Seminars in perinatology
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To examine trends in cesarean delivery for the overall population and for women with "no indicated risk" for cesarean section, and to summarize the available literature on "maternal request" cesarean deliveries. ⋯ There are no systematic data available on cesarean delivery by "maternal request." However, the rate of primary cesarean delivery is increasing rapidly for women of all ages, races, and medical conditions, as well as for births at all gestational ages. Since a first cesarean section virtually guarantees that subsequent pregnancies will be cesarean deliveries (the repeat cesarean delivery rate is now almost 91%), research is needed on physician practice patterns, maternal attitudes, clinical outcomes for mother and infant (harms, benefits), and clinical and nonclinical factors (institutional, legal, economic) that affect the decision to have a cesarean delivery.
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Seminars in perinatology · Oct 2006
Cesarean delivery on maternal request: wise use of finite resources? A view from the trenches.
Cesarean section rates are rising in the United States and were at an all time high of 29 percent in 2004. Within this context, the issue of cesarean section on maternal request has been described as being part of a "perfect storm" of medical, legal and personal choice issues, and the lack of an opposing view. An increasing cesarean section rate adds an economic burden on already highly stressed medical systems. ⋯ However, in our opinion, based on the current evidence regarding cesarean delivery on maternal request, promotion of primary cesarean section on request as a standard of care or as a mandated part of patient counseling for delivery will result in a highly questionable use of finite resources. As of 2004, 46 million Americans did not even have basic health insurance. It is critical that we not allow ourselves to be dragged into the eye of a "perfect storm." This conference is an important step in the rational and objective analysis of this issue.
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In responding to patient requests for cesarean section, physicians must consider ethical principles. Obstetricians have autonomy and beneficence-based obligations to the mother, and the mother and the obstetrician have beneficence-based obligations to the fetus. Maternal autonomy is usually accepted as the most compelling ethical canon. ⋯ Which choice is made should reflect the provider's believe about the strength of the supporting data. Given the need to recognize patient autonomy, to respect patient values even as one tries to motivate patients to work toward the highest health values, and to acknowledge women's primacy as fetal champions, a physician should be loathe to refuse unless the data regarding cesarean section by choice are wholly tilted away from maternal-child interests. If the data are in the realm of equipoise, even if not at the tipping point, discussing options, attempting to dissuade patients but ultimately acquiescing to their judgment would not be incompatible with obstetrical ethics.
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Seminars in perinatology · Aug 2006
ReviewVentilatory strategies in the prevention and management of bronchopulmonary dysplasia.
Bronchopulmonary dysplasia (BPD) leads to considerable mortality and morbidity in premature infants. Although mechanical ventilation is lifesaving in infants with respiratory distress syndrome (RDS), it may contribute to lung injury and subsequently to BPD. Appropriate ventilatory strategies for reducing BPD include redefining the goals for "adequate gas exchange," using less mechanical ventilation support, refining the methods of mechanical ventilation, and using alternative techniques. ⋯ High frequency ventilation has not been proven to reduce BPD. There is a lack of evidence-based guidelines on management of infants with established BPD. Optimization of clinical care practices and ancillary therapies need to be combined with ventilatory strategies to prevent and manage BPD.
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Seminars in perinatology · Apr 2006
ReviewOntogeny of autonomic regulation in late preterm infants born at 34-37 weeks postmenstrual age.
Late preterm infants (34-37 weeks postmenstrual age at birth) are intermediate between less mature preterm infants and infants born at 38 weeks or more in regard to autonomic brain stem maturation. Ventilatory responses to CO(2) in preterm infants born at 33 to 36 week are significantly higher than in infants born at 29 to 32 weeks both at 3 to 4 and 10 to 14 days postnatal age, but do not differ from full-term reference levels. The ventilatory response to hypoxia in preterm infants is biphasic; initial transient hyperventilation is followed by a return to baseline and then a decrease below baseline. ⋯ The relative risk for at least one extreme event in late preterm infants is increased (5.6 and 7.6, respectively, P < 0.008) compared with full-term infants and remains higher until 43 weeks postmenstrual age. The rate for Sudden Infant Death Syndrome in preterm infants born at 33 to 36 weeks is 1.37/1000 live births compared with 0.69 in infants born full term. Affected late preterm infants die at a older mean postmenstrual age compared with less mature infants (48 and 46 weeks, respectively), but die at a younger postmenstrual age than full-term infants (53 weeks, P < 0.05).