Unplanned Cesarean Birth Research Articles

Anatomical and physiological aspects of the mutual influence of circulatory hypoxia of the myometrium and non-progressive labour

Non-progressive labour occurs in almost 10% of deliveries and is a main reason for unplanned cesarean sections and operative vaginal births using obstetric forceps or vacuum extraction. This article describes the morphological transformation of the myometrium and uterine blood vessels that occurs during pregnancy. It is shown that the myometrium inevitably experiences hypoxia at the microstructural level during each normal or pathological labour. We analyzed recent studies of the mutual influence of myometrial hypoxia and labour dystocia. Experimental and clinical studies showed relationship between the pH values and lactate levels determined in the myometrium on its contractility. Further research is justified, including the study of the pH and lactate values in amniotic fluid in patients with non-progressive labor. Finally, that will allow for clarifying the conditions and timing of labour stimulation with oxytocin and identifying a group of patients for whom oxytocin administration is contraindicated or hopeless.

A Qualitative Study Exploring Women's Experiences of Unplanned Cesarean Surgery and Their Suggestions for Improving Care

The rate of unplanned cesarean birth is increasing and there is a growing body of evidence regarding the associated psychosocial harms. A phenomenological study exploring eight women's lived experiences of intrapartum cesarean birth in Nova Scotia was undertaken. Two groups of women were recruited, three receiving care from a midwife with transfer from a planned home birth and five women under the care of a physician. Semi-structured interviews were tape-recorded and transcribed. These data, combined with participantdiariesande-mails,wereanalyzedusingColazzi'smethod. Threemajorthemesemerged:1) Immediate and lingering emotional reactions, which were wide ranging, the majority negative, particularly fear, disappointment and self-doubt, 2) Mediating factors, most significantly, continuous contact with the baby and provider support, especially from midwives, and 3) Participant suggestions for improving care which included prenatal operating room (OR) tours, family-friendly OR policies, postnatal medical review with extended follow-up and peer support. This study adds to the already substantial evidence of associated psychosocial harms which can be mediated by concurrently reducing unnecessary cesarean surgery and implementing measures to improve the quality of cesarean care.

Impact of Peripartum Depression and Anxiety Symptoms on Unplanned Cesarean or Operative Vaginal Births: A Prospective Observational Study

Impact of Peripartum Depression and Anxiety Symptoms on Unplanned Cesarean or Operative Vaginal Births: A Prospective Observational Study

Skin-To-Skin Contact During Cesarean Birth in the United States over the Last Decade.

To assess skin-to-skin contact during cesarean birth, including incidence and maternal characteristics. A cross-sectional, retrospective study using survey methods was conducted. Women who had a cesarean birth within the last 10 years prior to January 2022 were recruited via social media. Descriptive statistics, chi square, and binary logistic regression analyses were calculated. There were 2,327 participants, of which 29.7% experienced skin-to-skin contact during their cesarean birth. This was reported to be less often than desired. Significant associations were found among skin-to-skin contact during cesarean birth and planned cesarean birth, previous cesarean birth, maternal age, level of education, and birth region. Previous vaginal birth and race were not significantly associated with skin-to-skin contact during cesarean birth. Most (93.65%) respondents identified as White. Barriers to skin-to-skin contact during cesarean birth may be birth region, unplanned or emergency cesarean births, younger age, lacking a college degree, and lack of previous cesarean births. There are differences in incidence and access to skin-to-skin contact during cesarean birth. Our findings emphasize the continued need to address disparities in care, increase maternal health care equity, and make skin-to-skin contact during cesarean birth available for all women who desire it.

Women's experience of unexpected caesarean section birth in Kitui County, Kenya.

In sub-Saharan Africa, 72% of all Caesarean section (CS) births are unplanned compared to 27% of unplanned CS births done in developed countries. Various researches have been conducted on lived experiences following unexpected CS birth but none in Kitui County, Kenya. This study described the lived experience of undergoing an unexpected CS and the role of cultural beliefs on childbirth among Kitui/Kamba women in Kenya. A descriptive phenomenology design was used in this study. In-depth interviews of women who experienced unplanned Caesarean birth in Kitui County, Kenya, were conducted. Colaizzi's method guided the analysis. Interviews were approximately 30 minutes long and audiotaped. A total of 12 mothers participated in the study. Fives themes and 11 sub-themes emerged from this study: fear (fear of disability and surgical complications), pain (physical and psychological pain), less of a woman (lowered self-esteem, powerless and worry), sullied (dispirited and will loss), and fallacy (misconception and effects of fallacy). Disruption, dissatisfaction with the birth process, and unmet expectations were negative experiences. Healthcare workers should be sensitive when informing mothers of unplanned CS. More research to look for coping strategies to reduce negative birthing experiences.

