Can the Rate of C-sections Performed in a Level I Perinatal Center Be Reduced? – An Analysis of the University Gynecology Clinic Rostock, 2008 – 2014

Abstract

Introduction In Germany the rate of deliveries by cesarean section is continually increasing. Many different reasons have been put forward to explain this trend. The aim of this study was to examine how the C-section rate developed at the University Gynecology Clinic Rostock, one of the biggest maternity hospitals and level I perinatal centers in Germany, based on various maternal and neonatal parameters. The aim was also to identify potential risk factors for C-sections.

Material and Method Various obstetric parameters were obtained from the birth cohort (2008 to 2014; n = 20 091) of the University Gynecology Clinic Rostock. The data was used to calculate parameter-specific C-section rates. Potential risk factors for C-section were identified by regression analysis.

Results The C-section rate dropped from 26.24% to 23.57%. The rate of repeat C-sections also declined. The mean age of the pregnant women increased. Nevertheless, the frequency of cesarean sections in pregnant women aged more than 35 years declined. Rates of being overweight or obese preconception increased. C-section rates increased as BMI values preconception increased. There was a perceptible trend towards attempting the vaginal delivery of children in breech presentation and of twins. The frequency of depressed neonates after vaginal delivery and after C-section decreased. Rates for mild and advanced acidosis increased after both C-sections and vaginal deliveries. Previous C-section, older maternal age, overweight and obesity prior to conception, breech presentation and multiple pregnancies all increased the risk of cesarean sections.

Conclusion This study showed that reducing the rates of C-sections without a deterioration in neonatal outcomes can be achieved even in a large maternity hospital that cares for many high-risk pregnancies.

