Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour

Passive second stage of labor: does a fourth hour increase maternal morbidity in nulliparous patients at term with epidural?

OBJECTIVES

Prolonging the passive second stage of labor could increase vaginal birth rate, but the data concerning maternal and fetal morbidity are contradictory. The French guidelines did not specify a maximum duration of the passive second stage. Our objective was to assess if allowing a 4th hour after full dilatation before pushing increased maternal morbidity, compared to 3 hours after full dilatation.

STUDY DESIGN

This single-center, retrospective, observational cohort study took place from January 1-December 31, 2020, in a tertiary maternity unit. All consecutive term nulliparous women who delivered under epidural anesthesia and without pathological fetal heart rate and reaching a second-stage passive phase of labor lasting at least 3 hours were included. We compared 2 groups according to the duration of the passive second stage: "3-hour group" and "4-hour group". In the "3-hour group," featuring a second-stage passive phase of up to 3 hours, pushing is initiated for favorable conditions, while a cesarean section is performed if conditions are deemed unfavorable. In the "4-hour group", obstetric conditions not justifying immediate pushing after three hours, and the obstetric team believed that an additional hour of expectant management could lead to a successful vaginal delivery. The principal endpoint was a composite criterion of maternal morbidity including obstetric anal sphincter injuries, postpartum hemorrhage, transfusion and intrauterine infection.

RESULTS

We included 111 patients in the "4-hour group" and 349 in the "3-hour group". Composite maternal morbidity did not increase in the "4-hour group" compared to the "3-hour group" (21 (18.9%) versus 61 (17.5%); p = 0.73). Neonatal morbidity was similar between the two groups. In the "4-hour group, 91 (82%) patients had vaginal deliveries", 62 (55,9%) by spontaneous vaginal delivery and 29 (26,1%) with instrumental assistance.

CONCLUSION

For selected patients, waiting for 4 hours at full dilation can be beneficial due to the high rate of vaginal delivery and low incidence of maternal and fetal complications.

Management of impacted fetal head at cesarean delivery

Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.

The use of bubble charts in analyzing second stage cesarean delivery rates

BACKGROUND

The incidence of second stage cesarean delivery has been rising globally because of the failure or the anticipated difficulty of performing instrumental delivery. Yet, the best way to interpret the figure and its optimal rate remain to be determined. This is because it is strongly influenced by the practice of other 2 modes of birth, namely cesarean delivery performed before reaching the second stage and assisted vaginal birth during the second stage. In this regard, a bubble chart that can display 3-dimensional data through its x-axis, y-axis, and the size of each plot (presented as a bubble) may be a suitable method to evaluate the relationship between the rates of these 3 modes of births.

OBJECTIVE

This study aimed to conduct an epidemiologic study on the incidence of second stage cesarean deliveries rates among >300,000 singleton term births in 10 years from 8 obstetrical units and to compare their second stage cesarean delivery rates in relation to their pre-second stage cesarean delivery rates and assisted vaginal birth rates using a bubble chart.

STUDY DESIGN

The territory-wide birth data collected between 2009 and 2018 from all 8 public obstetrical units (labelled as A to H) were reviewed. The inclusion criteria were all singleton pregnancies with cephalic presentation that were delivered at term (≥37 weeks' gestation). Pre-second stage cesarean delivery rate was defined as all elective cesarean deliveries and those emergency cesarean deliveries that occurred before full cervical dilatation was achieved as a proportion of the total number of births. The second stage cesarean delivery rate and assisted vaginal birth rate were calculated according to the respective mode of delivery as a proportion of the number of cases that reached full cervical dilatation. The rates of these 3 modes of births were compared among the parity groups and among the 8 units. Using a bubble chart, each unit's second stage cesarean delivery rate (y-axis) was plotted against its pre-second stage cesarean delivery rate (x-axis) as a bubble. Each unit's second stage cesarean delivery to assisted vaginal birth ratio was represented by the size of the bubble.

RESULTS

During the study period, a total of 353,434 singleton cephalic presenting term pregnancies were delivered in the 8 units, and 180,496 (51.1%) were from nulliparous mothers. When compared with the multiparous group, the nulliparous group had a significantly lower pre-second stage cesarean delivery rate (18.58% vs 21.26%; P<.001) but a higher second stage cesarean delivery rate (0.79% vs 0.22%; P<.001) and a higher assisted vaginal birth rate (17.61% vs 3.58%; P<.001). Using the bubble of their averages as a reference point in the bubble chart, the 8 units' bubbles were clustered into 5 regions indicating their differences in practice: unit B and unit H were close to the average in the center. Unit A and unit F were at the upper right corner with a higher pre-second stage cesarean delivery rate and second stage cesarean delivery rate. Unit D and unit E were at the opposite end. Unit C was at the upper left corner with a low pre-second stage cesarean delivery rate but a high second stage cesarean delivery rate, whereas unit G was at the opposite end. Unit C and unit G were also in the extremes in terms of pre-second stage cesarean delivery to assisted vaginal birth ratio (0.09 and 0.01, respectively). Although some units seemed to have very similar second stage cesarean delivery rates, their obstetrical practices were differentiated by the bubble chart.

CONCLUSION

The second stage cesarean delivery rate must be evaluated in the context of the rates of pre-second stage cesarean delivery and assisted vaginal birth. A bubble chart is a useful method for analyzing the relationship among these 3 variables to differentiate the obstetrical practice between different units.

The use of bubble charts in analyzing the global second-stage cesarean delivery rates: a systematic review

OBJECTIVE

This study aimed to systematically review the worldwide second-stage cesarean delivery rate concerning pre-second-stage cesarean delivery and assisted vaginal birth rates.

DATA SOURCES

PubMed, Medline Ovid, EBSCOhost, Embase, Scopus, and Google Scholar were queried from inception to February 2023, with the following terms: "full dilatation," "second stage," and "cesarean," with their word variations. Furthermore, an additional cohort of 353,434 cases from our recently published study was included.

STUDY ELIGIBILITY CRITERIA

Only original studies that provided sufficient information on the number of pre-second-stage cesarean deliveries, second-stage cesarean deliveries, and vaginal births were included for the calculation of different modes of delivery. Systemic reviews, meta-analyses, or case reports were excluded.

METHODS

Study identification and data extraction were independently performed by 2 authors. Selected studies were categorized on the basis of parity, study period, and geographic regions for comparison.

RESULTS

A total of 25 studies were included. The overall pre-second-stage cesarean delivery rate, the second-stage cesarean delivery rate, and the second-stage cesarean delivery-to-assisted vaginal birth ratio were 17.94%, 2.65%, and 0.19, respectively. Only 5 studies described singleton, term, cephalic presenting pregnancies of nulliparous women, and their second-stage cesarean delivery rates were significantly higher than those studies with cohorts of all parity groups (4.50% vs 0.83%; P<.05). In addition, the second-stage cesarean delivery rate showed a secular increase across 2009 (0.70% vs 1.05%; P<.05). Moreover, it was the highest among African studies (5.14%) but the lowest among studies from East Asia and South Asia (0.94%). The distributions of second-stage cesarean delivery rates of individual studies and subgroups were shown with that of pre-second-stage cesarean delivery and assisted vaginal birth using the bubble chart.

