Stephen J. Robson

Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia

BACKGROUND The rate of cesarean section in Australia now exceeds 30 percent, and evidence from population studies indicates that maternal requests for elective cesarean delivery might make an important contribution. The objective of this study was to explore the rate of such deliveries in Australia, in the absence of a formal investigation. METHODS An anonymous survey was sent to all 1,239 specialist obstetricians and 317 obstetric specialty trainees in Australia. Specialists were asked the number of elective cesarean deliveries they performed in 2006 that satisfied the National Institutes of Health definition of maternal request cesarean delivery. Trainees were asked whether they intended to agree to maternal requests for cesarean section in their future specialist practice. RESULTS The response rate from specialists was 98.6 percent, and from trainees was 81 percent. To account for possibility of multiple submissions, we performed two analyses: one using all responses, the other after removing 297 surveys in the second mail-out that were identical to surveys received from the first mail-out (n = 735). Proportions were similar in both groups. We estimated that between 8,553 and 12,434 maternal request cesarean sections were performed in Australia in 2006, representing at least 17 percent of all elective cesarean sections, and slightly more than 3 percent of all births. CONCLUSION Maternal request is an important contributor to cesarean section rates in Australia.

Elective caesarean delivery at maternal request: A preliminary study of motivations influencing women's decision-making

Background:  There is an extensive literature concerning caesarean section at maternal request, where no obstetric indication exists, yet little information about what motivates women to request such a delivery.

Birth outcomes for teenage women in New South Wales, 1998-2003.

Background:  Pregnancy and childbirth in teenage women are associated with obstetric and social risks, and there is evidence that the birth rate among teenagers in rural and remote areas of Australia is not in decline. The combination of non‐urban residence and young age at delivery might define a subgroup of women at special risk of adverse birth outcomes.

Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery

Background:  The use of Kjellands forceps is now uncommon, and published maternal and neonatal outcome data are from deliveries conducted more than a decade ago. The role of Kjellands rotational delivery in the ‘modern era’ of high caesarean section rates is unclear.

Obstetric management of the next pregnancy after an unexplained stillbirth: An anonymous postal survey of Australian obstetricians

Background:  Women who have an unexplained stillbirth are more likely to be delivered early, by induced labour or Caesarean section, in their next pregnancy. It is unclear whether these birth outcomes result from characteristics of the next pregnancy, or represent management strategies of obstetricians.

National decline in invasive prenatal diagnostic procedures in association with uptake of combined first trimester and cell‐free DNA aneuploidy screening

In late 2012, a new screening test for fetal aneuploidy based on circulating cell‐free DNA (cfDNA) became available to Australian women. The introduction of this technology in the United States has led to a reduction in invasive diagnostic procedures. Analysis of the number of amniocentesis and chorionic villus sampling (CVS) procedures performed in Australia from 1994 to 2014 shows that the introduction of cfDNA testing has been associated with the most rapid decline in invasive procedures in the last 20 years. This change has important implications for training in, and maintenance of, the procedural skills of amniocentesis and CVS.

Management of subsequent pregnancy after an unexplained stillbirth.

Purpose:To review the management of pregnancy after an unexplained stillbirth.Epidemiology:Approximately 1 in 200 pregnancies will end in stillbirth, of which about one-third will remain unexplained. Unexplained stillbirth is the largest single contributor to perinatal mortality. Subsequent pregnancies do not appear to have an increased risk of stillbirth, but are characterized by increased rates of intervention (induction of labor, elective cesarean section) and iatrogenic adverse outcomes (low birth weight, prematurity, emergency cesarean section and post-partum hemorrhage).Conclusions:There is no level-one evidence to guide management in this situation. Pre-pregnancy counseling is very important to detect and correct potential risk factors such as obesity, smoking and maternal disease. As timely delivery is the mainstay of management, early accurate determination of gestational age is vital. There is controversy regarding the pattern of surveillance, but evidence exists only for ultrasound and not for regular non-stress testing, nor formal fetal movement charting. There is an urgent need for more studies in this important area.

Power Doppler assessment of follicle vascularity at the time of oocyte retrieval in in vitro fertilization cycles.

OBJECTIVE To assess the practicality of using power Doppler (PD) to assess follicular vascularity at the time of oocyte retrieval. DESIGN Prospective study. SETTING University-affiliated IVF unit. PATIENT(S) Twenty-six women undergoing IVF treatment. INTERVENTION(S) Evaluation of follicular vascularity by using PD during oocyte retrieval. MAIN OUTCOME MEASURE(S) Subjective assessment of the impact of PD estimation of follicle vascularity during oocyte retrieval; reproducibility of grading of follicle vascularity. RESULT(S) Assessment of follicle vascularity by using PD during oocyte retrieval was found to be reproducible and to add minimally to the workload of the clinician and embryologist. The grade of follicle vascularity did not correlate with the yield of oocytes, fertilization rate, or concentration of hormones in follicular fluid. Although the study group was small, there was a statistically significant trend toward higher clinical pregnancy rates when the embryo transfer cohort contained at least one embryo from a highly vascular follicle (50% vs. 15.4%). CONCLUSION(S) Assessment of follicle vascularity by using PD at the time of oocyte retrieval was found to be a practical alternative to other methods.

Do women's perceptions of care at the time of unexplained stillbirth influence their wishes for management in subsequent pregnancy? : An Internet-based empirical study

Aim:  The aim of this study was to examine womens perceptions of their care at the time of unexplained stillbirth, and whether these appear to affect wishes for management in subsequent pregnancy.

Women's expectations of management in their next pregnancy after an unexplained stillbirth: an Internet-based empirical study.

Background:  Unexplained stillbirth is the largest contributor to perinatal death, accounting for one‐third of stillbirths. There appears to be no increase in perinatal death rates in the pregnancies that follow an unexplained stillbirth. However, these pregnancies have increased rates of induced labour and elective caesarean section, as well as preterm birth, low birthweight, instrumental delivery, ‘fetal distress’ and postpartum haemorrhage.