OBJECTIVE: To compare neonatal mortality and neonatal and maternal morbidity in planned vaginal delivery versus elective caesarean section for breech presentation at term. To identify factors associated with the risk of caesarean section during labour. DESIGN: Cohort study. SETTING: University Hospital of Geneva. POPULATION: Seven hundred and five consecutive singleton term breech presentations: 385 planned vaginal deliveries and 320 elective caesarean sections. METHODS: Relative risk and risk difference with their 95% confidence intervals (95% CI) were calculated for neonatal and maternal morbidity. Prognostic factors for the risk of intrapartum caesarean section were analysed by multiple logistic regression. MAIN OUTCOME MEASURES: 1. Neonatal mortality 2. Neonatal morbidity (eg. fracture, haematoma with hyperbilirubinemia, paresis, paralysis, visceral trauma, respiratory distress, umbilical cord arterial pH<7.0 with 5 minute Apgar score<7), corrected neonatal morbidity was defined as morbidity after exclusion of major malformations. 3. Maternal morbidity (eg. endometritis, urinary infection, pulmonary infection, surgical complications, hysterectomy, anaemia, pulmonary embolism, cardio-respiratory arrest). RESULTS: There were significantly fewer maternal complications in the planned vaginal delivery group than in the elective caesarean section group (risk difference 10.5%, 95% CI 3.9 to 17.0). Five neonates with major malformations died. There was no difference in corrected neonatal morbidity between the planned vaginal delivery and the elective caesarean section groups (risk difference 1.9%, 95% CI -1.0 to 4.9). Nulliparity, maternal age>30 years and a higher body mass index were independently associated with the risk (30%) of intrapartum caesarean section, but it was not possible to construct a predictive model useful for clinical practice. CONCLUSIONS: There is no firm evidence to recommend systematic elective caesarean section for breech presentation at term. Large unbiased studies are needed to determine whether a potential benefit for the newborns outweighs the increased risk for the mothers associated with elective caesarean section.

OBJECTIVE: To determine whether cesarean and operative vaginal deliveries are associated with an increased risk of maternal rehospitalization compared with spontaneous vaginal delivery. METHODS: A population-based cohort study was conducted by using the Canadian Institute for Health Information's Discharge Abstract Database between 1997/1998 and 2000/2001, which included 900,108 women aged 15-44 years with singleton live births (after excluding several selected obstetric conditions). RESULTS: A total of 16,404 women (1.8%) were rehospitalized within 60 days after initial discharge. Compared with spontaneous vaginal delivery (rate 1.5%), cesarean delivery was associated with a significantly increased risk of postpartum readmission (rate 2.7%, odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8-1.9); ie, there was 1 excess postpartum readmission per 75 cesarean deliveries. Diagnoses associated with significantly increased risks of readmission after cesarean delivery (compared with spontaneous vaginal delivery) included pelvic injury/wounds (rate 0.86% versus 0.06%, OR 13.4, 95% CI 12.0-15.0), obstetric complications (rate 0.23% versus 0.08%, OR 3.0, 95% CI 2.6-3.5), venous disorders and thromboembolism (rate 0.07% versus 0.03%, OR 2.7, 95% CI 2.1-3.4), and major puerperal infection (rate 0.45% versus 0.27%, OR 1.8, 95% CI 1.6-1.9). Women delivered by forceps or vacuum were also at an increased risk of readmission (rates 2.2% and 1.8% versus 1.5%; OR forceps: 1.4, 95% CI 1.3-1.5; OR vacuum: 1.2, 95% CI 1.2-1.3, respectively). Higher readmission rates after operative vaginal delivery were due to pelvic injury/wounds, genitourinary conditions, obstetric complications, postpartum hemorrhage, and major puerperal infection. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery, and operative vaginal delivery increase the risk of maternal postpartum readmission. LEVEL OF EVIDENCE: II-2.

OBJECTIVE:To determine whether changing the definition of the group to which induction is being compared (ie, noninduced delivering during the same week as those induced compared with two definitions of expectant management) changes the association of labor induction and increased cesarean risk.