CONCLUSION

The overall worldwide pre-second-stage cesarean delivery rate was 17.94%, the second-stage cesarean delivery rate was 2.65%, and the second-stage cesarean delivery-to-assisted vaginal birth ratio was 0.19. The African studies had the highest second-stage cesarean delivery rate (5.14%) and second-stage cesarean delivery-to-assisted vaginal birth ratio (1.88), whereas the studies from East Asia and South Asia were opposite (0.94% and 0.11, respectively).

Impacted fetal head extraction methods at second stage cesarean and subsequent preterm delivery: A multicenter study

OBJECTIVE

Second-stage cesarean delivery (CD) is associated with subsequent preterm birth (PTB). It has been suggested that an increased risk of PTB after second-stage cesarean delivery could be linked to a higher chance of cervical injury due to the extension of the uterine incision. Previous studies have shown that reverse breech extraction is associated with lower rates of uterine incision extensions compared to the "push" method. We aimed to investigate the association between the method of fetal extraction during second-stage CD and the rate of spontaneous PTB (sPTB), as well as other maternal and neonatal outcomes during the subsequent pregnancy.

METHODS

This was a multicenter retrospective cohort study. The study population included women in their first subsequent singleton delivery following a second-stage CD between 2004 and 2021. The main exposure of interest was the method of fetal extraction in the index CD ("push" method vs. reverse breech extraction). The primary outcome of this study was sPTB <37 weeks in the subsequent pregnancy. Secondary outcomes were overall PTB, trial of labor, and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling.

RESULTS

During the study period, 2969 index CD during second stage were performed, of those 583 met the inclusion criteria, of whom 234 (40.1%) had fetal extraction using the reverse breech extraction method, while 349 (59.9%) had the "push" method for extraction. In univariate analysis, women in those two groups had statistically similar rates of sPTB (3.7% vs. 3.0%; odds ratio [OR] 1.25, 95% CI: 0.49-3.19) and overall PTB (<37, <34 and <32 weeks), as well as other maternal, neonatal, and trial of labor outcomes. This was confirmed by multivariate analyses with an adjusted OR of 1.27 (95% CI: 0.43-3.71) for sPTB.

CONCLUSION

Among women with a previous second-stage CD, no significant difference was observed in PTB rates in the subsequent pregnancies following the "push" method compared to the reverse breech extraction method.

Comparing adverse maternal and perinatal outcomes in primary caesarean delivery during first versus second-stage of labour in Kenya: An institution-based cohort study

BACKGROUND

As caesarean delivery rates continue to increase globally, so are the number of second-stage caesarean deliveries. Second-stage caesareans may carry additional risk of complications for both the mother and fetus owing to fetal head impaction into the maternal pelvis and manipulations required for delivery. So far, data on this procedure's outcomes from low resource countries are limited.

OBJECTIVES

To compare adverse maternal and perinatal outcomes between second-stage and first-stage of labour intrapartum primary caesarean deliveries over 12 months at a tertiary referral obstetric hospital in Kenya.

METHODS

In a hospital-based cohort study, 222 women with singleton, cephalic presenting fetuses at term gestation who had intrapartum primary caesarean delivery during active labour were recruited post-partum. Second-stage caesarean deliveries (73) were compared to 149 first-stage caesarean deliveries. The proportion of caesarean deliveries in the second-stage of labour was estimated and the adverse maternal and perinatal outcomes were compared. The study was conducted from August 2021 to July 2022 at the Moi Teaching and Referral Hospital, Eldoret.

RESULTS

The proportion of second-stage caesarean deliveries among intrapartum primary caesarean deliveries was 4.3% [95% CI: 2.9% - 4.7%]. Compared to first-stage caesarean deliveries, second-stage caesarean deliveries had a significantly higher risk of adverse maternal outcomes (RR 3.272, 95% CI 2.28-4.71, P < 0.001), including intraoperative trauma, atony, blood transfusion, and a postoperative hospital stay of more than three days. Additionally, there was a higher risk of adverse perinatal outcomes (RR 2.748, 95% CI 2.45-4.50, P < 0.001), including increased risk of a 5-min APGAR ≤3, admission to NBU, and neonatal death.

CONCLUSIONS

An increased risk of adverse maternal and perinatal outcomes is associated with primary second-stage caesarean deliveries compared to primary first-stage caesarean deliveries.

Experiences of Impacted Foetal Head: Findings from a Pragmatic Focus Group Study of Mothers and Midwives

INTRODUCTION

We aimed to explore the lived experiences of caesarean birth complicated by impaction of the foetal head, for mothers and midwives.

METHODS

A pragmatic, qualitative, focus group study of mixed-participants was conducted, face-to-face. They were postpartum women (n = 4), midwives (n = 4), and a postpartum midwife (n = 1) who had experience of either providing care for impacted foetal head, and/or had experienced it during their own labour, in Fife, United Kingdom. Data were transcribed and were analysed using template analysis.

RESULTS

Three main themes emerged through analysis: (i) current knowledge of impacted foetal head; (ii) current management of impacted foetal head; and (iii) experiences and outcomes of impacted foetal head. Each theme was made up of various initial codes when data were analysed inductively. Finally, each theme could be overlaid onto the three core principles of the Tydeman Tube: (1) to improve outcomes for mother and baby in the second stage of labour; (2) to reduce the risk of trauma to mother and baby in complicated births; and (3) to increase respectful care for women in labour; thus allowing for a neat analytic template.

CONCLUSION

A lack of consensus regarding definition, management, and training were highlighted by the midwives. Women anticipated caesarean birth in late labour as straightforward and were therefore unaware of this potential complication. Women and midwives would welcome any new device to facilitate delivery of the impacted foetal head (IFH) as long as it is fully evaluated prior to widespread introduction. Women were not averse to being part of this evaluation process.

Failed vacuum and preterm delivery risk in the subsequent pregnancy: a multicenter retrospective cohort study

BACKGROUND

Second-stage cesarean delivery is associated with subsequent preterm delivery. Failed vacuum-assisted delivery is a subgroup of second-stage cesarean delivery in which the fetal head is engaged deeper in the pelvis and, thus, is associated with an increased risk of short-term maternal complications.

OBJECTIVE

This study aimed to investigate the maternal and neonatal outcomes of women at their subsequent delivery after a second-stage cesarean delivery with failed vacuum-assisted extraction vs after a second-stage cesarean delivery without a trial of vacuum-assisted extraction.

