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Canine Cesarean Section (CS) is primarily performed to increase survival of newborns and less commonly to save the life or reproductive future of the dam. Conducting proper ovulation timing to accurately predict the due date will allow a planned, elective CS as an excellent alternative to a high-risk natural whelping, and possible dystocia, for certain breeds and situations. Techniques for ovulation timing, anesthesia, and surgery tips are provided., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To measure forces applied to the fetal neck, in a simulation model for breech delivery, in both lithotomy versus all-fours position., Methods: We used a Laerdal SimMom simulator and a Birthing Baby together with PROMPT Flex Software. The descent of the fetus was accomplished using the Automatic Delivery Module 2. The baby was always in breech position; the SimMom in either all-fours or lithotomy positions. Sensors were located inside the fetal neck region to simulate forces applied to the plexus., Results: The lowest force on the fetal neck region was recorded for the delivery in all-fours position without further maneuvers (mean force 58.70 Newton, standard deviation 2.54 N). As weight was added to the baby, the force increased (i.e. + 500 g, mean force 71.8 N, SD 3.08 N, p < 0.001). Delivery in lithotomy position resulted in a mean force of 81.56 N (SD 19.55 N). The force significantly increased in case of delivery of the head without assistance from contractions (mean force 127.93 N, SD 23.10 N). In all-fours position, the delivery of the fetal head from pelvic floor level without contractions (Frank's Nudge maneuver) resulted in a mean force of 118.45 N (SD 15.48 N, p = 0.02). Maneuvers for shoulder dystocia (the inverted type that can occur during breech delivery) led to significantly higher mean forces independent from birthing positions., Conclusion: Breech delivery in all-fours position was associated with the lowest force acting on the fetal neck in our simulation model., (© 2022. The Author(s).)

A 9 yr old, unknown weight, intact female domestic shorthair presented for evaluation of dystocia with dyspnea. En route to the hospital for treatment, the owners noted the queen stopped breathing. On presentation, cardiopulmonary arrest was confirmed. The exact cause was unknown but suspected to be secondary to acute fulminant congestive heart failure or acute respiratory distress syndrome due to a large volume of serosanguineous fluid within the mouth and nose. Cardiopulmonary resuscitation (CPR) was immediately started. After 2 min of CPR without return of spontaneous circulation, the owners consented to perimortem Cesarean section. Two kittens were removed via emergency hysterotomy within 3-4 min. Both kittens were successfully resuscitated. CPR efforts were continued on the queen for 2 min after delivery of the kittens, at which time the owners elected to stop further resuscitative efforts. Both kittens were discharged from the hospital and were alive at last follow-up, 2 yr and 4 mo after birth. There are no previous reports regarding the use of a perimortem Cesarean section to deliver neonates in small animal medicine. Therefore, this report represents a novel treatment approach that can be considered in the case of maternal arrest during dystocia., (© 2023 by American Animal Hospital Association.)

Dystocia is an abnormal and difficult birth in which the first or the second stage of labour is markedly prolonged and subsequently found impossible for the dam to deliver without artificial aid. In cattle, it can be relieved by different obstetric methods, including the cesarean operation and fetotomy. Caesarean section is the extraction of the fetus or foeti from the dam, through a surgical opening in the abdominal wall and the uterus. This surgical method can be performed by about eight alternative surgical approaches in bovines with its advantages and disadvantages. However, the selection is dependent on many factors like the type of dystocia, the cows and environmental conditions, the availability of assistants, and the surgeon's preference. For cows, most surgeons use a standing left paralumbar celiotomy. However, the left oblique approach is also preferable under most circumstances because the uterus is readily exteriorized, limiting peritoneal cavity contamination. Besides, alternative approaches are also available that will further limit the potential for contamination but many junior surgeons perform the left paralumbar celiotomy using the same approach each time due to their comfort with one specific approach or lack of familiarity with other available options. Therefore, the objective of this review is to provide basic insights and highlight the cesarean section incision approaches with their relative advantages and disadvantages in cows., (© 2022 The Authors. Veterinary Medicine and Science published by John Wiley & Sons Ltd.)

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS.IMPACT STATEMENT What is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors. What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS. What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

Objective: To evaluate whether prophylactic administration of oxytocin plus ergonovine or oxytocin plus carboprost is more effective than oxytocin alone in reducing the need for additional uterotonics among women undergoing cesarean delivery for labor arrest., Methods: In this double-blind, three-arm randomized controlled trial, participants were assigned to receive either oxytocin 5 units intravenous alone, or with ergonovine 0.25 mg intravenous or carboprost 0.25 mg intramuscular immediately after delivery, followed with maintenance infusion of oxytocin 40 milliunits/minute in all groups. Uterine tone was assessed at 3, 5, and 10 minutes after delivery, and additional uterotonics were administered if deemed necessary. The primary outcome was intraoperative need for additional uterotonics. Secondary outcomes included uterine tone, calculated blood loss, and side effects. A sample size of 34 per group (n=102), based on the null hypothesis that there is no association between treatment assignment and the need for additional uterotonics, permitted independent post hoc pairwise comparisons between oxytocin plus ergonovine, oxytocin plus carboprost, and oxytocin alone using an adjusted P-value of .025. The association between the need for additional uterotonics and treatment group was assessed using the χ2 test., Results: From June 2013 through July 2019, 105 participants were randomized (35 per group) and data from 100 participants were analyzed: oxytocin (n=35), oxytocin plus ergonovine (n=33), and oxytocin plus carboprost (n=32). There was no difference in the requirement of additional intraoperative uterotonics across groups (oxytocin [37%] vs oxytocin plus ergonovine [33%] vs oxytocin plus carboprost [34%], P=.932). Uterine tone and calculated blood loss were similar across groups. Incidence of nausea or vomiting was higher in oxytocin plus ergonovine (85%; odds ratio [OR] 5.3, 95% CI 1.7-16.9, P=.003) and oxytocin plus carboprost (72%; OR 2.4, 95% CI 0.9-6.7, P=.086) compared with the oxytocin (51%) group., Conclusion: Compared with oxytocin alone, prophylactic use of a combination of uterotonic drugs did not reduce the need for additional uterotonics at cesarean delivery for labor arrest., Clinical Trial Registration: ClinicalTrials.gov, NCT01869556., Competing Interests: Financial Disclosure The author did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To report the surgical survival of dams and piglets and follow-up survival and future breeding potential of swine that underwent cesarean section for correction of dystocia., Study Design: Retrospective study., Animals: One hundred ten client-owned, female swine. All swine included in this study were breeding stock for market pigs to be used for exhibition purposes., Methods: Medical records of swine that underwent cesarean section at The Ohio State University Hospital for Farm Animals for resolution of dystocia between January of 2013 and July of 2018 were reviewed. Signalment, history, number of piglets per litter, treatments, and surgical procedure were recorded. Follow-up information (survival, complications, and additional pregnancies) was obtained via telephone interview., Results: A fetus was not palpable in 77 of 110 (70%) cases at presentation. The median litter size was eight piglets (range, 1-14), with medians of five (range, 0-13) live and one dead (range, 0-11) piglets per litter. Follow-up was available for 52 dams, of which 39 (75%) survived. Complications were recorded in 20 of 52 (38.46%) cases and included incisional seroma formation, lethargy, and anorexia. Twenty-three dams became pregnant and farrowed after the cesarean section, with no reported complication in 13 of these., Conclusion: Cesarean section in swine is associated with a good prognosis for recovery from the procedure and a fair to guarded prognosis for future breeding., Clinical Significance: Cesarean section may be considered for resolution of dystocia in swine. However, owners should be advised that nearly half of sows require assistance in subsequent deliveries., (© 2020 The Authors. Veterinary Surgery published by Wiley Periodicals LLC on behalf of American College of Veterinary Surgeons.)