Key words

cesarean section - neonatal outcome - breech presentation - twins

• References/Literatur

• 1 World Health Organization (WHO). Appropriate technology for birth. Lancet 1985; 326: 436-437
• 2 Gesundheitsberichterstattung des Bundes. Tabelle (gestaltbar): Entbindungen im Krankenhaus, u.a. nach Region. Online: http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/WS0100/_XWD_FORMPROC?TARGET=&PAGE=_XWD_2&OPINDEX=1&HANDLER=_XWD_CUBE.SETPGS&DATACUBE=_XWD_30&D.000=3736&D.100=10102 last access: 03.02.2017
• 3 DGGG – Deutsche Gesellschaft für Gynäkologie und Geburtshilfe. Absolute und relative Indikationen zur Sectio caesarea. AWMF-Registernummer: 015/054 (S1) 2010. Online: https://www.dggg.de/fileadmin/documents/leitlinien/archiviert/federfuehrend/015054_Absolute_und_relative_Indikationen_zur_Sectio_caesarea/015054_2010.pdf last access: 26.06.2017
• 4 Kolip P, Nolting HD, Zich K. Kaiserschnittgeburten – Entwicklung und regionale Verteilung, Faktencheck Gesundheit. Erstellt im Auftrag der Bertelsmann-Stiftung 2012 Online: http://www.bertelsmann-stiftung.de/de/publikationen/publikation/did/faktencheck-gesundheit-kaiserschnitt/ last access: 26.06.2017
• 5 Louwen F, Leuchter LM, Reitter A. Beckenendlagengeburt – mehr als Sectio vs. Spontangeburt. Z Geburtshilfe Neonatol 2012; 216: 191-194
• 6 Timofeev J, Reddy UM, Huang C. et al. Obstetric complications, neonatal morbidity, and indications for cesarean delivery by maternal age. Obstet Gynecol 2013; 122: 1184-1195
• 7 Barber EL, Lundsberg LS, Belanger K. et al. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011; 118: 29-38
• 8 Karlström A, Rådestad I, Eriksson C. et al. Cesarean section without medical reason, 1997 to 2006: a Swedish register study. Birth 2010; 37: 11-20
• 9 Mueller M, Kolly L, Bauman M. et al. Analysis of caesarean section rates over time in a single Swiss centre using a ten-group classification system. Swiss Med Wkly 2014; 144: w13921
• 10 Schuller R, Surbek D. Sectio caesarea: Aktuelle Kontroversen. Ther Umsch 2014; 71: 717-722
• 11 Fuglenes D, Oian P, Kristiansen IS. Obstetriciansʼ choice of cesarean delivery in ambiguous cases: is it influenced by risk attitude or fear of complaints and litigation?. Am J Obstet Gynecol 2009; 200: 48.e1-48.e8
• 12 Branch DW, Silver RM. Managing the primary cesarean delivery rate. Clin Obstet Gynecol 2012; 55: 946-960
• 13 Karlström A, Lindgren H, Hildingsson I. Maternal and infant outcome after caesarean section without recorded medical indication: findings from a Swedish case-control study. BJOG 2013; 120: 479-486
• 14 Hadar E, Melamed N, Tzadikevitch-Geffen K. et al. Timing and risk factors of maternal complications of cesarean section. Arch Gynecol Obstet 2011; 283: 735-741
• 15 Creanga AA, Bateman BT, Butwick AJ. et al. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor?. Am J Obstet Gynecol 2015; 213: 384.e1-384.e11
• 16 Solheim KN, Esakoff TF, Little SE. et al. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med 2011; 24: 1341-1346
• 17 Offermann H, Gebauer C, Pulzer F. et al. Cesarean section increases the risk of respiratory adaptive disorders in healthy late preterm and two groups of mature newborns. Z Geburtshilfe Neonatol 2016; 219: 259-265
• 18 Tita AT, Landon MB, Spong CY. et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009; 360: 111-120
• 19 Metsälä J, Kilkkinen A, Kaila M. et al. Perinatal factors and the risk of asthma in childhood–a population-based register study in Finland. Am J Epidemiol 2008; 168: 170-178
• 20 Thavagnanam S, Fleming J, Bromley A. et al. A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy 2008; 38: 629-633
• 21 Marrs T, Bruce KD, Logan K. et al. Is there an association between microbial exposure and food allergy? A systematic review. Pediatr Allergy Immunol 2013; 24: 311-320.e8
• 22 Penders J, Gerhold K, Stobberingh EE. et al. Establishment of the intestinal microbiota and its role for atopic dermatitis in early childhood. J Allergy Clin Immunol 2013; 132: 601-607.e8
• 23 Saling E. Das Kind im Bereich der Geburtshilfe. Stuttgart: Thieme; 1966
• 24 Stroth M. Die Sectio an der Universitätsfrauenklinik Rostock von 1997 – 2003 [Dissertation]. Rostock: Universität Rostock; 2007
• 25 Zhang J, Troendle J, Reddy UM. et al. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 2010; 203: 326.e1-326.e10
• 26 Kyvernitakis I, Reichelt J, Kyvernitakis A. et al. Trends of vaginal birth after cesarean delivery in Germany from 1990 to 2012: a population-based study. Z Geburtshilfe Neonatol 2014; 218: 203-209
• 27 Scholz R, Voigt M, Schneider KT. et al. Analysis of the German perinatal survey of the years 2007–2011 and comparison with data from 1995–1997: maternal characteristics. Geburtsh Frauenheilk 2013; 73: 1247-1251
• 28 Kottmel A, Hoesli I, Traub R. et al. Maternal request: a reason for rising rates of cesarean section?. Arch Gynecol Obstet 2012; 286: 93-98
• 29 Voigt M, Rochow N, Zygmunt M. et al. Risks of pregnancy and birth, birth presentation, and mode of delivery in relation to the age of primiparous women. Z Geburtshilfe Neonatol 2008; 212: 206-210
• 30 Rosenthal AN, Paterson-Brown S. Is there an incremental rise in the risk of obstetric intervention with increasing maternal age?. BJOG 1998; 105: 1064-1069
• 31 Briese V, Voigt M, Wisser J. et al. Risks of pregnancy and birth in obese primiparous women: an analysis of German perinatal statistics. Arch Gynecol Obstet 2011; 283: 249-253
• 32 Callaway LK, Prins JB, Chang AM. et al. The prevalence and impact of overweight and obesity in an Australian obstetric population. Med J Aust 2006; 184: 56-59
• 33 Hannah ME, Hannah WJ, Hewson SA. et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356: 1375-1383
• 34 Lansac J, Crenn-Hebert C, Rivière O. et al. How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network. Eur J Obstet Gynecol Reprod Biol 2015; 188: 79-82
• 35 Vlemmix F, Bergenhenegouwen L, Schaaf JM. et al. Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstet Gynecol Scand 2014; 93: 888-896
• 36 Whyte H, Hannah ME, Saigal S. et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191: 864-871
• 37 Lyons J, Pressey T, Bartholomew S. et al. Delivery of breech presentation at term gestation in Canada, 2003–2011. Obstet Gynecol 2015; 125: 1153-1161
• 38 Maier B, Georgoulopoulos A, Zajc M. et al. Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and womenʼs choices of mode of delivery. J Perinat Med 2011; 39: 385-390
• 39 Kyvernitakis A, Kyvernitakis I, Karageorgiadis A. et al. Rising cesarean rates of twin deliveries in Germany from 1990 to 2012. Z Geburtshilfe Neonatol 2013; 217: 177-182
• 40 Arikan I, Barut A, Harma M. et al. Cesarean section with relative indications versus spontaneous vaginal delivery: short-term outcomes of maternofetal health. Clin Exp Obstet Gynecol 2012; 39: 288-292
• 41 Choudhury AP, Dawson AJ. Trends in indications for caesarean sections over 7 years in a Welsh district general hospital. J Obstet Gynaecol 2009; 29: 714-717
• 42 Fuglenes D, Aas E, Botten G. et al. Why do some pregnant women prefer cesarean? The influence of parity, delivery experiences, and fear. Am J Obstet Gynecol 2011; 205: 45.e1-45.e9
• 43 Hainer F, Kowalcek I. Wünsche von Schwangeren an den Geburtsmodus. Z Geburtshilfe Neonatol 2011; 215: 35-40
• 44 Wiklund I, Edman G, Ryding E. et al. Expectation and experiences of childbirth in primiparae with caesarean section. BJOG 2008; 115: 324-331
• 45 Halvorsen L, Nerum H, Sørlie T. et al. Does counsellorʼs attitude influence change in a request for a caesarean in women with fear of birth?. Midwifery 2010; 26: 45-52