Indication For Cesarean Delivery Research Articles

Delivery routes in pregnancy with COVID-19 and the risk of intrapartum vertical transmission: a meta-analysis

BACKGROUND Mode of delivery has become an important highlight in managing pregnancy with coronavirus disease 2019 (COVID-19) due to the possible risk of viral transmission from mother to baby, especially during the peripartum period. This study aimed to review the mode of delivery and the possible risk of vertical transmission related to delivery routes in pregnant women with COVID-19.
 METHODS Literature research was conducted using PubMed, Scopus, Embase, and EBSCO database with the following keywords: SARS-CoV-2, COVID-19, pregnancy, vertical transmission, and delivery. The extracted data were as follows: author, country, study design number of cases, maternal age, mode of delivery, and the SARS-CoV-2 status in neonates.
 RESULTS Of 11 studies found, vaginal birth was reported in 218 cases (34.53%) and cesarean delivery was reported in 385 women (65.47%). The indication for cesarean delivery was majority due to COVID-19 related condition (53.61%). In total, 8 neonates who confirmed positive for COVID-19 by real-time polymerase chain reaction assay were reported. The pooled odds ratio (95% confidence interval) for SARS-CoV-2-positive neonates in cesarean delivery compared with vaginal birth was 0.622 (0.237–1.633) with p = 0.335.
 CONCLUSIONS Cesarean delivery is more common than vaginal delivery in patient with SARS-CoV-2 infection. Any delivery route is not related to possible risk of intrapartum vertical transmission, and cesarean delivery should be carried out based on the obstetric indication.

Association between epidural analgesia and indications for intrapartum caesarean delivery in group 1 of the 10-group classification system at a tertiary maternity hospital, Shanghai, China: a retrospective cohort study

BackgroundIn this study, we aimed to determine whether epidural analgesia affects the indications for intrapartum caesarean delivery, such as foetal distress, dystocia, or maternal request, in nulliparous term women with spontaneous labour (Group 1 in the 10-Group Classification System).MethodsWe conducted a retrospective cohort study and collected data from the electronic medical records of deliveries performed in our institution between 1 January 2017 and 30 June 2017. Women conforming to the criterion of Group 1 according to the 10-Group Classification System were enrolled. We compared labour outcomes between women with and without epidural analgesia and analysed the association between epidural analgesia and indications for caesarean by using multivariate logistic regression analysis.ResultsA total of 3212 women met the inclusion criteria, and 2876 were enrolled in the final analyses. Women who received epidural analgesia had a significantly lower intrapartum caesarean delivery rate (16.0% vs. 26.7%, P < 0.001), higher rates of amniotomy (53.4% vs. 42.3%, P < 0.001) and oxytocin augmentation (79.5% vs. 67.0%, P < 0.001), and a higher incidence of intrapartum fever (≥38 °C) (23.3% vs. 8.5%, P < 0.001) than those who did not receive epidural analgesia. There were no significant differences between the groups for most indications, except a lower probability of maternal request for caesarean delivery (3.9% vs. 10.5%, P < 0.001) observed in women who received epidural analgesia than in those who did not. Epidural analgesia was revealed to be associated with a decreased risk of maternal request for caesarean delivery (adjusted odds ratio [aOR], 0.30; 95% confidence interval [CI], 0.22–0.42; P < 0.001); however, oxytocin augmentation was related to an increased risk of maternal request (aOR, 2.34; 95%CI, 1.47–3.75; P < 0.001). Regarding the reasons for the maternal request for caesarean delivery, significantly fewer women complained of pain (0.5% vs. 4.6%, P < 0.001) or had no labour progress (1.3% vs. 3.6%, P < 0.001) among those who received analgesia.ConclusionsAmong the women in Group 1, epidural analgesia was associated with a lower intrapartum caesarean delivery rate, which may be explained by a reduction in the risk of maternal request for an intrapartum caesarean delivery.

Association of a unicornuate uterus with adverse obstetric outcomes: A retrospective cohort study.

