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This intervention study aimed to implement and evaluate the effectiveness of Health-Tracker, a post-discharge surgical site infection surveillance system. Participants were 730 women birthing by caesarean section at a large hospital over a 6-month period. Data were downloaded from clinical data systems and HealthTracker. Receiver operating characteristics were used to assess HealthTracker. Over a 6-month period, 382 women completed HealthTracker, with 83 scoring >6, indicating signs and symptoms of surgical site infection. Of this 83, 58 sought advice from health professionals, 29 returned to hospital, and 45 received antibiotics. A total of 20 infections from a total population of 730 were confirmed, with 14 out of 382 respondents confirmed via HealthTracker. Receiver operating characteristics identified HealthTracker as an excellent indicator of surgical site infection. HealthTracker is a feasible mHealth option for monitoring post-discharge surgical site infection post-caesarean section. In addition, by providing alerts, advising women to monitor their symptoms and seek treatment if necessary, HealthTracker has the potential to enhance self-efficacy for surgical wound monitoring at home. [ABSTRACT FROM AUTHOR]

Background: Opportunistic bilateral salpingectomy during benign gynaecologic surgery is advocated as a risk‐reducing strategy due to the inverse association of epithelial ovarian cancers observed in epidemiological studies in a low‐risk setting. Currently, no formal guidance exists for permanent surgical contraception at time of caesarean section in Australia. Aims: Our aim was to survey Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding bilateral salpingectomy compared to other procedures offered for permanent contraception at the time of caesarean section. Materials and Methods: An online survey was utilised to collect clinician demographics, opinions, barriers, and justifications in regard to options of permanent surgical contraception at time of caesarean section. Results: Bilateral salpingectomy was identified as the most effective method of permanent contraception at time of caesarean section. However, only 62% of respondents offer the procedure as a method of permanent contraception. The two most common reasons for clinicians to offer bilateral salpingectomy at time of caesarean section were evidence suggesting a link between the fallopian tube and gynaecological cancer (80%) and efficacy as a permanent form of contraception (16%). The primary barrier identified by 51% of respondents was perceived increased risk of surgical complications, followed by reasoning that it would not allow the possibility of future tubal reversal. Conclusion: This study identifies diverse opinions on surgical approach to permanent contraception at time of caesarean section and offered by clinicians of RANZCOG. Further research is required to establish safety profiles and short‐ and long‐term risks of bilateral salpingectomy. [ABSTRACT FROM AUTHOR]

Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications. [ABSTRACT FROM AUTHOR]

Background: Caesarean birth at full cervical dilatation can be technically challenging and may be associated with increased risks of maternal and neonatal morbidity, often secondary to difficulties in delivering a deeply impacted fetal head. The Fetal Pillow is a device designed to elevate an impacted fetal head out of the pelvis and reduce birth trauma. Aims: To evaluate birth outcomes following the introduction of the Fetal Pillow at a tertiary maternity hospital. Materials and Methods: This retrospective cohort study included all caesarean births at full cervical dilatation where the Fetal Pillow was utilised and compared with caesarean births where the Fetal Pillow was not used from October 2018 to December 2019. Maternal outcomes included uterine incision extension, blood loss, high dependency unit admission and postoperative length of stay. Neonatal outcomes included Apgar scores, resuscitation, cord arterial blood pH and lactate, nursery admission, birth trauma, jaundice and seizures. Results: There were 53 caesarean births where the Fetal Pillow was utilised and 48 where it was not. Baseline characteristics were similar between groups with mean maternal age across both groups of 30.4 (±5.3) years, mean gestational age at birth of 39.5 (±1.2) weeks and mean infant birth weight of 3543 (±441) g. There were no statistically significant differences between the two study groups for the maternal and neonatal outcomes considered. Conclusions: There was no evidence that use of the Fetal Pillow to elevate an impacted fetal head during caesarean birth when cervical dilatation is >7 cm was associated with a reduced rate of adverse maternal and neonatal outcomes. [ABSTRACT FROM AUTHOR]

To determine the changes in emergency and elective caesarean section (CS) rates since the COVID-19 pandemic, identify the groups most affected, and examine changes in the factors associated with CS rates, and reasons for CS. We conducted a retrospective cohort study using routinely collected data of 22,346 births from before the pandemic (January 2018–February 2020) and 18,597 births during the pandemic (March 2020–December 2021). Data were analysed using multinominal logistic regression. The CS rate increased by 4.1% (from 30.1% to 34.2%), reflecting increases of 2.3% in emergency CS (from 11.5% to 13.8%) and 1.7% in elective CS (from 18.7% to 20.4%). Large groups with notable increases were women who were nulliparous (7.2% increase), from South Asia (6.0%), obese (5.2%) and giving birth at a small hospital (6.1%). Compared to pre-pandemic, the relative risk of an emergency CS versus a vaginal delivery increased 1.36 times (adjusted relative risk ratio (aRRR) = 1.36; 95% CI = 1.27, 1.45) and the risk of having an elective CS increased 1.11 times (aRRR = 1.11; 95% CI = 1.04, 1.20). Factors associated with both emergency and elective CS were age, region of birth, reproductive history, body mass index, hypertension, diabetes, mode of antenatal care and hospital. Socio-Economic Indexes for Areas and antenatal care were only associated with elective CS. Baby gender was only associated with emergency CS. Preterm gestation at delivery was associated with reduced emergency but increased elective CS. Foetal compromise was the most common indication for emergency CS (43.2%) and increased the most (8.0%). Previous CS was the most common indication for elective CS (61.5%) and reduced the most (1.9%). Both emergency and elective CS rates increased significantly during the pandemic, with the former increasing at a higher rate. The persistent upward trend of CS rates, exacerbated by increasing proportions of nulliparous women undergoing CSs, is concerning. Australia has a very high caesarean section (CS) rate that varies greatly between groups of women with different socio-economic characteristics and reproductive histories. Information regarding changes in CS rate since the COVID-19 pandemic in Australia is limited. We conducted a study comparing CS rate before and during the pandemic, using routinely collected data. Both emergency and elective CS rates increased significantly during the pandemic with emergency CSs increased at a higher rate than elective CSs. Several groups of women experienced large increases in CS rate. Factors associated with and reasons for emergency CSs were different from those for elective CSs. Health services should be prepared to minimise effects of future pandemics on CS rate. To be most effective, interventions to reduce non-medically justified CSs should focus on women who are from South Asia, obese, admitted to a small hospital, and are nulliparous. Different approaches are needed to reduce emergency and elective CSs. [ABSTRACT FROM AUTHOR]

During induction of labour (IOL), the optimal timing of oxytocin following amniotomy is unknown, with limited data to guide decision‐making. This study aimed to see whether a 2‐h delay after amniotomy before starting oxytocin during IOL reduced the use of oxytocin as well as other positive or negative impact. A propensity‐score‐matched cohort study assessed the maternal, neonatal and process outcomes of 1168 women (584 per group) comparing immediate oxytocin to a 2‐h delay ('wait') after amniotomy. Women who waited were significantly less likely to receive oxytocin (61.2 vs 100%, P < 0.001) but more likely to receive antibiotics (14.7 vs 10.3%, P = 0.021), to be delivered by caesarean section (20.0 vs 14.6%, P = 0.013) and to be exclusively breastfeeding during discharge (77.2 vs 71.2%, P = 0.019). These findings provide further information for women and caregivers regarding the risks and benefits of a short delay before starting oxytocin. [ABSTRACT FROM AUTHOR]

