Labor Cesarean Delivery Research Articles

Nulliparous with Class III Obesity at Term: Labor Induction or Cesarean Delivery without Labor.

This study aimed to compare maternal and neonatal outcomes between labor induction versus cesarean delivery (CD) without labor among nulliparous individuals with class III obesity (body mass index [BMI] ≥40 kg/m2). A retrospective cohort study of all nulliparous singleton deliveries at ≥37 weeks with a BMI of ≥40 kg/m2 at delivery between March 2020 and February 2022. We excluded individuals with spontaneous labor, fetal malformations, and stillbirths. The primary outcome was a composite of maternal mortality and morbidity, including infectious and hemorrhagic morbidity. The secondary outcome was a neonatal composite. A subgroup analysis evaluated patients with a BMI of ≥50 kg/m2. Another subgroup analysis compared outcomes between CD without labor and an indicated CD following induction. A multivariable logistic regression was applied. For adjustment, we used possible confounders identified in a univariate analysis. Among 8,623 consecutive deliveries during the study period, 308 (4%) met the inclusion criteria. Among them, 250 (81%) underwent labor induction, and 58 (19%) had a CD without labor. The most common indications for CD without labor were fetal malpresentation (26; 45%), suspected macrosomia (8; 14%), and previous myomectomy (5; 9%). Indicated CD occurred in 140 (56%) of the induced individuals, with the two leading indications being labor arrest (87; 62%) and non-reassuring fetal heart rate tracing (51; 36%). The rates of composite maternal morbidity (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [CI]: 0.64-7.13) and composite neonatal morbidity (aOR = 3.62, 95% CI: 0.42-31.19) did not differ following a CD without labor compared to labor induction. The subgroup analyses did not demonstrate different outcomes between groups. Among nulliparous individuals with class III obesity at term who underwent induction, more than 50% had indicated CD; the rate of short-term maternal and neonatal morbidity, however, did not differ between labor induction and CD without labor. · The rate of unplanned CD among those who underwent labor induction was relatively high (56.0%).. · Outcomes did not differ between those who underwent CD without labor and those who were induced.. · Outcomes also did not differ between those who underwent CD without labor and those with CD in labor..

Immediate vs on-demand maternal oral full feeding after unplanned cesarean section during labor: a randomized controlled trial

The adoption of Enhanced Recovery After Cesarean is increasing, but evidence supporting individual interventions having a specific benefit to Enhanced Recovery After Cesarean is lacking. A key element in Enhanced Recovery After Cesarean is early oral intake. Maternal complications are more frequent in unplanned cesarean delivery. In planned cesarean delivery, immediate full feeding enhances recovery, but the effect of unplanned cesarean delivery during labor is not known. This study aimed to evaluate immediate oral full feeding vs on-demand oral full feeding after unplanned cesarean delivery in labor on vomiting and maternal satisfaction. A randomized controlled trial was conducted in a university hospital. The first participant was enrolled on October 20, 2021, the last participant was enrolled on January 14, 2023, and follow-up was completed on January 16, 2023. Women were assessed for full eligibility on arrival at the postnatal ward after their unplanned cesarean delivery. The primary outcomes were vomiting in the first 24 hours (noninferiority hypothesis and 5% noninferiority margin) and maternal satisfaction with their feeding regimen (superiority hypothesis). The secondary outcomes were time to first feed; food and beverage quantum consumed at first feed; nausea, vomiting, and bloating at 30 minutes after first feed, at 8, 16, and 24 hours after the operation, and at hospital discharge; parenteral antiemetic and opiate analgesia use; first breastfeeding and satisfactory breastfeeding, bowel sound, and flatus; second meal; cessation of intravenous fluid; removal of a urinary catheter; urination; ambulation; vomiting during the rest of hospital stay; and serious maternal complications. Data were analyzed using the t test, Mann-Whitney U test, chi-square test, Fisher exact test, and repeated measures analysis of variance as appropriate. Overall, 501 participants were randomized into immediate or on-demand oral full feeding (sandwich and beverage). Vomiting in the first 24 hours were reported by 5 of 248 participants (2.0%) in the immediate feeding group and 3 of 249 participants (1.2%) in the on-demand feeding group (relative risk, 1.7; 95% confidence interval, 0.4-6.9 [0.48%-8.28%]; P=.50), and the maternal satisfaction scores from 0 to 10 were 8 (6-9) for the immediate feeding group and 8 (6-9) for the on-demand feeding groups (P=.97). The times from cesarean delivery to the first meal were 1.9 hours (1.4-2.7) vs 4.3 hours (2.8-5.6) (P<.001), first bowel sound 2.7 hours (1.5-7.5) vs 3.5 hours (1.8-8.7) (P=.02), and second meal 7.8 hours (6.0-9.6) vs 9.7 hours (7.2-13.0) (P<.001). These intervals were shorter with immediate feeding. The participants were more likely to agree to recommend immediate feeding to a friend (228 [91.9%] in the immediate feeding group vs 210 [84.3%] in the on-demand feeding group; relative risk, 1.09; 95% confidence interval, 1.02-1.16; P=.009). However, at first feed for food, ate "nothing at all" rates were 10.4% (26/250) in the immediate group and 3.2% (8/247) in the on-demand group, and "eaten all" rates were 37.5% (93/249) in the immediate group and 42.8% (106/250) in the on-demand group (P=.02). Other secondary outcomes were not different. Compared with on-demand oral full feeding, immediate oral full feeding after unplanned cesarean delivery in labor did not increase the maternal satisfaction score and was not noninferior on postoperation vomiting. On-demand feeding with its emphasis on patient autonomy could be preferred, but the earliest full feeding should be encouraged and provided.