STUDY DESIGN

This was a multicenter retrospective cohort study. The study population included all women in their subsequent pregnancy after a second-stage cesarean delivery who delivered in all university-affiliated obstetrical centers (n=4) in a single geographic area between 2003 and 2021. Maternal and neonatal outcomes of women who had second-stage cesarean delivery after a failed vacuum-assisted delivery were compared with women who had second-stage cesarean delivery without a trial of vacuum-assisted delivery. The primary outcome of this study was preterm delivery at <37 weeks of gestation. The secondary outcomes were vaginal birth rate and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling.

RESULTS

During the study period, 1313 women met the inclusion criteria, of whom 215 (16.4%) had a history of failed vacuum-assisted delivery at the previous delivery and 1098 (83.6%) did not. In univariate analysis, women with previously failed vacuum-assisted delivery had similar preterm delivery rates (<37, <34, <32, and <28 weeks of gestation), a successful trial of labor after cesarean delivery rates, uterine rupture, and hysterectomy. However, multivariable analyses controlling for confounders showed that a history of failed vacuum-assisted delivery is associated with a higher risk of preterm delivery at <37 weeks of gestation (adjusted odds ratio, 2.05; 95% confidence interval, 1.11-3.79; P=.02), but not with preterm delivery at <34 or <32 weeks of gestation.

CONCLUSION

Among women with a previous second-stage cesarean delivery, previously failed vacuum-assisted delivery was associated with an increased risk of preterm delivery at <37 weeks of gestation in the subsequent birth.

The acceptability and feasibility of a randomised trial exploring approaches to managing impacted fetal head during emergency caesarean section: a qualitative study

BACKGROUND

Caesarean sections (CS) account for 26% of all births in the UK, of which at least 5% are done at full dilatation, in the second stage of labour. Second stage CS may be complicated by the fetal head being deeply impacted in the maternal pelvis, requiring specialist skills to achieve a safe birth. Numerous techniques are used to manage impacted fetal head, however, there are no national clinical guidelines in the UK.

AIM

To explore health professionals' and women's views on the acceptability and feasibility of a randomised controlled trial (RCT) designed to explore approaches to managing an impacted fetal head during emergency CS.

METHODS

Semi-structured interviews with 10 obstetricians and 16 women (6 pregnant and 10 who experienced an emergency second stage CS). Interviews were transcribed and analysed using systematic thematic analysis.

RESULTS

The findings considered the time at which you obtain consent, how and when information about the RCT is presented, and barriers and facilitators to recruiting health professionals and women into the RCT. Obstetricians emphasised the importance of training in the techniques, as well as the potential conflict between the RCT protocol and current site or individual practices. Women said they would trust health professionals' to use the most appropriate technique and abandon the RCT protocol if necessary. Similarly, obstetricians raised the tension between the RCT protocol versus safety in reverting to what they knew under emergency situations. Both groups reflected on how this might affect the authenticity of the results. A range of important maternal, infant and clinical outcomes were raised by women and obstetricians. However, there were varying views on which of the two RCT designs presented to participants would be preferred. Most participants thought the RCT would be feasible and acceptable.

CONCLUSIONS

This study suggests an RCT designed to evaluate different techniques for managing an impacted fetal head would be feasible and acceptable. However, it also identified a number of challenges that need to be considered when designing such an RCT. Results can be used to inform the design of RCTs in this area.

Feasibility of a RCT of techniques for managing an impacted fetal head during emergency caesarean section: the MIDAS scoping study

Background

Second-stage caesarean sections, of which there are around 34,000 per year in the UK, have greater maternal and perinatal morbidity than those in the first stage. The fetal head is often deeply impacted in the maternal pelvis, and extraction can be difficult. Numerous techniques are reported, but the superiority of one over another is contentious and there is no national guidance.

Objective

To determine the feasibility of a randomised trial of different techniques for managing an impacted fetal head during emergency caesarean.

Design

A scoping study with five work packages: (1) national surveys to determine current practice and acceptability of research in this area, and a qualitative study to determine acceptability to women who have experienced a second-stage caesarean; (2) a national prospective observational study to determine incidence and rate of complications; (3) a Delphi survey and consensus meeting on choice of techniques and outcomes for a trial; (4) the design of a trial; and (5) a national survey and qualitative study to determine acceptability of the proposed trial.

Setting

Secondary care.

Participants

Health-care professionals, pregnant women, women who have had a second-stage caesarean, and parents.

Results

Most (244/279, 87%) health-care professionals believe that a trial in this area would help guide their practice, and 90% (252/279) would be willing to participate in such a trial. Thirty-eight per cent (98/259) of parents reported that they would take part. Women varied in which technique they thought was most acceptable. Our observational study found that impacted head is common (occurring in 16% of second-stage caesareans) and leads to both maternal (41%) and neonatal (3.5%) complications. It is most often treated by an assistant pushing the head up vaginally. We designed a randomised clinical trial comparing the fetal pillow with the vaginal push technique. The vast majority of health-care professionals, 83% of midwives and 88% of obstetricians, would be willing to participate in the trial proposed, and 37% of parents reported that they would take part. Our qualitative study found that most participants thought the trial would be feasible and acceptable.

Limitations

Our survey is subject to the limitation that, although responses refer to contemporaneous real cases, they are self-reported by the surgeon and collected after the event. Willingness to participate in a hypothetical trial may not translate into recruitment to a real trial.

Conclusions

We proposed a trial to compare a new device, the fetal pillow, with a long-established procedure, the vaginal push technique. Such a trial would be widely supported by health-care professionals. We recommend that it be powered to test an effect on important short term maternal and baby outcomes which would require 754 participants per group. Despite the well-known difference between intent and action, this would be feasible within the UK.

Future work

We recommend a randomised controlled trial of two techniques for managing an impacted fetal head with an in-built internal pilot phase and alongside economic and qualitative substudies.

Study registration

This study is registered as Research Registry 4942.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 6. See the NIHR Journals Library website for further project information.

Interventions to reintroduce or increase assisted vaginal births: a systematic review of the literature

OBJECTIVE

To synthesise the evidence from studies that implemented interventions to increase/reintroduce the use of assisted vaginal births (AVB).

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

We included experimental, semi-experimental and observational studies that reported any intervention to reintroduce/increase AVB use.

DATA SOURCES

We searched PubMed, EMBASE, CINAHL, LILACS, Scopus, Cochrane, WHO Library, Web of Science, ClinicalTrials.gov and WHO.int/ictrp through September 2021.

RISK OF BIAS

For trials, we used the Cochrane Effective Practice and Organisation of Care tool; for other designs we used Risk of Bias for Non-Randomised Studies of Interventions.

DATA EXTRACTION AND SYNTHESIS

Due to heterogeneity in interventions, we did not conduct meta-analyses. We present data descriptively, grouping studies according to settings: high-income countries (HICs) or low/middle-income countries (LMICs). We classified direction of intervention effects as (a) statistically significant increase or decrease, (b) no statistically significant change or (c) statistical significance not reported in primary study. We provide qualitative syntheses of the main barriers and enablers for success of the intervention.

