E. Sheiner

Risk factors for wound infection following cesarean deliveries

Objective: To identify risk factors for early wound infection (diagnosed prior to discharge) following cesarean delivery. Methods: A population‐based study comparing women who have and have not developed a wound infection prior to discharge from Soroka University Medical Center, Ben Gurion University of the Negev, between 1988 and 2002. Results: Of the 19,416 cesarean deliveries performed during the study period, 726 (3.7%) were followed by wound infection. Using a multivariable logistic regression model, the following risk factors were identified: obesity (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.6–3.1); hypertensive disorders (OR = 1.7; 95% CI, 1.4–2.1); premature rupture of membranes (OR = 1.5; 95% CI, 1.2–1.9); diabetes mellitus (OR = 1.4; 95% CI, 1.1–1.7); emergency cesarean delivery (OR = 1.3; 95% CI, 1.1–1.5); and twin delivery (OR = 1.6; 95% CI, 1.3–2.0). Combined obesity and diabetes (gestational and pregestational) increased the risk for wound infection 9.3‐fold (95% CI, 4.5–19.2; P < .001). Conclusion: Independent risk factors for an early wound infection are obesity, diabetes, hypertension, premature rupture of membranes, emergency cesarean delivery, and twin delivery. Information regarding higher rates of wound infection should be provided to obese women undergoing cesarean delivery, especially when diabetes coexists.

Placental abruption in term pregnancies: clinical significance and obstetric risk factors

Objective: To determine the incidence, obstetric risk factors and pregnancy outcome of placental abruption at term. Methods: A comparison of all singleton term deliveries (≥ 37 weeks gestation) complicated with placental abruption to singleton term deliveries without placental abruption. Multivariate analysis was performed to investigate independent risk factors for placental abruption. Results: Placental abruption complicated 0.3% of all term deliveries (n = 72995). A multiple logistic regression model with backward elimination found the following factors to be independently associated with the occurrence of placental abruption in term pregnancies: pregnancy-induced hypertension (PIH), intrauterine growth restriction (IUGR), non-vertex presentation, hydramnios and advanced maternal age. Perinatal mortality was significantly higher in pregnancies complicated with placental abruption (OR = 30.0, 95% CI 19.7-45.6; p < 0.001). In order to assess whether the increased risk for perinatal mortality was due to the placental abruption or to its significant association with other risk factors, a multivariate analysis was constructed with perinatal mortality as the outcome variable. Placental abruption (OR = 50.5, 95% CI 32.2-79.1), cord prolapse, small for gestational age and congenital malformations were found to be independent risk factors for perinatal mortality. Conclusion: Abruption of the placenta at term was found to be significantly associated with PIH, non-vertex presentation, IUGR, hydramnios and advanced maternal age. Owing to the independent association found between placental abruption and perinatal mortality, these conditions should be carefully evaluated in order to reduce the occurrence of placental abruption.

Ethnic differences influence care giver's estimates of pain during labour

The present study compared the childbirth experience of two different ethnic groups living in the same area and sharing the same medical facilities. We investigated the influence of ethnic differences between patient and care provider on the interpretation of pain. The subjects were 225 Jewish and 192 Bedouin parturients, who were prospectively evaluated for their labour pain experience. The pain intensity level was assessed by the parturient (self-reported pain) and by a Jewish doctor and midwife (exhibited pain) in the initial active phase of labour, using the visual analog scale (VAS). On the day after delivery, the women were asked to evaluate the present pain intensity level. Although the means of the self-assessments of pain intensity levels at the initial active phase of Jewish and Bedouin parturients were similar (8.55 and 8.53 respectively, P = 0.25), the Jewish medical staff interpreted Bedouin women to experience less pain than Jewish women (6.89 vs. 8.52, P < 0.001). On the day after delivery, the Jewish womens evaluation of their pain intensity levels again resembled that of the Bedouin women (2.02 and 2.11 respectively, P = 0.52). The Pearson correlation coefficients between the measures of self-reported and exhibited pain, were higher for Jewish than for Bedouin women (0.74 and 0.63, respectively). In a multiple linear regression analysis, both self-reported and exhibited pain scores were associated significantly with ethnicity and parity. In the model predicting exhibited pain, the level of religious observance was negatively associated with pain intensity scores. We conclude that the ethnic background of the care provider is an important determinant in estimating the suffering of the patients. It is important for the clinician to be aware of the wide spectrum of factors that might influence pain expression and interpretation. The knowledge that there are inter-ethnic differences might prevent a stereotyped response to the patient in pain.