Adjunctive azithromycin prophylaxis protects women from uterine cesarean scar defect: A randomized controlled trial.

Cesarean scar defect (CSD) is a long-term outcome of cesarean section (CS) and associated with numerous gynecological and obstetric problems. Previous studies indicate that infection may be a risk factor for CSD. Adjunctive azithromycin was shown to reduce the risk of postoperative infection in patients undergoing non-elective primary cesarean delivery in labor or after the rupture of membranes compared with standard antibiotic prophylaxis. This study investigated the protective effect of adjunctive azithromycin in combination with single-dose cephalosporin against CSD in women undergoing non-elective cesarean delivery. A randomized, double-blind, controlled clinical trial was conducted in a University hospital in Shanghai, China. A total of 242 women who underwent their first non-elective CS were randomly assigned to receive 1500 mg cefuroxime sodium plus 500 mg intravenous azithromycin (n=121; experimental group) or 1500 mg cefuroxime sodium plus a placebo (n=121; placebo group). The primary outcome was CSD prevalence, as determined by transvaginal ultrasound and saline infusion sonohysterography within 6months of delivery. Secondary outcomes were changes in infectious indicators (eg hypersensitive C-reactive protein and procalcitonin), postoperative morbidity, and use of postoperative antibiotics. We also examined the operative procedure, pathogenic microorganism cultures, and fetal outcomes. Outcomes were compared between groups with the chi-squared test, Fisher's exact test, or Student's t test. Between May 2018 and May 2021, 121 women were randomized to each arm. Because the sonographic follow up was disrupted by the coronavirus disease 2019 pandemic and strict management policies, we merged the follow-up time points (6 weeks and 6months) into a single time period (6 weeks to 6months); 104 and 108 women in the experimental and placebo groups, respectively, completed the first sonographic follow up. CSD was diagnosed by sonography in 34/104 (32.7%) and 50/108 (46.3%) patients in the experimental and placebo groups, respectively (relative risk 0.71, 95% confidence interval 0.50-0.99; p=0.043). Characteristics of CSD and short-term infection outcomes did not differ between groups. A single dose of intravenous 500 mg azithromycin adjunctive to single-dose cefuroxime prophylaxis significantly reduced the incidence of CSD in women undergoing non-elective CS.

Seeking the Truth About Primary Elective Cesarean Delivery and Pelvic Floor Disorders: A Systematic Review and Meta-Analysis.