RESULTS

We included 16 studies (10 from LMICs), mostly of low or moderate methodological quality, which described interventions with various components (eg, didactic sessions, simulation, hands-on training, guidelines, audit/feedback). All HICs studies described isolated initiatives to increase AVB use; 9/10 LMIC studies tested initiatives to increase AVB use as part of larger multicomponent interventions to improve maternal/perinatal healthcare. No study assessed women's views or designed interventions using behavioural theories. Overall, interventions were less successful in LMICs than in HICs. Increase in AVB use was not associated with significant increase in adverse maternal or perinatal outcomes. The main barriers to the successful implementation of the initiatives were related to staff and hospital environment.

CONCLUSIONS

There is insufficient evidence to indicate which intervention, or combination of interventions, is more effective to safely increase AVB use. More research is needed, especially in LMICs, including studies that design interventions taking into account theories of behaviour change.

PROSPERO REGISTRATION NUMBER

CRD42020215224.

Magnetic resonance imaging in late pregnancy to improve labour and delivery outcomes - a systematic literature review

BACKGROUND

Magnetic resonance imaging (MRI) provides excellent soft tissue visualisation which may be useful in late pregnancy to predict labour outcome and maternal/neonatal birth trauma.

OBJECTIVE

To study if MRI in late pregnancy can predict maternal and neonatal outcomes of labour and birth.

METHODS

Systematic review of studies that performed MRI in late pregnancy or immediately postpartum. Studies were included if they imaged maternal pelvic or neonatal structures and assessed birth outcome. Meta-analysis was not performed due to the heterogeneity of studies.

RESULTS

Eighteen studies were selected. Twelve studies explored the value of MRI pelvimetry measurement and its utility to predict cephalopelvic disproportion (CPD) and vaginal breech birth. Four explored cervical imaging in predicting time interval to birth. Two imaged women in active labour and assessed mouldability of the fetal skull. No marker of CPD had both high sensitivity and specificity for predicting labour outcome. The fetal pelvic index yielded sensitivities between 59 and 60%, and specificities between 34 to 64%. Similarly, although the sensitivity of the cephalopelvic disproportion index in predicting labour outcome was high (85%), specificity was only 56%. In women with breech presentation, MRI was demonstrated to reduce the rates of emergency caesarean section from 35 to 19%, and allowed better selection of vaginal breech birth. Live birth studies showed that the fetal head undergoes a substantial degree of moulding and deformation during cephalic vaginal birth, which is not considered during pelvimetry. There are conflicting studies on the role of MRI in cervical imaging and predicting time interval to birth.

CONCLUSION

MRI is a promising imaging modality to assess aspects of CPD, yet no current marker of CPD accurately predicts labour outcome. With advances in MRI, it is hoped that novel methods can be developed to better identify individuals at risk of obstructed or pathological labour. Its role in exploring fetal head moulding as a marker of CPD should be further explored.

A comparison of technicques to disimpact the fetal head on a second stage caesearean simulator

Background

The rate of second stage caesarean section (CS) is rising with associated increases in maternal and neonatal morbidity, which may be related to impaction of the fetal head in the maternal pelvis. In the last 10 years, two devices have been developed to aid disimpaction and reduce these risks: the Fetal Pillow (FP) and the Tydeman Tube (TT). The aim of this study was to determine the distance of upward fetal head elevation achieved on a simulator for second stage CS using these two devices, compared to the established technique of per vaginum digital disimpaction by an assistant.

Methods

We measured elevation of the fetal head achieved with the two devices (TT and FP), compared to digital elevation, on a second stage Caesearean simulator (Desperate Debra ™ set at three levels of severity. Elevation was measured by both a single operator experienced with use of the TT and FP and also multiple assistants with no previous experience of using either device. All measurements were blinded

Results

The trained user achieved greater elevation of the fetal head at both moderate and high levels of severity with the TT (moderate: 30mm vs 12.5mm p<0.001; most severe: 25mm vs 10mm p<0.001) compared to digital elevation. The FP provided comparable elevation to digital at both settings (moderate: 10 vs 12.5mm p=0.149; severe 10 vs 10mm p=0.44).

With untrained users, elevation was also significantly greater with the TT compared to digital elevation (20mm vs 10mm p<0.01). However digital disimpaction was significantly greater than the FP (10mm vs 0mm p<0.0001).

Conclusion

On a simulator, with trained operators, the TT provided greater fetal head elevation than digital elevation and the FP. The FP achieved similar elevation to the digital technique, especially when the user was trained in the procedure.

Maternal and neonatal morbidities associated with cesarean delivery without labor compared with induction of labor around term

OBJECTIVE

We aimed to compare the maternal and neonatal morbidities associated with elective cesarean delivery (CD) without labor and those associated with induction of labor (IOL) at ≥38 weeks of gestation.

METHODS

This retrospective observational study from 2013 to 2020 included singleton pregnancies in nulliparous women at ≥38 weeks of gestation. Maternal and neonatal morbidities associated with elective CD without labor were compared with those associated with IOL.

RESULTS

Altogether, 395 women were recruited. Among these, 326 underwent delivery through IOL, while 69 underwent elective CD. The elective CD group exhibited higher maternal age, lower gestational age at birth, and lower neonatal birth weight than the IOL group (P<0.001). Moreover, the elective CD group exhibited longer hospital stay, higher rate of uterotonic agent usage, and lower rate of antibiotic usage after discharge. However, no differences were observed in postpartum bleeding, readmission, or number of outpatient visits (>3) after discharge between the groups. Perinatal morbidities were similar between the groups except the incidence of meconium-stained amniotic fluid. Elective CD exhibited similar rates of complications related to composite maternal morbidity when compared with IOL, but had a lower risk of complications related to composite neonatal morbidity (relative risk, 0.45; 95% confidence interval, 0.24-0.85).

CONCLUSION

Elective CD and IOL had similar rates of composite maternal morbidity but the former exhibited some benefits against obstetric wound infection. The elective CD group exhibited a decreased risk of composite neonatal morbidity despite lower gestational age at birth and higher maternal age.

Simulation and beyond - Principles of effective obstetric training

Simulation training provides a safe, non-judgmental environment where members of the multi-professional team can practice both their technical and non-technical skills. Poor teamwork and communication are recurring contributing factors to adverse maternal and neonatal outcomes. Simulation can improve outcomes and is now a compulsory part of the national training matrix. Components of successful training include involving the multi-professional team, high fidelity models, keeping training on-site, and focussing on human factors training; a key factor in adverse patient outcomes. The future of simulation training is an exciting field, with the advent of augmented reality devices and the use of artificial intelligence.

