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With global C-section rates rising, understanding potential consequences is imperative. Previous studies suggested links between birth mode and psychological outcomes. This study evaluates the association of birth mode and neurodevelopment in young children across two prospective cohorts, using repeated psychometric assessments. Data from the ELEMENT (Early Life Exposures in Mexico to Environmental Toxicants) and PROGRESS (Programming Research in Obesity, Growth, and Environment and Social Stress) cohorts, comprising 7158 and 2202 observations of 1402 children aged 2 to 36 months, and 726 children aged 5 to 27 months, respectively, were analyzed. Exclusion criteria for the cohorts were maternal diseases such as preeclampsia, renal or heart disease, gestational diabetes, and epilepsy. Neurodevelopment was gauged via Bayley's Scales of Infant Development: 2nd edition for ELEMENT and 3rd edition for PROGRESS. Mixed-effects models longitudinally estimated associations between birth mode and neurodevelopment scores, adjusting for cofounders. In ELEMENT, psychomotor development composite scores were significantly affected by birth mode from ages 2 to 8 months; the largest estimate within this range was at 2 months (β =-1.93; 95% CI: [-3.64, -0.22], reference: vaginal delivery). For PROGRESS, a negative association was found with motor development composite scores over all the studied age range (β=-1.91; 95% CI: [-3.01, -0.81]). The association was stronger between ages 6 to 18 months, with the strongest estimate at 11 months (β=-2.58; 95% CI: [-4.37, -0.74]). A negative impact of C-section on language scores in girls was estimated for the PROGRESS cohort (β=-1.92; 95% CI: [-3.57, -0.27]), most marked in ages 22 to 25 months (largest β at 24.5 months=-3.04; 95% CI: [-5.79, -0.30]). Children born by C-section showed lower motor and language development scores during specific age windows in the first three years of life. Further research is necessary to understand the complexities and implications of these findings., (© 2024. The Author(s).)

Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest.

In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.

Objective: To compare the rates of neonatal morbidity and cerebral palsy among preterm neonates (less than 37 weeks of gestation) delivered by cesarean for a nonreassuring fetal heart rate (FHR) tracing compared with those who did not., Methods: This was a secondary analysis of a multicenter randomized trial of MgSO4 for the prevention of cerebral palsy. Newborns of women delivered by cesarean delivery for nonreassuring FHR were compared with a control group composed of the offspring of women who labored for 2 hours or longer but did not undergo cesarean delivery for nonreassuring FHR regardless of the mode of delivery. Using multivariable analysis to adjust for potential confounders, our objective was to compare two outcomes: 1) composite neonatal morbidity (Apgar score 3 or less at 5 minutes, seizure, sepsis, necrotizing enterocolitis grade II or III, intraventricular hemorrhage grade III or IV, or death before discharge) and 2) neurologic injury (cerebral palsy) at 2 years or more of corrected age between the groups., Results: Of the 1,291 preterm neonates who met the inclusion criteria, 177 (14%) were delivered by cesarean for nonreassuring FHR compared with 1,114 (86%) in the control group. Composite neonatal morbidity was similar between the groups (30.5 compared with 22.2%, adjusted odds ratio [OR] 1.4, 95% confidence interval [CI] 0.9-2.1). The rate of cerebral palsy of any severity (8.3 compared with 4.0%, adjusted OR 2.3, 95% CI 1.2-4.5) and moderate-to-severe cerebral palsy at 2 years of corrected age (6.0 compared with 2.2%, adjusted OR 3.2, 95% CI 1.4-7.1) was significantly higher in children born through cesarean delivery for nonreassuring FHR., Conclusion: Nonreassuring fetal tracing deemed so serious as to require cesarean delivery is associated with an increased risk of cerebral palsy in preterm neonates., Level of Evidence: II.