A better understanding of the effect of elective cesarean delivery (CD) on the development of pelvic floor disorders can help obstetricians counsel pregnant women. This study aimed to perform a systematic review and meta-analysis evaluating whether primary elective CD is protective against pelvic floor disorders. Using the MOOSE criteria, electronic databases were searched for studies that compared the prevalence of pelvic floor disorders among primiparous women. Outcomes of interest were urinary incontinence (UI), fecal incontinence (FI), anal incontinence (AI), and pelvic organ prolapse (POP). Comparisons were made between CD before the onset of labor ("Elective CD"), CD after trial of labor ("Labor CD"), and vaginal delivery (VD). Risk ratios (RRs) were computed using STATA. Between-study heterogeneity was assessed via Cochrane's homogeneity test and review of the I2 statistic. Nineteen studies were included. The overall prevalence of UI for Elective CD was estimated at 7% (95% confidence interval [CI], 3%-13%), Labor CD at 14% (95% CI, 8%-21%), and VD at 26% (95% CI, 20%-32%). Meta-analysis demonstrated a decreased risk of UI after Elective CD compared with Labor CD (RR, 0.75; P = 0.011) or VD (RR, 0.43; P < 0.001). There was a decreased risk of FI or AI after Elective CD compared with VD, but not when compared with Labor CD. Only 2 studies examined POP, precluding meta-analysis. Among primiparous women, Elective CD may be protective against UI when compared with Labor CD. There was not a protective effect of Elective CD against FI and AI when compared with Labor CD. More data on the effect of elective CD on POP are needed.

Vaginal cleansing before cesarean delivery in labor to reduce infection: a randomized trial

Surgical site infections following cesarean delivery (CD) are a significant source of postoperative morbidity. Vaginal cleansing prior to CD may reduce infections; however, the quality of evidence regarding efficacy of vaginal preparation is low to moderate. We tested the hypothesis that preoperative vaginal cleansing with povidone-iodine among women undergoing CD after labor would decrease postoperative infectious morbidity.

Investigating Decreased Rates of Nulliparous Cesarean Deliveries during the COVID-19 Pandemic.

Preventing the first cesarean delivery (CD) is important as CD rates continue to rise. During the novel coronavirus disease 2019 (COVID-19) pandemic, quality improvement metrics at our hospital identified lower rates of CD. We sought to investigate this change and identify factors that may have contributed to the decrease. We compared nulliparous singleton deliveries at a large academic hospital during the COVID-19 pandemic (April through July 2020 during a statewide "stay-at-home" order) to those in the same months 1 year prior to the pandemic (April through July 2019). The primary outcome, mode of delivery, was obtained from the electronic medical record system, along with indication for CD. The cohort included 1,913 deliveries: 892 in 2019 and 1,021 in 2020. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ between the groups. Median gestational age at delivery was the same in both groups. The CD rate decreased significantly during the COVID-19 pandemic compared with prior (28.9 vs. 33.6%; p = 0.03). There was a significant increase in the rate of labor induction (45.7 vs. 40.6%; p = 0.02), but no difference in the proportion of inductions that were elective (19.5 vs. 20.7%; p = 0.66). The rate of CD in labor was unchanged (15.9 vs. 16.3%; p = 0.82); however, more women attempted a trial of labor (87.0 vs. 82.6%; p = 0.01). Thus, the proportion of CD without a trial of labor decreased (25.1 vs. 33.0%; p = 0.04). There was a statistically significant decrease in CD during the COVID-19 pandemic at our hospital, driven by a decrease in CD without a trial of labor. The increased rate of attempted trial of labor suggests the presence of patient-level factors that warrant further investigation as potential targets for decreasing CD rates. Additionally, in a diverse and medically complex population, increased rates of labor induction were not associated with increased rates of CD. · Primary CD rate fell during COVID-19 pandemic.. · Decrease was driven by more women attempting labor.. · Higher rate of induction without rise in CD rate was found..

