Objective
The purpose of this study was to determine whether surgical speed is associated with maternal outcomes in women who have a history of previous cesarean delivery (CD) and who require emergent delivery.
Study Design
This is a secondary analysis of a multicenter, prospective observational study of women with a history of previous CD. Women who attempted a vaginal birth after CD and required emergent CD were dichotomized into those with a skin incision-to-fetal delivery time of ≤2 min (I-D ≤2) or >2 min (I-D >2), based on the mode I-D. Rates of composite maternal complications and specific surgical complications were compared.
Results
Seven hundred ninety-three women had an emergency repeat CD: 108 women (13.6%) had I-D ≤2, and 685 women (86.4%) had I-D >2. The composite of maternal morbidity occurred in 36% of women with I-D≤2 and 23% with I-D>2 ( P < .01). Women with I-D ≤2 had higher odds of intraoperative transfusion, uterine artery ligation, and broad ligament hematoma. In a multivariable regression model, the only variable that remained associated with maternal outcome was I-D (relative risk, 1.66; 95% confidence interval, 1.23–2.23). There was no difference in the incidence of neonatal acidemia between groups.
Conclusion
Among women who underwent emergent repeat cesarean delivery, surgical speed was associated with an increased risk for maternal complications.
For cesarean deliveries (CDs) that are deemed emergent, a common practice is to perform a “stat” CD within 30 minutes of the decision to operate. The American College of Obstetricians and Gynecologists (ACOG) previously recommended that all hospitals that provide obstetric services have the capability to begin surgery within 30 minutes of the decision to perform a CD. However, because studies have failed to show improved neonatal outcomes when CD is performed within this timeframe, less emphasis has been placed on operating within a specific window of time. The current ACOG recommendations for management of a category III heart tracing, for example, state that the optimal timeframe for delivery has not been determined but that delivery should be accomplished “as expeditiously as possible.”
What is not known is how maternal outcomes are affected by emergent CDs. The interval from decision-to-delivery reflects the operation of systems-based practice (mobilization of clinical care teams, operating room set up, patient transport, and preoperative surgical preparation) and surgical speed. Although expeditious coordination of surgical care may be expected to increase the risk for adverse outcomes, there is a paucity of research regarding the impact of surgical speed on the risk of maternal operative complications.
Our objective was to determine whether surgical speed is associated with adverse maternal outcomes in women who have a history of CD and require emergent delivery. We hypothesized that shorter incision-to-delivery (I-D) times would be associated with increased risk for the composite outcome of maternal morbidity.
Materials and Methods
This is a secondary analysis of the CD registry, which has been created by the institutions that comprised the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network between 1999 and 2002. Data were collected prospectively for women with a history of CD who underwent repeat CD at 1 of the 19 participating centers. Detailed information regarding medical, surgical, and obstetric histories, intrapartum and postpartum course, and neonatal outcomes were collected.
Women with a history of a uterine scar who were attempting a trial of labor were included in this analysis if they underwent emergent CD. Emergent CD was defined as a surgery performed for the indication of nonreassuring fetal heart rate or umbilical cord prolapse. Women with multiple gestations, major fetal anomalies, and antepartum fetal death were excluded. I-D time was defined as the time interval in minutes between skin incision and delivery of the fetus, as recorded in intraoperative records. The mode I-D time for the study population was 2 minutes. Subjects were dichotomized into those with an I-D time of ≤2 minutes (I-D≤2) or >2 minutes (I-D>2) based on the mode, and the outcomes were assessed between these 2 groups.
The primary outcome was a composite of maternal operative complications that has been used in previous secondary analyses of this cohort designed to address questions regarding maternal morbidity that is related to mode of delivery. The composite included uterine rupture and dehiscence, atony, transfusion, uterine artery ligation, broad ligament hematoma, cystotomy, ileus, ureteral injury, hysterectomy, endometritis, thromboembolic disease, intensive care unit admission, and maternal death. Secondary outcomes were incidences of specific surgical complications. Maternal outcomes were reported until hospital discharge and up to 6 weeks after delivery for subjects who were readmitted during the postpartum period.
Data were analyzed with SAS software (version 9.1.3; SAS Institute Inc, Cary, NC). The relationships between I-D and categoric variables were compared with the use of the Pearson Χ 2 or Fisher exact tests. Continuous variables were compared with the use of the Wilcoxon rank-sum test or Student t test, as appropriate. Multivariate logistic-binomial regression was performed to adjust for potential confounding factors for the prediction of maternal morbidity. These potential confounding variables included gestational age at delivery, body mass index (BMI), race, and baseline disease. Two-sided probability values are reported; a probability value of < .05 was considered significant.