Effects of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial on Elective Induction and Obstetric Outcomes in Term Nulliparous Patients.

To evaluate the effect of publication of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial on perinatal outcomes in singleton, term, nulliparous patients. An interrupted time series analysis was performed using clinical data for nulliparous singleton births at 39 weeks of gestation or later at 13 hospitals in the Northwest region of the United States (January 2016-December 2020). A modified Poisson regression was used to model time trends and changes after the ARRIVE trial (August 9, 2018). Outcomes of interest were elective induction, unplanned cesarean births, hypertensive disorders of pregnancy, a composite of perinatal adverse outcomes, and neonatal intensive care unit admissions. The analysis included 28,256 births (15,208 pre-ARRIVE and 13,048 post-ARRIVE). The rate of elective labor induction was 3.6% during the pre-ARRIVE period (January 2016-July 2018) and 10.8% post-ARRIVE (August 2018-December 2020). In the interrupted time series analysis, elective induction increased by 42% (relative risk [RR] 1.42; 95% CI 1.18-1.71) immediately after the ARRIVE trial publication. Thereafter, the trend was unchanged compared with the pre-ARRIVE period. There was no statistically significant change in cesarean birth (RR 0.96; 95% CI 0.89-1.04) or hypertensive disorders of pregnancy (RR 0.91; 95% CI 0.79-1.06) immediately after the trial, and no change in trend. After the ARRIVE trial, there was no immediate change in adverse perinatal outcomes, but a statistically significant increase in trend of adverse perinatal events (1.03; 95% CI 1.01-1.05) when compared with a declining trend observed in the pre-ARRIVE period. Publication of the ARRIVE trial was associated with an increase in elective induction, and no change in cesarean birth or hypertensive disorders of pregnancy in singleton nulliparous patients giving birth at 39 weeks or later. There was a flattening of the pre-ARRIVE decreasing trend in perinatal adverse events.

Disparities by race/ethnicity in unplanned cesarean birth among healthy nulliparas: a secondary analysis of the nuMoM2b dataset

BackgroundRacial disparities exist in maternal morbidity and mortality, with most of these events occurring in healthy pregnant people. A known driver of these outcomes is unplanned cesarean birth. Less understood is to what extent maternal presenting race/ethnicity is associated with unplanned cesarean birth in healthy laboring people, and if there are differences by race/ethnicity in intrapartum decision-making prior to cesarean birth.MethodsThis secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) dataset involved nulliparas with no significant health complications at pregnancy onset who had a trial of labor at ≥ 37 weeks with a singleton, non-anomalous fetus in cephalic presentation (N = 5,095). Logistic regression models were used to examine associations between participant-identified presenting race/ethnicity and unplanned cesarean birth. Participant-identified presenting race/ethnicity was used to capture the influence of racism on participant’s healthcare experiences.ResultsUnplanned cesarean birth occurred in 19.6% of labors. Rates were significantly higher among Black- (24.1%) and Hispanic- (24.7%) compared to white-presenting participants (17.4%). In adjusted models, white participants had 0.57 (97.5% CI [0.45–0.73], p < 0.001) lower odds of unplanned cesarean birth compared to Black-presenting participants, while Hispanic-presenting had similar odds as Black-presenting people. The primary indication for cesarean birth among Black- and Hispanic- compared to white-presenting people was non-reassuring fetal heart rate in the setting of spontaneous labor onset.ConclusionsAmong healthy nulliparas with a trial of labor, white-presenting compared to Black or Hispanic-presenting race/ethnicity was associated with decreased odds of unplanned cesarean birth, even after adjustment for pertinent clinical factors. Future research and interventions should consider how healthcare providers’ perception of maternal race/ethnicity may bias care decisions, leading to increased use of surgical birth in low-risk laboring people and racial disparities in birth outcomes.