Objective: Our goal was to (1) describe self-reported cesarean delivery (CD) surgical techniques of Maternal-Fetal Medicine (MFM) fellows and (2) determine whether preferences were congruent with recommendations using US Preventive Services Task Force (USPSTF) criteria., Methods: MFM fellows were queried regarding their preferred CD technique via online survey. Preferences were compared to evidence-based recommendations using standard recommendation language and quality of evidence as outlined by the USPSTF. Categorical variables were compared by Chi-square analysis or Fisher's exact test, with p<0.05 considered statistically significant., Results: Of 233 active MFM fellows in August 2012, 167 completed the survey, resulting in a response rate of 71%. Statistically significant differences of preferences were noted when stratified by year in fellowship (blunt tip needles), gender (thromboprophylaxis, skin incision, fascial extension, uterine closure suture) and geographic region of fellowship (fascial extension, skin closure). CD techniques preferred by MFM fellows were congruent with recommendations designated as high or moderate level of certainty with regard to prophylactic antibiotics, uterine incision extension, uterine atony prevention and placenta removal, while incongruent with regards to pre-operative vaginal preparation and blunt needle preference., Conclusion: Among MFM fellow respondents, variation exists in preferred CD technique and vis-à-vis evidence-based recommendations.

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted., (Copyright © 2013 Mosby, Inc. All rights reserved.)

This study aimed to evaluate the rate of adverse neonatal or maternal outcomes in parturients with fetal heart rate tracings categorized as I, II or, III within the last 30 to 120 minutes of delivery. The MEDLINE Ovid, Scopus, Embase, CINAHL, and Clinicaltrials.gov databases were searched electronically up to May 2022, using combinations of the relevant medical subject heading terms, keywords, and word variants that were considered suitable for the topic. Only observational studies of term infants reporting outcomes of interest with category I, II, or III fetal heart rate tracings were included. The coprimary outcome was the rate of either Apgar score <7 at 5 minutes or umbilical artery pH <7.00. Secondary outcomes were divided into neonatal and maternal adverse outcomes. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale. Random-effect meta-analyses of proportions were used to estimate the pooled rates of each categorical outcome in fetal heart rate tracing category I, II, and III patterns, and random-effect head-to-head meta-analyses were used to directly compare fetal heart rate tracings category I vs II and fetal heart rate tracing category II vs III, expressing the results as summary odds ratio or as mean differences with relative 95% confidence intervals. Of the 671 articles reviewed, 3 publications met the inclusion criteria. Among them were 47,648 singletons at ≥37 weeks' gestation. Fetal heart rate tracings in the last 30 to 120 minutes before delivery were characterized in the following manner: 27.0% of deliveries had category I tracings, 72.9% had category II tracings, and 0.1% had category III tracings. A single study, which was rated to be of poor quality, contributed 82.1% of the data and it did not provide any data for category III fetal heart rate tracings. When compared with category I fetal heart rate tracings (0.74%), the incidence of an Apgar score <7 at 5 minutes were significantly higher among deliveries with category II fetal heart rate tracings (1.51%) (odds ratio, 1.56; 95% confidence interval, 1.23–1.99) and among those with category III tracings (14.63%) (odds ratio, 14.46; 95% confidence interval, 2.77–75.39). When compared with category II tracings, category III tracings also had a significantly higher likelihood of a low Apgar score at 5 minutes (odds ratio, 14.46; 95% confidence interval, 2.77–75.39). The incidence of an umbilical artery pH <7.00 were similar among those with category I and those with category II tracings (0.08% vs 0.24%; odds ratio, 2.85; 95% confidence interval, 0.41–19.55). When compared with category I tracings, the incidence of an umbilical artery pH <7.00 was significantly more common among those with category III tracings (31.04%; odds ratio, 161.56; 95% confidence interval, 25.18–1036.42); likewise, when compared with those with category II tracings, those with category III tracings had a significantly higher likelihood of having an umbilical artery pH <7.00 (odds ratio, 42.29; 95% confidence interval, 14.29–125.10). Hypoxic-ischemic encephalopathy occurred with similar frequency among those with categories I and those with category II tracings (0 vs 0.81%; odds ratio, 5.86; 95% confidence interval, 0.75–45.89) but was significantly more common among those with category III tracings (0 vs 18.97%; odds ratio, 61.43; 95% confidence interval, 7.49–503.50). Cesarean delivery occurred with similar frequency among those with category I (13.41%) and those with category II tracings (11.92%) (odds ratio, 0.87; 95% confidence interval, 0.72–1.05) but was significantly more common among those with with category III tracings (14.28%) (odds ratio, 3.97; 95% confidence interval, 1.62–9.75). When compared with those with category II tracings, cesarean delivery was more common among those with category III tracings (odds ratio, 4.55; 95% confidence interval, 1.88–11.01). Although the incidence of an Apgar score <7 at 5 minutes and umbilical artery pH <7.00 increased significantly with increasing fetal heart rate tracing category, about 98% of newborns with category II tracings do not have these adverse outcomes. The 3-tiered fetal heart rate tracing interpretation system provides an approximate but imprecise measurement of neonatal prognosis. [ABSTRACT FROM AUTHOR]