Six versus twelve hours of single-balloon catheter placement with oxytocin administration for labor induction: a randomized controlled trial

Induction of labor is common in the United States. Multiple previous studies have tried to outline a faster time to delivery to improve maternal and fetal outcomes. This study aimed to evaluate whether women who undergo induction of labor with a single-balloon catheter and oxytocin have a shorter time to delivery with planned removal of the catheter at 6 vs 12 hours. In this randomized controlled trial, induction oflabor was performed using a combination of single-balloon catheter and oxytocin. Term women, both nulliparous and multiparous, aged 18 to 50 years old with cephalic singletons were included if they were undergoing induction of labor with a Bishop score of <6 and cervical dilation of <2 cm. Women were randomized to planned removal of the single-balloon catheter at 6 hours vs 12 hours. The primary outcome was time from catheter insertion to delivery. We were powered to show a 4-hour time difference with a sample size of 89 women per group (n=178). Planned sensitivity analyses were performed to account for cesarean delivery in labor. From February 2019 to June 2020, 237 women were screened, 178 women were randomized, and 177 women were included in the final analysis (89 women in the 6-hour group and 88 women in the 12-hour group). Insertion to delivery time was significantly shorter in the 6-hour group (19.2 vs 24.3 hours; P=.04), and the proportion of women delivered by 24 hours was significantly greater in the 6-hour group (67.4% vs 47.4%; P<.01). There was no difference in the Bishop score at removal of the catheter or secondary maternal or neonatal outcomes. In a Cox proportional-hazards model censoring for cesarean delivery, the 6-hour group had a significantly shorter insertion to delivery time (hazard ratio, 0.67; P=.02). Induction of labor with a single-balloon catheter and oxytocin with planned removal of the catheter at 6 hours rather than 12 hours results in a shorter time from insertion to delivery without increasing the rate of cesarean delivery. Decreasing the length of time a single-balloon catheter is in place should be considered in clinical protocols.

44 Six vs. Twelve Hours of Foley Catheter Placement for Induction: A Randomized Controlled Trial

To evaluate whether time to delivery is shorter for women who undergo an induction with cook catheter and oxytocin for six as compared to twelve hours In this randomized controlled trial, labor induction was performed using combination cook catheter and oxytocin. Term women aged 18-50 years old with vertex singletons were included if they were undergoing induction of labor with a Bishop score less than 6 and dilation less than 2cm. Women were randomized to planned removal of the cook catheter at six or twelve hours. Primary outcome was insertion-to-delivery time. We were powered to detect a 4-hour difference with a sample size of 89 women per group (n=178). Planned sensitivity analyses were performed (a) excluding cesarean deliveries and (b) using Cox Proportional Hazards models censoring for cesarean delivery in labor. From February 2019-June 2020 237 women were screened and 178 were randomized 1:1. One person in the twelve-hour group was excluded because her induction was interrupted. Women were similar with regards to baseline characteristics including parity (71% nulliparous in six-hour group and 68% in the twelve-hour group; p=). Insertion-to-delivery time was significantly shorter in the six-hour group (19.2 vs. 24.3 hours, p=0.04) and the proportion of women delivered by 24 hours was significantly greater in the six-hour group (67% vs. 47%, p<0.01). There was no difference in Bishop score at removal. In the Cox Proportional Hazard Model, the six-hour group had a significantly shorter time to delivery (HR 0.67, p=0.02). (Figure 1). There were no differences in cesarean delivery rates (19% vs. 28%, p=0.15) nor any differences in other maternal or neonatal outcomes, including infection rates. Labor induction with a cook catheter and oxytocin with planned removal at 6 hours, rather than 12 hours, results in shorter time to delivery. Decreasing the planned length of time a cook catheter is in place should be considered in clinical protocols.

Changes in the Frequency of Cesarean Delivery in Nulliparous Women in Labor in a Canadian Population, 1992-2018.

To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women. We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed. The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018. The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors.