To estimate the association of unicornuate uterus (UU) with adverse obstetric outcomes. Using data from 26 737 singleton childbirths from a tertiary hospital from 1999 to 2019, we identified 44 births from women with a UU. A total of 367 births from women with a normal uterus were randomly selected as controls. The outcome measures were preterm birth (PTB), breech presentation, and cesarean delivery. The subdivisions of PTB and indications for cesarean delivery were described. The presence of UU was associated with an increased risk of PTB (adjusted risk ratio [aRR], 2.3; 95% confidence interval [CI], 1.1-4.9), breech presentation (aRR, 6.2; 95% CI, 2.9-13.2), and cesarean delivery (aRR, 2.1; 95% CI, 1.8-2.7). For women with a UU, most PTBs (7/9) were moderate to late PTBs, and approximately half of the PTBs (4/9) were iatrogenic due to preeclampsia (PE). Breech presentation, PE, and prior surgery for rudimentary horn resection were UU-related indications for cesarean delivery. Women with a UU have a higher risk of PTB, breech presentation, and cesarean delivery. Understanding of the subdivisions of PTBs and indications for cesarean delivery might help clinicians when counseling women with pregnancy complicated by a UU.

Evaluation of the risk of umbilical cord prolapse in the second twin during vaginal delivery: a retrospective cohort study

ObjectiveThis study aimed to evaluate the success rate of vaginal delivery, the reasons for unplanned caesarean delivery, the rate of umbilical cord prolapse and the risk of umbilical cord prolapse...

Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity

Investigators have attempted to derive tools that could provide clinicians with an easily obtainable estimate of the chance of vaginal birth after cesarean delivery for those who undertake trial of labor after cesarean delivery. One tool that has been validated externally was derived from data from the Maternal-Fetal Medicine Units Cesarean Registry. However, concern has been raised that this tool includes the socially constructed variables of race and ethnicity. This study aimed to develop an accurate tool to predict vaginal birth after cesarean delivery, using data easily obtainable early in pregnancy, without the inclusion of race and ethnicity. This was a secondary analysis of the Cesarean Registry of the Maternal-Fetal Medicine Units Network. The approach to the current analysis is similar to that of the analysis in which the previous vaginal birth after cesarean delivery prediction tool was derived. Specifically, individuals were included in this analysis if they were delivered on or after 37 0/7 weeks' gestation with a live singleton cephalic fetus at the time of labor and delivery admission, had a trial of labor after cesarean delivery, and had a history of 1 previous low-transverse cesarean delivery. Information was only considered for inclusion in the model if it was ascertainable at an initial prenatal visit. Model selection and internal validation were performed using a cross-validation procedure, with the dataset randomly and equally divided into a training set and a test set. The training set was used to identify factors associated with vaginal birth after cesarean delivery and build the logistic regression predictive model using stepwise backward elimination. A final model was generated that included all variables found to be significant (P<.05). The accuracy of the model to predict vaginal birth after cesarean delivery was assessed using the concordance index. The independent test set was used to estimate classification errors and validate the model that had been developed from the training set, and calibration was assessed. The final model was then applied to the overall analytical population. Of the 11,687 individuals who met the inclusion criteria for this secondary analysis, 8636 (74%) experienced vaginal birth after cesarean delivery. The backward elimination variable selection yielded a model from the training set that included maternal age, prepregnancy weight, height, indication for previous cesarean delivery, obstetrical history, and chronic hypertension. Vaginal birth after cesarean delivery was significantly more likely for women who were taller and had a previous vaginal birth, particularly if that vaginal birth had occurred after a previous cesarean delivery. Conversely, vaginal birth after cesarean delivery was significantly less likely for women whose age was older, whose weight was heavier, whose indication for previous cesarean delivery was arrest of dilation or descent, and who had a history of medication-treated chronic hypertension. The model had excellent calibration between predicted and empirical probabilities and, when applied to the overall analytical population, an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77), which is similar to the area under the receiver operating characteristic curve of the previous model (0.75) that included race and ethnicity. We successfully derived an accurate model (available at https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator), which did not include race or ethnicity, for the estimation of the probability of vaginal birth after cesarean delivery.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BackgroundA high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the “Two-child Policy” in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.MethodsData were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.ResultsThe rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984–9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116–14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311–0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007–16.455).Conclusions“Maternal request” has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.

