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The CDC offers new guidance on Zika virus and the labor and delivery unit. Plus: How are out-of-hospital trends moving? Also, a look at whether or not planned cesareans mean poorer outcomes for children.
An early release on the Centers for Disease Control and Prevention (CDC) MMWR website underscores the importance of following Standard Precautions in Labor & Delivery in the wake of emergence of the Zika virus. The outbreak, the report says, offers an opportunity for facility, nursing, and obstetric leadership to emphasize the importance of adhering to published infection control strategies to prevent transmission of infectious diseases in all health care settings.
In the report, CDC experts note that because obstetrical care is sometimes unpredictable and fast paced, use of Standard Precautions is essential to prevent possible transmission of Zika virus from patients to health care personnel. Among the recommendations for the Labor & Delivery setting are the following:
· Use of soap and water or alcohol-based products, at a minimum, before and after patient contact and after removing personal protective equipment (PPE), including gloves;
· Use of gloves for procedures that represent a small risk of body fluid exposure to areas of the body other than the hands, such as vaginal examination of a pregnant patient with minimal cervical dilation and intact membranes;
· Use of gloves and an impermeable gown for procedures such as placement of a fetal scalp electrode when membranes have already been ruptured or when handling newborns before blood and amniotic fluid have been removed from the newborn’s skin;
· Use of gloves, an impermeable gown, and a mask and eye protection when exposure to body fluids is anticipated, such as an amniotomy or placement of an intrauterine pressure catheter; and
· Use of gloves, an impermeable gown, a mask and eye protection, and knee-high impermeable shoe covers for procedures such as vaginal deliveries, manual placenta removal, bimanual uterine massage, and repair of vaginal lacerations.
All health care personnel on a team involved in the same procedure should wear the same level of PPE. Any occupational exposures to body fluids should be reported as soon as possible to the facility’s occupational health clinic to ensure appropriate assessment of health care personnel, particularly women who may be pregnant.
A look at out-of-hospital birth trends
A new analysis published in Birth indicates that the number of births happening in out-of-hospital settings is on the rise.
The researchers collected data from revised birth certificates from 47 states and Washington, DC and compared them with hospital births. They also looked at trends from 2004 to 2014.
Over the course of the studied period, out-of-hospital births increased by 72%, from 0.87% of births in the United States in 2004 to 1.50% in 2014. When compared to mothers who gave birth in the hospital, those who gave birth outside of the hospital were less likely to smoke (2.8% vs 8.5%) or to be obese before conceiving (12.5% vs 25.0%). Out-of-hospital mothers were also more likely to have a college education (39.3% vs 30.0%) and to initiate breastfeeding (94.3% vs 80.8%).
Of the women who had planned home birth, 67.1% paid for the deliveries themselves, in comparison to 31.9% of mothers who delivered in birth centers and 3.4% of those who delivered in a hospital. Vaginal births after cesarean (VBACs) counted for 4.6% of planned home births and 1.6% of hospital and birth center births. Overall sociodemographic and medical risk status for out-of-hospital births improved substantially from 2004 to 2014.
The researchers concluded that the improvements in the risk status of out-of-hospital births from 2004 to 2014 indicate that the appropriate selection of low-risk women has improved. The difference in self-pay rates seems to suggest that serious gaps in insurance coverage exist. The difference in VBAC rates may also indicate a lack of access to hospital VBACs.
Do planned cesarean deliveries mean poorer health?
A new report in PLOS Medicine from the University of Aberdeen appears to indicate that long-term health outcomes of children born via cesarean delivery are not substantially worse than those in children who are delivered vaginally after cesarean.
The data-linkage cohort included all second-born, term, singleton offspring delivered between January 1993 to December 2007 in Scotland to women with a history of cesarean delivery (n = 40,145). They were followed up until the end of January 2015. Outcomes assessed were obesity at age 5 years, hospitalization with asthma, learning disability, cerebral palsy, and death. Cox and binary logistic regression were used to compare outcomes following planned repeated cesarean (n = 17,919) and unscheduled repeat cesarean (n = 8847) to those following vaginal birth after cesarean (VBAC) (n = 13,379).
The risk of hospitalization with asthma was greater following repeat unplanned cesarean (3.7% vs 3.3%, adjusted hazard ratio [HR] 1.18, 95% CI 1.05–1.33) and planned cesarean (3.6% vs 3.3%, adjusted HR 1.24, 95% CI 1.09–1.42) when compared with VBAC. Death and learning disabilities were more common following unplanned repeat cesarean delivery (0.5% vs 0.4%, adjusted HR 1.50, 95% CI 1.00–2.25, and 3.7% vs 2.3%, adjusted odds ratio 1.64, 95% CI 1.17–2.29, respectively) than with VBAC. Risks of obesity at age 5 years and of cerebral palsy were similar for planned repeat cesarean, unplanned repeat cesarean, and VBAC.
Potential study limitations include the risk that the women who underwent unscheduled cesarean had intended to undergo a planned cesarean.
The researchers concluded that repeat cesarean delivery, unplanned or planned, was linked to an increased risk of hospitalization, but no difference in obesity risk was seen. The greater risk of death and learning disability following an unplanned repeat cesarean delivery in comparison to VBAC could indicate complications during labor. The authors called for further research, especially meta-analyses of rarer outcomes, to confirm how similar the risks are across delivery groups.