Use of the Robson classification to understand the increased risk of cesarean section in case of maternal obesity

BackgroundThe aim of this study was to identify characteristics of pregnant women with obesity that contribute to increased cesarean rate.MethodsRetrospective cohort in a single academic institution between 2012 and 2019. Women who delivered during this period were classified according to the Robson classification. Women with normal body mass index (N = 11,797) and with obesity (N = 2991) were compared. The contribution of each Robson group to the overall caesarean rate were compared.ResultsThe overall cesarean rate was higher for women with (28.1%) than without (14.2%, p < 0.001) obesity. This result came mainly from Robson group 5a (history of one cesarean). After adjustment for medical factors within this group, the association between maternal obesity and cesarean during labor was significant.ConclusionsThe higher cesarean rate in women with obesity is explained by Robson group 5a in which obesity is an independent risk factor of in labor cesarean delivery.

Fetal extraction maneuvers during cesarean delivery in the second stage of labor

Objective To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method. Methods A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012–2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events. Results Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p = .013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69–46.40% in others, p < .001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12–15% in others, p < .001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44–6.56, p = .0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081–7.448, p = .0342). Conclusion Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods. Abbreviations NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists.

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

829: Timing of cesarean delivery in women with more than one previous cesarean delivery

ACOG recommends performing repeat elective cesarean delivery (CD) at 39 weeks in women with one prior cesarean delivery, however there is uncertainty regarding timing of delivery for women with two or more previous CD. Our aim was to examine adverse maternal and neonatal outcomes of elective CD at gestational weeks 37 to 40+6 compared with pregnancy continuation in women with at least two previous cesareans. A retrospective cohort study of all women with at least two previous CD who delivered at term in Ontario, Canada between April, 2012 and March, 2017. Maternal and neonatal characteristics and outcomes were obtained from linked provincial and national databases. Multiple gestations and pregnancies with major fetal anomalies were excluded. Each gestational week of elective cesarean delivery was compared with ongoing pregnancy, culminating in cesarean delivery in labor, indicated CD not in labor or vaginal delivery. The primary outcome was a composite of adverse maternal outcomes. Secondary outcomes were composite adverse neonatal outcomes. During the 5-year study period 17,207 women were eligible for analysis. Elective CD from 39 weeks onwards was associated with the lowest adjusted risk of maternal composite adverse outcome (2.4% vs 6.9%, OR 0.36, 95% CI 0.2-0.65). This was primarily driven by lower rates of preeclampsia (0.4% vs 1.7%, p< 0.004), gestational hypertension (1.6% vs 3.6%, p=0.005) and uterine rupture, occurring in 1.7% of ongoing pregnancies. Elective CD at 37 weeks was associated with an increased risk of neonatal composite adverse outcome compared with ongoing pregnancies (OR 1.51, 95% CI 1.19-1.92). This risk was only decreased with elective CD at 39-39+6 weeks (10.3% vs 18.2%, OR 0.64, 95% CI 0.44-0.94). In women with two or more prior cesareans, the lowest rates of adverse maternal and neonatal outcomes were observed with elective CD between 39 to 39+6 weeks of gestation. This needs to be balanced against the risk of unplanned delivery prior to this gestational age.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

990: In labor urgent cesarean delivery: Comparison of failed TOLAC vs. intrapartum primary cesarean complications