Committee Opinion No. 415: Impacted Fetal Head, Second-Stage Cesarean Delivery

OBJECTIVE

To review the most effective clinical approaches to disengage an impacted fetal head during cesarean delivery.

TARGET POPULATION

Women who undergo cesarean delivery of an infant with a deeply impacted head.

OPTIONS

The "push" technique (from below) or the "pull" technique (reverse breech extraction).

OUTCOMES

Proper management of this clinical scenario can reduce maternal and perinatal morbidity and mortality.

BENEFITS, HARMS, AND COSTS

Using an evidence-informed approach when an impacted fetal head is anticipated has the potential to reduce maternal and fetal complications and short- and long-term harm and their associated costs. Research into the value of simulation learning, regular labour assessments, and team preparedness for possible interventions will help inform quality care.

EVIDENCE

The following search terms were entered into PubMed/Medline, Google Scholar, and Cochrane for the publication period 2012-2019: • 'Guidelines' 'manual' • 'Caesarean Section' • 'full dilation' • 'operative delivery' • 'impacted head' • 'Caesarean' AND 'full dilation' AND 'impacted head' • 'Caesarean' AND 'second stage of labour' OR 'second stage' AND 'impacted head' • 'Caesarean' OR 'operative delivery' AND 'impacted head' A total of 32 articles were retrieved and 24 were deemed appropriate to include as references. Many of these articles represented expert opinion. Randomized controlled trials had small sample sizes and were conducted in settings that limit the generalizability of their findings to the Canadian population.²⁰ INTENDED USERS: Intrapartum health care providers.

Complete cervical inversion and nearly inappropriate stitching with cesarean section during the second stage of labor: a case report

Cesarean section is a common obstetric operation and an important method for saving the lives of mothers and their neonates in dangerous situations. Nevertheless, cesarean section has a higher risk and might have more complications compared with natural delivery. A reasonable choice of delivery method is important for maternal and neonatal health. The incidence of complications after cesarean section for mothers and neonates during the second stage of labor significantly increases compared with planned cesarean section. During the second stage of labor, the fetal head is deep in the pelvic cavity. If a cesarean section is performed at this stage, it is prone to causing complications, including difficult delivery of the fetal head, delayed uterine incision, and massive hemorrhage, which seriously threaten the health of the mother and her neonate. For the first time, we report a case of cesarean section after complete opening of the uterine orifice, which led to almost mistakenly suturing the cervix to the uterus. This report will hopefully help surgeons anticipate such incidents during cesarean section in the future.

Can ultrasound on admission in active labor predict labor duration and a spontaneous delivery?

BACKGROUND

Identifying predictive factors for a normal outcome at admission in the labor ward would be of value for planning labor care, timing interventions, and preventing labor dystocia. Clinical assessments of fetal head station and position at the start of labor have some predictive value, but the value of ultrasound methods for this purpose has not been investigated. Studies using transperineal ultrasound before labor onset show possibilities of using these methods to predict outcomes.

OBJECTIVE

This study aimed to investigate whether ultrasound measurements during the first examination in the active phase of labor were associated with the duration of labor phases and the need for operative delivery.

STUDY DESIGN

This was a secondary analysis of a prospective cohort study at Landspitali University Hospital, Reykjavík, Iceland. Nulliparous women at ≥37 weeks' gestation with a single fetus in cephalic presentation and in active spontaneous labor were eligible for the study. The recruitment period was from January 2016 to April 2018. Women were examined by a midwife on admission and included in the study if they were in active labor, which was defined as regular contractions with a fully effaced cervix, dilatation of ≥4 cm. An ultrasound examination was performed by a separate examiner within 15 minutes; both examiners were blinded to the other's results. Transabdominal and transperineal ultrasound examinations were used to assess fetal head position, cervical dilatation, and fetal head station, expressed as head-perineum distance and angle of progression. Duration of labor was estimated as the hazard ratio for spontaneous delivery using Kaplan-Meier curves and Cox regression analysis. The hazard ratios were adjusted for maternal age and body mass index. The associations between study parameters and mode of delivery were evaluated using receiver operating characteristic curves.

RESULTS

Median times to spontaneous delivery were 490 minutes for a head-perineum distance of ≤45 mm and 682 minutes for a head-perineum distance of >45 mm (log-rank test, P=.009; adjusted hazard ratio for a shorter head-perineum distance, 1.47 [95% confidence interval, 0.83-2.60]). The median durations were 506 minutes for an angle of progression of ≥93° and 732 minutes for an angle of progression of <93° (log-rank test, P=.008; adjusted hazard ratio, 2.07 [95% confidence interval, 1.15-3.72]). The median times to delivery were 506 minutes for nonocciput posterior positions and 677 minutes for occiput posterior positions (log-rank test, P=.07; adjusted hazard ratio, 1.52 [95% confidence interval, 0.96-2.38]) Median times to delivery were 429 minutes for a dilatation of ≥6 cm and 704 minutes for a dilatation of 4 to 5 cm (log-rank test, P=.002; adjusted hazard ratio, 3.11 [95% confidence interval, 1.68-5.77]). Overall, there were 75 spontaneous deliveries; among those deliveries, 16 were instrumental vaginal deliveries (1 forceps delivery and 15 ventouse deliveries), and 8 were cesarean deliveries. Head-perineum distance and angle of progression were associated with a spontaneous delivery with area under the receiver operating characteristic curves of 0.68 (95% confidence interval, 0.55-0.80) and 0.67 (95% confidence interval, 0.55-0.80), respectively. Ultrasound measurement of cervical dilatation or position at inclusion was not significantly associated with spontaneous delivery.

CONCLUSION

Ultrasound examinations showed that fetal head station and cervical dilatation were associated with the duration of labor; however, measurements of fetal head station were the variables best associated with operative deliveries.

Impacted fetal head: A retrospective cohort study of emergency caesarean section

OBJECTIVE

To investigate risk factors, management and outcomes of impacted fetal head (IFH) at caesarean section (CS).

STUDY DESIGN

This is a retrospective cohort study of all women with singleton, cephalic pregnancies who had an emergency CS during one-year (2016) at North Bristol NHS Trust, UK (n = 838). The incidence of caesarean section at full dilatation (CSFD) and IFH were calculated using the annual birth rate. To identify risk factors for IFH, maternal, perinatal and intrapartum characteristics were compared according to the presence or absence of IFH, and separately for first- and second-stage CS. Techniques employed to disimpact the fetal head were described. Univariable and multivariable comparisons of maternal and perinatal outcomes were made between cases with and without an IFH. Characteristics and outcomes were compared using modified Poisson regression.

