Analyzing whether physicians use cesarean sections (c-sections) as defensive medicine (DM) has proven difficult. Using natural experiments arising out of Oregon court decisions overturning a state legislative cap on non-economic damages in tort cases, we analyze the impact of patient conditions on estimates of DM. Consistent with theory, we find heterogeneous impacts of tort laws across patient conditions. When medical exigencies dictate a c-section, tort laws have no impact on physician decisions. When physicians have latitude in their decision making, we find evidence of DM. When we estimate a model combining all women and not accounting for patient conditions (such as models estimated in previous studies) we obtain a result which is the opposite of DM, which we call offensive medicine (OM). The OM result appears to arise out of a bias in the difference-in-differences estimator associated with changes in the marginal distributions of patient conditions in control and treatment groups. The changes in the marginal distributions appear to arise from the impact of tort law on the market for midwives (substitutes for physicians for low-risk women). Our analysis suggests that not accounting for theoretically expected heterogeneity in physician reactions to changes in tort laws may produce biased estimates of DM.

Surgical site infections (SSI) are a significant cause of post-surgical morbidity and mortality. The objectives of this study were to determine the prevalence of SSI and identify risk factors for infections following cesarean section (CS). A prospective study of SSI after CS was carried out from January 2014 to December 2016 using the methodology of the American National Nosocomial Infection Surveillance System. Suspected SSIs were confirmed clinically by the surgeon, and or, by culture. Seven thousand two hundred thirty five CS were performed with an overall SSI prevalence of 2.1%, increasing from 1.7% in 2014 to 2.95% in 2016 (P = 0.010). Of 152 cases of SSI, the prevalence of infection was 46.7% in women ⩽30 years and 53.3% in women >30 years (P = 0.119). Of 148 culture samples from as many women, 112 (75.7%) yielded growth of microorganisms with 42 (37.5%) of isolates being multi-drug resistant (MDR). Women who did not receive prophylactic antibiotics (35.5%) developed SSI more often than those who did (P < 0.0001). These findings suggest that emergency CS and inappropriate antibiotic prophylaxis are risk factors for developing SSI. In the light of the emergence of MDR bacteria there is a need to implement revised prophylactic antibiotic policy as part of antimicrobial stewardship to decrease SSI rates.

Aim: To determine the differences in hemoglobin (Hb) levels in the first 2 days after birth in uncomplicated monochorionic twins in relation to birth order and mode of delivery. Methods: All consecutive uncomplicated monochorionic pregnancies with two live-born twins delivered at our center were included in this retrospective study. We recorded Hb levels at birth and on day 2, and analyzed Hb levels in association with birth order, mode of delivery, and time interval between delivery of twin 1 and 2. Results: A total of 290 monochorionic twin pairs were analyzed, including 171 (59%) twins delivered vaginally and 119 (41%) twins born by cesarean section (CS). In twins delivered vaginally, mean Hb levels at birth and on day 2 were significantly higher in second-born twins compared to first-born twins: 17.8 versus 16.1 g/dL and 18.0 versus 14.8 g/dL, respectively (p < .01). Polycythemia was detected more often in second-born twins (12%, 20/166) compared to first-born twins (1%, 2/166; p < .01). Hb differences within twin pairs delivered by CS were not statistically or clinically significant. We found no association between inter-twin delivery time intervals and Hb differences. Conclusions: Second-born twins after vaginal delivery have higher Hb levels and more often polycythemia than their co-twin, but not when born by CS.

We implemented six confounding adjustment methods: (1) covariate-adjusted regression, (2) propensity score (PS) regression, (3) PS stratification, (4) PS matching with two calipers, (5) inverse probability weighting and (6) doubly robust estimation to examine the associations between the body mass index (BMI) z-score at 3 years and two separate dichotomous exposure measures: exclusive breastfeeding v. formula only (n=437) and cesarean section v. vaginal delivery (n=1236). Data were drawn from a prospective pre-birth cohort study, Project Viva. The goal is to demonstrate the necessity and usefulness, and approaches for multiple confounding adjustment methods to analyze observational data. Unadjusted (univariate) and covariate-adjusted linear regression associations of breastfeeding with BMI z-score were −0.33 (95% CI −0.53, −0.13) and −0.24 (−0.46, −0.02), respectively. The other approaches resulted in smaller n (204–276) because of poor overlap of covariates, but CIs were of similar width except for inverse probability weighting (75% wider) and PS matching with a wider caliper (76% wider). Point estimates ranged widely, however, from −0.01 to −0.38. For cesarean section, because of better covariate overlap, the covariate-adjusted regression estimate (0.20) was remarkably robust to all adjustment methods, and the widths of the 95% CIs differed less than in the breastfeeding example. Choice of covariate adjustment method can matter. Lack of overlap in covariate structure between exposed and unexposed participants in observational studies can lead to erroneous covariate-adjusted estimates and confidence intervals. We recommend inspecting covariate overlap and using multiple confounding adjustment methods. Similar results bring reassurance. Contradictory results suggest issues with either the data or the analytic method.

