general anaesthesia. A total of 50 kittens were born by c-section: 30 kittens in group A and 20 in group P. The overall survival of the kittens was 90% at birth: 96.7% (29/30) for group A and 80% (16/20) for group P. The 24 h survival rate was 93.1% for group A and 87.5% for group P., Conclusions and Relevance: The results of the present study demonstrated that in cats undergoing c-section, both alfaxalone and propofol are feasible for the induction of general anaesthesia., Competing Interests: Conflict of interestThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Ensuring healthcare services are equipped to offer; emergency obstetric and newborn care (EmONC) is crucial for improving the quality of maternal and newborn care in low- and middle-income countries. We assessed the temporal trends of the availability and readiness of the healthcare system to provide EmONC in Burkina Faso., Methods: We analyzed the data from three national health facilities surveys, conducted in 2014, 2016 and 2018, using the WHO Service Availability and Readiness Assessment tool. We performed multivariable linear regression models to examine the trends., Results: Between 2014 and 2018, the percentage of healthcare facilities providing delivery service and blood transfusion significantly decreased (88.1% to 75.4% for delivery services and 67.3% to 50.2% for blood transfusion, p < 0.001). The readiness index of healthcare facilities to provide basic EmONC showed a negative trend according to public healthcare, primary healthcare, and Centre-Nord, Centre-sud, Hauts-Bassins, Nord, Plateau Central and Sud-ouest health regions., Conclusions: We observed multiple indications of a decline in the readiness of healthcare services to offer EmONC in Burkina Faso from 2014 to 2018. As such, bolstering the capabilities of health facilities to deliver EmONC is essential for hastening the decrease in maternal mortality., (© 2024. The Author(s).)

Background: Babies born via caesarean section in low-income settings face a higher risk of early-onset neonatal sepsis (EONS), which has greater mortality than late-onset sepsis. However, maternal factors contributing to EONS among caesarean-delivered babies in these settings, including Uganda, are not well documented. We determined maternal factors associated with EONS among term babies delivered by caesarian section at Mbarara Regional Referral Hospital (MRRH), southwestern Uganda., Methods: We conducted an unmatched case-control study at MRRH from December 2019 to March 2020. Cases were caesarean section-delivered term babies with EONS (within 72 h). Controls were caesarean section-delivered term babies without EONS. We enrolled mother-baby pairs for both groups, obtaining maternal data via structured questionnaires The diagnosis of EONS was made using the WHO Young Infant Integrated Management of Childhood Illnesses algorithm. Cases were consecutively recruited while controls were recruited by simple random sampling in a ratio of 1:2. We excluded newborns whose mothers were too ill to consent. We used multivariable logistic regression analysis to identify maternal factors associated with EONS., Results: We enrolled 52 cases and 104 controls. The mean age for the mothers was 27 (± 5.5) years. Neonates born to referred mothers had higher odds of EONS than those born to non-referred mothers (AOR = 6.2, 95% CI: 1.8-21). Additionally, decision-to-delivery time > 1 h for emergency caesarean section (AOR = 16, 95% CI: 4.2-65), antepartum hemorrhage (AOR = 8.0, 95% CI: 1.6-40), primiparity (AOR = 4.8, 95% CI: 1.1-21), and > 3 vaginal examinations after membrane rupture (AOR = 4.3, 95% CI: 1.5-12) were associated with EONS., Conclusions: Prime gravidity, antepartum hemorrhage, multiple vaginal examinations after membrane rupture, long decision-to-delivery time, and referral status were associated with EONS among term babies delivered by caesarean section at MRRH. To reduce EONS risk, clinicians should limit post-membrane rupture vaginal exams or consider prophylactic antibiotics if multiple exams are needed. Screening babies born to primiparous women, those referred, those with antepartum hemorrhage, multiple vaginal exams after membranes rupture, and long decision-to-delivery times, could aid prompt recognition of EONS and timely interventions. Implementing standard procedures to reduce caesarean decision-to-delivery time could reduce risk for EONS in this setting., (© 2024. The Author(s).)