Análise e monitoramento das taxas de cesárea no Brasil segundo a classificação de Robson

Objetivo: Discorrer o que a literatura apresenta sobre os fatores de riscos obstétricos das mulheres submetidas à cesárea, segundo a Classificação de Robson. Método: Trata-se, de uma revisão bibliográfica do método revisão integrativa da literatura, com abordagem qualitativa, realizado entre setembro de 2020 a fevereiro de 2021, por meio da busca de artigos indexados nas seguintes bases de dados: Scielo (Scientific Eletronic Library Online), BVS (Biblioteca Virtual em Saúde), Google Scholar, PubMed (National Center for Biotechnology Information), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), Revistas de Enfermagem. Os critérios de inclusão para a seleção dos conteúdos foram, artigos na linguagem portuguesa, inglesa e espanhola. Publicados nos referidos bancos de dados compreendendo os anos de 2011 a 2021. Como critérios de exclusão, não foram considerados artigos mediante a recompensação monetária, incompletos, duplicados e não convergentes com este estudo. Resultados: Este estudo ressalta que, a cesárea é um procedimento que possui mais risco para as mulheres, quando comparado ao parto normal, posto isso, em decorrência dos fatores de riscos para a mulher e recém nascidos, a cesariana realizada sem as existentes indicações médicas tem sido alvo de estudos em todo o mundo. Sendo assim, é necessário identificar a real indicação do parto cesáreo sem que isto ocorra somente por comodidade médica. Conclusão: Evidenciou-se no estudo, que é a utilização da Classificação de Robson mostra-se extremamente útil e pode auxiliar em programas para monitorar as indicações de cesáreas, com probabilidade de redução das taxas e mortalidade materna.

Language Preference and Risk of Primary Cesarean Delivery: A Retrospective Cohort Study.

While some medical indications for cesarean delivery are clear, subjective provider and patient factors contribute to the rising cesarean delivery rates and marked disparities between racial/ethnic groups. We aimed to determine the association between language preference and risk of primary cesarean delivery. We conducted a retrospective cohort study of nulliparous, term, singleton, vertex (NTSV) deliveries of patients over 18years old from 2011-2016 at an academic medical center, supplemented with data from the Massachusetts Department of Public Health. We used modified Poisson regression with robust error variance to calculate risk ratios for cesarean delivery between patients with English language preference and other language preference, with secondary outcomes of Apgar score, maternal readmission, blood transfusion, and NICU admission. Of the 11,298 patients included, 10.3% reported a preferred language other than English, including Mandarin and Cantonese (61.7%), Portuguese (9.7%), and Spanish (7.5%). The adjusted risk ratio for cesarean delivery among patients with a language preference other than English was 0.85 (95% CI 0.72-0.997; p = 0.046) compared to patients with English language preference. No significant differences in risk of secondary outcomes between English and other language preference were found. After adjusting for confounders, this analysis demonstrates a decreased risk of cesarean delivery among women who do not have an English language preference at one institution. This disparity in cesarean delivery rates in an NTSV population warrants future research, raising the question of what clinical and social factors may be contributing to these lower cesarean delivery rates.

ANALYSIS OF URGENCY, GESTATIONAL AGE AND CONTRIBUTING FACTORS FOR INCREASING CAESAREAN SECTION RATES

Background: Over the past few decades, the indications for Caesarean delivery have broadened thus increasing the rate of caesarean section beyond the set level of WHO. The indications vary in different health care facilities. It is essential to determine the factors responsible for increasing caesarean section rates. To Objectives: nd out the cesarean section rate based on urgency as per RCOG and gestational age as per the categorization of pregnancy by ACOG in a tertiary health care facility catering to large South Indian population. It also aimed to determine the associated conditions contributing for caesarean section. Retrospective analysis of women who underwent caesar Methods: ean section from Jan-2017 to June 2017. Data was analyzed with respect to gestational age, Urgency of caesarean section, maternal fetal indications, clinical characteristics and associated conditions. Neonatal outcomes measured were gestational age, birth weight and NICU admissions. Data was expressed as proportions and percentages. The CS Results: rate was 24.5% among7, 346 deliveries and 81% were emergency CS. Preterm Caesarean sections were done in 18% and term 81.5%. Category II CS were the commonest (49%) followed by Category I (32%). Scarred uterus was the most common indication (85%) for elective caesarean section and fetal distress was most common indication (55.7%) for emergency caesarean sections. The associated factors were prior Caesarean section (32%), Medical disorders in 21% and 2.4% prolonged infertility and ART conceptions. Obstetric conditions including mal presentation were responsible in 19%. On the whole fetal indications accounted for 62%. Conclusion: Fetal indications, especially fetal distress is the most common reason for caesarean section which may have contributed for increased rate of caesarean section. Hence following strict criteria for diagnosis of fetal distress and adopting policies for intrauterine resuscitation prior to decision making for cesarean section would contribute to reduction of CS rate at tertiary health care centers.

