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Abstract: Due to a long-term shortage of obstetricians, the Ministry of Health of Senegal and Dakar University Obstetric Department agreed in 1998 to train district teams consisting of an anaesthetist, [...]

Since 1964, the rate of cesarean section has quintupled to a point where, in 1988, it was performed for more than 25 percent of all deliveries in the United States. The cesarean section rate is considered too high from several viewpoints, and a report of efforts to lower it in one teaching hospital is presented. The facility, one of 10 regional perinatal centers in Florida, serves an indigent population, with obstetric patients attended by resident physicians and nurse-midwives. In 1987, new guidelines regarding cesarean section were introduced by a perinatologist. These allowed women meeting certain criteria who had previous cesareans to consider a trial of labor in subsequent pregnancies. This trial of labor included continuous monitoring of the fetal heart rate. New guidelines to determine when cesarean section should be performed were also established; difficult labor, fetal distress, and fetal malposition were paramount considerations. Results showed a decrease in the cesarean rate between 1986 and 1989 from 27.5 percent of all deliveries to 10.5 percent. First-time cesareans fell from 19.5 percent to 7.2 percent; repeat procedures fell from 8 to 3.3 percent. During the same time, the proportion of patients with previous cesarean deliveries who attempted labor more than doubled, from 32 to 84 percent. This was achieved concomitant with an improvement in the perinatal (earlier than 28 days after birth) mortality from 31.8 to 14.9 infant deaths per 1,000 live births. Neonatal mortality also decreased by more than half. Rates of neonatal complications remained stable. The success of the new program is attributed mainly to the centralized approach used in decision-making during labor and delivery. In many facilities, cesarean rates vary markedly for individual physicians. It appears that standardized approaches are beneficial for reducing cesarean rates. (Consumer Summary produced by Reliance Medical Information, Inc.)

Omphalocele and gastroschisis are birth defects of the abdominal wall in which the abdominal organs lie outside the body of the fetus. In the case of omphalocele, the organs are usually covered with a membranous sac; the condition is often (in as many as 40 percent of cases) associated with chromosomal abnormalities. In gastroschisis, the organs float without any covering in the amniotic fluid (in which the fetus is suspended); this is associated with a much lower rate of chromosomal and other anomalies (less than 5 percent). Improved methods of prenatal diagnosis now enable early detection of these defects, and questions arise as to the optimal management during the perinatal period (the weeks just before and just after birth). In particular, the advisability of vaginal versus cesarean delivery is being debated; older reports recommend cesarean section. To evaluate this issue, medical records of 125 cases of abdominal wall defects (56 with gastroschisis, 69 with omphalocele) treated by one neonatal surgical team over a two-year period were reviewed. Results showed that prenatal diagnosis had been made in 10 fetuses, of whom 9 survived. Approximately the same proportion of infants (one-fourth) in each group (omphalocele and gastroschisis) was delivered by cesarean section, and the rates of premature birth were also similar. A detailed description of the outcomes is provided. In general, infants with omphalocele had higher mortality and long-term morbidity, due mostly to other congenital anomalies. No differences according to method of delivery were found for neonatal survival (first six weeks after birth), short- or long-term infant outcome, or frequency of major anomalies. The overall survival rate was 80 percent, which is comparable to that in other studies. Cesarean section should be recommended in such cases only for obstetric reasons, and not because of the diagnosis of abdominal wall defect. (Consumer Summary produced by Reliance Medical Information, Inc.)