TOLAC attempts are constantly declining due to doctors' and patients' concern of failure complications. We aim to compare characteristics and perinatal complications of women undergoing urgent cesarean delivery (CD) due to failure of TOLAC (f-TOLAC) vs. intrapartum primary cesarean section A retrospective cohort study in a single center with strict TOLAC protocol, 2006-2014. Data from computerized records database. Excluded: preterm delivery, multiple gestation, TOLAC decline ad hoc. Maternal and neonatal outcomes are reported. Multivariate regression adjusted for covariates/mediators. During the study period 126,693 deliveries occurred with an overall CD rate of 11.7%. Women who experienced f- TOLAC were significantly older, of higher parity, experienced more previous vaginal deliveries, had lower rates of pregnancy hypertensive complications labor induction. f-TOLAC was associated with significantly higher rates of: uterine rupture, blood products transfusion and peripartum re-laparotomy (1.95% vs 0.004%, p<0.0001, 5.5% vs 2%, p<0.0001 and 1.3% vs. 0.0%, <0.0001, respectively). Primary intrapartum cesarean was associated with higher rates of: neonatal NICU admission (7.5% vs. 5%, p=0.014), prolonged maternal hospitalization (55.4% vs 49.4%, p=0.005) and Hb drop>3g/dL (22.4% vs. 18.8%, p=0.03). The rates of early postpartum hemorrhage, 5' Apgar <7 and maternal re-admission within 6 weeks were comparable in both groups. (19.7% vs. 18.8%, 3.4% vs 2.9%, p=0.523p=0.55 and 1.6% vs. 1.3%, p=0.653, respectively Adjusted for covariates, primary urgent CD compared to failed TOLAC, is associated with higher overall maternal morbidity: OR=1.43 95%CI[1.19-1.70] , p<0.0001. Failure of TOLAC which was managed by strict criteria and supervision is associated with lower overall maternal morbidity and no additional neonatal morbidity as compared to primary in labor CD. This data should be in mind while consulting women with previous cesarean about mode of delivery on their next pregnancy.

Emergent primary cesarean delivery and maternal operative morbidity

Background It is unknown how variations in surgical entry time in primary cesarean delivery (CD) may affect operative outcomes and maternal morbidity. Objective Determine whether performing a primary CD in labor emergently (“stat”) is associated with adverse maternal outcomes. Study design Retrospective cohort study of patients who underwent primary CD at The Mount Sinai Hospital during the years of 2011–2016. Women with a singleton pregnancy and without a prior uterine scar attempting a trial of labor were included. An emergent CD was defined as a skin-to-uterine incision (I-U) time of ≤3 minutes. Subjects were dichotomized into those with an I-U time of ≤3 minutes or ≥5 minutes. Results 1722 patients underwent primary CD and met eligibility criteria. 72 patients with an I-U time of 4 minutes were removed from the analysis. 196 patients (11.9%) had an I-U time ≤3 minutes and 1454 patients (88.1%) had an I-U time ≥5 minutes. There were no differences in any outcomes between groups. The likelihood of transfusion, hysterectomy, or admission to the intensive care unit (ICU) was 1.5% in the emergent group and 1.0% in the control group (p = .334). Postpartum length of stay was also similar between the groups (3.3 versus 3.2 days, p = .259). When 384 patients with I-U times >10 minutes were excluded, surgical outcomes remained similar between groups. Among the subgroup of patients who reached the second stage of labor, surgical outcomes were also similar between groups. Conclusions Emergent primary CD is not associated with increased maternal morbidity.

580: Non labor cesarean delivery - Is this a risk factor for uterine rupture during TOLAC?

The indication for primary cesarean delivery (CD) influences the chances for successful vaginal birth after cesarean (VBAC). Non-labor CD is associated with less developed lower uterine segment. We aimed to determine whether indication and labor status at primary CD alters the risk for uterine rupture. A retrospective case-control study of women having trial of labor after cesarean (TOLAC) in a single, tertiary, university affiliated medical center between August 1st 2007 and June 30th 2016. Deliveries complicated by uterine rupture were matched to successful vaginal deliveries by gravity, parity, gestational age, induction of labor and birth weight at index delivery in a 1:3 ratio. All cases medical charts were manually reviewed by study personnel to obtain maternal and primary CD data including previous vaginal birth after cesarean (VBAC), indication for CD, the labor stage in which it happened and CD complications. In-labor CD was defined if ≥3 cm dilatation and regular contractions. Indications for primary CD and CD characteristics were compared between study and control groups. Overall, during study period there were 75,682 deliveries, of them, 3,937 were TOLAC. Study group included 53 (1.34%) cases of uterine rupture at TOLAC that were matched to 159 women with successful VBAC (control group). Demographic and obstetrical data did not differ between groups. Indications to CD were similar in study and control groups (P>0.05, Figure). In-labor CD did not alter risk for uterine rupture at TOLAC. Women in study group had significantly lower rates of previous VBAC (15.1% vs. 28.9%, p=0.047) and higher rates of postpartum hemorrhage following the primary CD (3.7% vs. 1.25%, p=0.042, Table). Utilizing the multivariate logistic regression analysis, previous VBAC and postpartum hemorrhage at primary CD were no longer associated with uterine rupture. In our cohort, Indication, labor status and complications in primary CD did not alter the risk for uterine rupture.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Adding Azithromycin to Cephalosporin for Cesarean Delivery Infection Prophylaxis: A Cost-Effectiveness Analysis.