Caesarean delivery rate and indications at a secondary healthcare Facility in Ibadan, South Western Nigeria: a five-year review.

Caesarean delivery is an essential surgical skill within the primary care setting aimed at reducing maternal morbidity and mortality. To determine the rate and indications for caesarean deliveries with a view to improving on the service delivery in the study area. A retrospective review of all caesarean deliveries over a five-year period, January 1st, 2012 to December 31st, 2016. A total of 2321 deliveries were recorded during the study duration and 481 of them were through caesarean section (CS) giving a caesarean section rate of 20.4%. The rate was higher in the multigravida 255 (53.1%). The commonest indication for caesarean section was previous caesarean section 131 (27.2%). Emergency caesarean delivery accounted for 278 (57.8%). Only 16 (3.3%) stayed more than five days postoperatively while the rest, 465 (96.7%), stayed less than five days. There was a gradual yearly increase in rate from 12.1% in 2012 to 19.5% in 2016. The rate of CS in this study has shown a gradual yearly increase with emergency CS having a higher percentage. Early diagnosis and referral of high-risk pregnancies from peripheral hospitals could reduce emergency CS among the study population.

Intrapartum Cesarean Delivery Due to Nonreassuring Fetal Heart Rate and the Risk of Pediatric Infectious Morbidity-related Hospitalizations of the Offspring.

One of the most common indications for intrapartum cesarean delivery (CD) is nonreassuring fetal heart rate (NRFHR) patterns. We aimed to study the long-term effect of CD due to NRFHR on the risk for subsequent childhood infectious morbidity-related hospitalizations of the offspring. A population-based cohort study was performed, comparing total and different subtypes of infectious morbidity-related pediatric hospitalizations among offspring born by CD due to NRFHR versus labor dystocia (failure of labor to progress during the 1st or 2nd stage). The analysis included all singletons born between the years 1999-2014 at a single tertiary regional medical center. Infectious-related morbidities included hospitalizations involving a predefined set of International Classification of Diseases, 9th revision codes, as recorded in hospital computerized files. Infants with congenital malformations, multiple gestations, vaginal deliveries and vacuum failure were excluded from the analysis. Perinatal mortality cases were excluded from the long-term analysis. A Kaplan-Meier survival curve was used to compare the cumulative morbidity, and a Cox proportional hazards model was constructed to adjust for confounders. The study population included 9956 newborns who met inclusion criteria; among them, 5810 (58%) were born by CD due to NRFHR, and 4146 (42%) were born via CD following labor dystocia with normal fetal heart rate (comparison group). Offspring born following NRFHR had higher rates of infectious morbidity-related hospitalizations (11.4% vs. 9.1%; odds ratio, 1.3; 95% confidence interval, 1.1-1.5; P < 0.01; Kaplan-Meier survival curve P < 0.01). The association remained significant and independent while adjusting for gestational age, maternal age and comorbidities, using a Cox proportional hazards model (adjusted hazard ratio, 1.3; 95% confidence interval, 1.2-1.4; P < 0.01). In our population, CD due to NRFHR is a risk factor for pediatric infectious morbidity-related hospitalizations of the offspring.

Rationale of indications for caesarean delivery and associated factors among primigravidae in Tanzania

ObjectiveThis study aimed to determine the prevalence of modes of delivery and associated maternal and newborn outcomes among singleton primigravidae in the Iringa region of Tanzania. MethodsA cross-sectional, analytical hospital-based study was conducted in the Iringa region among 356 singleton primigravidae between April and August 2018. Convenience sampling and consecutive collection of data using a face-to-face interviewer-administered questionnaire was done. ResultsA total of 356 singleton primigravid women with a mean age of 22.0 years (range: 15–49) participated in the study. The majority of the participants (73.0%, n = 250) were in the 20–35 age group. Caesarean and vaginal delivery were performed in 41.3% (n = 147) and 58.7% (n = 209) of the cases, respectively. The maternal height and weight of the newborn were significantly associated with caesarean delivery; (p = 0.001) and (p = 0.029), respectively. After adjusting for all variables, birth asphyxia (AOR = 3.25, 95% CI: 1.867–5.646, p = 0.000) and low birth weight (AOR = 0.03, 95% CI: 0.003–0.211, p = 0.001) were associated with caesarean delivery. ConclusionsThe findings of our study indicated the prevalence of caesarean section to be three times more than that recommended by the World Health Organization. Pregnant women with a height of less than 150 cm should be considered for caesarean section. Therefore, it is necessary for stakeholders in the health sector to formulate guidelines for absolute indications for caesarean section.