Outcomes for Obstetrician or Midwifery Intrapartum Care of Low-Risk Hospital Births [ID: 1368407

INTRODUCTION: The objective of this study was to compare unplanned cesarean deliveries, labor interventions, and maternal and neonatal adverse outcomes in low-risk pregnant patients receiving intrapartum care managed by obstetricians or midwives. METHODS: We conducted a retrospective cohort study using perinatal data from a single academic tertiary center from 2013 to 2018. The sample included healthy nulliparous and multiparous patients with a term, singleton, vertex fetus managed by obstetricians or midwives. We included both induced and spontaneous labor as well as trial of labor after cesarean. We excluded patients with planned cesarean delivery or any high-risk diagnosis requiring prelabor transfer from midwife to obstetrician care. RESULTS: Our cohort included 7,694 patients; 3,543 (46%) received care from an obstetrician and 4,151 (54%) from a midwife. The overall cesarean rate was 11.8%. Patients receiving midwifery care had significantly lower cesarean rates (8.9% versus 15.2%, P&lt;.01), including when analyzed by parity. Patients receiving obstetrician care more frequently experienced induction/augmentation, neuraxial anesthesia, and operative vaginal delivery. Patients of obstetricians had a higher maternal adverse composite outcome (23% versus 18%, P&lt;.01). Midwifery patients had higher rates of shoulder dystocia (3% versus 2%, P&lt;.01). In logistic regression, midwifery care had lower adjusted odds of unplanned cesarean birth (adjusted odds ratio, 0.49 [0.40–0.60] 95% CI). CONCLUSION: Wider integration of midwifery care for low-risk labor and delivery may reduce rates of unplanned cesarean delivery and optimize effective patient-centered care. Additional studies are needed to identify the mechanisms underlying these findings and the implications for systems-based change to improve vaginal delivery rates in the U.S.

The Relationship Between Uterine Activity, Oxytocin Dosing, Labor Progress, and Mode of Birth in Nulliparas with Obesity: Minimal Usefulness of Montevideo Unit Measurement.

Maternal obesity and cesarean birth disproportionately affect Black parturients; thus, prevention of cesarean birth is a key modifiable factor to improve pregnancy outcomes and reduce disparities. The primary driver of unplanned cesarean birth among people with higher body mass index is prolonged labor duration. However, strategies to optimize outcomes in these situations have not been established. We aimed to evaluate the influence of oxytocin augmentation on uterine activity and labor progression in nulliparas with obesity. This secondary analysis involved nulliparas with obesity (BMI ≥30kg/m2) who had spontaneous labor onset followed by oxytocin augmentation and an intrauterine pressure catheter. Using Linear Mixed Models, we evaluated relationships between uterine activity measured in Montevideo units (MVU), oxytocin dose, and rate of cervical dilation normalized by labor duration. In this diverse sample (35.6% Caucasian, 16.11% African American, 40.2% Hispanic) of nulliparas with obesity (n = 87; BMI 35.54 ± 4.38kg/m2), 31% ended labor with cesarean birth. Among those with vaginal birth, only 13% had MVU ≥200 prior to the final 2hours of labor. MVUs were only minimally responsive to oxytocin dose and were not associated with labor progression nor birth route. MVU measurements may not be useful to diagnose labor arrest in nulliparas with obesity. Optimizing care for birthing people with obesity is essential for improving perinatal outcomes and for reducing racial health disparities.

Contextualizing disparities in NTSV cesarean rates with county-level data

The rate of cesarean births among nulliparous women with a term singleton fetus in vertex presentation (NTSV) is a quality indicator for perinatal care. Black women are disproportionately affected by high rates of unplanned cesarean birth and are at increased risk for the associated complications. We sought to describe disparities in the county-level NTSV cesarean birth rate in the United States to understand how cesarean disparities vary by place.

Individuals' Experiences of Having an Unplanned Cesarean Birth: A Qualitative Analysis.