RESULTS

CSFD accounted for 2.1 % of all births. IFH complicated 1.5 % of all births (11.3 % of emergency CS), with 55.8 % occurring prior to full cervical dilatation. Increased rates of IFH at CS were associated with: oxytocin augmentation (RR = 2.47 [1.61-3.80]), full cervical dilatation (RR = 4.24 [2.96-6.07], mid/low station (RR = 4.14 [2.72-6.32]), moulding (RR = 4.39 [2.55-7.54]) and caput (RR = 6.60 [3.09-14.10]). Junior operators documented IFH more than consultants (RR = 9.61 [1.35-68.2]). The strategies recorded for managing IFH included: tocolysis, reverse breech extraction and vaginal push up (33.7 %, 14.7 % and 11.6 % cases respectively) with two or more techniques used in 21.1 % cases. IFH at CS was independently associated with an increased risk of uterine extensions (RR = 3.09 [1.96-4.87]) and a composite adverse perinatal outcome (RR = 1.66 [1.21-2.28]).

CONCLUSIONS

IFH is a common and heterogeneous complication associated with increased complications for both mother and baby, independent of those of CSFD. Obstetricians must remain vigilant to the possibility of IFH at all emergency CS, particularly those at full cervical dilatation or with evidence of obstructed labour. There is an urgent need for a standardised management algorithm and training in evidence-based disimpaction techniques.

Incidence of second-stage (fully dilated) cesarean sections and how best to represent it: A multicenter analysis

OBJECTIVE

To gather multicenter data on the incidence of second-stage cesarean sections and suggest alternative methods by which the data can be represented.

METHODS

Retrospective, observational study over a 12-month study period. Numbers of term, singleton live births were collated from each of six maternity units. Data were separated by mode of delivery-unassisted vaginal birth, assisted (instrumental) vaginal delivery and elective, first-stage, and second-stage cesarean sections. Second-stage cesarean sections were expressed as a proportion of all deliveries, of all laboring women (i.e. excluding elective cesarean sections), and all women who reach full dilatation (i.e. excluding elective and first-stage cesarean sections).

RESULTS

Of the 28 867 deliveries included in the analysis, 493 of these were second-stage cesarean sections. This represented an incidence of 1.7% of all deliveries, 2.0% of all women in labor, and 2.5% of all women who reach full dilatation.

CONCLUSION

Second-stage cesarean sections continue to be common. Safe delivery of a deeply impacted fetal vertex is essential in modern obstetric practice.

Opinion de comité n° 415 : Césarienne au deuxième stade avec enclavement de la tête fœtale

OBJECTIF

Passer en revue les stratégies cliniques les plus efficaces pour désengager une tête fœtale enclavée pendant la césarienne.

POPULATION CIBLE

Les femmes qui subissent une césarienne lorsque la tête fœtale est fortement enclavée.

OPTIONS

La technique par poussée (par le bas) ou par traction (grande extraction du siège par voie abdominale). RéSULTATS: La prise en charge adéquate de cette situation clinique peut réduire les risques de morbidité et mortalité maternelle et périnatale. BéNéFICES, RISQUES ET COûTS: Lorsque l'on anticipe un enclavement de la tête fœtale, il est possible de réduire le risque de complications maternelles et fœtales, les atteintes à court et à long terme ainsi que les coûts associés en adoptant une stratégie fondée sur des données probantes. Les recherches sur la valeur de l'apprentissage par simulation, les évaluations régulières pendant le travail et la préparation de l'équipe aux interventions possibles aideront à orienter les soins de qualité. DONNéES PROBANTES: Les termes de recherche suivants ont été utilisés dans les bases de données PubMed-Medline, Google Scholar et Cochrane pour la période de publication de 2012 à 2019 : • "Guidelines" "manual" • "Caesarean Section" • "full dilation" • "operative delivery" • "impacted head" • "Caesarean" AND "full dilation" AND "impacted head" • "Caesarean" AND "second stage of labour" OR "second stage" AND "impacted head" • "Caesarean" OR "operative delivery" AND "impacted head" Au total, 32 articles ont été récupérés et 24 ont été jugés adéquats comme références. Plusieurs de ces articles étaient des opinions d'experts. Les essais cliniques randomisés avaient des échantillons de petite taille et ont été menés dans des contextes qui limitent la généralisabilité de leurs résultats à la population canadienne²⁰.

PROFESSIONNELS CIBLES

Fournisseurs de soins de santé intrapartum.

The acceptability to women of techniques for managing an impacted fetal head at caesarean section and of randomised trials evaluating those techniques: a qualitative study

BACKGROUND

This study aimed to explore women's views on the acceptability of different techniques for managing an impacted fetal head at caesarean; and the feasibility and acceptability of conducting a trial in this area.

METHODS

Qualitative semi-structured interviews with a systematic sample of women who experienced second stage emergency caesarean section at a tertiary National Health Service (NHS) hospital in England, UK. Thematic analysis was used to extract women's views.

RESULTS

Women varied in their perceptions of the acceptability of different techniques for managing impacted fetal head. Trust in medical expertise and prioritising the safety of the baby were important contextual factors. Greater consensus was found around informed choice in trials where subthemes considered the timing of invitation, reduced capacity to give consent in emergency situations, and the importance of birth outcomes and having good rapport with healthcare professionals who invite women into trials. Finally, women reflected on the importance of supportive antenatal and postpartum education for impacted fetal head.

CONCLUSIONS

This research provides information on the acceptability of techniques and any trial to evaluate these techniques. Findings illustrate the importance of context and quality of care to both acceptability and approaching women to take part in a future trial.

Full Dilatation Caesarean Section and the Risk of Preterm Delivery in a Subsequent Pregnancy: A Historical Cohort Study

Full dilatation caesarean sections (CS) have increased risk of uterine extensions, which leads to cervical trauma that has been associated with an increased risk of spontaneous preterm birth (sPTB) in a subsequent pregnancy. The aim of this study was to determine if CS at full dilatation increased the risk of sPTB in a subsequent pregnancy in our unit. A historical cohort study was performed on women delivered by emergency CS between 2008–2015 (n = 5808) in a university hospital who had a subsequent pregnancy in this time frame (n = 1557). Women were classified into two exposure groups; those who were 6–9 cm and those fully dilated at index CS. The reference group was CS at 0–5 cm dilated. The primary outcome was sPTB < 37 weeks’ gestation. CS at 6–9 cm or fully dilated did not significantly increase the odds of sPTB in a subsequent pregnancy (aOR 1.64, 95% CI: 0.83–3.28, p = 0.158; aOR 1.86, 95% CI: 0.91–3.83; p = 0.090, respectively). However, a short interpregnancy interval of <1 year significantly increased the odds of sPTB in a subsequent pregnancy (aOR 3.10, 95% CI: 1.71–5.61). This study has found a short interpregnancy interval following a CS conferred a higher risk of sPTB than full dilatation CS. This finding highlights postnatal contraception and increased surveillance of women with short interpregnancy interval post CS as possible interventions to reduce sPTB.