A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity.

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai‘i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state’s largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai‘i.

768 Use of standardized documentation tool for indication of primary cesarean section in nulliparous women

Cesarean births in the United States have increased from 1996 to 2011, with nearly one third of deliveries via cesarean. Efforts to promote safe vaginal births through best-practice strategies aim to reduce the number of cesarean deliveries in the most variably managed low-risk patients: nulliparous, term, singleton gestation, vertex presentation (NTSV). The California Maternal Quality Care Collaborative (CMQCC) introduced a pre-cesarean checklist for labor dystocia to promote vaginal birth. This quality improvement project aims to look at the effectiveness of a standardized documentation tool on adherence to guidelines of indications for primary cesarean delivery at a tertiary care center. The institutional review board at Santa Clara Valley Medical Center waived review of this quality improvement project. A standardized documentation tool was implemented for use on February 1, 2018. Electronic delivery reports were queried 6 months prior and after implementation, then narrowed to NTSV deliveries. Primary outcome was to determine if the documented indication for cesarean met criteria based on guidelines. Secondary outcomes included verification of documented metrics (time of membrane rupture, oxytocin administration, length of second stage) and if there was an indication for cesarean delivery. Individual charts were reviewed by two physicians. Statistical analysis was performed using chi-square and t-test as appropriate. Utilization rate was 14.8 vs. 64.2% (pre- vs. post-, p=<0.001). There was no significant difference between patient demographics or stated indication for cesarean. Primary outcome was confirmed in 78.4 vs. 87.4% (p=0.16) of cases. Supporting metrics were verified in 94.3 vs. 92.6% (p=0.87) of cases. Overall, a qualified indication for cesarean was found in 87.5 vs. 92.6% (p=0.360) of cases. The NTSV cesarean rate was 20 vs. 25% pre- and post-implementation, respectively. The use of a standardized documentation tool did not result in a statistically significant difference in adherence to primary cesarean guidelines at a single tertiary care center.

510 Contemporary trends in cesarean delivery rates and indications

The American College of Obstetrics and Gynecology (ACOG) introduced updated guidelines for labor management (2014) and fetal heart rate interpretation in an attempt to reduce cesarean delivery (CD) rates – especially the primary CD. We sought to describe CD rates and indications at a single center in order to assess the impact of these guidelines on trends in clinical practice. Retrospective cohort study of women ≥ 23 weeks gestation delivering at a single tertiary care referral center from 2013 - 2018. Demographic characteristics, mode of delivery, and main CD indication were ascertained by individual chart review. Main CD indications were defined as repeat CD, non-reassuring fetal status (NRFS), malpresentation, maternal indications (i.e. placenta previa or genital HSV), failed labor (any stage labor arrest), or other (i.e. fetal anomaly, elective). Polynomial (cubic) regression models were used to model rates of CD and main indications over time. Subgroup analyses further examined trends for nulliparous women. Of 24,637 women delivered during the study period, 24,050 women were included in the analysis; 7,835 (32.6%) had a CD. No clinically significant changes in the overall CD rate appeared during the study period (min 30.9% in 2014, max 34.6% in 2018). While CD for NRFS significantly changed over time - decreasing to a nadir in 2015 then rising (p=0.003), there were no differences in any other CD indications over time (Figure 1). When limited to nulliparous women, the rates of CD were similarly stable during the study period (min 30.7% in 2014, max 35.6% in 2013) and there were no differences in any primary CD indications over time (Figure 2). Despite the changes in labor management definitions and guidelines encouraging vaginal birth, rates of CD and indications for CD particularly failed labor, repeat CD, and malpresentation have not significantly changed over time. Studies should evaluate whether factors like patient preference and practice/provider variation contribute to the steady rate of CD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1148 Racial disparities in cesarean delivery rates: can a machine learning model reduce these biases?