Background: Caesarean section is a common surgery, with almost 23 million procedures performed globally each year. Postpartum haemorrhage, in association with caesarean section surgery, is a leading global cause of maternal morbidity and mortality. Perioperative iron deficiency anaemia is a risk factor for intraoperative bleeding. Therefore, anaemia is an important and modifiable risk factor for bleeding during caesarean section surgery. Recent recommendations advise that all preoperative patients with anaemia (defined as haemoglobin concentration (Hb) < 130 g/L), regardless of sex, be assessed and treated to normalise haemoglobin levels. It is unclear how this recommendation translates to pregnant women where the World Health Organization (WHO) defines anaemia at a much lower threshold (Hb < 110 g/L). We aimed to determine the prevalence, and characterization, of Hb levels < 130 g/L perioperatively in women undergoing caesarean section. Method: We conducted a retrospective cohort study of 489 consecutive women who underwent caesarean section over a 12-week period, in a single-centre tertiary referral maternity unit in Australia. We calculated the proportion of women who were anaemic (Hb < 130 g/L) at four time points—first hospital appointment, third trimester, preoperatively and on discharge from hospital. The proportion of women who were iron deficient (ferritin level < 30 μg/L) at their first hospital appointment was determined. Results: Haemoglobin was measured in 479 women. Ferritin was measured in 437 of these women. The mean (SD) Hb at the first hospital appointment, third trimester, preoperatively, and postoperatively on discharge was 126.7 (11.4) g/L, 114.6 (10.6) g/L, 124.1 (12.4) g/L, and 108.0 (13.6) g/L respectively. Iron deficiency was present in 148 (33.9%) women at their first hospital appointment; 107 of 248 (43.1%) women with anaemia and 41 of 189 (21.7%) with no anaemia. 29 women were found to have moderate anaemia (Hb 80−109 g/L) with 18 of these 29 (62.1%) women having iron deficiency. Only 68 (45.9%) women with iron deficiency at their first hospital appointment received treatment. The prevalence of anaemia classified as Hb < 130 g/L versus the WHO classification of Hb < 110 g/L from all causes was 57.4% versus 6.1% at first hospital appointment, 94% versus 26.1% in third trimester, and 66.0% versus 12.2% preoperatively. Postoperatively at least 40% of women had Hb < 130 g/L on hospital discharge versus at least 23% of women using WHO definition of Hb < 110 g/L. Of the 112 women with hospital discharge Hb < 110 g/L, 35 (31.3%) women were iron deficient at their first hospital appointment. Conclusion: Over one in three women were iron deficient at their first hospital appointment. 62% of women with moderate anaemia (Hb 80–109 g/L) also had iron deficiency. At least four in 10 women were anaemic (Hb < 130 g/L) on hospital discharge. Less than half of the women with anaemia were treated. Our data suggests that 30% of postoperative anaemia may be prevented with intensive treatment of iron deficiency in early pregnancy. Large prospective studies, are needed to determine outcomes after caesarean section in women, stratified by preoperative Hb and ferritin levels. The prevalence of anaemia in our data suggests it is a moderate public health problem. [ABSTRACT FROM AUTHOR]

Background: The use of intrapartum interventions is becoming increasingly common globally. Interventions during birth, including caesarean section (CS), epidural analgesia and synthetic oxytocin infusion, can be important in optimizing obstetric care, but have the potential to impact breastfeeding. This study aimed to identify whether women who have certain intrapartum interventions have greater odds of unfavourable breastfeeding outcomes, both the immediate post-partum period and in the months after birth. Methods: This was a population-based cohort study of singleton livebirths at ≥37 weeks' gestation between 2010 and 2018 in Victoria, Australia using routinely-collected state-wide data from the Victorian Perinatal Data Collection (VPDC) and the Child Development Information System (CDIS). The interventions included were pre-labour CS, in-labour CS, epidural analgesia, and synthetic oxytocin infusion (augmentation and/or induction of labour). Outcomes were formula supplementation in hospital, method of last feed before hospital discharge and breastfeeding status at 3-months and 6-months. Descriptive statistics and multivariable logistic regression models adjusting for potential confounders were employed. Results: In total, 599,191 women initiated breastfeeding. In-labour CS (aOR 1.96, 95%CI 1.93,1.99), pre-labour CS (aOR 1.75, 95%CI 1.72,1.77), epidural analgesia (aOR 1.45, 95%CI 1.43,1.47) and synthetic oxytocin infusion (aOR 1.24, 95%CI 1.22,1.26) increased the odds of formula supplementation in hospital. Long-term breastfeeding data was available for 105,599 infants. In-labour CS (aOR 0.79, 95%CI 0.76,0.83), pre-labour CS (aOR 0.73, 95%CI 0.71,0.76), epidural analgesia (aOR 0.77, 95%CI 0.75,0.80) and synthetic oxytocin infusion (aOR 0.89, 95%CI 0.86–0.92) decreased the odds of exclusive breastfeeding at 3-months post-partum, which was similar at 6-months. There was a dose-response effect between number of interventions received and odds of each unfavourable breastfeeding outcome. Conclusion: Common intrapartum interventions are associated with less favourable breastfeeding outcomes, both in hospital and in the months after birth. This confirms the importance of only undertaking interventions when necessary. When interventions are used intrapartum, an assessment and identification of women at increased risk of early discontinuation of breastfeeding has to be performed. Targeted breastfeeding support for women who have intrapartum interventions, when they wish to breastfeed, is important. [ABSTRACT FROM AUTHOR]

Background: Women who have previously had a caesarean section often face the choice between planning for a vaginal birth after caesarean (VBAC) or an elective repeat caesarean section (CS) for future pregnancies. Informing a woman of her individualised chance of a successful VBAC can aid her decision making. Aims: The aim is to create two VBAC prediction models using an Australian cohort – one for use in labour when labour variables are known, and one for use antenatally when labour characteristics are unknown. Materials and Methods: This study was a retrospective analysis of perinatal data in Victoria, Australia, over a 10‐year period. During this time, 22 062 women were recorded as attempting a VBAC with a term singleton live birth. The data were separated into three parts. A 'training set' was used to build the complete VBAC prediction model and the antenatal VBAC prediction model using multivariate logistic regression. The models were then adjusted to only include the variables that contributed to model performance. The models were validated by testing the receiver operating characteristic (ROC) area under the curve within the 'validation set'. Then the models were tested for accuracy within the 'test set'. Results: Using a 'test set' of data, the models demonstrated an area under the ROC curve of 0.7887 and 0.7384 for the complete and antenatal models respectively, showing adequate performance of both models. Conclusions: With these models, Australian women can be counselled about their predicted chance of VBAC success. [ABSTRACT FROM AUTHOR]

Background: This study follows the 2017 UK INFANT Collaborative Group RCT, which compared neonatal outcomes with and without the use of the INFANT cardiotocograph decision support system for over 46 000 patients in labour. The original trial failed to demonstrate a significant improvement to neonatal outcomes; however, the study design was subject to methodological critique. Aims: This Australian retrospective cohort study aimed to report perinatal outcomes before and after the introduction of INFANT decision support software for cardiotocograph use in labour. Materials and Methods: The study cohort was divided into two equivalent 18‐month epochs, before and after the introduction of INFANT‐Guardian® CTG decision support system. Propensity score matching analysis was undertaken to balance pre‐ and post‐implementation groups by baseline covariates. The matched cohort included 11 154 public‐funded women between November 2016 and 2019, with a singleton live fetus ≥34 + 0 weeks, being induced or in spontaneous labour. The main outcome measures were: a composite measure of serious adverse neonatal outcome comprising of one or more of: admission to intensive care nursery >48 h, Apgar <4 at 5 min, cord arterial pH <7.0, hypoxic ischaemic encephalopathy grade 2 or 3, therapeutic hypothermia, neonatal death. Results: The incidence of the composite primary outcome was significantly lower following implementation of INFANT (0.57% vs. 1.00%; OR 0.57, 95%CI 0.37–0.88; P = 0.01). A significant reduction in nursery admission >48 h was also observed (0.05% vs. 0.30%; OR 0.18, 95%CI 0.05–0.60; P = 0.002). Conclusions: INFANT software is associated with a reduction in serious adverse neonatal outcomes, without increasing the rate of operative delivery. [ABSTRACT FROM AUTHOR]