METHODS:A New York State birth-certificate database was used to estimate odds ratios for cesarean delivery associated with labor induction at term. The analyses used three definitions of controls: cesarean delivery after induction compared with after spontaneous labor by week (week-to-week), induction at a given gestation age compared with expectant management of all other women after gestational age (all above), or induction at a given gestational age compared with expectant management of all other women at or after that gestational age (at or above). Chi-square logistic regression was used for comparisons and adjustment for possible confounders.

RESULTS:All variations of comparison groups were associated with increased unadjusted cesarean risk after induction, although not after 39 weeks in the all-above group. After adjustment, increased risk persisted from 37 to 41 weeks using the week-to-week group and from 38 to 41 weeks in the at-or-above group (odds ratios 1.24 to 1.45) but was no longer significant in the all-above group. The excess cesarean delivery risk associated with labor induction is between 1 and 2 per 25 inductions.

CONCLUSION:Labor induction is associated with increased cesarean risk whether using a week-to-week comparison group or an expectant group that includes women the same week or beyond that of the index induction, even after adjustment for parity, high-risk factors, and demographic variables. Although the magnitude of increased risk for a given woman undergoing induction is not large, women nonetheless should be informed of this increased risk.

LEVEL OF EVIDENCE:II.

OBJECTIVE:To determine whether changing the definition of the group to which induction is being compared (ie, noninduced delivering during the same week as those induced compared with two definitions of expectant management) changes the association of labor induction and increased cesarean risk.

METHODS:A New York State birth-certificate database was used to estimate odds ratios for cesarean delivery associated with labor induction at term. The analyses used three definitions of controls: cesarean delivery after induction compared with after spontaneous labor by week (week-to-week), induction at a given gestation age compared with expectant management of all other women after gestational age (all above), or induction at a given gestational age compared with expectant management of all other women at or after that gestational age (at or above). Chi-square logistic regression was used for comparisons and adjustment for possible confounders.

RESULTS:All variations of comparison groups were associated with increased unadjusted cesarean risk after induction, although not after 39 weeks in the all-above group. After adjustment, increased risk persisted from 37 to 41 weeks using the week-to-week group and from 38 to 41 weeks in the at-or-above group (odds ratios 1.24 to 1.45) but was no longer significant in the all-above group. The excess cesarean delivery risk associated with labor induction is between 1 and 2 per 25 inductions.

CONCLUSION:Labor induction is associated with increased cesarean risk whether using a week-to-week comparison group or an expectant group that includes women the same week or beyond that of the index induction, even after adjustment for parity, high-risk factors, and demographic variables. Although the magnitude of increased risk for a given woman undergoing induction is not large, women nonetheless should be informed of this increased risk.

LEVEL OF EVIDENCE:II.

OBJECTIVE:To evaluate the role of parturition in the recurrence of endometriosis.

DESIGN:Retrospectively analyzed, prospectively obtained data.

SETTING:Unit of Physiopathology of Reproduction, Health Care Unit of Rimini, and University of Bologna Cervesi General Hospital, Cattolica, Italy.

PATIENT(S):Three hundred forty-five patients with stage II-IV endometriosis, dysmenorrhea, and infertility were treated for endometriosis and divided into four groups according to parity and mode of parturition.

INTERVENTION(S):The patients were laparoscopically treated for endometriosis upon the occurrence and recurrence of the disease. Ultrasound measurements of the uterine internal ostium (IOS) were performed at each study interval.

MAIN OUTCOME MEASURE(S):Degree of dysmenorrhea, occurrence and recurrence of endometriosis, and uterine IOS measurements were established and related to parity and mode of parturition.

RESULT(S):After parturition, dysmenorrhea recurrence was significantly higher in nulliparous women than in women with vaginal parturition. The endometriosis recurrence rate was higher in women who did not have vaginal parturition. The IOS significantly enlarged after vaginal delivery but not after cesarean delivery. There were significant negative correlations between IOS and the recurrence of endometriosis and dysmenorrhea. Odds ratios indicated that as the IOS enlarged, the risk of recurrence decreased.

CONCLUSION(S):Vaginal parturition plays a protective role in the recurrence of endometriosis.