Objective: To examine how the demographic and other population changes affected birth and obstetric outcomes in Louisiana, and the effect of the hurricane on racial disparities in these outcomes.

Methods: Vital statistics data were used to compare the incidence of low birth weight (LBW) (<2500 g), preterm birth (PTB) (37 weeks' gestation), cesarean section, and inadequate prenatal care (as measured by the Kotelchuck index), in the 2 years after Katrina compared to the 2 years before, for the state as a whole, region 1 (the area around New Orleans), and Orleans Parish (New Orleans). Logistic models were used to adjust for covariates.

Results: After adjustment, rates of LBW rose for the state, but preterm birth did not. In region 1 and Orleans Parish, rates of LBW and PTB remained constant or fell. These patterns were all strongest in African American women. Rates of cesarean section and inadequate prenatal care rose. Racial disparities in birth outcomes remained constant or were reduced.

Conclusions: Although risk of LBW/PTB remained higher in African Americans, the storm does not appear to have exacerbated health disparities, nor did population shifts explain the changes in birth and obstetric outcomes.

(Disaster Med Public Health Preparedness. 2010;4:S39-S45)

Cardiac arrest in pregnancy is a rare occurrence, particularly in the emergency department setting. The resuscitation of a pregnant patient in cardiac arrest is unique in a number of ways. Early identification and treatment of possible etiologies, appropriate response to the physiologic changes present in pregnancy, relief of potential vena cava obstruction by the gravid uterus, and expeditious preparation for possible cesarean delivery are important considerations for a successful resuscitation. We report and discuss the case of a pregnant patient with pulmonary edema and cardiac dysfunction who presented with severe hypoxemia and subsequent cardiac arrest and underwent a perimortem cesarean delivery and simultaneous fetal and maternal resuscitation in the emergency department.

The objective of this study was to explain the variation in cesarean section rates among hospitals (obstetrical departments) in Sweden, and to discuss its potential economic consequences. Using data from The Swedish Medical Birth Registry 1991, we made a cross-sectional study of the cesarean section rate at the departmental level. We identified some 20 determinants, demand-related as well as supply-related. A general model including all these regressors was specified. After reducing this model, we were able to explain about one-quarter of the variation. We conclude that the large variation in cesarean section rates indicates inefficiency, due mainly to overutilization, but perhaps also underutilization. It is difficult to calculate the economic consequences or the welfare loss to society. We estimated an additional cost for unnecessary cesarean sections of 13—16 million Swedish crowns (SEK) per year.

This paper tests the null hypothesis of a zero effect of cesarean section rate on health outcome against the alternative of a positive effect. Using data from 59 hospitals in Sweden from 1988–92, we specify two separate linear regression models for health outcome, one with perinatal mortality, and the other with rate of asphyxia, as dependent variable. We estimate the models by single-year cross-section regressions and as pooled data systems. The null hypothesis cannot be rejected, i.e., we do not find any significant positive effect of cesarean section rate on health outcome. Thus, we conclude that an increase in cesarean section rate does not imply lower perinatal mortality or lower rate of asphyxia. This in turn indicates that the minimum cesarean section rate is optimal.

We described a case of pregnancy, delivery and peurperium of 28 years old multipara with twins pregnancy in bicornuate, unicollis uterus. Each fetus was placed in separate horn of uterus. Biological mature pregnancy was delivered by cesarean section. During the peurperium the involution disturbances of one of the uterus horns were observed. The case was discussed in context of other similar anomalies.

Ten pairs of full-term and 8 pairs of preterm twins from combined vaginal and Cesarean section deliveries were evaluated on measures of neonatal temperament, developmental status, and integrity to determine if the Cesarean-delivered infant was compromised relative to its vaginally-delivered twin. There were no significant differences, within groups, between the vaginal and Cesarean section infants on measures of risk and developmental status. Analyses of variance of paired comparisons performed on the temperament measures indicated that, for the full-term group, there were no significant differences in ratings between vaginally and Cesarean-delivered infants. In contrast, preterm infants delivered by Cesarean section were more active during sleep than their vaginally-delivered cotwins. This finding, together with previous findings demonstrating a relation between this measure and temperament at 9, 18, and 24 months of age, suggested that the preterm Cesarean-delivered infant may be at risk in this area when compared with its twin. In the main, however, the results demonstrated that infants born by Cesarean section following vaginal delivery of their twins were not more compromised than their twin siblings.

