BACKGROUND:

• The increasing cesarean section rate has resulted in more women who have undergone multiple cesarean sections
  • Significant risks include intraperitoneal adhesions, hemorrhage and organ injury
• The risks of unscheduled delivery need to be balanced against the risk of early term delivery
• Miller et al. (American Journal of Perinatology 2018) assessed whether women undergoing a higher order cesarean (3 cesarean deliveries or more) had a difference in perinatal outcome based on timing of delivery

METHODS:

• Retrospective cohort study
• Participants: Women with singleton gestations and a history of three or more prior cesareans
• Higher order cesareans were delivered at two centers
  • One center delivers at 39 weeks gestation
  • One center delivers at 37 weeks gestation (following after fetal lung maturity analysis or antenatal steroids)
• Primary outcomes
  • maternal and neonatal morbidities
• Adjustments were made for confounders, including maternal age, race/ethnicity, gravidity, parity, body mass index (BMI) at delivery, number of previous cesareans, concomitant major medical problems, indication for delivery (i.e., scheduled versus unscheduled), and gestational age at delivery

RESULTS:

• 440 women met criteria
• 2% of women were delivered at the 39 week institution vs 56.8% who delivered at the 37 week institution
• Delivery at 37-weeks was associated with a decrease in unscheduled deliveries (15.3 vs. 41.1%; p < 0.001)
• Planned delivery at 37 weeks was initially associated with decreased
  • Incidence of composite maternal morbidity (1.6 vs. 7.9%; p = 0.002)
  • 5-minute Apgar scores less than 7 (0.4 vs. 6.4%; p < 0.001),
• These differences were no longer significant after adjusting for confounders
• There were no other differences in perinatal outcomes

CONCLUSION:

• There were no significant differences between delivery at 37- and 39 weeks gestation for maternal or neonatal outcome
• However, delivery at 37 weeks did lead to fewer unscheduled deliveries
• The current study was powered (80%) to detect a 10-fold increased incidence of bowel injury and a 5-fold increased incidence of transfusion but not more rare outcomes such as maternal death or hysterectomy
• Authors recommend a well powered RCT to further determine impact on maternal and neonatal risks

Learn More – Primary Sources:

Optimal Timing of Delivery in Women with Higher Order Cesareans: A Cohort Study

Related ObG Topics:

What is the Best Practices Prevention Bundle for Post Cesarean Infection?

Does Vaginal Cleansing Prevent Endometritis Following Cesarean Section?

Does Azithromycin Cut Infection-associated Costs Following Cesarean Section?

Which is the Better Suture to Prevent C-Section Wound Complications?