Placenta previa: obstetric risk factors and pregnancy outcome.

Objective: To determine the incidence, obstetric risk factors and perinatal outcome of placenta previa. Study design: All singleton deliveries at our institution between 1990 and 1998 complicated with placenta previa were compared with those without placenta previa. Results: Placenta previa complicated 0.38% ( n = 298) of all singleton deliveries ( n = 78 524). A back-step multiple logistic regression model found the following factors to be independently correlated with the occurrence of placenta previa: maternal age above 40 years (OR 3.1, 95% CI 2.0-4.9), infertility treatments (OR 3.1, 95% CI 1.8-5.6), a previous Cesarean section (OR 1.8, 95% CI 1.4-2.4), a history of habitual abortions (OR 1.3, 95% CI 1.3-2.7) and Jewish ethnicity (OR 1.3, 95% CI 1.1-1.8). Pregnancies complicated with placenta previa had significantly higher rates of second-trimester bleeding (OR 156.0, 95% CI 87.2-277.5), pathological presentations (OR 7.6, 95% CI 5.7-10.1), abruptio placentae (OR 13.1, 95% CI 8.2-20.7), congenital malformations (OR 2.6, 95% CI 1.5-4.2), perinatal mortality (OR 2.6, 95% CI 1.1-5.6), Cesarean delivery (OR 57.4, 95% CI 40.7-81.4), Apgar scores at 5 min lower than 7 (OR 4.4, 95% CI 2.3-8.3), placenta accreta (OR 3.6, 95% CI 1.1-9.9) postpartum hemorrhage (OR 3.8, 95% CI 1.2-10.5), postpartum anemia (OR 5.5, 95% CI 4.4-6.9) and delayed maternal and infant discharge from the hospital (OR 10.9, 95% CI 7.3-16.1) as compared to pregnancies without placenta previa. In a multivariable analysis investigating risk factors for perinatal mortality, the following were found to be independent significant factors: congenital malformations, placental abruption, pathological presentations and preterm delivery. In contrast, placenta previa and Cesarean section were found to be protective factors against the occurrence of perinatal mortality while controlling for confounders. Conclusion: Although an abnormal implantation per se was not an independent risk factor for perinatal mortality, placenta previa should be considered as a marker for possible obstetric complications. Hence, the detection of placenta previa should encourage a careful evaluation with timely delivery in order to reduce the associated maternal and perinatal complications.

Risk factors for arrest of descent during the second stage of labor

Objective: To define obstetrical risk factors for arrest of descent during the second stage of labor and to determine perinatal outcome. Study design: All singleton, vertex, term deliveries with an unscarred uterus, between the years 1988 and 1999 were included. Univariable and multivariable analysis were performed to investigate independent risk factors associated with arrest of descent during the second stage of labor and the perinatal outcome. Results: The study included 93 266 deliveries, of these 1545 (1.7%) were complicated with arrest of descent during the second stage of labor. Using a multivariable analysis, the following obstetric risk factors were found to be significantly associated with arrest of descent: nulliparity (OR=7.8, 95% CI=6.9–8.7; P<0.001), birth weight >4 kg (OR=2.3, 95% CI=1.9–2.8; P<0.001), epidural analgesia (OR=1.8, 95% CI=1.6–2.0; P<0.001), hydramnios (OR=1.6, 95% CI=1.3–2.0; P<0.001), hypertensive disorders (OR=1.5, 95% CI=1.3–1.8; P<0.001), gestational diabetes A1 and A2 (OR=1.5, 95% CI=1.2–1.8; P<0.001), male gender (OR=1.4, 95% CI=1.2–1.5; P<0.001), premature rupture of membranes (PROM, OR=1.3, 95% CI=1.04–1.6; P=0.021), and induction of labor (OR=1.2, 95% CI=1.02–1.4; P=0.030). Deliveries complicated by arrest of descent resulted in cesarean section in 20.6%, vacuum extraction in 74.0%, and forceps delivery in 5.4%. Newborns delivered after arrest of descent during the second stage of labor had significantly higher rates of low Apgar scores (<7) at 1 and 5 min, as compared to the controls (12.7 vs. 2.1%, P<0.001; and 0.9 vs. 0.2%, P<0.001, respectively). Nevertheless, no significant differences were noted between the groups regarding perinatal mortality (0.38 vs. 0.44%; P=0.759). Conclusions: Major risk factors for arrest of descent during the second stage of labor were nulliparity, fetal macrosomia, epidural analgesia, hydramnios, hypertensive disorders and gestational diabetes mellitus. These risk factors should be carefully evaluated during pregnancy in order to actively manage high‐risk pregnancies.