Prophylactic administration of uterotonics ensures adequate uterine contraction at elective caesarean section to prevent substantial haemorrhage. Royal College of Obstetricians and Gynaecologists guidelines advise the administration of oxytocin at 5 IU as a 'slow bolus' but there are variations in clinical practice. This study aimed to determine the beliefs and uterotonic usage practices at elective caesarean section by surveying anaesthetist members of the Obstetric Anaesthesia Special Interest Group in Australia and New Zealand. Questionnaires were emailed to Obstetric Anaesthesia Special Interest Group members and the response rate was 33%, with analysis of 279 completed reports. Oxytocin was the most commonly used first-line uterotonic, but extensive variation in oxytocin bolus use was identified. Thirty-eight per cent of anaesthetists routinely administered Royal College of Obstetricians and Gynaecologists guideline-recommended 5 IU, whereas 38% favoured low dose (<5 IU), 10% high dose (≥10 IU) oxytocin and 13% carbetocin (100 µg). More than 50% felt the evidence was weak for guideline-recommended 5 IU. Wide variation in the duration of oxytocin administration was also identified. Fifty-eight per cent of anaesthetists routinely gave follow-up oxytocin infusions, most commonly at 40 IU over 4 hours, but there was significant variation in the dosage (10-40 IU) and administration duration (1 hour to ≥6 hours). In conclusion, there is significant variation in oxytocin usage practices at elective caesarean section among Australian and New Zealand anaesthetists. This variation may be due to a lack of strong evidence to guide practice. This emphasises the need for high quality trials in this clinically important area. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection (SSI) following caesarean section is a serious but underreported problem with an estimated incidence of 5–9%. It is essential to identify adherence to established prevention strategies to reduce the incidence rate. Aims: The aims of this study were to quantify unwarranted variation from evidence‐based practice on the prevention of SSI at caesarean section in Australia; and to identify predictors of not implementing an existing infection prevention bundle: pre‐incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal. Materials and methods: An online cross‐sectional survey of obstetricians and obstetric Diplomates was conducted in 2016. The primary outcome was adherence to an existing infection prevention bundle, with demographic and clinical variables predicting adherence through multivariable binary logistic regression. Results: Forty‐nine percent of respondents (response rate 39.6%) reported implementing zero or only one element of the infection prevention bundle. The types of respondents most likely to have poor adherence were Diplomates (adjusted odds ratio (aOR) 2.58), obstetricians practising in private hospitals (aOR 3.34), those usually practising in public and private hospitals (aOR 2.23), and those not usually implementing a surgical safety checklist (aOR 3.77). Conclusions: Adherence to best practice at caesarean section is low among many Australian obstetricians. Infection control practitioners and obstetricians need to collaboratively implement surgical safety checklists at caesarean section, and monitor implementation using process key performance indicators, and audit and feedback. These strategies will reduce unwarranted variation from evidence‐based infection control practice. [ABSTRACT FROM AUTHOR]

Background: Maternity care is a significant contributor to overall healthcare expenditure, and private care is seen as a mechanism to reduce the cost to public funders. However, public funders may still contribute to part of the cost of private care. The paper aims to quantify (1) the cost to different funders of maternal and early childhood healthcare over the first 1000 days for both women giving birth in private and public hospitals; (2) any variation in cost to different funders by birth type; and (3) the cost of excess caesarean sections in public and private hospitals in Australia. Methods: This study utilised a whole of population linked administrative dataset, and classified costs by the funding source. The mean cost to different funders for private hospital births, and public hospital births in the Australian state, Queensland are presented by time period and by birth type. The World Health Organization's (WHO's) C-model was used to identify the optimal caesarean section rate based upon demographic and clinical factors, and counterfactual analysis was utilised to identify the cost to different funders if caesarean section had been utilised at this rate across Australia. Results: We found that for women who gave birth in a public hospital as a public patient, the mean cost was $22 474. For women who gave birth in a private hospital the mean cost was $24 731, and the largest contributor was private health insurers ($11 550), followed by Medicare ($7261) and individuals ($3312). Private hospital births cost government funders $10 050 on average; whereas public hospital public patient births cost government funders $21 723 on average and public hospital private patient births cost government funders $20 899 on average. If caesarean section deliveries were reduced, public hospital funders could save $974 million and private health insurers could save $216 million. Conclusion: Private hospital births cost government funders less than public hospital births, but government funders still pay for around 40% of the cost of private hospital births. Caesarean sections, which are more frequently performed in private hospitals, are costly to all funders and reducing them could impart significant cost savings to all funders. [ABSTRACT FROM AUTHOR]

Summary: Background: Measuring obesity at a single time point does not explain the independent association between C‐section birth and obesity in a child's life course. Objectives: This study aimed to explore the longitudinal link between C‐section with obesity trajectories during childhood. Methods: We analysed data from a nationally representative birth cohort study named "Longitudinal Study of Australian Children (LSAC)", commenced in 2004. General obesity was measured through the Body Mass Index (BMI) and abdominal obesity by the Waist Circumference (WC) using the biennially collected data from age 2 to 13 years (2006‐2016). Group‐based trajectory modelling was applied to identify the distinct pattern of BMI & WC trajectories. Multivariable multinomial logistic regression models were used to assess the association between C‐section and obesity trajectories after adjusting for perinatal factors. Results: Of the 3524 study children, 30% were born by C‐section. Three distinct BMI trajectory groups emerged: stable normal (60%), moderately rising (33%) and accelerated (7%). The WC trajectories were, stable normal (58%), moderate (34%) and accelerated (8%). Compared with the stable normal group, children born through C‐section had a higher risk to follow accelerated trajectories for both BMI (OR:1.72; 95% CI: 1.28‐2.32) and WC (OR: 1.51; 95% CI: 1.15‐1.98) with P‐value <0.01. Adjustment of potential confounders did not alter these associations substantially. Conclusions: C‐section birth significantly increases the risk of having an accelerated obesity trajectory in children. Limiting the C‐section for absolute clinical causes and early institution of preventive approach can reduce the obesity burden among children delivered through C‐section. [ABSTRACT FROM AUTHOR]

Objective. To compare the incidence of prelabour Caesarean delivery (PCD) at early term (37 weeks and 0 days (37°) to 38 weeks and 6 days (386) of gestation) between Australian states and hospital sectors over time and to compare these rates with those of England and the United States of America (USA). Method. A population-based descriptive study of 556 040 singleton PCDs at term (37°-406 weeks) in all public and private hospitals in Australian states, 2005-16, was performed. The primary outcome was the early-term PCD rate, defined as early-term PCDs as a percentage of all term PCDs. Results. Across Australian states, the early-term PCD rate fell from 56.4% in 2005 to 52.0% in 2016. Over a similar period, England's rate fell from 48.2% in 2006-07 to 35.2% in 2016-17, while the USA's rate fell from 47.4% in 2006 to 34.2% in 2016. Australian public hospitals reduced their rate from 54.2% in 2005 to 44.7% in 2016, but the rate increased in private hospitals from 59.1% in 2005 to 62.5% in 2016. There was considerable variation between states and hospital sectors. Conclusions. The early-term PCD rate increased in Australian private hospitals from 2005 to 2016. The public hospital rate fell by nearly 10% over the period but remained ,10% above the English and USA national rates. [ABSTRACT FROM AUTHOR]

Background: Post-term gestation beyond 41+6 completed weeks of gestation is known to be associated with a sharp increase in the risk of stillbirth and perinatal mortality. However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks.Methods: We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression.Results: The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55-2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89-2.78) following instrumental birth and 1.44 (95% CI 1.17-1.78) following emergency caesarean section; 1.43 (95% CI 1.16-1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03-1.45) for 3rd or 4th degree perineal tear (all women). The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26-12.57) among nulliparous women and 4.71 (95% CI 3.90-5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86-2.06) following any labour and 1.47 (95% CI 1.38-1.56) following induction of labour.Conclusions: Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation. [ABSTRACT FROM AUTHOR]

Aim: This study aims to evaluate the effectiveness of HealthTracker, a surgical site infection surveillance system that aims to improve the notification of surgical site infection for women after giving birth by caesarean section. Design: This protocol is an intervention study to evaluate the effectiveness of the surveillance system called "HealthTracker" in monitoring surgical site infections post caesarean section. Methods: This study will use a mobile web application to automatically send a text message inviting all women who give birth to a live baby by caesarean section over six months during 2020–2021, at an Australian tertiary referral hospital. The text message invites women to complete a web‐based validated Wound Healing Questionnaire. The estimated number of eligible women in six months is 700 (caesarean section rate: 34% of 4,000 births annually). Intervention: the proposed "HealthTracker" surveillance system facilitates active patient‐reported surgical site infection identification through an automated mobile text message linking women to an individualized online Wound Healing Questionnaire. Discussion: This project aims to provide a consistent, reliable and cost effective surgical site infection surveillance tool to improve post caesarean section surgical site infection reporting, can be scaled for broader utilization and will provide valuable information to decision makers regarding surgical site infection prevention. Impact: Study findings will provide insights into whether HealthTracker is an efficient and cost effective platform for a systematic and consistent approach to surgical site infection surveillance that can be adopted more broadly, across the local health organization, the State and across other surgical specialty areas. This information will equip hospitals and clinicians with knowledge to better identify patient outcomes related to SSI post discharge from hospital and inform decision making related to preventative strategies, providing the necessary momentum to introduce practice change initiatives aimed at reducing surgical site infection rates. Trial Registration: ACTRN12620001233910. [ABSTRACT FROM AUTHOR]