Racial Disparities in Cesarean Delivery Rates: Can a Machine Learning Model Reduce These Biases? Variation exists in both rates of and indication for cesarean delivery (CD) by race which may be due to provider bias. As machine learning (ML) models trained on provider behaviors become more common, it is critical to ensure that these biases are not being replicated and amplified. The objective of this study is to identify whether there are differences in CD rate by race in our total delivery population and whether these persist in a supervised ML model. 39,452 deliveries were performed with this distribution: 21,360 White, 6,976 LatinX, 5,048 Asian, 3,733 Black, and 2,335 Other. Actual rates of CD differed by race: White subjects had the lowest rate (17.8%), Black subjects the highest rate (26.5%), p < 0.001 (Figure 1). As expected, the ML model recommended lower CD rates for all races (Table 1); however, the model recommendations reduced the disparity for some races (White, Black, Other) while exacerbating it for others (Asian, Hispanic). Consistent with the literature, significant variability exists by race in the CD rate. Despite excluding race as a predictor, a ML model trained on low CD rate physicians demonstrated persistent differences in recommendation by race. This suggests that low CD rate physicians also treat patients differently based on race, and consideration should be given to mitigation strategies in creating prescriptive ML models.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

311 Development of a prediction model for cesarean delivery among term women with presumed intraamniotic infection

To identify factors associated with cesarean delivery (CD) among term laboring women who develop an intrapartum fever due to presumed intraamniotic infection and to develop a predictive model for CD to assist in patient counseling. We performed a multi-center, retrospective cohort study among febrile, term laboring women between January 1, 2015 and December 31, 2017. We excluded women who had a documented non-obstetric source of infection, received antibiotics on admission for other indications, used immunosuppressant medication chronically, or had an intrauterine fetal demise. The medical record was reviewed, and sociodemographic, labor, and clinical characteristics were extracted. We identified the factors associated with CD and built our predictive model using backward stepwise regression. The final model was shown through the area under the receiver operating characteristic curve (AUC). The cohort consisted of 850 febrile laboring women, of whom 295 (34.7%) had a CD. Indications for Cesarean delivery included 34.6% for failure to progress, 33.6% for non-reassuring fetal heart tracing, 29.8% for arrest of descent, and 2.0% for failed operative delivery due to maternal exhaustion. The final model included stage of labor stratified by cervical exam dilation (less than 6 cm of dilation in latent labor, 6 cm to 9.5 cm in active first stage of labor, and 10 cm dilation in second stage of labor), duration of rupture of membranes (in hours), and if labor was induced. Our final model had an AUC of 0.74 (95% CI 0.71-0.78) with a Hosmer-Lemeshow test P=0.07. Using a predicted probability cutoff of 0.47, the model’s sensitivity was 54.7%, specificity was 80.7% with a positive predictive value of 60.1% and negative predictive value of 77.0% to predict CD. Information available at the time of development of an intrapartum fever may be used to counsel patients regarding the likelihood of CD. Our study was limited by unavailable electronic fetal monitoring data which also heavily influences CD risk.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

49 Normal Labor Curve in Twin Gestations

Failure to progress is the leading indication for cesarean delivery in trials of labor of twin gestations. However, assessment of labor progression in twin labors is managed according to singleton labor curves. This study aims to establish a partogram for twin deliveries that reflects normal and abnormal labor progress, as well as customized labor curves for different subgroups of twins. A multi-center retrospective cohort analysis of twin deliveries recorded in three tertiary medical centers between the years 2003-2017 was conducted. Eligible parturients were twin gestations ≥34 weeks with cephalic presentation of the presenting twin and ≥2 documented cervical examinations during labor. Exclusion criteria were elective cesarean delivery without trial of labor, major fetal anomalies, and fetal demise. Twin gestations comprised the study group while singletons counterparts formed the comparison group. Statistical analysis was performed with Python 3.7.3. A total of 1,375 twin deliveries and 142,659 singleton deliveries met the inclusion criteria. Parturients with twins used epidural analgesia more frequently (74.2% vs. 54.8%, p<0.001) and underwent more labor inductions (24.2% vs. 15.3%, p<0.001) as compared to singletons. Active phase duration was significantly longer in twins as compared to singletons in both nulliparous and multiparous parturients (p=0.005, p<0.001 respectively) (Figure 1). Epidural use and labor induction further slowed labor progression in twins as compared with singletons (p=0.02, p<0.001 respectively) (Figure 2). Twin labors are characterized by slower progression of the active phase of labor as compared with singletons. Nulliparity, epidural analgesia and induction of labor slow labor progression further. Implementation of these findings to clinical management might lower cesarean delivery rate due to protracted labor in twin gestations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1002 What category II features prompt the diagnosis of NRFS in the first stage?

