Evaluation of cesarean delivery rates and factors associated with cesarean delivery among women enrolled in a pregnancy cohort study at two tertiary hospitals in Thailand.

BACKGROUND: Cesarean delivery rates have increased globally resulting in a public health concern. We estimate rates of cesarean deliveries among Thai women using the World Health Organization (WHO) Robson Classification system and compare rates by Robson group to the Robson guideline for acceptable rates to identify groups that might benefit most from interventions for rate reduction. METHODS: In 2017 and 2018, we established cohorts of pregnant women aged ≥ 18 years seeking prenatal care at two tertiary Thai hospitals and followed them until 6-8 weeks postpartum. Three in-person interviews (enrollment, end of pregnancy, and postpartum) were conducted using structured questionnaires to obtain demographic characteristics, health history, and delivery information. Cesarean delivery indication was classified based on core obstetric variables (parity, previous cesarean delivery, number of fetuses, fetal presentation, gestational week, and onset of labor) assigned to 10 groups according to the Robson Classification. Logistic regression was used to identify factors associated with cesarean delivery among nulliparous women with singleton, cephalic, term pregnancies. RESULTS: Of 2,137 participants, 970 (45%) had cesarean deliveries. The median maternal age at delivery was 29 years (interquartile range, 25-35); 271 (13%) participants had existing medical conditions; and 446 (21%) had pregnancy complications. The cesarean delivery rate varied by Robson group. Multiparous women with > 1 previous uterine scar, with a single cephalic pregnancy, ≥ 37 weeks gestation (group 5) contributed the most (14%) to the overall cesarean rate, whereas those with a single pregnancy with a transverse or oblique lie, including women with previous uterine scars (group 9) contributed the least (< 1%). Factors independently associated with cesarean delivery included age ≥ 25 years, pre-pregnancy obesity, new/worsen medical condition during pregnancy, fetal distress, abnormal labor, infant size for gestational age ≥ 50th percentiles, and self-pay for delivery fees. Women with existing blood conditions were less likely to have cesarean delivery. CONCLUSIONS: Almost one in two pregnancies among women in our cohorts resulted in cesarean deliveries. Compared to WHO guidelines, cesarean delivery rates were elevated in selected Robson groups indicating that tailored interventions to minimize non-clinically indicated cesarean delivery for specific groups of pregnancies may be warranted.

Correlation of transabdominal and transvaginal sonography for the assessment of uterocervical angle at 16-24 weeks' gestation.

The objective of this study was to determine the correlation between transabdominal (TAS) and transvaginal sonography (TVS) uterocervical angle (UCA) measurement in pregnant women with no history of previous preterm birth. A cross-sectional study involving singleton pregnancies between 16 and 24 weeks of gestation who underwent routine foetal anatomical scan was conducted. The TAS-UCA measurement was performed before voiding and with an empty bladder. A total of 256 women completed the sonography. The mean maternal age was 32 ± 6.68 years. The mean gestation age at the time of ultrasound assessment was 19 ± 1.71 weeks. The mean prevoid TAS-UCA was 119.74 ± 33.12° and the mean postvoid TAS-UCA was 110.73 ± 25.30°. There was a significant difference between prevoid and postvoid TAS-UCA measurement (p < .05). The mean TVS-UCA was 103.91 ± 26.42°. The Pearson correlation coefficients of prevoid and postvoid TAS-UCA with TVS-UCA were 0.438 and 0.601, respectively. In conclusion, the postvoid TAS-UCA has moderate correlation with TVS-UCA measurement and is better than the prevoid TAS-UCA in women with low risk for preterm birth.IMPACT STATEMENTWhat is already known on this subject? TVS is the gold standard for cervical length (CL) assessment for prediction preterm birth. However, TVS requires an experienced or trained sonographer and some women decline TVS because of the embarrassment and discomfort during examination. Several studies have demonstrated the correlation between TAS and TVS and suggested that TAS could be an alternative for CL screening. UCA has been reported as a new predictor of spontaneous preterm birth and is usually performed by TVS. Thus, it is interesting to evaluate whether TAS can be a substitute procedure for TVS in UCA measurement.What the results of this study add? TAS may be used as a substitute procedure for TVS and the postvoid TAS is more appropriate than prevoid TAS for UCA measurement.What the implications are of these findings for clinical practice and/or further research? TAS may be an alternative method for UCA measurement when TVS is unavailable or in pregnant women who decline TVS-UCA measurement. However, further study should be conducted to confirm the association between TVS-UCA and postvoid TAS-UCA before deciding to use postvoid TAS-UCA as a screening tool for preterm prediction.

Comparison of transabdominal and transvaginal ultrasonography for the assessment of cervical length at 16-23 weeks of gestation.

The aim of this study was to assess the relationship between transabdominal and transvaginal ultrasonography for the cervical length assessment and to evaluate the predictive value of the transabdominal ultrasonography cervical length assessment for predicting preterm birth. A prospective cohort study was conducted. Transabdominal and transvaginal ultrasonography cervical length assessments were performed in 160 pregnant women between 16 and 23 + 6 weeks of gestation. Transabdominal ultrasonography cervical length assessment was positively correlated with the transvaginal ultrasonography cervical length assessment. Mean ± standard deviation of the cervical length was significantly different between transabdominal and transvaginal ultrasonography (36.4 ± 5.4 vs. 41.2 ± 5.4 mm, p < .001). Transabdominal cervical length was shorter than the transvaginal cervical length with a mean difference of 4.8 mm. The sensitivity, specificity, positive predictive value and negative predictive value for predicting preterm birth when the transabdominal cervical length was ≤35 mm, were 50%, 52.1%, 9.1%, and 91.6%, respectively. In conclusion, transabdominal ultrasonography cervical length assessment is positively correlated with the transvaginal ultrasonography cervical length assessment. Transabdominal cervical length assessment was not a good predictor of preterm birth.

Comparisons of the morbidity outcomes in repeated cesarean sections using midline and Pfannenstiel incisions.

AIM: The aim of this study was to evaluate operative complications, operative time, postpartum complications and neonatal outcome in repeated cesarean section between previous low midline and previous Pfannenstiel cesarean section. MATERIAL AND METHODS: This was a prospective comparative study conducted at the King Chulalongkorn Memorial Hospital in pregnant women with indication of repeated cesarean section for either low midline or Pfannenstiel incisions. RESULTS: A total of 320 pregnant women with previous cesarean section were enrolled into two groups: low midline (n = 160) and Pfannenstiel (n = 160) groups. Operative complications, postpartum complications and neonatal outcomes were not statistically different between the groups (P > 0.05). Median times for total operative time (50 vs 50 min, P = 0.833), time from skin incision to the uterus (4 vs 4 min, P = 0.877), and time from uterine incision to fetal delivery (3 vs 2 min, P = 0.871) were comparable between the groups. CONCLUSIONS: Operative complications, operative time, postpartum complications and neonatal outcomes were comparable between low midline and Pfannenstiel groups in repeated cesarean sections irrespective of the previous technique used.