Results
Seven hundred ninety-three women had an emergency repeat CD. A flow diagram of subjects included in the analysis is presented in Figure 1 . One hundred eight women (13.6%) had I-D≤2; 105 procedures (97.2%) were performed for nonreassuring fetal status, and 3 procedures (2.8%) were performed for cord prolapse. Six hundred eighty-five women (86.4%) had I-D>2: 668 procedures (97.5%) were performed for nonreassuring fetal status and 17 procedures (2.5%) were performed for cord prolapse. The groups were similar with respect to average age and BMI, race, baseline maternal disease, and median gestational age at delivery ( Table 1 ). Baseline maternal disease was classified as a woman with asthma, diabetes mellitus, chronic hypertension, thyroid disease, renal disease, or a connective tissue disorder diagnosed before pregnancy. The groups differed with respect to the distribution of patients in each BMI category; there were relatively more patients with low or normal BMI in the I-D≤2 group.
| Characteristic | Incision-to-delivery | P value | |
|---|---|---|---|
| >2 minutes (n = 685) | ≤2 minutes (n = 108) | ||
| Age, y a | 28.3 ± 6 | 27.7 ± 5.8 | .39 |
| Advanced maternal age, % (n) | 14.7 (101) | 11.1 (12) | .32 |
| Race, % (n) | .73 | ||
| African American | 48.3 (331) | 50 (54) | |
| White | 30.2 (207) | 29.6 (32) | |
| Hispanic | 16.6 (114) | 17.6 (19) | |
| Asian | 91.7 (11) | 8.3 (1) | |
| Native American | 0.3 (2) | 0.9 (1) | |
| Other/unknown | 2.9 (20) | 0.9 (1) | |
| Body mass index, kg/m 2 a | 33.5 ± 7.4 | 32.1 ± 7.3 | .08 |
| Body mass index class, % (n) | .03 | ||
| Underweight (<18.5 kg/m 2 ) | 6.2 (42) | 11.1 (12) | |
| Normal (18.5-24.9 kg/m 2 ) | 6.8 (46) | 11.1 (12) | |
| Overweight (25-29.9 kg/m 2 ) | 26.9 (183) | 30.6 (33) | |
| Obese (>29.9 kg/m 2 ) | 60 (409) | 47.2 (51) | |
| Baseline maternal disease, % (n) b | 22.3 (153) | 14.8 (16) | .08 |
| Gestational age at delivery, wk c | 39.4 (37.7–40.4) | 39.5 (37.9–40.2) | .91 |
b Includes the following diagnoses: asthma, diabetes mellitus, chronic hypertension, thyroid disease, renal disease, and connective tissue disorders
The composite of maternal morbidity occurred in 36% of women with I-D≤2 and 23% of women with I-D>2 ( P < .01). The unadjusted risk for maternal morbidity was 3.33 (95% confidence interval, 2.82–4.03) for women with I-D≤2. There was 1 maternal death in both the I-D>2 group (1.4%) and the I-D≤2 (3.6%; P = .48). At the time of surgery, uterine rupture was noted in 36 (5.3%) patients with I-D>2 and 23 (21.3%) with I-D≤2. The unadjusted risks for individual adverse maternal outcomes are presented in Table 2 . Women with I-D≤2 had a higher risk of intraoperative transfusion, uterine artery ligation, and broad ligament hematoma. Cystotomy occurred in 3.7% of patients with I-D≤2 vs 1.3% of patients with ID>2 ( P = .07). Postpartum transfusion was required in 6.5% of women with I-D≤2 and 2.9% of women with ID>2 ( P = .06). The differences in rates of the remaining intraoperative and postoperative adverse events did not reach statistical significance. Many of the adverse outcomes were infrequent, and the comparison groups were small.
| Maternal adverse outcome | Incision-to-delivery, n (%) | Relative risk | 95% confidence interval | P value | |
|---|---|---|---|---|---|
| >2 minutes | ≤2 minutes | ||||
| Composite morbidity | 159 (23.2) | 39 (36.1) | 3.33 | 2.82–4.03 | < .01 |
| Intraoperative events | |||||
| Atony | 32 (4.7) | 4 (3.7) | 0.78 | 0.27–2.27 | .19 |
| Intraoperative transfusion | 12 (1.8) | 7 (6.5) | 3.89 | 1.50–10.10 | < .01 |
| Uterine artery ligation | 10 (1.5) | 9 (8.3) | 6.1 | 2.7–13.9 | < .01 |
| Broad ligament hematoma | 3 (0.4) | 4 (3.7) | 8.7 | 2.1–37.2 | < .01 |
| Cystotomy | 9 (1.3) | 4 (3.7) | 2.89 | 0.87–9.55 | .09 |
| Exploratory laparotomy or hysterectomy | 6 (0.9) | 3 (2.8) | 3.23 | 0.80–13.13 | .11 |
| Postoperative events | |||||
| Postpartum transfusion | 20 (2.9) | 7 (6.5) | 2.30 | 0.95–5.59 | .06 |
| Deep vein thrombosis | 3 (4.2) | 1 (3.6) | 0.85 | 0.08–8.55 | .43 |
| Endometritis | 65 (9.5) | 8 (7.4) | 0.76 | 0.36–1.64 | .49 |
| Wound complication | 11 (1.6) | 1 (0.9) | 0.57 | 0.07–4.48 | .33 |
| Postoperative ileus | 7 (1) | 1 (0.9) | 0.91 | 0.11–7.43 | .39 |
| Intensive care unit admission | 2 (7.1) | 7 (9.7) | 1.40 | 0.27–7.19 | .29 |
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