Objective: To investigate whether fetal head station at the index cesarean delivery is associated with a subsequent trial of labor success rate among primiparous women., Methods: A retrospective cohort study conducted at two tertiary medical centers included all primiparous women with subsequent delivery after cesarean delivery for second-stage dystocia during 2009-2019, identified from the electronic medical record databases. Univariate and multivariate analyses were performed to assess the factors associated with successful trial of labor after cesarean (TOLAC) (primary outcome). Additionally, all women with failed TOLAC were matched one-to-one to women with successful TOLAC, according to factors identified in the univariate analysis., Results: Of 481 primiparous women with prior cesarean delivery for second-stage dystocia, 64.4% (n=310) attempted TOLAC, and 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index cesarean delivery, as compared with those with higher head station (79.0% vs 60.5%, odds ratio [OR] 2.46, 95% CI 1.49-4.08). The proportion of neonates weighing more than 3,500 g in the subsequent delivery was lower in those with successful TOLAC compared with failed TOLAC (29.7% vs 43.2%, OR 0.56, 95% CI 0.33-0.93). In a multivariable analysis, lower fetal head station at the index cesarean delivery was the only independent factor associated with TOLAC success (adjusted OR 2.38, 95% CI 1.43-3.96). Matching all women with failed TOLAC one-to-one to women with successful TOLAC, according to birth weight and second-stage duration at the subsequent delivery, lower fetal head station at the index cesarean delivery remained the only factor associated with successful TOLAC., Conclusion: Lower fetal head station at the index cesarean delivery for second-stage dystocia was independently associated with a higher vaginal birth after cesarean rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to deliver vaginally after prior second-stage arrest., Competing Interests: Financial Disclosure Abraham Tsur disclosed that he holds minority shares as inventor of the mechanical device for prevention of preterm birth commercially named the “Lioness.” They also received funding from Anthem AI and NewSight. The other authors did not report any potential conflicts of interest., (Copyright © 2020 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Clinical records of all 212 ewes undergoing emergency caesarean surgery at a veterinary teaching hospital between January 2008 and December 2019 were evaluated retrospectively. Their age ranged from 1 to 10 years (median = 4 years), with German merino the predominant breed (48.1% of cases). The most frequently diagnosed indications were insufficient cervical dilatation (n = 94, 44.3%), uterine torsion (n = 50, 23.6%), foetopelvic disproportion (n = 31, 14.6%) and vaginal prolapse intra partum (n = 11, 5.2%). Fifty-four (25.5%) of the 212 ewes additionally suffered from one or more concurrent, pre-existing conditions. Overall ewe mortality until hospital discharge was 10.8% (23/212), and 3.8% (n = 6) for the 158 ewes without a history of concurrent disorders. Mortality during hospitalization increased to 31.5% (17/54) for those with pre-existing conditions. Total lamb mortality was 49.1% (173/352) until hospital discharge. Pre-existing conditions (p = .001) and the presence of post-surgical complications (p = .025) were identified as significant factors influencing dam mortality, while delayed presentation for veterinary attention with an observed duration of labour of >12 hr was identified as the most influential factor on total lamb mortality (p = .010). The presence of dead or emphysematous foetuses was not significant for ewe mortality. Follow-up information on further outcomes was available for 156 (82.5%) of the 189 discharged ewes. Eighty-nine animals (57.1%) were re-bred in the following season and achieved a 93.3% (83/89) pregnancy rate, while the remainder had either been slaughtered (n = 56, 35.9%), sold (n = 5, 3.2%) or had died of unknown causes (n = 3, 1.9%). The subsequent incidence of dystocia was 15.6% (n = 12) in the 77 ewes with available information on lambing ease. Adequate management of underlying conditions and timely intervention are important factors for best possible short-term outcomes. In the long term, the subsequent pregnancy rate was good and the incidence of subsequent dystocia was within the normal range., (© 2020 Wiley-VCH GmbH.)