Background: Australia's caesarean rate is higher than Organisation for Economic Co-operation and Development (OECD) average, and is rising. Vaginal birth after caesarean (VBAC) is safe for selected women. Midwifery continuity of care (CoC) is associated with higher rates of vaginal birth compared to other models; however, impacts on VBAC attempts and success are unknown., Aims: The primary aim was to determine if there is a difference in achieving VBAC between CoC and non-CoC (NCoC) models. The secondary aim was to determine if there is a difference in the proportion of women attempting VBAC between these models., Materials and Methods: Retrospective review of antenatal records and birthing data of all women who birthed in 2021 with one or more previous caesareans. Women were included if they had two or fewer caesareans. Women were excluded if contraindications to VBAC existed., Results: There were 142/1109 (12.8%) women who had previous caesareans and were eligible to attempt VBAC. There were 47/109 (43.1%) women who attempted vaginal birth after one caesarean with 78.7% success. After one caesarean, women in CoC were more likely to achieve VBAC than NCoC (45.2% vs 26.1%; relative risk (RR) 1.76, 95% CI 1.04-3.00), although when stratified by private and midwifery CoC models, women in midwifery CoC models were more likely to be successful (private RR 0.69, 95% CI 0.23-2.07 vs midwifery RR 2.48, 95% CI 1.50-4.11). Women in CoC were more likely to attempt VBAC (54.7% vs 34.8%; RR 1.57, 95% CI 1.02-2.41), and receive counselling about VBAC (92.5% vs 62%; RR 1.48, 95% CI 1.41-3.11)., Conclusion: CoC improves the rate of attempted and successful VBAC through several factors, including increased counselling and greater provision of birth choices., (© 2024 Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Although caesarean delivery at periviable gestations may minimize birth trauma, it may not necessarily improve perinatal outcomes. The aim of this study was to assess the impact of mode of birth on outcomes for breech versus cephalic presentation at 22 + 0-25 + 6 weeks.Methods: Retrospective cohort study of single, nonanomalous infants at 22 + 0-25 + 6 weeks gestation born at a tertiary center in Australia. Neonatal outcomes were analyzed comparing both breech and cephalic presentation and mode of delivery.Results: Six hundred and eighty eight women fulfilled the inclusion criteria with 39.7% (273/688) breech and 60.3% (415/688) cephalic infants. Survival was 31.5% (86/273) and 38.1% (158/415) in the breech and cephalic cohorts respectively. Vaginal breech infants had reduced odds of survival compared to the vaginal cephalic group (aOR 0.37, 95% CI 0.17-0.75, p < .01) with no difference in survival if delivery occurred by caesarean section. Vaginal breech birth had higher odds of very low Apgar scores, stillbirth, and neonatal death. At 22 + 0-22 + 6 weeks, outcomes were universally fatal. At 24 + 0-24 + 6 and 25 + 0-25 + 6 weeks, vaginal breech birth had lower odds of survival (aOR 0.33, 95% CI 0.13-0.84, p < .05 and aOR 0.10, 95% CI 0.03-0.34, p < .001 respectively) compared to caesarean breech births.Conclusions: Caesarean section improves perinatal outcomes for periviable breech infants > 24 + 0 weeks. [ABSTRACT FROM AUTHOR]

Background: Induction of labour (IOL) and caesarean section (CS) rates continue to increase in Australia, New Zealand and globally. There is evidence that CS rates are decreased in the context of medically indicated and elective IOL; therefore, the emerging concept of using IOL as means of preventing CS warrants investigation. Aims: To assess obstetricians' opinions of elective IOL at 39 weeks gestation, its feasibility, generalisability and utility as a means of preventing CS in Australia and New Zealand. Materials and Methods: A de‐identified cross‐sectional survey was distributed electronically to all Fellows and trainees of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). The survey was voluntary and distributed with the approval of the RANZCOG Continuing Education Committee. The survey addressed opinions relating to rates of and indications for IOL, the perceived validity of those indications and explored the acceptability of using a screening tool to predict women at increased risk of intra‐partum CS and tailoring obstetric management to include the option of IOL at 39 weeks gestation. Results: The overall response rate was 34% (492/1423) (including trainees) and the response rate was 53% (394/750) for currently practising obstetricians. The majority (90%) of responders agreed on medical and clinical indications for IOL. There was no consensus on the validity of IOL if a woman were at apparent high risk of intra‐partum CS; however, 81% (360/443) of clinicians would be interested in a tool that could predict those women at risk. Conclusions: There is heterogeneity of obstetrician's beliefs on using IOL at 39 weeks as a mechanism to reduce the CS rate. [ABSTRACT FROM AUTHOR]

Background: Caesarean scar ectopic pregnancy (CSP) is defined as blastocyst implantation occurring in a uterine scar. The incidence of CSP continues to rise with increasing caesarean section rates; prevalence is estimated to be 1:1800 to 1:2226 of all pregnancies. To date, over 30 treatment regimens have been published. The Royal College of Obstetricians and Gynaecologists guidelines (2016) state there is insufficient evidence to support one specific intervention over another. Aim: To review outcomes of medical and surgical management of CSP cases at a single tertiary centre over a nine‐year period, in order to establish the safest and most effective management approach. Materials and Methods: An audit was undertaken of patients treated for CSP between January 2009 and March 2017 at King Edward Memorial Hospital, Western Australia. Patient demographic and treatment outcome data were extracted from medical records. Results: Fifty‐one patients were identified as having CSP diagnosed during this time period, of which five were excluded due to lack of data, leaving a total of 46 cases. The majority of patients (52%, n = 24) elected for initial surgical management, while 41% (n = 19) trialled medical management. Seven percent (n = 3) opted for conservative management. Success rates of surgical, medical and conservative management were 100%, 53% and 0% respectively (P < 0.001). Medical management was associated with prolonged follow‐up; there was no difference in complication rates between surgical and medical managements. Conclusions: In this audit, surgical management was the most effective way to manage CSP. There was no significant difference in complication rates between the two groups. [ABSTRACT FROM AUTHOR]

Background: Placenta praevia (PP) is a rare obstetric condition associated with significant maternal and perinatal morbidity. Traditionally, the degree of PP has been classified into minor and major; however, there are very few robust studies that compare the maternal outcomes of these types of PP. Aims: To identify any significant differences in obstetric outcomes between major and minor PP, including antepartum, intraoperative and postpartum complications. Materials and Methods: A retrospective cohort study was conducted at the Royal Brisbane & Women's Hospital between 2009 and 2018; all women were diagnosed with PP. Results: Of the total of 368 women recruited, over half of the participants were diagnosed with major PP (57%), while the remaining had minor PP. Women with major PP, compared to women with minor PP, had an increased risk of antepartum haemorrhage (odds ratio (OR) 2.77, P < 0.001), delivery at an earlier gestational age (36.1 vs 37.4 weeks), general anaesthesia (OR 3.25, P < 0.001), greater proportion of emergency lower segment (51% vs 40%) and classical caesarean (7.7% vs 3.8%), increased number of uterotonics (incidence rate ratio (IRR) 1.17, P < 0.031), greater blood loss (IRR 1.32, P < 0.001) and higher frequency of blood transfusion (IRR 2.00, P < 0.027), and longer postpartum hospital stay (IRR 1.26, P < 0.001). Hysterectomy was performed for three women with major PP, compared to one with minor PP. Conclusions: The degree of PP significantly impacts obstetric outcomes, with major PP associated with worse maternal morbidity antenatally, intraoperatively and postpartum. Therefore, to optimise patient care, this study emphasises the importance of identifying and distinguishing between different types of PP. [ABSTRACT FROM AUTHOR]

Background: Placenta praevia is characterised by an inferior placental margin that overlies or falls within 20 mm of the endocervical os. It remains a common cause of antepartum haemorrhage and is associated with adverse maternal and neonatal outcomes. Aims: We aimed to determine the association between antepartum and postpartum haemorrhage and adverse outcomes in cases of placenta praevia. Materials and Methods: The study population included women diagnosed with placenta praevia, who delivered between 1 April 2007 and 30 April 2017. The endpoints of interest included blood transfusion, emergency caesarean section, peripartum hysterectomy and admission to intensive care. Results: There were 513 cases of placenta praevia, of which 67.3% delivered at term. Antepartum haemorrhage was associated with an increased risk of blood transfusion (relative risk (RR) 3.29; 95% CI 2.04–5.32), emergency caesarean section (RR 1.38; 95% CI 1.18–1.62) and preterm delivery, after 32 weeks gestation (RR 4.21; 95% CI 2.77–6.38). Postpartum haemorrhage more than doubled the risk of blood transfusion (RR 9.08 95% CI 5–16.44) and admission to the intensive care unit (RR 10.44; 95% CI 2.34–46.59), as well as increased the risk of peripartum hysterectomy (1.4%). We also described the management of 12 cases of placenta praevia (2.3% of the study population) delivered vaginally. Conclusions: Antepartum and postpartum haemorrhage in cases of placenta praevia are predictors of several adverse outcomes. However, the high rate of term deliveries reaffirms the current practice of expectant management. [ABSTRACT FROM AUTHOR]

