Cesarean in the second stage associated with endometritis

Image: PD 

1. Cesarean section performed in the second stage of labor was associated with a three times greater risk of endometritis than those performed in the first stage of labor. 

2. The difference in risk of endometritis remained significant when controlled for maternal age, diabetes, and obesity. 

Evidence Rating Level: 2 (Good)

Study Rundown: This study found that cesarean delivery preformed during the second stage of labor was associated with a greater risk of postpartum endometritis compared with those performed during the first stage of labor. This is the first study to assess endometritis risk by timing of surgery relative to labor stage, though other studies have conducted investigations using time-dependent analyses. Prior studies have identified associations of endometritis with time since rupture of membranes and the use of internal monitors.

A number of significant differences exist between the two groups evaluated in this study, including indication for cesarean and whether labor was spontaneous or induced, that were not accounted for in the analysis. Specifically, women who underwent second stage cesarean were more likely to have had a failed vacuum or forceps delivery, which could bias results away from the null. Future studies might replicate findings in a larger, multi-center sample that accounts for baseline differences in groups and also assess the clinical utility of a more rigorous infectious control strategy in women undergoing second stage Cesarean deliveries.

Click to read the study in AJOG

Relevant Reading: Number of cervical examinations and risk of intrapartum maternal fever Antibiotic prophylaxis for cesarean section

In-Depth [retrospective cohort study]: Researchers compared infectious morbidity in women who underwent cesarean delivery in the first stage of labor, defined as cervical dilation <10cm, (n=2,105, 84.0%) or the second stage of labor, defined as complete (10 cm) cervical dilation (n=400, 16.0%). The primary outcome was endometritis. Secondary outcomes included wound infection, maternal fever, and suspected or confirmed neonatal sepsis.

Compared with those who had cesarean sections performed during the first stage of labor, women who received second stage cesarean sections were more likely to develop postpartum endometritis (4.25% vs. 1.52%, OR=2.88, 95% CI=1.58-5.23). This risk was potentiated but remained significantly increased after adjusting for potential confounders, including diabetes, obesity, and maternal age (aOR=2.78, 95% CI=1.51-5.09). There was no significant difference in risks of wound infection and neonatal sepsis between the two groups.

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