Objectives: In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes., Methods: Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes., Results: Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003)., Conclusions: Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Objective: Assess the impact of implementation by simple distribution of a "colour code" protocol for emergency caesareans on the course over time of the "decision-delivery interval" (DDI) and neonatal outcome., Design: Observational study in 26 maternity units of the AURORE perinatal network, conducted between October 1, 2017, and April 30, 2018. Each maternity ward́ was supposed to prospectively include 20 consecutive cases of caesareans performed either as an emergency, that is, as a code orange, or an extreme emergency, that is, code red. We compared the DDIs observed in 2017 to those in 2007 according to the degree of emergency, the maternity unit level of care, and their adherence to the protocol. Neonatal outcome in 2007 and 2017, assessed from laboratory and clinical indicators, was also compared, overall and according to the degree of emergency., Results: The DDI was significantly lower in 2017 (n = 478) than in 2007 (n = 447), regardless of the degree of emergency and the level of care (p < 0.0001). In 2017, all code red caesareans were performed in less than 15 min in level 3 maternity units compared with 73 % (p = 0.039) in 2007. Fewer than 20 % of the caesareans in the 2007 study period were performed in less than 15 min in level 1 and 2 maternity units. Today, this is the case for 83 % of these caesareans in level 2 units (p < 0.001) and 36 % in level 1 (p = 0.01). In 2017, code orange caesareans were performed in less than 30 min in 96 % of cases in level 3 units, 67 % in level 2, and 33 % in level 1, compared respectively with 67 % (p = 0.015), 25 % (p < 0.0001) and 16 % (p = 0.0003) in 2007. We did not observe any difference in the neonatal outcome between 2007 and 2017 or as a function of the DDI expected based on the caesarean colour code., Conclusion: The implementation of the colour code protocols was associated with an improved DDI and better adherence to the recommendations in all 26 maternity units in this perinatal network., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To examine whether the decision and indications for performing intrapartum cesarean delivery vary by time of day., Methods: We conducted a secondary analysis of a multicenter observational cohort of 115,502 deliveries (2008-2011), including nulliparous women with term, singleton, nonanomalous live gestations in vertex presentation who were attempting labor. Those who attempted home birth, or underwent cesarean delivery scheduled or decided less than 30 minutes after admission were excluded. Time of day was defined as cesarean delivery decision time among those who delivered by cesarean and delivery time among those who delivered vaginally, categorized by each hour of a 24-hour day. Primary outcomes were decision to perform cesarean delivery and the indications for cesarean delivery (labor dystocia, nonreassuring fetal status, or other indications). Secondary outcomes included whether a dystocia indication adhered to standards promoted to reduce cesarean delivery rates. Bivariate analyses were performed using χ and Kruskal-Wallis tests for categorical and continuous outcomes, respectively, and generalized additive models with smoothing splines explored nonlinear associations without adjustment for other factors., Results: Seven thousand nine hundred fifty-six (22.1%) of 36,014 eligible women underwent cesarean delivery. Decision for cesarean delivery (P<.001) decreased from midnight (21.2%) to morning, reaching a nadir at 10:00 (17.9%) and subsequently rising to peak at 21:00 (26.2%). The frequency of cesarean delivery for dystocia also was significantly associated with time of day (P<.001) in a pattern mirroring overall cesarean delivery. Among cesarean deliveries for dystocia (n=5,274), decision for cesarean delivery at less than 5 cm dilation (P<.001), median duration from 5 cm dilation to cesarean delivery decision (P=.003), and median duration from complete dilation to cesarean delivery decision (P=.014) all significantly differed with time of day. The frequency of nonreassuring fetal status and "other" indications were not significantly associated with time of day (P>.05)., Conclusion: Among nulliparous women who were attempting labor at term, the decision to perform cesarean delivery, particularly for dystocia, varied with time of day. Some of these differences correlate with labor management differences, given the changing frequency of latent phase cesarean delivery and median time in active phase.

Background: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce., Objective: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda., Methods: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda)., Findings: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated., Conclusions: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor., Competing Interests: The authors have no competing interests to declare., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.)

Objective: This study sought to quantify perinatal and maternal morbidity and mortality associated with forceps and vacuum delivery compared with Caesarean delivery in the second stage of labour and to estimate whether these associations differed by pelvic station., Methods: The investigators conducted a population-based, retrospective cohort study of term singleton deliveries by operative delivery with prolonged second stage of labour in Canada (2003-2013) using national hospitalization data. The primary study outcomes were severe perinatal morbidity and mortality (i.e., seizures, assisted ventilation, severe birth trauma, and perinatal death) and severe maternal morbidity and mortality (i.e., severe postpartum hemorrhage, cardiac complication, and maternal death). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) after stratifying by indication (dystocia or fetal distress). The Breslow-Day chi-square test for heterogeneity in ORs was used to test effect modification by pelvic station (outlet, low, or midpelvic)., Results: There were 61 106 deliveries included in the study. Among women with dystocia, forceps and vacuum deliveries were associated with higher rates of perinatal morbidity and mortality compared with Caesarean delivery (forceps: aOR 1.56; 95% CI 1.13-2.17; vacuum: aOR 1.44; 95% CI 1.06-1.97). Vacuum delivery was associated with lower rates of maternal morbidity and mortality compared with Caesarean delivery (dystocia: aOR 0.64; 95% CI 0.51-0.81; fetal distress: aOR 0.43; 95% CI 0.32-0.57). Pelvic station did not significantly modify the associations between forceps or vacuum and perinatal or maternal morbidity and mortality., Conclusion: Forceps and vacuum delivery is associated with increased rates of severe perinatal morbidity and mortality compared with Caesarean delivery among women with dystocia, whereas vacuum delivery is associated with decreased rates of severe maternal morbidity and mortality., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

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)'.]., (© 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Context: There is increasing evidence for Müllerian-inhibiting substance (MIS)/anti-Müllerian hormone (AMH) physiologic activity in the human uterus, so it is relevant to study how MIS/AMH levels impact pregnancy., Objective: To investigate the association of MIS/AMH levels with the risk of adverse obstetric outcomes., Design: Retrospective cohort study., Setting: Academic fertility center., Patients: Women who became pregnant through in vitro fertilization between January 2012 and October 2016. Exclusion criteria were: oocyte donation, gestational carrier, multiple gestations, miscarriage before 20 weeks, or medically indicated preterm deliveries., Interventions: None., Main Outcome Measures: There were two primary outcomes, preterm birth and cesarean delivery for arrest of labor. Because MIS/AMH level is highly skewed by certain infertility diagnoses, the preterm birth analysis was stratified by polycystic ovary syndrome (PCOS) diagnosis, and the cesarean delivery for arrest of labor analysis was stratified by diminished ovarian reserve diagnosis. χ2, Mann-Whitney, and t tests were used as appropriate. A P value of <0.05 was considered statistically significant., Results: Among women with PCOS, those who delivered prematurely had substantially higher MIS/AMH levels (18 vs 6.4 ng/mL, P = 0.003) than did those who delivered at term. At the highest MIS/AMH values, preterm deliveries predominated; above the 90th percentile in women with PCOS, all deliveries were premature. No effect of MIS/AMH level was observed in women without PCOS. We found no association between MIS/AMH values and cesarean delivery for labor arrest., Conclusion: In women with PCOS, substantially elevated MIS/AMH levels are significantly associated with preterm birth, suggesting closer follow-up and further studies to elucidate the underlying mechanisms.