The experience of an unplanned cesarean birth may be a risk factor for mood disorders and other challenges in the postpartum period, yet qualitative data on the patient experience are limited. We sought to understand individuals' experiences of having an unplanned cesarean birth. This was a secondary analysis of a prospective qualitative investigation among low-income postpartum individuals at a single-, tertiary-care center in which the primary aim was to evaluate patients' postpartum pain experience after a cesarean birth. Participants completed a 60-minute face-to-face interview on postpartum days 2 to 3. Only participants who labored prior to their cesarean birth were included in this analysis. Transcripts were analyzed by two separate authors using the constant comparative method. Themes are illustrated using direct quotes. A total of 22 individuals were included in this analysis; the majority (n=16, 72.7%) experienced a primary cesarean birth. Over half (n=12, 54.5%) identified as Hispanic and one-third (n=7, 31.8%) identified as non-Hispanic Black race and ethnicity. Four themes regarding the experience of a cesarean birth after labor were identified, including feelings of anguish, belief that vaginal birth is "normal," poor experiences with care teams, and feelings of self-efficacy. Subthemes were identified and outlined. In this cohort, individuals who experienced an unplanned cesarean birth after labor expressed feelings of self-blame, failure, and mistrust. Given the association of unplanned cesarean birth with mood disorders in the postpartum period, efforts to enhance communication and support may offer a means of improving individual experiences. · In this cohort, many individuals expressed negative feelings after an unplanned cesarean birth.. · Conversely, positive themes related to feelings of self-efficacy were identified.. · Efforts to enhance communication and support after an unplanned cesarean birth are warranted..

The Pathophysiology of Labor Dystocia: Theme with Variations.

Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.

Advancing understanding of maternal age: correlating epigenetic clocks in blood and myometrium

BackgroundAdvanced maternal age is currently a term defined by chronological age. However, a group of biomarkers known as epigenetic clocks, which can predict morbidity and mortality, has been used to estimate measures of biological aging. Uterine myometrial function during the process of parturition may be influenced by aging, as labor dystocia, unplanned intrapartum cesarean birth, and postpartum hemorrhage are more common in older individuals. The purpose of this study was to evaluate the use of epigenetic clocks in maternal myometrium and blood for predicting age and to evaluate the correlation of epigenetic age between the tissues.ResultsWe compared epigenetic age in blood and myometrial samples provided by women undergoing planned cesarean birth at term gestation. Chronological age ranged from 20 to 50 with a median (IQR) age of 35.5(8) years. The MethylationEPIC BeadChip was used to obtain DNA methylation data, and then epigenetic age was calculated using the Horvath, Hannum, GrimAge, and PhenoAge clocks. Spearman correlations of epigenetic age with chronological age were calculated. We tested the relationship of epigenetic age in maternal blood to epigenetic age in myometrium. Age acceleration, for each clock, was also correlated between tissues. Twenty-seven participants provided samples, and 21 matched specimens were included in the final analysis after quality control. Spearman correlation between maternal chronological age and epigenetic age were significant in three of the four clocks (pan-tissue Horvath, Hannum, and GrimAge), for both myometrium and blood samples. Correlations between blood epigenetic age and maternal age ranged from 0.72 to 0.87 (all p < 0.001). Correlations between myometrial epigenetic age and maternal age were also significant (0.62–0.70, p = 0.002), though lower than correlations seen in blood. Maternal blood epigenetic age also correlated with epigenetic age in myometrium with each of these three clocks 0.60 (p = 0.004, Horvath), 0.63 (p = 0.003, Hannum), and 0.80 (p < 0.001, GrimAge). GrimAge age acceleration had the highest correlation between tissues among the clocks (0.49, p = 0.02).ConclusionsGiven the limited sample, this study provides insight into the potential use of epigenetic age derived from blood as a proxy for myometrial epigenetic age, which may be a useful biomarker in estimating myometrial biological age in relationship to myometrial dysfunction. GrimAge outperformed the other tested clocks in terms of concordance of epigenetic age and age acceleration between tissues; however, the Horvath and Hannum clocks may be useful depending on the outcome of interest in pregnancy.