Objective To delineate risk factors for adverse outcomes among those who underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) and ascertain whether neonatal or maternal morbidity can be predicted accurately. Methods The Consortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton gestations between 37.0 and 41.6 weeks who underwent CD for NRFHT. Composite adverse neonatal outcomes (CANO) included Apgar <5 at 5 min, seizures, mechanical ventilation, sepsis, intraventricular hemorrhage, necrotizing enterocolitis or neonatal death. Composite adverse maternal outcomes (CAMO) included endometritis, blood transfusion, wound complication, admission to intensive care unit, thromboembolism, hysterectomy or death. Bivariable analysis and multivariable Poisson regression were used to identify risk factors independently associated with adverse outcomes. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for adverse outcomes. Results Of 228,438 births in the database, 7310 individuals (3.7%) met inclusion criteria. Among this cohort, CANO occurred 3.8% of the time. CANO was less common among people over 35 years (9.8% versus 18.4% p < .01) but was more common among those with at least high-school education (15.3% versus 11.2%; p < .01), varying by ethnicity (p < .01). CAMO occurred in 3.4% and was less common among those undergoing induction of labor (37.3% versus 49.4%; p < .01) and more common among those with clinical chorioamnionitis (8.4% versus 4.3%; p < .01). The area under the curve (AUC) for ROC curve to identify CANO was 0.63 implying a limited ability to predict neonatal adverse outcomes. The AUC for identifying women with maternal adverse outcomes was 0.69 also indicating a moderate prediction ability. Conclusions Among singletons between 37 and 41 weeks who labored, the rate of CD for NRFHT was about 3.7% and among them CANO occurred in 3.8%. While risk factors for adverse neonatal outcomes following CD for NRFHT are identifiable, they do not suffice to predict them. [ABSTRACT FROM AUTHOR]

Introduction: To determine the impact of prior vaginal birth on neonatal and maternal outcomes among individuals undergoing a trial of labor after two cesarean births. Materials and methods: This was a cross-sectional study using the U.S. National Vital Statistics 2014–2018 period linked birth and infant death data. Inclusion criteria were term, cephalic, singleton pregnancies with two prior cesarean births. The primary exposure variable was a trial of labor after cesarean vs prelabor repeat cesarean birth. Cohorts were defined by the presence or absence of a prior vaginal birth. The primary outcome was a composite of adverse neonatal outcomes (Apgar score <5 at 5 min, assisted ventilation >6 h, neonatal seizures, or neonatal death within 27 days). Secondary outcomes included a maternal composite and the cesarean birth rate. Propensity score matching was used to account for baseline differences in treatment allocation within each cohort, and conditional logistic regression assessed the association between the exposure and outcomes. Results: The composite neonatal adverse outcome was significantly higher in those undergoing a trial of labor after cesarean compared to prelabor repeat cesarean birth in both individuals without a prior vaginal birth (8.2 vs 11.6 per 1000 live births, OR 1.41; 95% CI 1.12–1.70) and with a prior vaginal birth (9.6 vs 12.4 per 1000 live births, OR 1.30; 95% CI 1.08–1.57). The composite maternal adverse outcome was significantly higher among individuals without a prior vaginal birth undergoing trial of labor after cesarean (6.0 vs 9.5 per 1000 live births, OR 1.59; 95% CI 1.26–2.09), but was similar in those with a prior vaginal birth (7.9 vs 9.3 per 1000 live births, OR 1.18; 95% CI 0.97–1.46). Conclusion: In individuals with two prior cesarean births, trial of labor after cesarean was associated with increased neonatal adverse outcomes when compared to prelabor repeat cesarean birth, irrespective of a history of vaginal birth. In individuals with a prior vaginal birth, the composite maternal adverse outcome was not elevated in the trial of labor cohort. [ABSTRACT FROM AUTHOR]