Introduction: Cesarean section is one of the common obstetric procedures done when the childbirth is not anticipated to occur by the normal vaginal delivery. There has been increased rate of cesarean section globally as well as in our country in recent decades., Methods: This descriptive cross-sectional study has been carried out by reviewing a year of data from maternity ward of Paschimanchal Community Hospital, Prithvi Chowk, Pokhara. The total number of delivery, their modes either vaginal or cesarean, indications for the cesarean section and their outcomes were analyzed. The obtained data was entered and analyzed in Microsoft Excel., Results: Total of 257 cases underwent delivery during the study period and 174 (63.27%) were by cesarean section. Oligohydramnios is the most common indication for cesarean section. Around 25 (14.36%) of the women underwent repeat cesarean section., Conclusions: The rate of cesarean section was quite high in our study and further studies are recommended for understanding of causes and other associated factors with it.

Canine intrauterine bacteriological flora during dystocia is unknown. Thus, frequency (bacterial growth (not) detected), quality (species and number of different bacterial isolates) and quantity (colony-forming units) of intrauterine bacteria in relation to in utero foetal death in 50 bitches undergoing emergency Caesarean section were investigated. Bacterial growth was quantified from single colonies, (+) (0.5), to strong growth, +++ (3) and was observed in 34 bitches (68%), with Staph. epidermidis (n = 12), Staph. intermedius-group (n = 7), β-haemolytic streptococci (n = 6), Staph. aureus, α- and γ-haemolytic streptococci (n = 4 each) being most common and one to four bacteria per sample. Regarding the quantity, most often (n = 46) low growth was identified. In bitches with living pups only (group I), mean number of isolates was 0.78 ± 0.83 compared to 1.60 ± 1.10 (living + stillborn pups, group II) and 1.0 ± 1.15 (stillborn pups only, group III) and mean bacterial growth in groups I/II/III was + (1.0, quantity), + (1.4) and ++ (1.6). Taking just positive samples into consideration, mean number of bacterial isolates was significantly higher in group II compared to I (p = .0088). We concluded that the canine uterus cannot be considered free of bacteria during dystocia. Mean numbers of different bacterial isolates and quantity of bacterial growth are higher in bitches with in utero foetal death., (© 2018 Blackwell Verlag GmbH.)

OBJECTIVE To characterize signalment, clinical signs, reproductive history, surgical management, and outcomes of beef cattle undergoing cesarean section because of dystocia at a veterinary teaching hospital. DESIGN Retrospective case series with nested cohort study. ANIMALS 173 beef cattle admitted to a veterinary teaching hospital from 2001 through 2010 that underwent cesarean section because of dystocia. PROCEDURES Medical records were reviewed and information collected on cattle signalment; reproductive history; cause of dystocia; anesthetic protocol; surgical management; number, sex, and body weight of calves delivered (alive or dead); perioperative treatment; duration of hospitalization; and discharge status. A questionnaire regarding postoperative fertility was mailed to all owners, and owners who did not respond were contacted via telephone. RESULTS Overall mortality rate for calves was high, with 37.6% (62/165) of calves delivered dead or dying ≤ 24 hours after cesarean section. Mortality rate was higher for female versus male calves and for calves from dams with signs of labor for ≥ 3 hours versus < 3 hours before hospital admission. Overall mortality rate for dams was low, with only 10 of 161 (6.2%) dams failing to survive for ≥ 21 days after hospital discharge. Postoperative fertility rate was acceptable, with 75% (44/59) of dams that were rebred after cesarean section giving birth to ≥ 1 live calf. CONCLUSIONS AND CLINICAL RELEVANCE Cesarean section was a clinically useful method for resolving dystocia in beef cattle, providing a high dam survival rate and an acceptable postoperative fertility rate. Beef cattle producers should seek veterinary assistance whenever clinical signs of dystocia are noticed, preferably within 6 hours after onset of parturition.

Dystocia can be defined broadly as "difficult birth" or more specifically as difficulty in the bitch expelling the pups through the cervix, vagina, and vestibule. It is a fairly common emergency presented to the small animal practitioner with an incidence rate of approximately 5%. The incidence of dystocia is highest in toy and brachycephalic breeds, and occurs frequently in small litters (<3 pups) due to fetal oversize and delayed onset of labor. As duration of labor progresses, the mortality of the pups and even the bitch increases, with the highest number of stillborn pups occurring after 6 hours from the time of active parturition. Practitioners should understand the mechanism of normal parturition so that abnormalities can be readily identified and medical or surgical intervention performed in a safe and timely manner., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We present a case of a 28-year-old woman second gravida with a full-term pregnancy who presented to us in active phase of labour with third degree uterovaginal prolapse complicated by entrapment of fetal head by dystocia of cervix and fetal distress. Patient was immediately shifted to the operation theatre and prompt delivery was conducted by giving Duhrssen's incision on the highly vascular, oedematous prolapsed cervix. The outcome was an alive and healthy male baby. Duhrssen's incision was stitched with minimal blood loss. Postnatal management included antibiotics and daily intravaginal packing. Patient was discharged along with the baby in satisfactory condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: women´s experience of emergency caesarean section is often described as less positive compared to a vaginal birth or a planned caesarean section. Midwifery care for women where deviations from a normal birth process are present is a challenge. The aim of study was to compare self-reported birth outcomes for women undergoing birth through spontaneous onset of labour between those who actually had a vaginal birth and those who eventually had an emergency caesarean section., Design and Setting: the study was part of a prospective longitudinal cohort study of parents' experiences, attitudes, and beliefs related to childbirth., Method and Findings: questionnaires were answered by 870 women in midpregnancy, two months postpartum and one year after birth. 766 women (88%) had a vaginal birth, and 104 (12%) had an emergency caesarean section. The most common indications of emergency caesarean section were dystocia, foetal distress, and malpresentation. Women in the emergency caesarean group were more likely to be primiparous (59.6%) and have a body mass index > 30 (10.7%). Childbirth fear was twice as common among these women, and they were more likely to have preferred a caesarean delivery when asked about birth preference in the middle of pregnancy (OR 3.7, Cl 1.8-7.5). Induction of labour (OR 2.5, Cl 1.6-4.0), the use of oxytocin for augmentation (OR 1.9, Cl 1.3-2.9), and the use of epidural as pain relief during labour (OR 5.6, Cl 3.6-8.7) were more common among women having an emergency caesarean section. Transport of the new-born to a neonatal intensive care unit was three times as common. More than a third (37%) of the women in the caesarean group preferred a caesarean section in case of another birth. Childbirth fear was more common one year after birth with 32% of these women describing their fear as moderate or strong (OR 3.6, CI 2.1-6.0)., Key Conclusions: women undergoing emergency caesarean section are more likely to experience fear and to have a negative birth experience. It is essential for the midwife to promote a sense of control, involve the woman in the procedure, and create security in a threatening situation. This is made possible in relationship characterized by mutuality, trust, on-going dialogue, shared responsibility, and enduring presence., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Aims: To report on the opinions and reported practices of Australian obstetricians and general practice (GP) obstetricians, in the definition and management of spontaneous first stage of labour, in low-risk nulliparous women., Materials and Methods: Cross-sectional survey sent electronically to all Australian Specialist obstetricians (FRANZCOG) and Diplomates. Respondents answered questions regarding care of nulliparous women in spontaneous labour at term across three domains: (i) practitioners' characteristics; (ii) current practice; (iii) opinion regarding joint statement by ACOG/SMFM (Society of Maternal Fetal Medicine) 'Safe prevention of primary caesarean section'., Results: The dataset included responses from 664 participants, representing 29% of Specialists and 11% of Diplomates. Responses varied in the criteria used to define normal labour, and the diagnosis and management of prolonged labour. Clinicians with more post-qualification experience considered the minimal acceptable progress to be faster than those with fewer years of experience (P = 0.02). Clinicians working in higher acuity hospitals were more likely to augment labour for longer prior to recommending a caesarean section for active phase arrest, compared to those in lower acuity hospitals (P = 0.025). The majority of respondents (58.2%) already based their practice on the ACOG/SMFM 'Safe prevention of primary caesarean section' statement, or would now consider changing their practice., Conclusion: There is a lack of consensus among Australian obstetricians and GP obstetricians regarding definition of normal progress in first stage of labour and how to manage abnormal progress; however, many are open to new recommendations for practice., (© 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: To describe delivery management of singleton stillbirths in a population-based, multicenter case series., Methods: We conducted a retrospective chart review of 611 women with singleton stillbirths at 20 weeks of gestation or greater from March 2006 to September 2008. Medical and delivery information was abstracted from medical records. Both antepartum and intrapartum stillbirths were included; these were analyzed both together and separately. The primary outcome was mode of delivery. Secondary outcomes included induction of labor and indications for cesarean delivery. Indications for cesarean delivery were classified as obstetric (abnormal fetal heart tracing before intrapartum demise, abruption, coagulopathy, uterine rupture, placenta previa, or labor dystocia) or nonobstetric (patient request, repeat cesarean delivery, or not documented)., Results: Of the 611 total cases of stillbirth, 93 (15.2%) underwent cesarean delivery, including 43.0% (46/107) of women with prior cesarean delivery and 9.3% (47/504) of women without prior cesarean delivery. No documented obstetric indication was evident for 38.3% (18/47) of primary and 78.3% (36/46) of repeat cesarean deliveries. Labor induction resulted in vaginal delivery for 98.5% (321/326) of women without prior cesarean delivery and 91.1% (41/45) of women with a history of prior cesarean delivery, including two women who had uterine rupture. Among women with a history of prior cesarean delivery who had spontaneous labor, 74.1% (20/27) delivered vaginally, with no cases of uterine rupture., Conclusion: Women with stillbirth usually delivered vaginally regardless of whether labor was spontaneous or induced or whether they had a prior cesarean delivery. However, 15% underwent cesarean delivery, often without a documented obstetric indication.