To determine the risk of catastrophic complications (including death) among pregnant women who have undergone a previous cesarean section, the medical records of all deliveries (10,835) at one hospital in a three-year period were reviewed. Seven hundred and eleven deliveries (6.6 percent) involved women with a previous cesarean section. Four hundred twenty-four women in this group attempted vaginal delivery, of whom 312 succeeded. Catastrophic complications included: maternal or fetal death; hemorrhage that required transfusion of five or more units of blood; hysterectomy (removal of the uterus); ligation (tying) of a major artery; or uterine rupture. By these criteria, 17 women with a previous cesarean section (eight had more than one) suffered catastrophic complications. These included two maternal and three fetal deaths. Eleven women had serious hemorrhage, eight of whom underwent hysterectomy. Nine had uterine rupture, and eight had placenta previa (attachment of the placenta near the opening of the uterus, associated with bleeding during delivery) or other abnormal conditions of the placenta. The overall rate of very serious complications of pregnancy after cesarean section was 1 patient out of 42, with a risk of maternal or fetal death in 1 out of 143 such pregnancies. These results indicate much higher rates than have been reported in other studies, and may partly be the result of the population studied (primarily black and Hispanic, and poor). The criteria for inducing labor in these women were the same criteria used for women without a prior cesarean, another factor that might have led to the high rate of uterine rupture. The overall frequency of catastrophic complications in this group of women with previous cesarean sections was 2.4 percent. Awareness of this possibility should affect decision-making when a patient's first cesarean section is contemplated. (Consumer Summary produced by Reliance Medical Information, Inc.)

The reasons for the increased cesarean section rate in the US are controversial. Some propose that cesarean operations have increased because the procedure reduces fetal and infant complications. Some have also suggested that cesarean rates have increased five-fold since the 1960s because the operation itself has become safer. To help identify factors that influence delivery decisions, and to determine the effect the delivery route has on the pregnancy outcome, 1,030 caesareans performed by 11 obstetricians were studied. The caesareans performed at two Green Bay hospitals from 1986 through 1988 were compared with 1,076 vaginal deliveries. The cesarean delivery rate represented 14 percent of the 7,335 single fetus deliveries during the overall study period. The cesarean rate of individual physicians ranged from 5.6 to 19.7 percent, and the cesarean rate of physician groups ranged from 9.8 to 18 percent. The differences in the cesarean rate between individual physicians and group practices were not related to increased high risk patients, socioeconomic status, service status (clinic or private physician), or the length of time the physician has been in practice. There were no differences between high and low cesarean rate groups with respect to infant well-being at birth (Apgar score), need for neonatal resuscitation, or length of respirator use. Physicians' individual practice style was related to the cesarean section rate. It is thought that this variation is also due to the intense medical-legal climate facing the practice of obstetrics. It appears that cesarean section rates can be lowered without compromising newborn and fetal safety. (Consumer Summary produced by Reliance Medical Information, Inc.)

The use of cesarean delivery increased in the 1970s. It was commonly believed that once a woman had a cesarean, all subsequent deliveries had to be by cesarean as well. This recommendation was based on the premise that the uterus that was scarred by cesarean incisions was at risk for rupture if labor was allowed to proceed. However, recent studies have indicated that the risk of rupture is low and the success rate for vaginal delivery is high after previous cesarean section. In an effort to reverse the trend toward unnecessary cesarean sections, many patients with a previous history of cesarean delivery are now offered a trial of labor and the option of a vaginal delivery if certain criteria are met. The American College of Obstetricians and Gynecologists recommends that a woman who has had a low transverse incision should be encouraged to delivery vaginally. However, a 1987 report found that despite the safety and success of vaginal birth after cesarean (VBAC) most women still have subsequent cesareans, and in half of the cases VBAC is not even offered. The reasons why VBAC was not chosen were investigated by sending a questionnaire to 257 women who had had a cesarean delivery and who received their prenatal care from either a private physician or hospital-based clinic. Of the 160 who responded by returning the questionnaire, 53 stated that they themselves were the primary decision-makers about the delivery. However, their decision was also influenced by the opinion of their husband or partner. Women delivering at a public hospital were more likely to be influenced by the physician than women delivering at a private hospital. The main reasons why women chose a VBAC were the longer recovery time after cesarean section, and wanting the experience of a vaginal birth. The most common reasons why women chose repeat cesarean section were that they knew what to expect, they wanted to avoid the pain of labor, and they liked the convenience and timing of the delivery. Social needs were more important in making VBAC decisions than the medical risks involved. It was not possible to tell how well-informed the patients were in this study. To help patients understand the medical probabilities and to help the physicians understand the patients' social requirements, counseling should begin after the first cesarean delivery. Since the physician plays a primary role in delivery decisions, it is suspected that VBAC has not been successfully promoted. (Consumer Summary produced by Reliance Medical Information, Inc.)