Background: Despite the rising incidence of caesarean scar pregnancy (CSP), as yet there are no consensus or evidence‐based guidelines for management. Aims: To review diagnosis, treatment and management of all women with CSP over a 5 year period at Mater Mothers' Hospital, Brisbane, Australia. Materials and methods: Retrospective cohort study of CSP between 2013–2018. Data reviewed included demographics, presenting symptoms, gestational age, ultrasound findings, human chorionic gonadotrophin levels, treatment success, complications, and if available, subsequent pregnancy outcomes. Results: Twenty‐eight women were treated for CSP during the study period. Initial diagnosis was delayed in ten (36%). Overall success rates of initial treatment were 22/28 (79%). Of the six cases of failed treatment, five had been treated with systemic methotrexate alone. All women requiring further intervention had fetal pole present, and 50% had fetal cardiac activity. Failure rate of systemic methotrexate alone was 5/11 (45%). Eleven women deemed appropriate for conservative management did not require further treatment or experience complications. Nine women had data available for subsequent pregnancies, of whom two developed placenta accreta. Conclusion: This study provides data that may assist in guideline development and decision‐making for management of CSP. Conservative management in carefully selected women appeared to be safe. Nearly half of women treated with systemic methotrexate alone required another treatment modality, suggesting a role for intralesional treatment, particularly in the presence of fetal pole ± fetal cardiac activity. More than one in five women with documented subsequent pregnancies were diagnosed with placenta accreta. [ABSTRACT FROM AUTHOR]

Background: Expediting delivery in the second stage of labour often involves a choice between a caesarean section at full dilatation or mid‐cavity instrumental delivery. Accumulating evidence suggests that the mode of delivery may influence the risk of preterm birth in the subsequent pregnancy. Aims: To directly compare first birth caesarean section at full dilatation with mid‐cavity instrumental delivery for the risk of preterm birth in the subsequent pregnancy (second birth). A further aim was to identify predictive factors associated with these index modes of delivery. Materials and Methods: This is a retrospective cohort study involving three maternity hospitals in western Sydney over the period of 2006–2017. Inclusion criteria were nulliparous women with a singleton term cephalic first birth delivered by caesarean section at full dilatation or mid‐cavity instrumental delivery, and whose second birth also occurred under our care. Data were analysed separately for first and second births. Results: There were 425 caesarean section at full dilatation and 874 mid‐cavity instrumental cases which met inclusion criteria. The risk of preterm birth in the second birth was 5.7% compared to 3.2%, respectively (risk ratio 1.76; 95% CI 1.04–3.00; P = 0.035). After excluding causes of preterm birth not related to previous mode of delivery, the risk of spontaneous preterm birth was 4.3% compared to 2.0%, respectively (risk ratio 2.18; 1.14–4.19; P = 0.019). Conclusion: Caesarean section at full dilatation is associated with a significantly higher rate of preterm birth in the subsequent pregnancy compared to a mid‐cavity instrumental delivery. This should be considered in second‐stage mid‐cavity decision‐making. [ABSTRACT FROM AUTHOR]

Background: An Australian health-service implemented an 'enhanced recovery after elective caesarean' pathway with next-day discharge., Problem: Previous anecdotal reports indicated that a large percentage of eligible women were not discharged the next day and therefore were not regarded as having completed the pathway. Psychosocial factors were expected to be the leading reason for prolonged hospitalisation., Aim: The study objectives were to: enumerate the percentage of women assessed as eligible for EREC who subsequently did not complete the pathway and the reasons; and to describe women's antenatal satisfaction with preparation, preferences, and perceived support. Women who completed the pathway versus those who did not were compared on antenatal biopsychosocial characteristics., Methods: This exploratory prospective cohort study enrolled consenting eligible women from antenatal clinics and used patient records and questionnaire data. Comparative statistical techniques were used., Findings: 62 % of women did not complete the pathway, with medical and obstetric factors being the most common reasons (80 %). There was statistically significant evidence of lower antenatal stress levels for those who completed EREC (median=5) relative to those who did not (median=8; P = 0.035); although these findings may not be of clinical importance. Antenatally, 51 % of women felt prepared for early discharge, 36 % needed more information, 19 % disliked hospital, 93 % agreed that family togetherness after birth was important. Most agreed that staff (76 %) and family (67 %) supported the pathway., Conclusion: This study indicated that a large percentage of women assessed as eligible did not complete EREC and that obstetric and medical factors, rather than psychosocial characteristics, largely explained this. This provides reassurance to clinicians and women that discharge home is working as intended and is useful for planning similar models of care. Higher stress levels in the antenatal period were demonstrated for women who did not complete EREC suggesting the need for further research into how to support these women., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2024. Published by Elsevier Ltd.)

Background: During pregnancy, the Epworth Sleepiness Scale can be used as a surrogate marker for maternal sleep‐disordered breathing, a condition that is becoming increasingly prevalent in obstetric populations and is associated with a multitude of pregnancy complications. Aims: The aim of this observational study was to investigate the relationship between the Epworth Sleepiness Scale score and indication and mode of delivery during pregnancy. Materials and Methods: The Epworth Sleepiness Scale was completed by 178 women at Mater Mothers' Hospital, Brisbane, Australia. Results: Women with a score ≥11 were less likely to achieve a spontaneous vaginal delivery (aOR 0.43, 95% CI 0.21–0.88, P = 0.02), and were more likely to have an instrumental (aOR 2.81, 95% CI 1.30–6.08, P = 0.01) or any operative birth (instrumental and caesarean section aOR 2.32, 95% CI 1.14–4.71, P = 0.02). These women were also more likely to have an operative birth for intrapartum fetal compromise (aOR 2.62, 95% CI 1.21–5.69, P = 0.015), as well as an infant with poor neonatal outcomes (aOR 2.77, 95% CI 1.09–7.03, P = 0.03). Conclusions: These results show that symptoms of sleep‐disordered breathing are associated with emergency operative birth, particularly when the indication for operative birth was intrapartum fetal compromise. [ABSTRACT FROM AUTHOR]

Aim: Epidemiological studies on associations between Caesarean sections (C-sections) and attention-deficit hyperactivity disorder (ADHD) have been inconsistent, and we performed a meta-analysis.Methods: We systematically searched PubMed and Embase to December 2018 and included nine hospital-based and population registry studies published in 2011-2018. These covered a total study cohort of more than 2.5 million people in eight countries: Australia, Brazil, Denmark, Finland, Germany, Sweden, Turkey and the UK. The analysis provided summary odds ratios (ORs) and 95% confidence intervals (CI) while taking heterogeneity into account.Results: We found that that C-sections were associated with a small increase in the risk of ADHD (OR 1.14, 95% CI 1.11, 1.17, I2 0%) in offspring. In subgroup analyses, the association remained for both infants born after elective C-sections (OR, 1.15, 1.11, 1.19, I2 0%) and emergency C-sections (OR, 1.13, 1.1, 1.17, I2 45.4%). However, these were only marginally significant when we pooled data from siblings from other pregnancies (OR, 1.06, 1.00-1.13, I2 0%), implying that the association was due to confounding.Conclusion: The statistically significant association between C-sections and ADHD in children can be partially explained by unmeasured confounding. Further research controlling for important confounders is required before firm conclusions can be drawn. [ABSTRACT FROM AUTHOR]

Background: The long‐acting oxytocic agent; carbetocin, has been consistently shown to reduce the need for additional uterotonics at caesarean section, but not postpartum haemorrhage (PPH). While promising, current evidence is limited by heterogenicity in study design and findings. Aims: To examine whether carbetocin confers clinical or economic benefit compared to oxytocin at caesarean section in an all‐risk Australian population. Materials and Methods: A retrospective cohort study was undertaken of all singleton caesarean sections at a public tertiary hospital from 2008 to 2010 (n = 2499). From 1 January 2008 to 24 March 2009 all women received prophylactic oxytocin 5–10 units slow push intravenously at delivery, after which all patients received 100 μg intravenous carbetocin. Outcomes were PPH (≥1000 mL) and the requirement of secondary uterotonics. A post hoc cost analysis was also performed. Results: A total of 1467 and 1024 patients received carbetocin and oxytocin, respectively. Incidence of PPH ≥1000 mL was 7.8% for carbetocin compared to and 9.7% for oxytocin (odds ratio (OR) 0.79, 95% CI 0.59–1.05). Moderate blood loss >500 mL was significantly reduced with carbetocin; occurring in 27.3% versus 39.4% (OR 0.57, 95% CI 0.49–0.68). There was a 20.0% reduction in secondary uterotonic treatment with carbetocin (OR 0.42, 95% CI 0.35–0.49). Average drug costs were lower with oxytocin at $4.74 versus $36.42/patient. However, the 1.9% reduction in PPH with carbetocin resulted in a $63.46 reduction in cost per patient, with a cost‐effectiveness ratio of $1667 to prevent one case of PPH ≥1000 mL. Conclusions: Carbetocin reduced moderate blood loss >500 mL, but not PPH ≥1000 mL. Carbetocin conferred a 20% reduction in secondary uterotonic treatment, as well as lowering direct medical costs. [ABSTRACT FROM AUTHOR]