Objective: To compare adverse outcomes among preterm births that underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) versus those that did not.Study Design: Consortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton at 23.0 to 36.6 weeks who labored for at least 2 h. Composite adverse neonatal outcomes included any of the following intraventricular hemorrhage grade III or IV, seizures, mechanical ventilation, sepsis, necrotizing enterocolitis 2 or 3, or neonatal death. Composite adverse maternal outcomes included any of the following postpartum hemorrhage, endometritis, blood transfusion, chorioamnionitis, admission to intensive care unit, thromboembolism, or death.Results: Of 228,438 births, 29,592 (13.0%) delivered preterm, and 16,679 (56.4%) labored for at least 2 hrs. CD for NR FHRT was done in 1,220 (7.3%). The rate of composite adverse neonatal outcome was different among those that had CD for NR FHRT (26.7%) versus those that did not (16.6%; aRR 1.59, 95% CI 1.43-1.76). Composite adverse maternal outcomes did not differ between the groups. The area under the curve for risk factors to identify composite adverse neonatal outcome was 0.81, and for composite adverse maternal outcomes, 0.64.Conclusions: Subsequent to CD for NR FHRT, composite adverse neonatal outcome is 59% higher among preterm births when compared to delivery with reassuring tracing; composite adverse maternal outcomes did not differ between the groups. [ABSTRACT FROM AUTHOR]

Venous thromboembolism accounts for approximately 9% of pregnancy-related deaths in the United States. National guidelines recommend postpartum risk stratification and pharmacologic prophylaxis in at-risk individuals. Knowledge on modern rates of postpartum pharmacologic thromboprophylaxis and its associated risks is limited. This study aimed to describe the rate of, and factors associated with, initiation of postpartum pharmacologic prophylaxis for venous thromboembolism, and to assess associated adverse outcomes. This was a secondary analysis of a multicenter cohort of individuals delivering on randomly selected days at 17 US hospitals (2019–2020). Medical records were reviewed by trained and certified personnel. Those with an antepartum diagnosis of venous thromboembolism, receiving antepartum anticoagulation, or known SARS-CoV-2 infection were excluded. The primary outcome was use of postpartum pharmacologic thromboprophylaxis. Secondary outcomes included bleeding complications, surgical site infection, hospital readmission, and venous thromboembolism through 6 weeks postpartum. The rate of thromboprophylaxis administration was assessed by mode of delivery, institution, and continuance to the outpatient setting. Multivariable regression models were developed using k-fold cross-validation with stepwise backward elimination to evaluate factors associated with thromboprophylaxis administration. Univariable and multivariable logistic models with propensity score covariate adjustment were performed to assess the association between thromboprophylaxis administration and adverse outcomes. Of 21,114 individuals in the analytical cohort, 11.9% (95% confidence interval, 11.4%–12.3%) received postpartum pharmacologic thromboprophylaxis; the frequency of receipt was 29.8% (95% confidence interval, 28.7%–30.9%) following cesarean and 3.5% (95% confidence interval, 3.2%–3.8%) following vaginal delivery. Institutional rates of prophylaxis varied from 0.21% to 34.8%. Most individuals (83.3%) received thromboprophylaxis only as inpatients. In adjusted analysis, cesarean delivery (adjusted odds ratio, 19.17; 95% confidence interval, 16.70–22.00), hysterectomy (adjusted odds ratio, 15.70; 95% confidence interval, 4.35–56.65), and obesity (adjusted odds ratio, 3.45; 95% confidence interval, 3.02–3.95) were the strongest factors associated with thromboprophylaxis administration. Thromboprophylaxis administration was not associated with surgical site infection (0.9% vs 0.6%; odds ratio, 1.48; 95% confidence interval, 0.80–2.74), bleeding complications (0.2% vs 0.1%; odds ratio, 2.60; 95% confidence interval, 0.99–6.80), or postpartum readmission (0.9% vs 0.3%; adjusted odds ratio, 1.38; 95% confidence interval, 0.68–2.81). The overall rate of venous thromboembolism was 0.06% (95% confidence interval, 0.03%–0.10%) and was higher in those receiving prophylaxis (0.2%) compared with those not receiving prophylaxis (0.04%). Approximately 1 in 10 patients received postpartum pharmacologic thromboprophylaxis in this US cohort. Rates of prophylaxis varied widely by institution. Cesarean delivery, hysterectomy, and obesity were predominant factors associated with postpartum thromboprophylaxis administration. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Quality of obstetric care may not be constant within clinics and hospitals. Night shifts and weekends experience understaffing and other organizational hurdles in comparison with the weekday morning shifts, and this may influence the risk of maternal deaths. Objective: To analyze the hourly variation of maternal mortality within Mexican health institutions. Methods: We performed a cross-sectional multivariate analysis of 3,908 maternal deaths and 10,589,444 births that occurred within health facilities in Mexico during the 2010–2014 period, using data from the Health Information Systems of the Mexican Ministry of Health. We fitted negative binomial regression models with covariate adjustment to all data, as well as similar models by basic cause of death and by weekdays/weekends. The outcome was the Maternal Mortality Ratio (MMR), defined as the number of deaths occurred per 100,000 live births. Hour of day was the main predictor; covariates were day of the week, c-section, marginalization, age, education, and number of pregnancies. Results: Risk rises during early morning, reaching 52.5 deaths per 100,000 live births at 6:00 (95% UI: 46.3, 62.2). This is almost twice the lowest risk, which occurred at noon (27.1 deaths per 100,000 live births [95% U.I.: 23.0, 32.0]). Risk shows peaks coinciding with shift changes, at 07:00, and 14:00 and was significantly higher on weekends and holidays. Conclusions: Evidence suggests strong hourly fluctuations in the risk of maternal death with during early morning hours and around the afternoon shift change. These results may reflect institutional management problems that cause an uneven quality of obstetric care. [ABSTRACT FROM AUTHOR]