Collagen IV and Laminin are localized in cells and tissue of numerous human organs including the uterus, where these polypeptides control either age changes, or uterus growth in pregnancy, or ripening and dilatation in labor. Authors examined the polypeptides distribution of collagen IV and Laminin in the human pregnant uterus, in normal and dystocic labor, to clarify their physiologic role, by distribution and/or their changes in prolonged dystocic labor. We collected lower uterine segment (LUS) fragments during cesarean section (CS); these biopsies were treated with basic morphological staining for the observation of microscopic- anatomic details. Other samples were processed with immunohistochemical staining for collagen IV and for membrane bound Laminin. All morphological and immunochemical results were analyzed with quantitative analysis of images and statistical analysis of data. Both Collagen IV and Laminin show changes in the pregnant uterus before 4 hours of full cervical dilatation in patients after 4 hours. All the three types of the human uterine cells, mucosal, submucosal and smooth muscular cells, are more reduced in LUS after 4 hours of cervical dilatation in dystocic labor. The connective tissues (including fibroblast) show the most evident changes in the dystocic LUS, collagen IV and laminin changes during cervical dilatation in prolonged dystocic labor, with a decreased elasticity with increased roughness and dryness. The LUS anatomical modifications during labor can be the cause of pathological changes in protracted dystocic labor. In the dystocic labor that lasts more than 4 hours from the complete cervical ripening and dilatation, the laminin and collagen IV concentration reduces in the LUS tissue. In dystocic labor, delivery should be completed before the 3 hours of full dilation, to avoid a reduction of laminin and collagen IV and a worsening of LUS healing for the next pregnancy., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Objectives The aim of this study was to describe the incidence of feline dystocia with respect to breed. Methods The data used were reimbursed claims for veterinary care insurance and/or life insurance claims in cats registered in a Swedish insurance database from 1999-2006. Results The incidence rates for dystocia were about 22 cats per 10,000 cat-years at risk, 67 per 10,000 for purebred cats and seven per 10,000 for domestic shorthair cats. The median age was 2.5 years. A significant effect of breed was seen. An incidence rate ratio (IRR) that was significantly higher compared with other purebred cats was seen in the British Shorthair (IRR 2.5), the Oriental group (IRR 2.2), Birman (IRR 1.7), Ragdoll (IRR 1.5) and the Abyssinian group (IRR 1.5). A significantly lower IRR was seen in the Norwegian Forest Cat (IRR 0.38), the Maine Coon (IRR 0.48), the Persian/Exotic group (IRR 0.49) and the Cornish Rex (IRR 0.50). No common factor among the high-risk breeds explained their high risk for dystocia. There was no effect of location; that is, the incidence rate did not differ depending on whether the cat lived in an urban or rural area. Caesarean section was performed in 56% of the cats with dystocia, and the case fatality was 2%. Conclusions and relevance The incidence rate for dystocia was of a similar magnitude in purebred cats as in dogs. The IRR varied significantly among breeds, and the main cause for dystocia should be identified separately for each breed. A selection for easy parturitions in breeding programmes is suggested.