Background: Since caesarean sections (CSs) before 39+0 weeks gestation are associated with higher rates of neonatal respiratory morbidity, it is recommended to delay elective CSs until 39+0 weeks. However, this bears the risk of earlier spontaneous labour resulting in unplanned CSs, which has workforce and resource implications, specifically in smaller obstetric units. Aim: To assess, in a policy of elective CSs from 39+0 weeks onward, the number of unplanned CSs to prevent one neonate with respiratory complications, as compared to early elective CS. Materials and Methods: We performed a decision analysis comparing early term elective CS at 37+0–6 or 38+0–6 weeks to elective prelabour CS, without strict medical indication, at 39+0–6 weeks, with earlier unplanned CS, in women with uncomplicated singleton pregnancies. We used literature data to calculate the number of unplanned CSs necessary to prevent one neonate with respiratory morbidity. Results: Planning all elective CSs at 39+0–6 weeks required 10.9 unplanned CSs to prevent one neonate with respiratory morbidity, compared to planning all elective CSs at 38+0–6 weeks. Compared to planning all elective CSs at 37+0–6 weeks we needed to perform 3.3 unplanned CSs to prevent one neonate with respiratory morbidity. Conclusion: In a policy of planning all elective pre‐labour CSs from 39+0 weeks of gestation onward, between three and 11 unplanned CSs have to be performed to prevent one neonate with respiratory morbidity. Therefore, in our opinion, fear of early term labour and workforce disutility is no argument for scheduling elective CSs <39+0 weeks. [ABSTRACT FROM AUTHOR]

Aim: This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section)., Methods: A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022., Results: We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole., Conclusion: We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Background: Following a primary caesarean section (CS), women must decide between attempted vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS) in subsequent pregnancies. Both options carry potential morbidity and mortality for mother and child, with the most feared being uterine rupture and its consequences. In attempts to reduce morbidity, several predictive nomograms have been developed to assist in delivery mode decisions. Aim: To assess the validity of the predictive nomogram developed by Grobman et al. in our regional Australian population. Materials and Methods: In our retrospective analysis, patients at term, with one previous CS who had a trial of labour were assigned a 'Grobman score' based on antenatal details. Outcomes were noted and patient groups analysed according to percentage deciles of estimated VBAC success, compared with actual VBAC success rates. Results: A total of 395 women underwent trial of labour after a single prior CS, with a VBAC success rate of 83%. The Grobman model displayed adequate calibration and the re‐calibrated model good calibration with the slope coefficient of 0.87 (95% CI 0.54–1.19) and intercept 0.19 (95% CI −0.34–0.72). Discrimination was moderate with receiver operating characteristic area of 0.71 (95% CI 0.67–0.76). Conclusion: This analysis supports further validation studies in larger Australian settings, and suggests that use of the original Grobman predictive nomogram may be appropriate in Australia. [ABSTRACT FROM AUTHOR]

Vulval lichen sclerosus (VLS) is a chronic inflammatory skin condition affecting the anogenital area in women. Serious long‐term consequences of VLS include the risk of developing squamous cell carcinoma of the vulva as well as of scarring and alteration of vulval architecture. The treatment of choice for genital lichen sclerosus in females is potent to very potent topical corticosteroids. There are few published data on the course of VLS in pregnancy. We present our experience of managing 33 pregnancies in 29 women with VLS. [ABSTRACT FROM AUTHOR]

Background: There are global concerns regarding excessive caesarean rates, which could be reduced by identification of risk factors leading to preventative measures such as induction of labour. Aims: This study aims to describe the association between antenatal ultrasound and emergency caesarean section for: (i) failure to progress; (ii) other indications; and (iii) any indication. Materials and Methods: Women who had an ultrasound in pregnancy between 36(+0/7) to 38(+6/7) weeks at Royal Prince Alfred Hospital from January 2005 to June 2009 were included. Ultrasound parameters were linked to clinical parameters from the maternity database. Missing clinical data were imputed and multiple logistic regression performed. Results: Fetal biometry data were available for 2006 pregnancies. After adjusting for maternal age, height, body mass index, parity, previous caesarean section and diabetes, caesarean section for failure to progress was associated with estimated fetal weight (odds ratio (OR) 2.24 (95% CI: 1.76–2.84) per 500 g increase); or biparietal diameter (OR 1.51 (1.16–1.97) per 5 mm increase) and abdominal circumference (OR for the 4th quartile (>75th centile) compared with the 10–25th centile group was 2.09 (1.13–3.85)).* There were also non‐linear associations between components of fetal biometry and caesarean section for fetal distress and for any indication. Conclusions: Components of fetal biometry in the third trimester are associated with intrapartum caesarean section for failure to progress. These parameters could be incorporated into models to predict emergency caesarean section which could lead to implementation of preventative strategies. *[Corrections added on 29 January 2018, after first online publication, '(OR for the 4th quartile (>7th centile)' has been changed to '(OR for the 4th quartile (>75th centile)'.] [ABSTRACT FROM AUTHOR]

Rising rates of caesarean section (CS) have been attributed, in part, to maternal‐choice CS (MCCS). There are few published data regarding maternal and perinatal risks comparing MCCS with planned vaginal birth (VB) in uncomplicated first pregnancies to inform choice. We report the results of a pragmatic patient‐preference cohort study of private patients in Australia: 64 women planning MCCS and 113 women planning VB. There were few differences in outcome between the two groups. The study highlighted the well‐recognised difficulties in undertaking prospective research into MCCS. [ABSTRACT FROM AUTHOR]

Background: There is emerging evidence that caesarean section at full dilatation is associated with an increased risk of subsequent spontaneous preterm birth. Aim: To investigate the association between caesarean section at full dilatation and spontaneous preterm birth in subsequent pregnancies. Materials and methods: This was a retrospective cohort study of women who had two consecutive births at Royal Prince Alfred Hospital, 1989–2015. Our main comparison group was women who had emergency caesarean sections during the first stage of labour. Secondary comparison groups were women who had elective caesarean sections, instrumental deliveries and unassisted vaginal deliveries. The primary outcome was spontaneous preterm birth (<37 weeks gestation) in a subsequent pregnancy. Results: There were 2672 women who had an emergency caesarean section, with 2142 (80%) performed during the first stage of labour and 533 (20%) at full dilatation. The rates of spontaneous preterm birth in a subsequent pregnancy were 1.7% and 3.8%, respectively (odds ratio 2.2 (95%CI 1.3–3.8), P = 0.003). The hazard ratio for spontaneous onset of labour at any given gestation from 20 weeks until full term was 1.4 (95%CI 1.2–1.6) and did not change after adjusting for maternal age and body mass index. Conclusion: There is a significantly higher rate of subsequent spontaneous preterm birth in women who had a caesarean section at full dilatation compared with women who had a caesarean section during the first stage of labour. Awareness of this as a risk factor may warrant referral to a high‐risk obstetric or preterm birth clinic. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To determine the variation in caesarean section rates among immigrant populations. Background: Australia is one of the most multicultural in the world and is also among those with the highest caesarean section rates. Design: Secondary data analysis. Methods: Routinely collected data from a Local Heath District between 2011 and 2015 were analysed. Women were categorized into regional groups based on country of birth. Obstetrical risk was classified using the Robson classification. Results/Findings: In total 48 711 women gave birth, of whom 64.0% were born overseas; 13 966 had a caesarean section (28.7%). South and Central Asia women had a high number of caesarean sections (n = 4139; 29.6% of all caesarean sections), a high overall adjusted caesarean section rate (31.4%; 95% CI, 30.5%–32.3%), and consistently high caesarean section rates among women with single cephalic term pregnancy without a previous caesarean section. High adjusted caesarean section rates were seen among South East Asia women with nulliparous, single cephalic, term pregnancy, and spontaneous labour. Demographic and clinical characteristics explained 83.5% of the variation in overall caesarean section rates between country of birth and 21.8% to 100% depending on Robson group. Conclusions: Caesarean section rates varied by country of birth and within some Robson groups. The studied factors had various effects on the variation in caesarean section rates between country of birth and Robson groups. [ABSTRACT FROM AUTHOR]

