Increased complications associated with emergent repeat cesarean
1. Incision to delivery time of ≤2 minutes was associated with greater risk of maternal morbidity during repeat cesarean delivery.
2. Uterine rupture and intraoperative transfusion were more likely among women undergoing faster emergent cesarean deliveries.
Evidence Rating Level: 2 (Good)
Study Rundown: While the rate of cesarean delivery (CD) has plateaued in recent years, CD still constitutes nearly a third of singleton births in the United States. Women who have had a prior CD can choose between elective repeat CD or a trial of labor after CD (TOLAC) in a subsequent pregnancy; TOLAC can result in successful vaginal birth or may require an emergent CD in the instance of maternal or fetal distress. Successful TOLAC is associated with the lowest morbidity, elective repeat CD is associated with intermediate morbidity while failed TOLAC with emergent CD is associated with the greatest morbidity. While an optimal delivery timeframe in emergent situations has not been established, current guidelines recommend delivery as soon as possible to optimize fetal wellbeing. In the current work, authors assessed whether speed of surgery was associated with maternal outcomes in women who underwent emergent repeat CD during TOLAC. They found that incision to delivery (I-D) time of ≤2 minutes was associated with increased risk of maternal complications.
Strengths of the study included prospectively collected data. This post hoc analysis was limited by retrospective chart review, small subset size of women with I-D time ≤2 minutes, and exclusion of multiple gestations and delivery of infants with congenital anomalies. Further large-scale prospective studies are needed to characterize the relationship between surgical time and maternal morbidity in pregnant women with a history of CD.
Relevant Reading: Decision-to-incision times and maternal and infant outcomes
In-Depth [prospective cohort]: This study compared maternal outcomes among women undergoing TOLAC who required emergent repeat CD where I-D time was ≤2 minutes (n = 108) compared to >2 minutes (n = 685). The primary outcome was a composite of maternal complications including uterine rupture, blood transfusion, intensive care unit admission and death. Analysis was adjusted for confounders such as pre-existent maternal disease and gestational age.
Women who underwent rapid emergent repeat CD, those with I-D time ≤2 minutes, were more likely to experience maternal complications (RR 1.66, CI 1.23-2.23). These women were also more likely to experience uterine rupture or dehiscence, intraoperative blood transfusion, uterine artery ligation and broad ligament hematoma (all p<0.01).
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