Potential association between male infertility and occupational psychological stress.

Learning ObjectivesRecall past findings associating sperm parameters with occupational exposure to chemicals or work-related psychological distressUnderstand in what occupational, health, and demographic respects workers with male factor infertility differ from those seen for female infertility.Note which if any aspects of occupational stress were associated with male infertility in this study.Identify any clinical implications of these findings. The purpose of this work was to investigate the influence of working conditions, occupational exposures to potential reproductive toxic agents, and psychological stress on male fertility. The study population consisted of 202 consecutive male patients attending a fertility clinic. Of those, 106 patients had attended the clinic because of a male infertility problem (case group), 66 patients had attended the clinic because of a female infertility problem (control group), and 30 patients had a combined infertility problem (male and female). Male infertility was associated with working in industry and construction as compared with other occupations (78.6% vs 58.3%, P = 0.044). Industry and construction workers were of lower educational level than the other workers (mean: 12.1 vs 13.4 years, P = 0.021). These patients also tended to smoke more than the other workers (OR = 2.53, 95% CI = 1.08 to 5.98), more often worked in shifts (OR = 3.12, 95% CI = 1.19 to 8.13), reported physical exertion in work (OR = 3.35, 95% CI = 1.44 to 7.80), and were more exposed to noise and welding (OR = 3.84, 95% CI = 1.63 to 9.14, OR = 4.40, 95% CI = 1.11 to 1.76, respectively). Male infertility (case group) was found to be statistically related to higher marks in all four measures of burnout as compared with the controls. The largest difference was obtained in the measure of cognitive weariness (mean:2.9vs 2.1, P < 0.001). In a multiple logistic regression analysis, industry and construction jobs (adjusted OR = 2.2, 95% CI 1.2 to 2.7) and cognitive weariness (adjusted OR = 1.8, 95% CI = 1.03 to 4.6) were found to be independent risk factors for male infertility problems. Male infertility was independently associated with industry and construction jobs as well as job burnout.

Incidence, obstetric risk factors and pregnancy outcome of preterm placental abruption: a retrospective analysis

Objective: To determine obstetric risk factors for the occurrence of preterm placental abruption and to investigate its subsequent perinatal outcome. Study design: A retrospective comparison of all singleton preterm deliveries complicated with placental abruption, between the years 1990-1998, to all singleton preterm deliveries without placental abruption, in the Soroka University Medical Center. Results: Placental abruption complicated 300 (5.1%) of all preterm deliveries (n = 5934). A back-step multivariable analysis found the following factors to be independently correlated with the occurrence of preterm placental abruption: grandmultiparity (more than five deliveries), early gestational age, severe pregnancy-induced hypertension, previous second-trimester bleeding and non-vertex presentation. These pregnancies had a significantly lower rate of preterm premature rupture of membranes than preterm pregnancies without placental abruption. Pregnancies complicated with preterm placental abruption had significantly higher rates of cord prolapse, non-reassuring fetal heart rate patterns, congenital malformations, Cesarean deliveries, perinatal mortality, Apgar scores lower than 7 at 5 min, postpartum anemia and delayed discharge from the hospital than did preterm deliveries without placental abruption. In order to assess whether the increased risk for perinatal mortality was due to the placental abruption, or due to its significant association with other risk factors, a multivariable analysis was constructed with perinatal mortality as the outcome variable. Placental abruption (OR 3.0, 95% CI 2.1-4.1) as well as cord prolapse, previous perinatal death, low birth weight and congenital malformations were found to be independent risk factors for perinatal mortality. Conclusion: Preterm placental abruption is an unpredictable severe complication associated with significant perinatal morbidity and mortality. Factors found to be independently associated with placental abruption were grandmultiparity, severe pregnancy-induced hypertension, malpresentation, earlier gestational age and a history of second-trimester vaginal bleeding.