Background: There is global concern about rising caesarean section rates. Identification of risk factors could lead to preventative measures., Aims: To describe the association between neonatal head circumference and (i) caesarean section for failure to progress, (ii) intrapartum caesarean section overall., Materials and Methods: This was a retrospective cohort study of 11 687 singleton live births with cephalic presentation, attempted vaginal birth and at least 37 completed weeks gestation from January 2005 to June 2009. Neonatal head circumference was grouped into quartiles and multiple logistic regressions performed., Results: The rates of caesarean section for failure to progress were 4.1, 6.4, 8.8 and 14.3% in successive head circumference quartiles. Rates of intrapartum caesarean section overall were 8.7, 12.1, 15.8 and 21.5%. The odds ratios for caesarean section for failure to progress were: 1.00, 1.33 (95% CI 1.02- 1.73), 1.54 (1.18-2.02) and 1.93 (1.44-2.57) for successive head circumference quartiles after adjusting for multiple demographic and clinical factors. The adjusted odds ratios for intrapartum caesarean section for any indication were: 1.00, 1.52 (95% CI 1.24-1.87), 1.99 (1.62-2.46) and 2.38 (1.89-3.00), respectively., Conclusions: There is a strong positive relationship between head circumference quartile and both caesarean section for failure to progress and caesarean for any indication. If this finding is confirmed using ultrasound measurements, there is potential for head circumference to be incorporated into predictive models for intrapartum caesarean section with a view to offering interventions to reduce the risk of caesarean section., (© 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: Many countries have noted a substantial increase in the cesarean section rate (CSR). Several methods for lowering the CSR have been described. Understanding the impact of clinical audits on the CSR may aid in lowering CSR. Thus, our aim is to elucidate the effect of clinical audits on the CSR., Materials and Methods: We retrospectively analyzed 3781 pregnant women who gave birth in a medical center between January 2008 and January 2011. Pregnant women who delivered between January 2008 and July 2009 were enrolled as the pre-audit group (n = 1592). After August 2009, all cesarean section cases that were audited were enrolled in the audit group (n = 2189). The CSR was compared between groups., Results: The overall CSR (34.5% vs. 31.1%, adjusted odds ratio [OR] = 0.83, p = 0.008) and the cesarean section rate due to dystocia (9.6% vs. 6.2%, p < 0.001) were significantly lower in the audit group than the pre-audit group. However, there was no significant difference in the rate of operative vaginal delivery between groups. Consensus on the unnecessity for cesarean section was achieved in 16 (8.2%) of 195 audit cases in the monthly audit conference. In nulliparous pregnant women (n = 2148), multivariate analysis revealed that clinical audit (OR = 0.78), maternal age (OR = 1.10), gestational age at delivery (OR = 0.80), and fetal body weight at birth (OR = 1.0005) were independent predictors of cesarean section (all p < 0.05). Most variables of maternal and perinatal morbidity and mortality did not differ before and after audits were implemented., Conclusion: Clinical audits appear to be an effective strategy for reducing the CSR. Therefore, we recommend strict monitoring of the indications in dystocia for cesarean section to reduce the CSR., (Copyright © 2016. Published by Elsevier B.V.)

The objectives of this study were to investigate the prevalence of dystocia in camel herds, its forms in primi- and multipara, the risks to fetus and dam, and the associated hematobiochemical changes. A total of 1890 calvings were surveyed for the prevalence of dystocia. Cases with dystocia (n=107) were examined for causes and treated with traction, fetotomy or Cesarean section. Logistic regression was performed to identify risk factors. The dependent variables were the fetal and maternal mortality, while the independent variables were parity, duration of dystocia, causes of dystocia, and method of treatment. Blood samples were collected from all dystocia camels and six controls for hematology and concentrations of serum amyloid A (SAA), haptoglobin (Hp), estradiol-17β (E2), progesterone (P4), total protein, albumin, calcium, phosphorus, magnesium, blood urea nitrogen (BUN), creatinine and aspartate aminotransferase (AST). The overall prevalence of dystocia was 8.6%. Risk of dystocia was higher in camels managed in an intensive system than in those in a free system (Odds ratio=1.9, P=0.0003) and higher in primipara than in multipara (Odds ratio 1.7, P=0.005). Abnormal posture was the most important cause of dystocia (51.4%). Uterine torsion was the second most important cause (23.4%) and was mainly observed in multipara (P=0.0006). Dystocia was linked to high fetal mortality (87.9%). A significant relationship was found between fetal death and duration of dystocia (Odds ratio=8.04, P=0.005). The percentage of dam mortality was 17.8%. Significant associations were detected between dam mortality rate and the duration of dystocia (Odds ratio=4.74, P=0.03) and fetal viability (Odds ratio=5.82, P=0.02). Increasing duration of dystocia was associated with significant increases in SAA, Hp, BUN and AST, but with decreases in E2 (P<0.05). After a transient period of elevation, the white blood cell and neutrophil counts decreased (P<0.05). In conclusion, abnormal posture and uterine torsion were found to be the common causes of dystocia in dromedary camels, and fetal and maternal deaths were mainly associated with the duration of dystocia., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Introduction: A protocol including judicious use of oxytocin augmentation was investigated to determine whether it would change how oxytocin was used and eventually influence labor and fetal outcomes., Material and Methods: The population of this cohort study comprised 20 227 delivering women with singleton pregnancies ≥37 weeks, cephalic presentation, spontaneous or induced onset of labor, without previous cesarean section. Women delivering from 2009 to 2013 at Stavanger University Hospital, Norway, were included. Data were collected prospectively. Before implementing the protocol in 2010, oxytocin augmentation was used if progression of labor was perceived as slow. After implementation, oxytocin could only be started when the cervical dilation had crossed the 4-h action line in the partograph., Results: The overall use of oxytocin augmentation was significantly reduced from 34.9% to 23.1% (p < 0.01). The overall frequency of emergency cesarean sections decreased from 6.9% to 5.3% (p < 0.05) and the frequency of emergency cesarean sections performed due to fetal distress was reduced from 3.2% to 2.0% (p = 0.01). The rate of women with duration of labor over 12 h increased from 4.4% to 8.5% (p < 0.01) and more women experienced severe estimated postpartum hemorrhage (2.6% vs. 3.7%; p = 0.01). The frequency of children with pH <7.1 in the umbilical artery was reduced from 4.7% to 3.2% (p < 0.01)., Conclusions: The frequency of emergency cesarean section was reduced after implementing judicious use of oxytocin augmentation. Our findings may be of interest in the ongoing discussion of how the balanced use of oxytocin for labor augmentation can best be achieved., (© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal., Methods: A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis., Results: The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78)., Conclusions: About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.