Non-reassuring fetal status (NRFS), as detected by continuous electronic fetal monitoring (EFM), is a common indication for cesarean delivery (CD) in the first stage. This study aims to identify Category II EFM features that place patients at risk for CD for NRFS. We performed a nested case control study of singleton term pregnancies admitted for labor or induction. Cases were patients with NRFS as the sole indication for CD in the first stage. Controls were all other deliveries without NRFS. We excluded patients with NRFS as a co-indication for CD and second stage NRFS. Trained obstetrical research nurses extracted EFM data from the 60 mins before delivery. The primary outcome was a composite of high risk category II EFM features including minimal variability, recurrent late or variable decelerations, >1 prolonged deceleration, or tachycardia. Secondary outcomes were individual components of the composite, total deceleration area (TDA) and TDA ≥ 90th percentile. We performed a sensitivity analysis comparing first stage CD for NRFS to first stage CD without NRFS. 476 patients had a first stage CD for NRFS. There were 7500 patients who delivered without NRFS. Although presence of composite high-risk Category II EFM features was similar between CD for NRFS and control deliveries [34.7% vs 32.8%, aOR 1.23; 95% CI 0.90-1.69], those undergoing CD for NRFS were more likely to have recurrent late decelerations and ≥ 1 prolonged deceleration and less likely to have minimal variability. TDA was higher in the NRFS group, however TDA>90th percentile was similar between groups. In a sensitivity analysis of first stage CD for NRFS vs first stage CD without NRFS, those with NRFS were more likely to have composite high risk Category II features [aOR 3.59; 95% CI 2.21-5.83]. The majority of first stage CD for NRFS do not have Category II EFM features previously described as ‘high-risk’ for adverse outcomes. Recurrent late and prolonged decelerations are the most common features prompting providers to perform a first stage CD for NRFS.

670 Neonatal outcomes after cesarean for non-reassuring fetal status in the first stage of labor

Non-reassuring fetal status (NRFS) is the second most common indication for cesarean delivery (CD) accounting for 1 in 4 cesareans. We sought to evaluate neonatal outcomes following CD for NRFS. This was a secondary analysis of a prospective cohort study. We included singleton term pregnancies admitted for labor or induction of labor between 2010-2014. The primary outcome was fetal acidemia defined as umbilical artery (UA) pH < 7.1. Secondary outcomes were UA base excess, lactate, and neonatal composite morbidity (hypoxic-ischemic encephalopathy, meconium aspiration syndrome, hypothermia treatment, intubation, mechanical ventilation, neonatal seizure, death). The exposure was first stage CD for any indication that included NRFS and the control group was all other deliveries. Multivariable logistic regression and the Zhang method was used to estimate relative risk and adjust for confounders. We also performed a sensitivity analysis of patients who underwent CD for the sole indication of NRFS. Of the 8580 patients in the cohort, 721 (8.4%) had a first stage CD for NRFS. Among these, 476 (66.0%) were for the sole indication of NRFS. The risk of fetal acidemia was 5 times higher among patients undergoing CD for NRFS compared to all other deliveries (7.3% vs 1.2%, aRR 5.45[95% CI 3.35-8.68]). UA base excess and lactate were higher among patients with CD for NRFS. CD for NRFS was associated with an increased risk of composite neonatal morbidity (4.0% vs 1.0%, aRR 2.52 [95% CI 1.30-4.78]). After restricting the analysis to patients who had CD for the sole indication of NRFS, the risk of fetal acidemia and neonatal morbidity remained significantly higher in the CD for NRFS group than control deliveries. CD for NRFS is associated with an increased risk of fetal acidemia and composite neonatal morbidity. Although the vast majority of infants delivered for NRFS have normal outcomes, these results suggest that the diagnosis of NRFS using continuous fetal monitoring in labor is predictive of adverse outcomes.