Background Adolescent pregnancy is defined as pregnancy in girls aged 10-19 years and can be associated with increased risks. Aim To investigate obstetric and perinatal outcomes in a cohort of adolescent girls from a major Australian tertiary centre. Materials and Methods This was a nine-year retrospective cohort study of women who birthed at the Mater Mother's Hospital ( MMH) in Brisbane, Australia between 1 January 2007 and 31 December 2015. The adolescent cohort was aged <19 years and the control group was aged 20-24 years. Results Over the study period the total study cohort comprised 8904 women. Of these, the adolescent cohort consisted of 1625 girls (18.2%) and the control group consisted of 7279 women (81.8%). Adolescents were more likely to be nulliparous, single, of Indigenous ethnicity or to have refugee status. They had higher rates of smoking, asthma, diabetes mellitus and thyroid disease. They were more likely to have an uncomplicated spontaneous vaginal delivery but were less likely to have an intact perineum and had higher rates of pre-term delivery and low birth weight babies. There were no differences in rates of postpartum haemorrhage. Conclusions Teenage pregnancy results in poorer obstetric and perinatal outcomes. A focus on optimising maternal health care and providing culturally appropriate antenatal and intrapartum care is imperative to improving outcomes. [ABSTRACT FROM AUTHOR]

Background To characterise maternal demographics and ascertain whether clinically important differences exist in the intrapartum and neonatal outcomes associated with assisted reproductive technology ( ART). Materials and methods A retrospective study was undertaken between January 2007 and December 2013 of all singleton pregnancies conceived via ART at a major tertiary unit in Brisbane, Australia. Intrapartum outcomes were mode of delivery and indication for emergency caesarean. Neonatal outcomes investigated were gestation at delivery, birth weight, Apgar scores, acidosis at birth, respiratory distress, need for resuscitation, admission to neonatal intensive care and stillbirth. Results There were 4733 (7.4%) ART and 59 277 (92.6%) spontaneous conception pregnancies. Women who conceived using ART were less likely to have a spontaneous vaginal delivery (odds ratio ( OR) 0.60, 95% CI 0.57-0.64) and were more likely to require operative or assisted birth: elective caesarean (adjusted OR ( aOR) 1.31, 95% CI 1.22-1.40), emergency caesarean ( aOR 1.19, 95% CI 1.09-1.28), or instrumental delivery ( aOR 1.45, 95% CI 1.32-1.58). Neonates who were conceived using ART were less likely to be born at term ( aOR 0.64, 95% CI 0.58-0.71) and have lower birth weights. No differences were observed in rates of respiratory distress, admission to the neonatal intensive care unit, or stillbirth between the ART and spontaneous conception cohorts. The odds of neonatal acidosis ( OR 0.71, 95% CI0.63-0.81) were lower in the ART cohort. Conclusion Although higher rates of operative deliveries were seen for women who conceive using ART, neonatal outcomes were generally no different between the two cohorts. [ABSTRACT FROM AUTHOR]

Background In Australia, more than 20% of women giving birth are 35 years or older. Advanced maternal age ( AMA) is a risk factor for stillbirth, and many clinicians now recommend induction of labour ( IOL) at around term gestation. The aim of this study is to determine if AMA is associated with emergency caesarean section ( CS) following IOL. Methods A retrospective cohort study was undertaken using routinely collected de-identified data. Live-born, singleton, cephalic, non-anomalous pregnancies undergoing IOL between 37 + 0 and 42 + 0 weeks were included. Previous CS and privately insured admission status were excluded. Mode of delivery was compared for women ≥38 years ( AMA) and women <38 years. The primary outcome was birth by CS. Bivariate and multivariate logistic regression analyses were undertaken. Results A total of 7459 women were included (≥38 years n = 718, 9.6%; <38 years n = 6741, 90.4%). AMA women had similar rates of unassisted vaginal births ( OR 1.15, 95% CI 0.98-1.35, P = 0.080) and CS ( OR 1.08, 95% CI 0.90-1.30, P = 0.407) but fewer instrumental deliveries ( OR 0.69, 95% CI 0.55-0.87, P = 0.002) compared to women <38 years. When controlled for confounders, AMA was independently associated with a two-fold increase in birth by CS following IOL ( adjusted OR 2.29; 95% CI 1.64-3.20; P < 0.001). There were no differences in neonatal outcomes. Conclusion Following IOL, AMA was associated with a two-fold increased likelihood of birth by CS in both nulliparous and multiparous women. However, the majority of AMA women birthed vaginally. Clinicians may find this information useful when counselling older women who are undergoing term IOL. [ABSTRACT FROM AUTHOR]

Background Obesity in pregnancy is a growing health problem conferring higher risk to both the woman and her infant. Internationally, peak bodies offer little guidance regarding the method and timing of delivery in these patients. Our hypothesis is that induction of labour ( IOL) at term will not increase the caesarean section ( CS) rate when compared to expectant management. Aims To compare perinatal outcomes between IOL and expectant management in obese women at term. Methods A retrospective cohort study of all term, singleton, vertex deliveries at the Townsville Hospital and Health Service from January 2011 to June 2015 in women with a body mass index ( BMI) ≥ 35. Women undergoing IOL at 37 weeks were compared with women expectantly managed at that gestational age. Similar comparisons were made at 38, 39 and 40 weeks. χ2 tests and binary logistic regression were used for statistical comparison. The primary outcome measure was mode of delivery, with secondary measures of perinatal morbidity also considered. Results There was no difference in outcome of CS, or other maternal secondary outcomes. There was no difference in rates of neonatal nursery admission. Expectant management at 38 weeks was associated with lower odds of post-partum haemorrhage (odds ratio 0.371; 95% confidence interval 0.163-0.845). Conclusions In women with a BMI ≥ 35, IOL does not affect the CS rate, or the risk of neonatal adverse events, but may increase the rate of postpartum haemorrhage when compared with expectant management. [ABSTRACT FROM AUTHOR]

The article offers information on a study related to routine induction of labor at 39 weeks in low-risk nulliparous women. Topics discussed include that Induction of labor (IOL) is recommended when maternal and perinatal risks of continuing pregnancy are higher than risks of IOL; according to studies one-quarter of Australian women birth in a private hospital with an obstetrician; and women-centered care recognizes a woman's preference for care and provision of choice.

Background: Pregnancies in patients with solid organ transplants have higher rates of complications and caesarean sections (CS). Aim: To perform an audit of the pregnancy outcomes in transplant recipients, to determine the rate of CS in our cohort, the appropriate skin incision for CS in these patients and to formulate recommendations for preoperative planning. Materials and Methods: This is a retrospective cohort study. All patients who had a solid organ transplant were identified from the obstetrics database. The operation records of the transplant recipients who delivered by CS were reviewed and the de‐identified data were evaluated for pregnancy outcomes. Results: This cohort consisted of 22 women: six had simultaneous pancreas and kidney (SPK) transplants and 16 had kidney transplants. Over a ten‐year period, four women had two pregnancies and one had a twin pregnancy, thus 27 babies were born. The rate of CS was 58% (n = 15) and the surgical approach in 13 of these patients was by Pfannenstiel incision. One patient had an elective midline incision at the first CS, which was repeated in the next pregnancy. Two CS were complicated by bladder injury, both occurring in SPK recipients. Conclusion: Patients with solid organ transplants have a higher rate of CS and SPK patients may be at a higher risk of bladder injuries during CS. Our data suggest that Pfannenstiel skin incision is still suitable for these patients. We recommend reviewing the operative details of the transplant operation and a pelvic magnetic resonance imaging for pre‐operative planning. [ABSTRACT FROM AUTHOR]