Learning from women: Improving experiences of respectful maternity care during unplanned caesarean birth for women with diverse ethnicity and racial backgrounds

ProblemWomen from diverse ethnicity and racial backgrounds have few opportunities to share birth experiences to inform improvements in care. BackgroundRespectful maternity care is recognised as a global women’s health priority. Integrating that framework into diverse care systems and models may help bridge care gaps for women who had unexpected birth experiences, including unplanned caesarean birth. AimTo describe the experiences of women who had unplanned caesarean births and use knowledge gained to inform best practice recommendations that embody respectful maternity care. MethodsQualitative data were analysed from focus groups involving a convenience sample of 11 English speaking women, from diverse ethnic and racial backgrounds, with prior unplanned caesarean experience. Respectful maternity care was used as the lens for interpreting women’s narratives using Thorne’s interpretive description. The study site was an outpatient prenatal clinic within an urban academic, tertiary-care medical centre in the United States. FindingsTwo predominant, contrasting themes emerged: “not feeling well cared for” and “feeling well supported”. Positive experiences included sources of support and strength from the midwifery practice, group prenatal care, and a doula program. Eight domains of respectful maternity care were applied to findings, highlighting current positive institutional practices and proposing areas for future quality improvement. ConclusionKey practices promoting respectful maternity care include adequate communication and information sharing between pregnancy care providers and women, and a more robust informed consent process. Further emphasis on respectful maternity care is needed to support women to make shared decisions that best fit their circumstances and preferences.

Private provider incentives in health care: The case of caesarean births

Private doctors and hospitals face incentives to intervene in the process of childbirth because they are employed and paid differently from their public counterparts. While private obstetric care has been associated with higher rates of caesarean birth, it is unclear to what extent this is attributable to unobserved selection effects related to clinical need or patient preferences. Using administrative birth data on over 280,000 births in Australia between 2007 and 2012, we implement an instrumental variables framework to account for the endogeneity of choice of care. We also exploit Australia's institutional framework to examine the differences in doctor-level and hospital-level incentives. We find that giving birth in a private hospital leads to a 4 percentage point increase in the probability of having an unplanned caesarean birth. Over our study period, this equates to an additional 3241 caesarean births.

Birth Satisfaction During the Early Months of the COVID-19 Pandemic in the United States.

Purpose:The purpose of this study was to describe birth satisfaction in women who gave birth in U.S. hospitals during the earliest months of the COVID-19 pandemic (March–July 2020).Study Design and Methods:A cross-sectional survey of 747 postpartum women who gave birth in the United States during the early COVID-19 pandemic was conducted. Participants in the United were recruited via social media. They completed a questionnaire that included demographic, health, and obstetric experience questions, and the Birth Satisfaction Scale-Revised. Descriptive statistics, t-tests, analysis of variance (ANOVA) models, and nonparametric correlations were performed.Results:Higher birth satisfaction scores were associated with higher income, marriage, white race, vaginal birth, having a birth partner present, and sufficient support during birth. Factors negatively associated with birth satisfaction were separation from infant, unplanned cesarean birth, neonatal intensive care unit admission, hypertension, preeclampsia, hemorrhage, depression, and anxiety.Clinical Implications:Presence of birth partners, sufficient birth support, and minimizing separation of mother and infant improve birth satisfaction. Obstetric complications, including unplanned cesarean birth, negatively affect birth satisfaction. There are racial disparities in birth satisfaction. It is critical to develop further interventions to end racism in maternal health care.

A Nurse-Navigated, Postpartum Support Text Messaging Intervention: Satisfaction Among Primiparous Women.

More than 50% of maternal deaths in the United States occur during the first year following childbirth. Nearly 40% of these deaths occur between days 1 and 41 of the postpartum period. Historically, women receive less attention from healthcare providers during the postpartum period when compared with the care provided during pregnancy and childbirth. Women may not return for scheduled follow-up care until 4 to 6 weeks after birth, if they return at all. The role of postpartum nurse navigator (PPNN) was developed to deliver a novel, text messaging intervention as part of a randomized controlled trial to 43 primiparous women who experienced an unplanned cesarean birth. Through daily, interactive text messaging, the PPNN assessed study participants' general well-being, assisted with symptom navigation, offered anticipatory guidance, and provided informational support until 4 weeks postpartum. Satisfaction with the intervention was evaluated using a survey that incorporated quantitative and qualitative responses. Overwhelmingly, 93% of participants rated their overall experience with the text messaging intervention as outstanding or good. At least 95% of the participants indicated that they would likely choose to receive daily text messaging from a PPNN following a subsequent birth. Convenient access to professional nurse support for women postbirth warrants further evaluation.