Key content In order to provide appropriate counselling about the risk to future pregnancies imposed by caesarean delivery, providers must be knowledgeable about and able to synthesise a multitude of variables such as institutional policies, the clinical implications of each current delivery option for future pregnancies, patient understanding of maternal and neonatal risks and benefits, the woman's reasons for requesting this type of delivery and the woman's desired family size., The rate of successful vaginal birth after caesarean section ranges 50-85%, with lower rates associated with both modifiable factors (gestational age >40 weeks, maternal obesity, short interpregnancy interval and increased birthweight) and non-modifiable factors (maternal age, non-white ethnicity, pre-eclampsia and recurrence of the indication for the initial caesarean delivery)., In future pregnancies, the risk of adverse outcomes such as haemorrhage, endometritis, operative injury, hysterectomy and maternal death goes up with each additional caesarean section., Learning objectives To be knowledgeable about and able to provide accurate counselling for three important clinical situations: caesarean delivery on maternal request; women with a history of one or two caesarean deliveries; and women with a history of three or more caesarean deliveries., Ethical issues When counselling women about the risks of caesarean delivery on future pregnancies, providers should always consider the principles of beneficence and non-maleficence while synthesising a myriad of scenarios and outcomes. If properly counselled on the risks, benefits and alternatives of a delivery decision, her autonomy should be respected. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia.Data Sources: Electronic databases (Ovid MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and Scopus) were initially queried in June 2020 and updated in November 2020. The following 3 concepts were introduced and refined using the controlled vocabulary of the database: vaginal birth, shoulder dystocia, and simulation training. There were no limitations to the year of publication as part of the search strategy.Study Eligibility Criteria: We included all studies that reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes.Methods: Two authors independently assessed the abstracts and full-text articles of all studies for eligibility and evaluated the quality of the included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The coprimary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs).Results: Of the 372 articles reviewed, 16 publications, which included 428,552 deliveries with 217,713 (50.8%) deliveries during the preintervention and 210,839 (49.2%) deliveries during the postinterventional period, were included in the meta-analysis. The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from 12.1% to 5.7% (risk ratio, 0.37; 95% Cr, 0.26-0.57; probability of reduction 100%). The overall proportion of neonatal brachial plexus palsy decreased, but with less precision, from 0.3% to 0.1% (risk ratio, 0.53; 95% Cr, 0.21-1.26; probability of reduction 94%). Two studies followed newborns with brachial plexus palsy for at least 12 months. One study that reported on persistent neonatal brachial plexus palsy at 12 months among 1148 shoulder dystocia cases noted a reduction in persistent neonatal brachial plexus palsy from 1.9% to 0.2% of shoulder dystocia cases (risk ratio, 0.13; 95% confidence interval, 0.04-0.49). In contrast, the study that reported on persistent neonatal brachial plexus palsy at 12 months for all deliveries noted that it did not change significantly, namely from 0.3 to 0.2 per 1000 births (risk ratio, 0.77; 95% confidence interval, 0.31-1.90). Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly from 1.2% to 1.7% of vaginal deliveries (risk ratio, 1.39; 95% Cr, 1.19-1.65; probability of increase 100%). Compared with the preimplementation period, the cesarean delivery rate increased postimplementation from 21.2% to 25.9% (risk ratio, 1.22; 95% Cr, 0.93-1.59; probability of increase 93%). We created an online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) that permits calculation of the absolute risk reduction and absolute risk increase attributable to the intervention vis-à-vis the incidence of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries.Conclusion: Introduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia case; the data on persistence of neonatal brachial plexus palsy beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and rate of cesarean deliveries. [ABSTRACT FROM AUTHOR]