In June 2000, I arrived a few minutes late to the American College of Obstetricians and Gynecologists' headquarters for a meeting of the Committee on Obstetric Practice. As Chair, I [...]

Last month, I reviewed the factors that have driven the dramatic increase in cesarean delivery (CD) rates over the past several years. This month, I'll review the potential impact of [...]

We present two cases of WPW syndrome in pregnancy. Risk factors for development of supraventricular tachycardia and the anaesthetic management during caesarean section are discussed. We recommend that regional anaesthesia can be given in patients with WPW syndrome; Phenylephrine is the best vasopressor for treatment of hypotension during spinal blockage and Adenosine is the first line therapy for the acute termination of PSVT. Keywords: pregnancy, caesarean section, Wolf Parkinson White Syndrome, supraventricular tachycardia, adenosine, Phenylephrine, In women of reproductive age, the commonest arrhythmia seen is paroxysmal supraventricular tachycardia (SVT). (1) Wolf Parkinson White syndrome accounts for the majority of supraventricular tachycardia in this population; with [...]

Peripartum cardiomyopathy (PPCM) is a relatively rare but life-threatening disorder. PPCM classically presents during pregnancy between the last trimester and six months following delivery, with the majority of cases presenting in the early postpartum period. Here, we report the occurrence of cardiac arrest in an undiagnosed case of PPCM after subarachnoid block (SAB) for Caesarean section. This case report highlights the need for a detailed preoperative assessment in apparently healthy parturients and includes a focused review of various anesthetic techniques used in patients with PPCM scheduled for Caesarean section. Keywords: anesthesia, peripartum cardiomyopathy, cardiac arrest, subarachnoid block, combined spinal epidural, Table of Contents Abstract Introduction Case Report Discussion References Introduction Peripartum cardiomyopathy (PPCM) is a relatively rare form of heart disease of unknown etiology with an incidence between 1:1300 and [...]

Introduction: Patients with situs inversus without ciliary dysfunction have multiple structural and functional abnormalities especially in terms of cardiac, spine and airway malformations, posing a challenge to a safe anesthetic. Case: A 40 year old female was admitted with spontaneous onset of labor with a breech presentation for urgent cesarean section. Her medical history included dextrocardia, which prompted a thorough physical examination for other possible structural anomalies, especially pertaining to her cardiovascular system, airway and the spine. The case was found to be total situs inversus without any evidence of ciliary dysfunction. An epidural anesthetic was planned, with careful dosing of and monitoring for hemodynamic changes. The case proceeded uneventfully and the epidural catheter was also used for postoperative pain control. Conclusion: We describe here the evaluation of and the precautions taken during the care such a patient who underwent a successful cesarean section delivery and post-operative pain management with an epidural anesthetic. Keywords: Situs inversus, epidural, cesarean section, anesthesia, Table of Contents Abstract Introduction Case Report Discussion Conclusion References Introduction Situs inversus is a congenital visceral malrotation anomaly that results from disturbances in establishment of left-right asymmetry. It can [...]

Level 1: Likely reliable evidence Intrauterine growth restriction (IUGR) is often managed by induction of labor to reduce the risk of neonatal morbidity or stillbirth. However, due to concerns about [...]

In many low-income countries, maternal refusal of caesarean delivery, even in the case of absolute necessity, is a concern. This study assessed attitudes towards women's refusal of caesarean delivery of [...]

A 34-year-old woman was in labor at an Indiana hospital when the fetal heart rate dropped from 150 to 90. After several attempts to improve the rate, the nurse called [...]

A patient who sustained a recurrent cardiopulmonary resuscitation due to status asthmaticus during one pregnancy followed by a birth of an apparently normal infant is described. Promptly performed caesarean delivery [...]

WASHINGTON -- Any decision to choose between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section [...]

Washington -- Any decision between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section have been [...]

RENO, NEV. -- From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician [...]

LOS ANGELES -- Planned cesarean sections could cut the risk of perinatal death of twins by 75%, according to a review of 8,073 twin births resulting in the delivery of [...]