Background: Cesarean section is the commonest obstetric operative procedure worldwide. When used appropriately cesarean sections can improve infant and/or maternal outcomes. However, when used inappropriately the potential harm may exceed the potential benefit of cesarean section. Appreciating the limited information in this area the current study assessed the rate and factors associated with cesarean section in Felegehiwot referral hospital, Bahir Dar, northwest Ethiopia., Method: The study was a retrospective analysis of eligible patient records that included 2967 pregnant women who had underwent either cesarean or vaginal delivery from July 1, 2012 to June 31, 2013. The data were double entered to EPI-INFO 3.5.2 and analyzed with SPSS. Binary logistic regression model was fitted to identify independent factors associated with cesarean section., Result: The proportion of women who underwent cesarean section in this study was 25.4%. Obstructed labor (30.7%), fetal distress (15.9%) and abnormal presentation (13.4%) were the major obstetric indications for cesarean section. The odd of undergoing cesarean section was higher among mothers in rural residence (AOR = 1.63, 95% CI: 1.21, 2.20), mothers reported to have pregnancy risk factors (AOR = 2.31, 95% CI: 1.74, 3.07) and lower among mothers in age category of 15-19 (AOR = 0.63, 95% CI: 0.43, 0.93)., Conclusion: Obstetric factors occurring around birth, including obstructed labor and fetal distress were the main reasons leading to Cesarean Section rather than background characteristics assumed to be a risk. The results imply that there is a need for timely and accurate screening of women during obstetric care and, decision to perform cesarean section should be based on clear, compelling and well-supported justifications.

Objective: To determine the effect of obesity on decision-to-incision and decision-to-delivery time intervals in emergency Caesarean section., Methods: We performed a retrospective study of emergency Caesarean sections performed between 2005 and 2009. Indications for emergency Caesarean section were defined as those posing an immediate threat to the life of the mother or fetus. The primary outcomes were the time intervals from decision for emergency delivery to skin incision, and decision to delivery of the infant. The secondary outcome was a composite of poor neonatal outcomes comprising umbilical cord artery pH lt; 7.20, Apgar score lt; 7 at five minutes, admission to NICU, or neonatal death., Results: A total of 232 women underwent emergency Caesarean section, and 140 of these met the inclusion criteria. At the time of delivery, 78/140 (55.7%) patients were categorized as obese (BMI ≥ 30kg/m2). The median decision-to-incision and decision-to-delivery intervals were significantly longer in the obese group, with a median delay of 4.5 minutes in both time intervals. Time-to-event analysis demonstrated prolongation of the decision-to-incision interval in the obese group (hazard ratio 0.71, P lt; 0.05). There was no difference in the neonatal composite outcome, but there was a significant reduction in median five-minute Apgar score in the obese group (P = 0.02)., Conclusion: Obesity is associated with prolonged decision-to-incision and decision-to-delivery intervals, without associated neonatal morbidity, in a tertiary hospital setting. Further studies are required to assess the specific factors limiting expedient delivery in this population.

Background: Caesarean delivery (C-section) rates have been increasing dramatically in the past decades around the world. This increase has been attributed to multiple factors such as maternal, socio-demographic and institutional factors and is a burning issue of global aspect like in many developed and developing countries. Therefore, this study examines the relationship between mode of delivery and time to event with provider characteristics (i.e., covariates) respectively., Methods: The study is based on a total of 1142 delivery cases from four private and four public hospitals maternity wards. Logistic regression and Cox proportional hazard models were the statistical tools of the present study., Results: The logistic regression of multivariate analysis indicated that the risk of having a previous C-section, prolonged labour, higher educational level, mother age 25 years and above, lower order of birth, length of baby more than 45 cm and irregular intake of balanced diet were significantly predict for C-section. With regard to survival time, using the Cox model, fetal distress, previous C-section, mother's age, age at marriage and order of birth were also the most independent risk factors for C-section. By the forward stepwise selection, the study reveals that the most common factors were previous C-section, mother's age and order of birth in both analysis. As shown in the above results, the study suggests that these factors may influence the health-seeking behaviour of women., Conclusions: Findings suggest that program and policies need to address the increase rate of caesarean delivery in Northern region of Bangladesh. Also, for determinant of risk factors, the result of Akaike Information Criterion (AIC) indicated that logistic model is an efficient model.

Objectives: To evaluate the efficacy and safety of double balloon catheter for induction of labour in Chinese women with one previous caesarean section and unfavourable cervix at term., Design: Retrospective cohort study., Setting: A regional hospital in Hong Kong., Patients: Women with previous caesarean delivery requiring induction of labour at term and with an unfavourable cervix from May 2013 to April 2014., Major Outcome Measures: Primary outcome was to assess rate of successful vaginal delivery (spontaneous or instrument-assisted) using double balloon catheter. Secondary outcomes were double balloon catheter induction-to-delivery and removal-to-delivery interval; cervical score improvement; oxytocin augmentation; maternal or fetal complications during cervical ripening, intrapartum and postpartum period; and risk factors associated with unsuccessful induction., Results: All 24 Chinese women tolerated double balloon catheter well. After double balloon catheter expulsion or removal, the cervix successfully ripened in 18 (75%) cases. The improvement in Bishop score 3 (interquartile range, 2-4) was statistically significant (P<0.001). Overall, 18 (75%) cases were delivered vaginally. The median insertion-to-delivery and removal-to-delivery intervals were 19 (interquartile range, 13.4-23.0) hours and 6.9 (interquartile range, 4.1-10.8) hours, respectively. Compared with cases without, the interval to delivery was statistically significantly shorter in those with spontaneous balloon expulsion or spontaneous membrane rupture during ripening (7.8 vs 3.0 hours; P=0.025). There were no major maternal or neonatal complications. The only factor significantly associated with failed vaginal birth after caesarean was previous caesarean section for failure to progress (P<0.001)., Conclusions: This is the first study using double balloon catheter for induction of labour in Asian Chinese women with previous caesarean section. Using double balloon catheter, we achieved a vaginal birth after caesarean rate of 75% without major complications.

Objective: To establish whether failure to progress during labor poses a risk factor for another non-progressive labor (NPL) during the subsequent delivery., Methods: A retrospective cohort study including singleton pregnancies that failed to progress during the previous labor and resulted in a cesarean section (CS) was conducted. Parturients were classified into three groups for both previous and subsequent labors: CS due to NPL stage I, stage II and an elective CS as a comparison group., Results: Of 202 462 deliveries, 10 654 women met the inclusion criteria: 3068 women were operated due to NPL stage I and 1218 due to NPL stage II. The comparison group included 6368 women. Using a multivariable logistic regression models, NPL stage I during the previous delivery was found as an independent risk factor for another NPL stage I in the subsequent labor (adjusted odds ratio [OR] = 2.9; 95% confidence interval [CI] = 2.4-3.7; p < 0.001). Similarly, NPL at stage I or II was found to be an independent risk factor for a NPL stage II during the subsequent labor (adjusted OR = 1.4; 95% CI = 1.1-2.1; p = 0.033; adjusted OR = 5.3; 95% CI = 3.7-7.5; p < 0.001; respectively)., Conclusion: A previous CS due to a NPL is an independent risk factor for another NPL in the subsequent pregnancy and for recurrent cesarean delivery.