No consensus exists for the optimal mode of delivery for twin fetuses. Opinions vary by type of institution (university medical center vs community hospital), country or continent (North America vs Western Europe) and personal preference of individual physicians. This article lists clinical considerations in arriving at the decision and presents them in the form of a decision tree.

Limited data suggest that cesarean section (CS) may be the preferred method of delivery for triplets. Despite this, it is also felt that the third triplet is at great risk at delivery. We reviewed our experience of 14 triplet pregnancies at Northwestern University between 1981 and 1985. All deliveries were attended by neonatal teams in sufficient number to resuscitate each infant. Of the 14 pregnancies, two ended in previable loss. Thirty-six infants were born from 12 pregnancies of a mean gestational age of 33 weeks (28-38 weeks). The overall survival was 97.3%. Two women delivered vaginally. While the first was successful, the second resulted in vaginal delivery of the first two triplets followed by emergency CS for the third. That infant had a cord blood pH of 6.96(BE-19), was resuscitated and survived. All 10 CS were successful. The mean cord blood gas tensions and pH were normal. In addition, Apgar scores, the requirement for mechanical ventilation or supplemental oxygen, and mortality did not differ between the first and thirdborn triplet. These observations suggest that CS was beneficial. Our very low mortality rate supports the concept that CS delivery and aggressive neonatal resuscitation and therapy greatly enhances survival.

Fourteen triplet deliveries conducted between 1 January 1981 and 30 June 1986 at the principal teaching hospitals of Northwestern University Medical School are reviewed. Maternal demographic characteristics are listed, as are the obstetric outcomes, including mode of delivery, and the fetal outcome. The recent literature of triplet delivery is reviewed.

The rate of triplet delivery in our study was 0.37 per 1,000 live births. About two-thirds of the pregnancies resulted from the use of fertility-inducing agents. Ultrasonic confirmation was available in all cases. The majority of women were delivered by cesarean section (85%). No consistent pattern of presentation was seen. The mean weight of all 42 infants was 1,779 g (± 594). Unlike-sex triplets accounted for most of the sets (77%). The mean 5-min Apgar score of all infants was 9 and had no association with the order of deliveries. The weight differences by sex regardless of birth order were clinically insignificant. Neonatal mortality was 2.3%

We investigated if it is possible to use the data collected in twins to identify areas with high rates of operative deliveries, preterm deliveries and low birthweight infants in singletons. Our data correspond to all deliveries registered in Belgium in 1983. A significant correlation was found between the rates of cesarean sections in twins and in singletons. A significant correlation was also found between the rate of deliveries at a gestational age of less than 32 weeks in twins and the rate of deliveries at less than 37 weeks in singletons. However, correlations between other preterm rates, low birthweight rates and vacuum extraction or forceps rates, were nonsignificant. We conclude that the use of twins as tracers of the quality of care in singletons is of limited value.

A retrospective review of triplets delivered at a Boston perinatal center from 1977 to 1986 was performed. Comparison was made between this group (study group) and previously published data on triplets in our institution (control group). Since 1977 there was a more liberal use of abdominal delivery. Cesarean sections (CS) of all triplets with malpresentation was our protocol. Of the 15 sets of triplet pregnancies in the study group, 11 were delivered by CS and 4 by vaginal delivery, vs only 1 CS in the control group wich consisted also of 15 triplets. The corrected mortality rate in the study group was lower than in the control group (2.6% vs 7.1%) but did not reach statistical significance. Apgar scores at 1 and 5 minutes were significantly higher in the study group (P < 0.002). Apgar scores for the third triplet were also higher in the study group (P < 0.05). In comparing the combined mortality and morbidity between the study group and the control group, no difference was found in the first triplet, but those of the second and third triplets were significantly lower in the study group. Of interest is the finding that the combined mortality and morbidity was not different statistically among the first, second, and third triplets in the study group, while in the control group an increase from the first to the third triplet was noted (21%, 31%, and 43%, respectively). A more liberal approach toward abdominal delivery of pregnancies of higher fetal number is advocated.