Postpartum Maternal Mortality and Cesarean Delivery

INSERM, Unite Mixte de Recherche S149, Institut Federatif de Recherche 69, Epidemiological Research Unit on Perinatal and Women's Health, Hopital Tenon, Paris, France.
Obstetrics and Gynecology (Impact Factor: 5.18). 10/2006; 108(3 Pt 1):541-8. DOI: 10.1097/01.AOG.0000233154.62729.24
Source: PubMed


A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery.
A population-based case-control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996-2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders.
After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries.
Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.

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    • "For Kankins et al., “The range … for permanent brachial plexus injury that could be avoided with cesarean section on request would appear to vary between 1 in 5000 and 1 in 10,000 vaginal births” [33]. Moreover, we know that the risk of maternal mortality after a cesarean is higher than after vaginal delivery [34]. Known risks of cesarean deliveries include thromboembolic, infectious, traumatic, and hemorrhagic complications [35]. "
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    ABSTRACT: Background The number of infants with a birth weight > 97th percentile for gestational age has increased over the years. Although some studies have examined the interest of inducing labor for fetuses with macrosomia suspected in utero, only a few have analyzed this suspected macrosomia according to estimated weight at each gestational age. Most studies have focused principally on neonatal rather than on maternal (and still less on perineal) outcomes. The principal aim of this study was to assess whether a policy of induction of labor for women with a constitutionally large-for-gestational-age fetus might reduce the occurrence of severe perineal tears; the secondary aims of this work were to assess whether this policy would reduce either recourse to cesarean delivery during labor or neonatal complications. Methods This historical cohort study (n = 3077) analyzed records from a French perinatal database. Women without diabetes and with a cephalic singleton term pregnancy were eligible for the study. We excluded medically indicated terminations of pregnancy and in utero fetal deaths. Among the pregnancies with fetuses suspected, before birth, of being large-for-gestational-age, we compared those for whom labor was induced from ≥ 37 weeks to ≤ 38 weeks+ 6 days (n = 199) to those with expectant obstetrical management (n = 2878). In this intention-to-treat analysis, results were expressed as crude and adjusted relative risks. Results The mean birth weight was 4012 g ± 421 g. The rate of perineal lesions did not differ between the two groups in either primiparas (aRR: 1.06; 95% CI: 0.86-1.31) or multiparas (aRR: 0.94; 95% CI: 0.84-1.05). Similarly, neither the cesarean rate (aRR: 1.11; 95% CI: 0.82-1.50) nor the risks of resuscitation in the delivery room or of death in the delivery room or in the immediate postpartum or of neonatal transfer to the NICU (aRR = 0.94; 95% CI: 0.59-1.50) differed between the two groups. Conclusions A policy of induction of labor for women with a constitutionally large-for-gestational-age fetus among women without diabetes does not reduce maternal morbidity.
    Full-text · Article · May 2014 · BMC Pregnancy and Childbirth
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    • "Cesarean delivery increases the risk of maternal and neonatal morbidity and mortality,1–3 and its incidence is increasing.4 There has been controversy surrounding the early initiation of epidural labor analgesia, because observational studies have demonstrated its association with increased rates of cesarean delivery.5–9 "
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    ABSTRACT: Retrospective studies have associated early epidural analgesia with cesarean delivery, but prospective studies do not demonstrate a causal relationship. This suggests that there are other variables associated with early epidural analgesia that increase the risk of cesarean delivery. This study was undertaken to determine the characteristics associated with early epidural analgesia initiation. Information about women delivering at 37 weeks or greater gestation with epidural analgesia, who were not scheduled for cesarean delivery, was extracted from the McGill Obstetric and Neonatal Database. Patients were grouped into those who received epidural analgesia at a cervical dilation of ≤3 cm and >3 cm. Univariable and multivariable logistic regression was used to determine the maternal, neonatal, and labor characteristics that increased the risk of inclusion in the early epidural group. Of the 13,119 patients analyzed, multivariable regression demonstrated odds ratios (OR) of 2.568, 5.915 and 10.410 for oxytocin augmentation, induction, and dinoprostone induction of labor (P < 0.001). Increasing parity decreased the odds of early epidural analgesia (OR 0.780, P < 0.001), while spontaneous rupture of membranes (OR 1.490) and rupture of membranes before labor commenced (OR 1.288) were also associated with early epidural analgesia (P < 0.001). Increasing maternal weight (OR 1.049, P = 0.002) and decreasing neonatal weight (OR 0.943, P < 0.001) were associated with increasing risk of early epidural analgesia. Labor augmentation and induction, nulliparity, rupture of membranes spontaneously and before labor starts, increasing maternal weight, and decreasing neonatal weight are associated with early epidural analgesia. Many of these variables are also associated with cesarean delivery.
    Full-text · Article · Aug 2013 · Local and Regional Anesthesia
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    • "Caesarean delivery carries a two-to-threefold risk of maternal mortality (Villar et al., 2007; Deneux-Tharaux et al., 2006) and an increased risk of maternal and perinatal morbidity (Villar et al., 2007). There is a need for simple, low cost interventions to increase the likelihood of normal vaginal birth. "
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    ABSTRACT: Background. Caesarean birth rates in North America continue to rise, in the absence of benefit for mothers and babies. One reason may be that hospitalized labouring women spend most of their labours in recumbent or semi-recumbent positions. Although hands-and-knees position has theoretical advantages, efforts to encourage its adoption in practice are severely hampered by the lack of compelling evidence that it is beneficial. Before a definitive, large scale trial, with spontaneous vaginal birth as the primary outcome, could be justified in terms of time, effort, and expense, several feasibility and acceptability questions had to be addressed. We aimed to enrol 60 women in a pilot study to assess feasibility and acceptability of the trial protocol, and to obtain estimates of treatment effects on method of birth and persistent back pain. Methods. We conducted a pilot study at two North American hospitals. In ten months of recruitment, 30 nulliparous women in labour at term were randomly allocated to either usual care (use of any position during labour except hands-and-knees) or to try hands-and-knees for 15 min every hour during labour. Data were collected about compliance, acceptability, persistent back pain, intrapartum interventions, and women’s views of their experiences. Results. Although mean length of time from randomization to delivery was over 12 hours, only 9 of the 16 women allocated to repeated hands-and-knees used it more than twice. Two of the 14 in the usual care group used hands-and-knees once. Twenty-seven women had regional analgesia (15 in the hands-and-knees group and 12 in the usual care group). Eleven in the hands-and-knees group and 14 in the usual care group had spontaneous vaginal births. One woman (in the hands-and-knees group) had a vacuum extraction. Four women in the hands-and-knees group and none in the usual care group gave birth by caesarean section. Hourly back pain ratings were highly variable in both groups, covering the full range of possible scores. Given the low compliance with the hands-and-knees position, it was not possible to explore relationships between use of the position and persistent back pain scores. When asked to rate their overall satisfaction with their birth experiences, the hands-and-knees group’s ratings tended to be lower than those in the usual care group, although 11 in the hands-and-knees group and 8 in the usual care group stated they would probably or definitely try the position in a subsequent labour. Conclusion. We concluded that we could not justify the time and expense associated with a definitive trial. However such a trial could be feasible with modifications to eligibility criteria and careful selection of suitable settings.
    Full-text · Article · Feb 2013 · PeerJ
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