Objective: To compare trend of primary cesarean delivery rate and composite neonatal and maternal adverse outcomes in low-risk pregnancies among racial and ethnic groups: non-Hispanic White, non-Hispanic Black, and Hispanic.Methods: This population-based cohort study used U.S. vital statistics data (2015-2019) to evaluate low-risk, nulliparous patients with nonanomalous singletons who labored and delivered at 37-41 weeks of gestation. The primary outcome was the primary cesarean delivery rate. Secondary outcomes included composite neonatal adverse outcome (Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure, or death), and composite maternal adverse outcome (intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy), as well as infant death. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% CIs.Results: Among 4.3 million births, 60.6% identified as non-Hispanic White, 14.6% identified as non-Hispanic Black, and 24.8% identified as Hispanic. The rate of primary cesarean delivery was 18.5% (n=804,155). An increased risk for cesarean delivery was found in non-Hispanic Black (21.7%, aRR 1.24, 95% CI 1.23-1.25) and Hispanic (17.3%, aRR 1.09, 95% CI 1.09-1.10) individuals, compared with non-Hispanic White individuals (18.1%) after multivariable adjustment. There was an upward trend in the rate of primary cesarean delivery in all racial and ethnic groups ( P for linear trend<0.001 for all groups). However, the racial and ethnic disparity in the rate of primary cesarean delivery remained stable during the study period. The composite neonatal adverse outcome was lower in Hispanic individuals in all newborns (10.7 vs 8.3 per 1,000 live births, aRR 0.74, 95% CI 0.72-0.75), and in newborns delivered by primary cesarean delivery (18.5 vs 15.0 per 1,000 live births, aRR 0.73, 95% CI 0.70-0.76), compared with non-Hispanic White individuals.Conclusion: Using a nationally representative sample in the United States, we found racial and ethnic disparities in the primary cesarean delivery rate in low-risk nulliparous patients, which persisted throughout the study period. [ABSTRACT FROM AUTHOR]

We appreciate Dr. Carmichael's and Dr. Snowden's interest in our article in the November 2022 issue.[1] They raise concerns regarding using the U.S. vital statistics data set that we would like to address. The U.S. vital statistics data set is the largest nationally representative, population-based data set on maternal health and pregnancy outcomes available in the United States.[2] We wholeheartedly agree with Drs. Carmichael and Snowden that there is a need for changes in how vital statistics data are collected and validated, but we disagree that these imperfections should preclude the use of these data. [Extracted from the article]

Objective: We aimed to evaluate whether delivering during the early the coronavirus disease 2019 (COVID-19) pandemic was associated with increased risk of maternal death or serious morbidity from common obstetric complications compared with a historical control period.Methods: This was a multicenter retrospective cohort study with manual medical-record abstraction performed by centrally trained and certified research personnel at 17 U.S. hospitals. Individuals who gave birth on randomly selected dates in 2019 (before the pandemic) and 2020 (during the pandemic) were compared. Hospital, health care system, and community risk-mitigation strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in response to the early COVID-19 pandemic are described. The primary outcome was a composite of maternal death or serious morbidity from common obstetric complications, including hypertensive disorders of pregnancy (eclampsia, end organ dysfunction, or need for acute antihypertensive therapy), postpartum hemorrhage (operative intervention or receipt of 4 or more units blood products), and infections other than SARS-CoV-2 (sepsis, pelvic abscess, prolonged intravenous antibiotics, bacteremia, deep surgical site infection). The major secondary outcome was cesarean birth.Results: Overall, 12,133 patients giving birth during and 9,709 before the pandemic were included. Hospital, health care system, and community SARS-CoV-2 mitigation strategies were employed at all sites for a portion of 2020, with a peak in modifications from March to June 2020. Of patients delivering during the pandemic, 3% had a positive SARS-CoV-2 test result during pregnancy through 42 days postpartum. Giving birth during the pandemic was not associated with a change in the frequency of the primary composite outcome (9.3% vs 8.9%, adjusted relative risk [aRR] 1.02, 95% CI 0.93-1.11) or cesarean birth (32.4% vs 31.3%, aRR 1.02, 95% CI 0.97-1.07). No maternal deaths were observed.Conclusion: Despite substantial hospital, health care, and community modifications, giving birth during the early COVID-19 pandemic was not associated with higher rates of serious maternal morbidity from common obstetric complications.Clinical Trials Registration: ClinicalTrials.gov, NCT04519502. [ABSTRACT FROM AUTHOR]