Problem: There is minimal evidence regarding the role or impact of birth plans from the perspective of women experiencing scheduled caesarean birth., Background: Quality maternity care requires respect for women's preferences. Evidence suggests birth plans enable communication of women's preferences and may enhance agency when vaginal birth is intended, however there is limited evidence of how this translates in the perioperative environment where caesarean birth is the intended outcome., Aim: Explore the experiences and perspectives of women who had utilised a scheduled caesarean birth plan at an Australian tertiary maternity hospital., Methods: A cross-sectional design was used; 294 participants completed the survey within two weeks post-birth. Descriptive statistics were used to analyse quantitative data, qualitative responses were analysed using content analysis., Findings: Over half of the women requested lowering of the surgical-screen at birth, most requested immediate skin-to-skin with their babies; around two-thirds of these preferences were met. Use of a birth plan for scheduled caesarean section supported women's ability to communicate their desires and choices, enhancing agency and reinforcing the significance of the caesarean birth experience. Qualitative data revealed two main categories: Perceptions and experiences; and Recommendations for improvement, with corresponding sub-categories., Discussion: Findings provide unique opportunities to consider the provision of woman-centred care within the highly technocratic perioperative environment., Conclusion: All women, regardless of birth mode, have a right to respectful maternity care that prioritises their wishes and agency. This study provides evidence for the positive utility of birth plans in caesarean birth, local adaptation is encouraged., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Background Caesarean section ( CS) is a significant risk factor for venous thromboembolism; however, the optimal method of thromboprophylaxis around the time of CS is unknown. Aims To examine current thromboprophylaxis practice during and following CS in Australia and New Zealand, and the willingness of obstetricians to participate in a randomised controlled trial ( RCT) comparing different methods of thromboprophylaxis after CS. Materials and Methods An online survey was sent to fellows and trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results There were 488 responses from currently practising obstetricians (response rate 23.4%). During CS, 48% and 80% of obstetricians recommended intermittent pneumatic compression ( IPC) and elastic stockings ( ES), respectively. Following CS, 96-97% of obstetricians recommended early ambulation, 87-90% recommended ES, 23-36% recommended IPC, and 42-65% recommended low molecular weight heparin ( LMWH) depending on clinical factors. Increased BMI ( OR 3.42; 95% CI 2.87-4.06), emergency CS ( OR 1.88; 95% CI 1.67-2.16) and older maternal age ( OR 1.37; 95% CI 1.26-1.49) were associated with more frequent LMWH use. Of obstetricians who prescribed LMWH, 70% adjusted the dose depending on maternal weight. LMWH therapy was most commonly recommended until discharge from hospital (31%), <5 days (24%) and 5-7 days (15%). Most obstetricians (58-79%) were willing to enrol women in a RCT, but less likely if the woman had an increased BMI or emergency CS. Conclusions There is considerable variation in clinical practice regarding thromboprophylaxis during and following CS. Obstetricians support a RCT to assess different methods of thromboprophylaxis following CS. [ABSTRACT FROM AUTHOR]

Background: High levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention.Method: Between May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here.Results: 1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine (n = 339) women were randomised (intervention n = 170; controls n = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n = 91; controls n = 93). Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p = 0.27) and emergency CS rates (18 % vs 25 %, p = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p = 0.05). Postnatally women who received psycho-education reported that the 'decision aid' helped reduce their fear (53 % vs 37 %, p = 0.02).Conclusion: Following a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies.Trial Registration: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012. [ABSTRACT FROM AUTHOR]

Background: Early utilisation of neuraxial anaesthesia has been recommended to reduce the need for general anaesthesia in obese parturients. The insertion and management of labour epidurals in obese women is not straight-forward. The aim of this pilot study was to compare the failure rate of extension of epidural analgesia for emergency caesarean section, in pregnant women with a body mass index (BMI) ≥ 40 kg/m², to those with a BMI < 30 kg/m². The results will be used to calculate the sample size of a planned prospective study. Methods: In this retrospective, (1:1) case-control pilot study, obese subjects and control subjects were selected from the obstetric database, if they delivered between January 2007 and December 2011. All subjects used epidural analgesia during labour and subsequently required anaesthesia for Category 1 or 2 Caesarean Section. Data was extracted from the patient medical record. Failure to extend was analysed using liberal and restrictive definitions. Chi-square or Fisher's exact tests were used to detect differences between groups. Multiple logistic regression was used to examine variables predictive of extension failure. Results: There were 63 subjects in each group. The mean BMI of the obese group was 45.4 (5.8) kg/m² and 23.9 (3.0) kg/m² in the control group. The odds ratio for failure to extend the existing epidural blockade (liberal definition) was 2.48 (95 % CI:1.02 - 6.03) for the obese group compared with the control group (adjusted for age, parity and gestation). Using the restrictive definition, the odds ratio for failure in the obese group was 6.78 (95 % CI:1.43 - 32.2). The combination of respiratory co-morbidity and gestational diabetes significantly predicted extension failure. Surgical time and epidural complications on labour ward were significantly greater in the obese group. Conclusions: In this small retrospective cohort, patients with a BMI ≥ 40 kg/m² were significantly more likely to fail epidural extension for caesarean section. The presence of respiratory co-morbidity and gestational diabetes were significant predictors of extension failure; their clinical relevance requires further evaluation. [ABSTRACT FROM AUTHOR]

Background The 2000 publication of the Term Breech Trial significantly impacted obstetric practice in Australia with a rapid increase in delivery of term breech singletons by caesarean section. More reassuring data from European centres who continued to offer vaginal breech deliveries to carefully selected women have led to a softening of international guidelines which now support an individualised approach to management. The application of this principle to an Australian population, particularly in the wake of such a major change in obstetric practice, has not previously been demonstrated. Aim To compare short-term neonatal and maternal morbidity for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery. Materials and Methods Eleven-year single-centre retrospective study with intention-to-treat analysis based on intended mode of delivery. Results Two hundred and forty-three of 766 (31.7%) eligible women elected for planned vaginal breech delivery. The overall success rate in this group was 58%. Morbidity rates were low and compare favourably with similar international studies. However, there was a nonsignificant trend towards higher rates of short-term serious neonatal and maternal morbidity in the planned vaginal delivery group (1.6 vs 0.4%, P = 0.08 and 8.2 vs 4.8%, P = 0.06, respectively). Conclusions Attempted vaginal delivery for breech presentation remains an option in carefully selected women under strict obstetric protocols. [ABSTRACT FROM AUTHOR]

Background Caesarean section rates in Australia have risen to >30%, with repeat caesarean delivery the most common indication. One method of reducing caesarean delivery rates is to increase rates of vaginal birth after caesarean section ( VBAC). Aims To determine the combined effect of two management strategies on the rates of successful VBAC in women experiencing their first pregnancy following primary caesarean section. Methods Prospective cohort study from May 2009 to October 2010 at a metropolitan Australian teaching hospital. The strategies studied were (i) allocating responsibility for VBAC candidates attempting labour to the hospital's three high-risk obstetric consultants and (ii) implementing a next birth after caesarean ( NBAC) antenatal clinic designed to counsel and support women deciding on mode of birth for their next pregnancy after a primary caesarean section. Data were collected from Obstetrix, a NBAC logbook and medical records of 396 eligible women who gave birth during the study period. Results Overall VBAC rates improved from 17.2% in 2006 prior to implementation of the combined strategies, to 27.0% over the studied period ( P < 0.001). Of those women who desired and attempted a VBAC, the success rate was 64.4%. Regression analysis identified an increased likelihood of attempted vaginal birth where malpresentation was the indication for previous caesarean, while Eastern Asian ethnicity was associated with increased likelihood of choosing repeat caesarean. Conclusions A dedicated NBAC clinic and more consistent approach to labour management can help improve VBAC rates. Further targeted counselling towards women with previous malpresentation and/or East Asian descent may further improve VBAC attempt rates. [ABSTRACT FROM AUTHOR]

Aim To determine the feasibility of a multicentre randomised controlled trial ( RCT) to investigate whether digital rotation of the fetal head from occiput posterior ( OP) position in the second stage of labour reduces the risk of operative delivery (defined as caesarean section ( CS) or instrumental delivery). Methods We conducted the study between December 2010 and December 2011 in a tertiary referral hospital in Australia. A transabdominal ultrasound was performed early in the second stage of labour on women with cephalic, singleton pregnancies to determine the fetal position. Those women with a fetus in the OP position were randomised to either a digital rotation or a sham procedure. In all other ways, participants received their usual intrapartum care. Data regarding demographics, mode of delivery, labour, post natal period and neonatal outcomes were collected. Results One thousand and four women were consented, 834 achieved full dilatation, and 30 were randomised. An additional portable ultrasound scan and a blinded 'sham' digital rotation were acceptable to women and staff. Operative delivery rates were 13/15 in the digital rotation (four CS and nine instrumental) and 12/15 in the sham (three CS and nine instrumental) groups, respectively. Conclusion A large double-blinded multicentre RCT would be feasible and acceptable to women and staff. Strategies to improve recruitment such as consenting women with an effective epidural in active labour should be considered. This would be the first RCT to answer a clinically important question which could significantly affect the operative delivery rate in Australia and internationally. [ABSTRACT FROM AUTHOR]