Ultrasound before operative vaginal delivery: why and how

Safe management of the second stage of labor is important. Wait for spontaneous delivery, operative vaginal deliveries and second stage cesarean sections are all options when prolonged second stage occurs. The important question is which option to choose. Fetal head station and fetal head position are used to decide mode of delivery; this has traditionally been decided by performing a digital vaginal examination. Studies have shown that theses clinical examinations of both fetal head station and position are unreliable and that ultrasound might be better option. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) published in 2018 guidelines on intrapartum ultrasound and recommends that ultrasound is performed for ascertainment of fetal head position and station before considering or performing an instrumental vaginal delivery for slow progress or arrested labor in the second stage. The determination of the fetal head position, fetal head station and the movement of the fetal head can easily be determined with the help of ultrasound and can help the clinicians in making the right decision on how to proceed when prolonged second stage of labor is diagnosed.

CRAFT (Cerclage after full dilatation caesarean section): protocol of a mixed methods study investigating the role of previous in-labour caesarean section in preterm birth risk

BACKGROUND

Full dilatation caesarean sections are associated with recurrent early spontaneous preterm birth and late miscarriage. The risk following first stage caesarean sections, are less well defined, but appears to be increased in late-first stage of labour. The mechanism for this increased risk of late miscarriage and early spontaneous preterm birth in these women is unknown and there are uncertainties with regards to clinical management. Current predictive models of preterm birth (based on transvaginal ultrasound and quantitative fetal fibronectin) have not been validated in these women and it is unknown whether the threshold to define a short cervix (≤25 mm) is reliable in predicting the risk of preterm birth. In addition the efficacy of standard treatments or whether benefit may be derived from prophylactic interventions such as a cervical cerclage is unknown.

METHODS

There are three distinct components to the CRAFT project (CRAFT-OBS, CRAFT-RCT and CRAFT-IMG).

CRAFT-OBS

Observational Study; To evaluate subsequent pregnancy risk of preterm birth in women with a prior caesarean section in established labour. This prospective study of cervical length and quantitative fetal fibronectin data will establish a predictive model of preterm birth.

CRAFT-RCT

Randomised controlled trial arm; To assess treatment for short cervix in women at high risk of preterm birth following a fully dilated caesarean section.

CRAFT-IMG

Imaging sub-study; To evaluate the use of MRI and transvaginal ultrasound imaging of micro and macrostructural cervical features which may predispose to preterm birth in women with a previous fully dilated caesarean section, such as scar position and niche.

DISCUSSION

The CRAFT project will quantify the risk of preterm birth or late miscarriage in women with previous in-labour caesarean section, define the best management and shed light on pathological mechanisms so as to improve the care we offer to women and their babies.

TRIAL REGISTRATION

CRAFT was prospectively registered on 25th November 2019 with the ISRCTN registry ( https://doi.org/10.1186/ISRCTN15068651 ).

Risks associated with cesarean delivery during prolonged second stage of labor

BACKGROUND

Data regarding maternal and fetal morbidities are limited to surgical morbidity per each additional hour in the second stage of labor.

OBJECTIVE

This study aimed to quantify perinatal morbidities associated with cesarean delivery by duration of the second stage of labor.

STUDY DESIGN

Our work is a retrospective cohort study of cesarean deliveries during the second stage of labor using the Consortium on Safe Labor database. All term, singleton pregnancies in cephalic presentation were included. Women with stillbirth or contraindications to vaginal delivery were excluded. Groups were divided by duration of the second stage of labor: ≤3 hours, 3-4 hours, 4-5 hours, 5-6 hours, and >6 hours. The primary outcome was a composite of maternal morbidities. The secondary outcomes were a composite of neonatal morbidities and individual maternal and neonatal morbidities. Baseline demographic and clinical characteristics were compared among groups. Univariate and multivariate analyses were performed.

RESULTS

We included 6273 women in total. In addition, 3652 women (58.2%) went through the second stage for ≤3 hours, 854 (13.6%) for 3 to 4 hours, 618 (9.9%) for 4 to 5 hours, 397 (6.3%) for 5 to 6 hours, and 752 (12.0%) for >6 hours. Neither the maternal nor neonatal morbidity composite outcomes were statistically different among the groups. Extended maternal length of stay (>5 days), increased birthweight, and lower rates of general anesthesia were associated with an increased duration of the second stage of labor. Chorioamnionitis, wound complications, postpartum hemorrhage, and thrombosis did not increase over time.

CONCLUSION

Women should be counseled regarding the duration of the second stage of labor, which should include a discussion of the risks associated with a cesarean delivery with a prolonged second stage of labor. However, these risks may not be as high as anticipated.

Reducing emergency cesarean delivery and improving the primiparous experience: Findings of the RECIPE study

OBJECTIVE

The ability to predict the need for emergency Cesarean delivery holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean delivery and Improving the Primiparous Experience) was to externally validate a Cesarean delivery risk prediction model. This model, developed by the Genesis study, identified five key predictive factors for emergency Cesarean delivery: maternal age, maternal height, BMI, fetal head circumference (HC) and fetal abdominal circumference (AC).

STUDY DESIGN

This prospective, observational study was conducted in two tertiary referral perinatal centers. Inclusion criteria were as follows: primiparous women with a singleton, cephalic presentation fetus in the absence of fetal growth restriction (FGR), oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned Cesarean delivery. Between 38 + 0 and 40 + 6 weeks' gestational age, participants attended for prenatal assessment that enabled the determination of an individualized risk calculation for emergency Cesarean delivery during labour based on maternal height, BMI, fetal HC and AC, with crucially both participants and care providers being blinded to the resultant risk prediction score. Labor, delivery and postnatal outcomes were ascertained. Calibration and receiver operator curves were generated to determine the predictive capacity for emergency Cesarean delivery of the Genesis risk prediction model in this cohort.

RESULTS

559 primiparous participants were enrolled from May 2017 to April 2019, of whom 142 (25 %) had an emergency Cesarean delivery during labour. Participants with a low predicted risk score (<10 %) had a mean predicted rate of 8% (+/- standard deviation of 2%) and a similarly low actual observed rate of Cesarean delivery (8%). Participants with a high predicted risk (>50 %) had a mean predicted Cesarean delivery rate of 64 % (+/- standard deviation of 9%) and also had a high actual observed Cesarean delivery rate (62 %). The calibration curve and receiver operating characteristic curve demonstrated that this validation study had comparable discriminatory power for emergency Cesarean delivery to that described in the original Genesis study. The Area Under the Curve (AUC) in Genesis was 0.69, whereas the AUC in RECIPE was 0.72, which reflects good predictive capacity of the risk prediction model.

CONCLUSION

The accuracy of the Genesis Cesarean delivery prediction tool is supported by this validation study.

Fetal extraction maneuvers during cesarean delivery in the second stage of labor

Objective: To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method.Methods: A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012-2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events.Results: Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p = .013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69-46.40% in others, p < .001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12-15% in others, p < .001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44-6.56, p = .0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081-7.448, p = .0342).Conclusion: Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods.Abbreviations: NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit.