Objective: To describe coronavirus disease 2019 (COVID-19) severity in pregnant patients and evaluate the association between disease severity and perinatal outcomes.Methods: We conducted an observational cohort study of all pregnant patients with a singleton gestation and a positive test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who delivered at 1 of 33 U.S. hospitals in 14 states from March 1 to July 31, 2020. Disease severity was classified by National Institutes of Health criteria. Maternal, fetal, and neonatal outcomes were abstracted by centrally trained and certified perinatal research staff. We evaluated trends in maternal characteristics and outcomes across COVID-19 severity classes and associations between severity and outcomes by multivariable modeling.Results: A total of 1,219 patients were included: 47% asymptomatic, 27% mild, 14% moderate, 8% severe, 4% critical. Overall, 53% were Hispanic; there was no trend in race-ethnicity distribution by disease severity. Those with more severe illness had older mean age, higher median body mass index, and pre-existing medical comorbidities. Four maternal deaths (0.3%) were attributed to COVID-19. Frequency of perinatal death or a positive neonatal SARS-CoV-2 test result did not differ by severity. Adverse perinatal outcomes were more frequent among patients with more severe illness, including 6% (95% CI 2-11%) incidence of venous thromboembolism among those with severe-critical illness compared with 0.2% in mild-moderate and 0% in asymptomatic (P<.001 for trend across severity). In adjusted analyses, severe-critical COVID-19 was associated with increased risk of cesarean birth (59.6% vs 34.0%, adjusted relative risk [aRR] 1.57, 95% CI 1.30-1.90), hypertensive disorders of pregnancy (40.4% vs 18.8%, aRR 1.61, 95% CI 1.18-2.20), and preterm birth (41.8% vs 11.9%, aRR 3.53, 95% CI 2.42-5.14) compared with asymptomatic patients. Mild-moderate COVID-19 was not associated with adverse perinatal outcomes compared with asymptomatic patients.Conclusion: Compared with pregnant patients with SARS-CoV-2 infection without symptoms, those with severe-critical COVID-19, but not those with mild-moderate COVID-19, were at increased risk of perinatal complications. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Unlike neonatal morbidity with preterm birth (PTB; <37 weeks), maternal complications with PTB are infrequently reported. We aimed to assess the risk of postpartum hemorrhage (PPH)-related maternal morbidity among preterm versus term deliveries. METHODS: This was a secondary analysis of an IRB-approved retrospective cohort of all in-house singleton deliveries over 1 year. Demographics, pregnancy and delivery characteristics were abstracted from charts. Individuals who delivered preterm were compared to those who delivered at term (>37 weeks) for the primary outcome of composite maternal morbidity (CMM—blood loss >1,000 mL, uterotonic use, transfusion, uterine tamponade, surgical intervention, intensive care unit [ICU] admission, hysterectomy, and maternal death). Multivariable regression was performed to assess the adjusted relative risk (aRR) of preterm delivery on CMM with variables specified a priori. RESULTS: Of the 4,554 deliveries in our level 4 hospital, 4,514 (99%) met the inclusion criteria, with 1,062 (23%) delivering preterm. The overall CMM was 23.2%, with it being 30.4% in PTB and 21.0% in term births. Controlling for age, body mass index greater than 30 kg/m2, nulliparity, insurance status, race, smoking status, and cesarean delivery, preterm deliveries had a 42% higher rate of the CMM compared to term births (aRR 1.42: 95% CI, 1.27, 1.60). Transfusion, ICU admission, and hysterectomy were significantly more common among PTB than term. CONCLUSION: Preterm deliveries were associated with significantly higher rates of postpartum hemorrhagic CMM than those who delivered at term. Interventional trials are needed to decrease the hemorrhagic morbidity with PTB. [ABSTRACT FROM AUTHOR]