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Grand Rounds

Three Previous Cesarean Deliveries: When to Deliver?

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BACKGROUND AND PURPOSE:

  • Breslin et al. (Obstetrics & Gynecology, 2019) sought to determine whether earlier delivery is associated with lower adverse perinatal outcomes in women who have had 3 previous cesarean sections

METHODS:

  • Secondary analysis of prospective cesarean section registry
  • Participants
    • 3 previous cesarean sections, undergoing scheduled or emergent repeat section
    • Live, singleton gestations
    • 37 through 41 weeks
  • Exclusion criteria
    • Non-low transverse incision
    • Antepartum stillbirth
    • Previous myomectomy
    • Fetal anomalies
    • More or fewer than three cesareans
    • TOLAC
  • Statistical Analysis
    • Logistic regression models
    • Adjusted for confounders
  • Primary outcome: Composites of maternal and neonatal morbidity

RESULTS:

  • 821 women included

Maternal morbidity composite: 9.86%

  • Adjusted odds of maternal morbidity: Higher at 37 weeks and 38 weeks compared to 39 weeks
    • 37 weeks: adjusted odds ratio (OR) 1.73 (95% CI, 0.63–4.7)
    • 38 weeks: aOR 2.23 (95% CI, 1.05–4.74)
    • 40 and ≥41 weeks: Maternal morbidity not statistically different vs 39 weeks
  • Individual outcomes
    • 38 week delivery associated with increased atony, postpartum transfusion and endometritis, but individually did not reach statistical significance

Neonatal morbidity composite: 10.5%

  • Adjusted odds of neonatal morbidity: Higher at 37 weeks vs 39 weeks (not for other weeks less than or greater than 39 weeks)
    • 37 weeks: aOR 2.81 (95% CI, 1.2–6.6)

Additional Findings

  • After adjusting for confounding variables, maternal and neonatal morbidity occurred least frequently at 39 weeks
  • Spontaneous labor occurred in 10% of the cohort prior to scheduled cesarean section
    • No increase in maternal morbidity for those women who presented in labor prior to cesarean

CONCLUSION:

  • In women with three previous CDs, adverse outcomes were not reduced by delivering prior to 39 weeks
    • Possible that less developed lower segment may account for increased maternal morbidity prior to 39 weeks
  • Authors conclude elective delivery at 39 weeks is safe and is associated with decreased maternal morbidity compared to delivery at 37 or 38 weeks

Learn More – Primary Sources:

Impact of timing of delivery on maternal and neonatal outcomes for women after three previous caesarean deliveries; a secondary analysis of the caesarean section registry

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Related ObG Topics:

Delivery at 37 or 39 Weeks for Higher Order Cesarean Sections?
Suture or Staple for Tertiary or Higher-Order C-Section Closure?

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