Objective: To review the major indications for cesareans performed by Médecins Sans Frontières (MSF) personnel from the Operational Center Brussels., Methods: A retrospective study was undertaken of all singleton cesarean deliveries from 2008-2012 for which indications were recorded. Location of project, age of patient, type of anesthesia, and duration of operation were also recorded., Results: A total of 14 151 singleton cesarean deliveries were identified from 17 countries. Among the 15 905 indications recorded, the most common was failure to progress or cephalopelvic disproportion (4822 [30.3%]), followed by previous uterine scar (2504 [15.7%]), non-reassuring fetal status (2306 [14.5%]), and fetal malpresentation (1746 [11.0%]). Other indications were placenta or vasa previa (794 [5.0%]), uterine rupture (676 [4.3%]), hypertensive disorders (659 [4.1%]), placental abruption (520 [3.3%]), pre-rupture (450 [2.8%]), and cord prolapse (365 [2.3%])., Conclusion: Indications for cesareans in MSF settings differ from those in higher-income countries. Further investigation is needed for adequate emergency obstetric care coverage., (Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the rate of cesarean delivery and its indications at public emergency obstetric care (EmOC) hospitals in a district in Bangladesh., Methods: In a retrospective, cross-sectional study, data were extracted from the Safe Motherhood Promotion Project database and operation theater registers for cesarean deliveries at three district and three subdistrict EmOC hospitals in Narsingdi between January 1 and December 31, 2008. Information on cesarean deliveries and their indications, and maternal and neonatal outcomes were analyzed descriptively., Results: Among 3329 deliveries, 1075 (32.3%) occurred by cesarean. The frequency of cesarean delivery ranged from 17.8% (147 of 824 deliveries) to 56.3% (174 of 309) among the six hospitals. Information on indications was available for 1043 cesarean deliveries. The main indications were previous cesarean delivery (251 deliveries, 24.1%), fetal distress (228, 21.9%), and prolonged or obstructed labor (214, 20.5%). There were no maternal deaths, but 10 (1.0%) cesarean deliveries resulted in stillbirth., Conclusion: The overall rate of cesarean delivery was high at EmOC hospitals. Interventions to improve decision making and limit possible unnecessary cesarean operations are needed., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the mode of delivery in women after a successful external cephalic version by performing a systematic review and meta-analysis., Data Sources: We searched MEDLINE, Embase, ClinicalTrials.gov, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library for studies reporting on the mode of delivery in women after successful external cephalic version at term and women with a spontaneous cephalic-presenting fetus., Methods of Study Selection: Two reviewers independently selected studies, extracted data, and assessed study quality. The association between mode of delivery and successful external cephalic version was expressed as a common odds ratio with a 95% confidence interval (CI)., Tabulation, Integration, and Results: We identified three cohort studies and eight case-control studies, reporting on 46,641 women. The average cesarean delivery rate for women with a successful external cephalic version was 21%. Women after successful external cephalic version were at increased risk for cesarean delivery for dystocia (odds ratio [OR] 2.2, 95% CI 1.6-3.0), cesarean delivery for fetal distress (OR 2.2, 95% CI 1.6-2.9), and instrumental vaginal delivery (OR 1.4, 95% CI 1.1-1.7)., Level of Evidence: Women who have had a successful external cephalic version for breech presentation are at increased risk for cesarean delivery and instrumental vaginal delivery as compared with women with a spontaneous cephalic presentation. Nevertheless, with a number needed to treat of three, external cephalic version still remains a very efficient procedure to prevent a cesarean delivery.

Symphysiotomy to manage shoulder dystocia is seldom used in the western world. For this reason, in well-resourced countries knowledge of its recuperation rate and the management of physical discomfort in the post-partum period is scarce. We describe two cases of symphysiotomy for shoulder dystocia. Both babies did very well in the postpartum period. The short-term 6-week and 6-month follow-up of both mothers is described. Short-term maternal complications were minor and based on prolonged immobilization. In accordance with the international literature, the short-term and long-term follow-up after symphysiotomy for shoulder dystocia was good and there were no major maternal or neonatal complications. We therefore wish to advocate symphysiotomy as a good and safe option to deliver a baby in cases of severe shoulder dystocia, when all other manoeuvres fail.

Objective: To delineate adverse obstetric and neonatal outcomes as well as indications for cesarean delivery by maternal age in a contemporaneous large national cohort., Methods: This was a retrospective analysis of electronic medical records from 12 centers and 203,517 (30,673 women aged 35 years or older) women with singleton gestations stratified by maternal age. Logistic regression was performed to investigate maternal and neonatal outcomes for each maternal age strata (referent group, age 25.0-29.9 years), adjusting for race, parity, body mass index, insurance, pre-existing medical conditions, substance and tobacco use, and site. Documented indications for cesarean delivery were analyzed., Results: Neonates born to women aged 25.0-29.9 years had the lowest risk of birth weight less than 2,500 g (7.2%; P<.001), admission to neonatal intensive care unit (11.5%; P<.001), and perinatal mortality (0.7%; P<.001). Hypertensive disorders of pregnancy were higher in women aged 35 years or older (cumulative rate 8.5% compared with 7.8%; 25.0-29.9 years; P<.001). Previous uterine scar was the leading indication for cesarean delivery in women aged 25.0 years or older (36.9%; P<.001). For younger women, failure to progress or cephalopelvic disproportion (37.0% for those younger than age 20.0 years and 31.1% for those aged 20.0-24.9-years; P<.001) and nonreassuring fetal heart tracing (28.7% for those younger than 20.0 years and 21.2% for those aged 20.0-24.9-years; P<.001) predominated as indications. Truly elective cesarean delivery rate was 20.2% for women aged 45.0 years or older (adjusted odds ratio 1.85 [99% confidence interval 1.03-3.32] compared with the referent age group of 25.0-29.9 years)., Conclusions: Maternal and obstetric complications differed by maternal age, as did rates of elective cesarean delivery. Women aged 25.0-29.9 years had the lowest rate of serious neonatal morbidity., Level of Evidence: : II.