To investigate the cost-effectiveness of adding azithromycin to standard cephalosporin regimens of cesarean delivery prophylaxis by considering the maternal outcomes in the current and potential subsequent pregnancies. A cost-effectiveness model was created using TreeAge to compare the outcomes of using azithromycin-cephalosporin with cephalosporin alone in a theoretical cohort of 700,000 women, the approximate number of nonelective cesarean deliveries annually in the United States that occur during labor or after membrane rupture. Outcomes examined included endometritis, wound infection, sepsis, venous thromboembolism, and maternal death in the current pregnancy and uterine rupture, cesarean hysterectomy, and maternal death in subsequent pregnancies, including cost and quality-adjusted life-years for both pregnancies. Probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000 per quality-adjusted life-year. Sensitivity analyses were used to determine the robustness of our results. Compared with cephalosporin alone for prophylaxis, our model showed 16,100 fewer cases of endometritis, 17 fewer cases of sepsis, eight fewer cases of venous thromboembolism, and one fewer maternal death with azithromycin-cephalosporin. Additionally, this strategy prevented 36 uterine ruptures and four cesarean hysterectomies in the subsequent pregnancy. Overall, the addition of azithromycin led to both lower costs and higher quality-adjusted life-years when compared with standard cephalosporin prophylaxis. In sensitivity analysis, we found that as long as the cost of azithromycin remained below $930 (baseline cost $27), it was cost-effective. For women who undergo cesarean delivery in labor or after membrane rupture, compared with cephalosporin alone, the addition of azithromycin to cesarean delivery infection prophylaxis is less costly and leads to better maternal outcomes in the index delivery and subsequent deliveries. These findings support the use of prophylactic azithromycin at the time of cesarean delivery.

Cesarean Delivery in Adolescents

Rates of cesarean delivery among low risk women of all ages have risen markedly over the past two decades, and adolescents are not immune to this trend. In subsequent pregnancies, nearly 90% of these women will deliver by repeat cesarean, which carries significant risks of maternal and infant morbidity and mortality secondary to adhesive disease, abnormal placentation and uterine rupture. To date, understanding of risk factors for cesarean delivery in adolescents is limited, and we therefore sought to examine how adolescent maternal age affects indication for primary cesarean delivery in a cohort of nulliparous women delivering vertex presenting singletons at term. This was a retrospective cohort study in an urban academic tertiary care center evaluating age related risk factors for, and characteristics of, mode of delivery for nulliparous women delivering vertex-presenting singletons at term. Adolescents were half as likely to undergo cesarean delivery overall (OR=0.48; 95%CI 0.43, 0.54), and more than one third less likely to undergo cesarean delivery in labor (OR=0.59; 95%CI 0.53, 0.66). Adjustment for potential confounders did not alter the strength of these associations. Adolescents were half as likely to undergo cesarean delivery for failure to progress (OR=0.49, 95%CI 0.43-0.54). There was no difference in the odds of cesarean delivery for non-reassuring fetal status (OR=0.91, 95%CI 0.77-1.06), nor genital herpes (OR=1.44, 95%CI 0.57-3.68). Induction, macrosomia, oxytocin augmentation and any labor complication were all associated with increased risk of cesarean delivery. There was no difference in the duration of second stage for adolescents who delivered by cesarean delivery compared with adults (240.0 vs. 237.7 minutes, p=0.84), but those adolescents who delivered vaginally had a second stage that was one third shorter than adults (62.5 vs 100.3 minutes, p<0.001). Adolescents are half as likely to undergo primary cesarean delivery overall, and 40% less likely to undergo a primary cesarean delivery in labor, even after adjustment for multiple maternal, neonatal and labor characteristics. This difference is not explained by differences in the duration of the second stage of labor.