A standardized post-cesarean analgesia regimen reduces postpartum opioid use

Background Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen. Objective To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth. Study design A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared. Results Of 2340 women who underwent cesarean birth during the study period (1 July 2017 − 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (p < .001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12 h (57.3 ± 23.8 vs 48.6 ± 26.2 MME, p < .001), 24 h (98.1 ± 34.1 vs 82.1 ± 38.8 MME, p < .001), and 48 h (165.8 ± 58.3 vs 134.9 ± 66.2 MME, p < .001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p < .001). Conclusion Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

Women's experiences of skin-to-skin cesarean birth compared to standard cesarean birth: a qualitative study.

Background:Skin-to-skin contact between mother and infant immediately after birth is recommended regardless of delivery method; however, it is less common after cesarean delivery. We aimed to describe and compare women’s experiences of cesarean birth with and without skin-to-skin contact at an urban tertiary care hospital.Methods:In this hermeneutic phenomenologic study, we used semistructured telephone interviews from 2015 to 2018 to interview a convenience sample of women who delivered at term by scheduled skin-to-skin cesarean birth at an urban tertiary care hospital in Toronto, Ontario. Women were invited to participate if they had had a previous planned or unplanned cesarean birth and a scheduled skin-to-skin cesarean birth between 2013 and 2017. Participants were excluded if they had antenatally diagnosed conditions, they delivered before 37 weeks, they had general anesthesia, their condition was unstable at the time of surgery, a skin-to-skin cesarean birth was not possible or they declined skin-to-skin cesarean birth. Interviews were recorded, transcribed and analyzed by means of thematic analysis.Results:Ten women were interviewed 1–19 months postpartum. Four central themes emerged: support for skin-to-skin cesarean birth (women feeling supported by their families and health care providers); control (participants experiencing greater control during their skin-to-skin cesarean birth); connection with the infant, which enabled women to be active participants in their delivery, enhanced bonding and intimacy, facilitated breastfeeding and bolstered confidence during early parenthood; and logistic considerations, with participants recognizing that skin-to-skin cesarean birth required additional resources.Interpretation:These findings refine what is known about skin-to-skin cesarean birth and provide a critical perspective, that of mothers. They support the transformation of traditional operating room dynamics to a more patient-centred environment.

509 Is identifying as black enough to increase your risk of unplanned cesarean birth?

Black women are at increased risk of cesarean delivery (CD), though why is unknown. Unplanned CD is associated with increased maternal morbidity and mortality. We aimed to investigate whether race and other maternal demographic characteristics were associated with increased risk of unplanned CD at two academic hospitals. We conducted a retrospective cohort study of births > 34 weeks GA between 2017 and 2019, at two academic centers with a shared residency. Our primary outcome was CD after a trial of labor (unplanned CD). Multiple gestations, VBAC, elective repeat or primary CD, and contraindications for vaginal delivery were excluded. Median income by zip code was obtained from 2018 census data. Self-identified race, ethnicity & marital status, as well as age, parity, pregravid BMI, CD indication, & mode of delivery were extracted from the electronic medical record. Odds of unplanned CD were estimated by multivariate logistic regression. 18,946 deliveries were included in the analysis (10,616 from Hospital A and 8,339 from Hospital B). The rate of CD was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, BMI, and parity, women of Black and Asian races had significantly increased odds of unplanned CD; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Adjusted OR for Hispanic women was 1.09 (0.89, 1.34). At Hospital A, those who identified as single compared to married had an aOR of 1.27, (1.09,1.47) and those in the lowest income quartile had an aOR of 1.26 (1.04, 1.52). (Table) Rates of unplanned CD were significantly higher in Black compared to White women at 2 large teaching hospitals, even after adjustment for age, BMI, parity, and zip code income strata, while Hispanic women compared to White women had no increased odds of unplanned CD. The magnitude of increased odds of CD for Black women is much higher than any other predictor or socioeconomic status. Future work is urgently needed to better understand differences in provider care or patient attributes that may contribute to these findings.