Umbilical cord prolapse and perinatal outcomes

Objectives: To determine obstetric risk factors and perinatal outcomes of pregnancies complicated by umbilical cord prolapse. Methods: A population‐based study was performed comparing all deliveries complicated by cord prolapse to deliveries without this complication. Statistical analysis was performed using multiple logistic regression models. Results: Prolapse of the umbilical cord complicated 0.4% (n=456) of all deliveries included in the study (n=121 227). Independent risk factors for cord prolapse identified by a backward, stepwise multivariate logistic regression model were: malpresentation (OR=5.1; 95% CI 4.1–6.3), hydramnios (OR=3.0; 95% CI 2.3–3.9), true knot of the umbilical cord (OR=3.0; 95% CI 1.8–5.1), preterm delivery (OR=2.1; 95% CI 1.6–2.8), induction of labor (OR=2.2; 95% CI 1.7–2.8), grandmultiparity (>five deliveries, OR=1.9; 95% CI 1.5–2.3), lack of prenatal care (OR=1.4; 95% CI 1.02–1.8), and male gender (OR=1.3; 95% CI 1.1–1.6). Newborns delivered after umbilical cord prolapse graded lower Apgar scores, less than 7, at 5 min (OR=11.9, 95% CI 7.9–17.9), and had longer hospitalizations (mean 5.4±3.5 days vs. 2.9±2.1 days; P<0.001). Moreover, higher rates of perinatal mortality were noted in the cord prolapse group vs. the control group (OR=6.4, 95% CI 4.5–9.0). Using a multiple logistic regression model controlling for possible confounders, such as preterm delivery, hydramnios, etc., umbilical cord prolapse was found to be an independent contributing factor to perinatal mortality. Conclusions: Prolapse of the umbilical cord is an independent risk factor for perinatal mortality.

Predictors of recommendation and acceptance of intrapartum epidural analgesia.

We conducted this prospective study to characterize the obstetric and sociodemographic variables that predict physicians’ recommendations and patients’ acceptance of intrapartum epidural analgesia. The study population consisted of 447 consecutive, low-risk parturients in early active labor. Epidural analgesia was recommended to 393 patients (87.9%), however only 164 (41.7%) consented to receive it. A multiple logistic regression analysis demonstrated that the severity of pain, as assessed by the medical staff (odds ratio [OR] = 1.5, 95% confidence interval [CI] 1.13, 1.93), low parity (OR = 0.57, 95% CI 0.44, 0.74), and low maternal age (OR = 0.89, 95% CI 0.79, 0.99) were significant factors affecting recommendations of epidural analgesia. In a multivariate analysis, severity of subjective pain (OR = 1.39, 95% CI 1.16, 1.68), low parity (OR = 0.80, 95% CI 0.73, 0.99), high education (OR = 90.09, 95% CI 27.02,257.06), and the patients’ being secular compared with religious (OR = 2.14, 95% CI 1.08,4.21) were found to be independent predictors of acceptance of epidural analgesia. There are differences between patients offered and those not offered epidural analgesia and between parturients who accept and those who do not accept this analgesia. Implications: We studied the factors that influence the recommendation of epidural analgesia by obstetricians, as well as its acceptance by the laboring patients at a university hospital in Israel. Epidural analgesia was recommended more often to low parity, younger women exhibiting more pain. Parturients who perceived greater pain were more secular, had low parity, and had a higher level of education were more likely to accept it.

Overestimation and underestimation of labor pain.

OBJECTIVEnTo define factors affecting the ability of the medical staff to estimate the level of pain during labor.nnnMETHODSnThe study population consisted of 255 consecutive women. All parturients were asked to rate their pain level, using a visual analog scale. At the same time, the caregivers estimated the degree of pain as was exhibited by the parturients, using the same scale. Patients whose pain level was either overestimated or underestimated were compared to patients whose pain was correctly estimated.nnnRESULTSnIn about half of the women (50.6%) enrolled in our study the level of pain was estimated correctly by the caregivers, while similar proportions of women had their pain level overestimated (24.3%) and underestimated (25.1%) by the caregivers. While the majority (54.5%) of patients who were in their second or third deliveries were equally estimated by the personnel with regard to their pain intensity levels, most of the grandmultiparous women had their labor pain underestimated by the medical staff. (57.1%, P<0.001). None of the caregivers had more than five children. Although the mostly secular medical staff could properly estimate the pain levels of most secular patients (52.3%), the labor pain of 44% of the religious parturients was underestimated (P=0.003). The ability to estimate properly the patients suffering was found to be unaffected by age, family status, educational level, presence of companion during labor and participation in childbirth preparation course.nnnCONCLUSIONnThe wider the cultural gap between the caregiver and the patient, the less accurate was the interpretation of patients pain.