Cesarean Delivery in Adolescents

Study ObjectiveTo examine the effect of maternal age on indication for primary cesarean delivery in low-risk nulliparous women. DesignRetrospective cohort study. SettingUrban academic tertiary care center. ParticipantsNulliparous women younger than 35 years of age delivering vertex-presenting singletons at term. InterventionsParticipants underwent spontaneous, operative or cesarean delivery. Main Outcome MeasuresMode of delivery, indication, and timing of cesarean delivery. ResultsAdolescents were half as likely to undergo cesarean delivery overall (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.43-0.54), and more than one-third less likely to undergo cesarean delivery in labor (OR, 0.59; 95% CI, 0.53-0.66). Adjustment for potential confounders did not alter the strength of these associations. Adolescents were half as likely to undergo cesarean delivery for failure to progress (OR, 0.49; 95% CI, 0.43-0.54). There was no difference in the odds of cesarean delivery for nonreassuring fetal status (OR, 0.91; 95% CI, 0.77-1.06), or genital herpes (OR, 1.44; 95% CI, 0.57-3.68). Induction, macrosomia, oxytocin augmentation, and any labor complication were all associated with increased risk of cesarean delivery. There was no difference in the duration of second stage for adolescents who delivered by cesarean delivery compared with adults (240.0 vs 237.7 minutes; P = .84), but adolescents who delivered vaginally had a second stage that was one-third shorter than adults (62.5 vs 100.3 minutes; P < .001). ConclusionAdolescents are half as likely to undergo primary cesarean delivery overall, and 40% less likely to undergo a primary cesarean delivery in labor, even after adjustment for multiple maternal, neonatal, and labor characteristics. This difference is not explained by differences in the duration of the second stage of labor.

Does midtrimester cervical length aid in predicting vaginal birth after cesarean?

A longer midtrimester cervical length (CL) is associated with an increased chance of cesarean delivery, but CL has not been used to predict the chance of successful trial of labor after cesarean delivery (TOLAC). The objective of this study was to identify whether midtrimester CL improves the prediction of vaginal birth after cesarean delivery (VBAC) among women undergoing a TOLAC. Women with 1 prior cesarean and a singleton gestation in the vertex position who had a routine CL assessment between 18 and 24 weeks and chose to undergo a TOLAC were identified. Midtrimester CL and characteristics identifiable in early prenatal care that have been used in a validated predictive model for VBAC (ie, age, body mass index, race/ethnicity, prior vaginal delivery, prior VBAC, and indication for prior cesarean delivery) were abstracted from the medical record. Multivariable regressions with VBAC as the dependent variable, with and without CL, were created and their predictive capacity compared using receiver-operating characteristic curves and reclassification tables. Of the 678 women who met inclusion criteria, 517 (76.3%) experienced a VBAC. Mean midtrimester CL was lower in women who achieved a VBAC compared with those who required a cesarean delivery in labor (4.3 ± 0.8 cm vs 4.7 ± 0.8 cm, P < .001). In a multivariable logistic regression, midtrimester CL (centimeters) was significantly associated with a reduced chance of VBAC (adjusted odds ratio [aOR], 0.60; 95% confidence interval [CI], 0.47-0.76). Although the addition of CL improved the area under the receiver-operating characteristic curve (aOR, 0.695 [95% CI, 0.648-0.743] vs aOR, 0.727 [95% CI, 0.681-0.773]; P= .03), it did not significantly enhance the clinical value of the model, as quantified by net reclassification improvement (P= .11). Shorter midtrimester CL is associated with a greater chance of vaginal birth after a TOLAC. However, midtrimester CL does not significantly improve the clinical value of a previously developed VBAC prediction model.