Comparison of outcomes at full-dilation cesarean section with and without the use of a fetal pillow device

OBJECTIVE

To identify whether use of the fetal pillow device resulted in a reduction in intraoperative complications, such as uterine incision extension, requirement for breech extraction, etc. Other maternal outcomes (duration of hospital stay, requirement for blood transfusion, and requirement for return to hospital or operating theatre) were also reviewed. Neonatal outcomes of APGAR-5, arterial pH, and requirement for intensive care admission were assessed.

METHODS

A retrospective cohort analysis was completed for fully dilated cesarean deliveries completed between January 2014 and December 2018 at Ipswich Hospital, Australia. In total, 174 patient records were identified (114 with pillow, 60 without). Logistic and linear regressions were used to assess the outcomes associated with fetal pillow use.

RESULTS

There were no significant differences in operative complications between the pillow and no-pillow groups (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.26-1.22, P=0.146). Linear regression analysis showed a decrease in hospital length of stay (hours) (-9.4, 95% CI -17.80 to -0.99, P=0.029) and a higher neonatal arterial pH at delivery (0.06, 95% CI 0.03-0.09, P=0.0001) in the pillow group.

CONCLUSION

At full dilation cesarean, operative complications are not increased when employing the fetal pillow with maternal benefits of decreased hospitalization.

Factors associated with postcesarean blood transfusion: a case control study

Objective: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD.Methods: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio.Results: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001).Conclusions: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.

Simulation of an impacted fetal head extraction during cesarean section: description of the creation and evaluation of a new training program

Background Although cesarean sections at full dilatation are increasing, training in delivering a deeply impacted fetal head is lacking among obstetricians. The purpose of the study was to implement and evaluate a theoretical and simulation-based training program for this obstetrical emergency. Methods We developed a training program consisting of a theoretical introduction presenting a clinical algorithm, developed on the basis of the available literature, followed by a simulation session. We used the Kirkpatrick's framework to evaluate the program. A questionnaire was distributed, directly before, immediately and 6 weeks after the training. Self-perceived competencies were evaluated on a 6-point Likert scale. Pre- and post-test differences in the Likert scale were measured with the Wilcoxon signed rank test. Additionally, the training sessions were video recorded and rated with a checklist in relation to how well the algorithm was followed. Results Eleven residents and eight senior physicians took part to the training. More than 40% of participants experienced a comparable situation after the course during clinical work. Their knowledge and self-perceived competencies improved immediately after the training program and 6 weeks later. Major improvements were seen in the awareness of the algorithm and in the confidence in performing the reverse breech extraction (14.3% of the participants felt confident with the maneuver in the pre-training assessment compared with 66.7% 6 week post-training). Conclusion Our theoretical and simulation-based training program was successful in improving knowledge and confidence of the participants in delivering a deeply impacted fetal head during a cesarean section performed at full dilation.

Preferred way of delivery of the impacted fetal head in cesarean sections during second stage of labor

AIM

To compare maternal and neonatal outcomes between the 'head first' and 'legs first' delivery methods during a second stage cesarean section.

METHODS

We conducted a retrospective study between January 2009 and May 2015 at a large public university tertiary referral center. Included were all women who underwent cesarean delivery with a fully dilated cervix and a fetal head at the level of the ischial spines or below. The study population was divided into two groups according to way of fetal delivery: The 'legs first' (reverse breech) method and the 'head first' method. Demographics and maternal and fetal outcomes were retrieved for both groups.

RESULTS

During the study period 447 women underwent a cesarean section while their cervix was fully dilated. Of them, 321 met the inclusion criteria: One hundred and twenty-one (38%) were delivered using the 'legs first' method and 200 (62%) were delivered using the 'head first' method. Indication for surgery and fetal head station was similar for both groups. While no difference in overall intraoperative uterine incision extension rate was observed, a higher rate of uterine incision extension was demonstrated in the 'head first' group in cases in which the second stage was longer than 180 min (33 vs 8 cases, P = 0.02). No differences in maternal postoperative complication rates and neonatal outcomes were observed.

CONCLUSION

Fetal extraction via the 'legs first' method during prolonged second stage of labor may lower maternal morbidity. Method of delivery does not seem to have an effect on neonatal outcomes.

Cesarean during labor: Is induction a risk factor for complications?

INTRODUCTION

Evaluate the impact of labor induction on maternal complications following caesarean section during labor.

MATERIAL AND METHODS

Retrospective, single-center study between 2015 and 2017. Were included singleton pregnancies who had cesarean section during labor after 37WG. Labor induction procedures included either transcervical balloon catheters or prostaglandins. Degree of emergency of the cesarean was decided according to color code (green, orange and red). We identified and compared intra and postoperative complications according to the mode of labor onset, and then to the mode of labor induction.

RESULTS

882 patients were included, 416 with spontaneous labor and 464 with labor induction. No significant difference was found for postoperative complications between the two groups. Patients with spontaneous labor had fewer green-code caesareans than patients with elective induction (29.3% vs. 40.3% p<0.001) and had more uterine pedicle injuries (6.3% vs. 3.0% p=0.022). Nevertheless, no difference was found for postpartum hemorrhage (PPH) between these two groups (41.59% vs. 43.32% p=0.60). The subgroup study of patients with labor induction showed that those necessitating 2 methods of labor induction had more severe PPH (22.2% vs. 8.1% p after Bonferroni correction = 0.002).

CONCLUSIONS

Elective induction does not result in an increased risk of cesarean section during labor complications. Only the use of prostaglandin following transcervical balloon catheter increased the risk of severe postpartum hemorrhage.

Comparison of maternal and perinatal morbidity between elective and emergency caesarean section in singleton-term breech presentation

The objective of the study was to compare maternal and neonatal adverse outcomes between elective caesarean section (ElCS) and emergency caesarean section (EmCS) for singleton-term breech presentation. This study included women with singleton breech presentation who underwent ElCS or EmCS at term during 2007-2015 at Siriraj Hospital (Thailand). Complete data were collected for 2178 pregnant women. Of those, 1322 (60.7%) women underwent EmCS, and 856 (39.3%) delivered by ElCS. Maternal and perinatal morbidity were compared. There was no maternal or perinatal death in either group. Maternal morbidity was comparable between groups, except for longer hospital stay in the EmCS group (p = .047). One-minute Apgar score was significantly lower in the EmCS group (p = .040). There was no significant difference in 5-min Apgar score between groups. No significant difference was observed for serious maternal and neonatal morbidity between women who underwent ElCS versus those who underwent EmCS for singleton-term breech presentation.IMPACT STATEMENTWhat is already known on this subject? Emergency caesarean section (EmCS) is generally known to be associated with a higher risk of maternal and neonatal complications than elective caesarean section (ElCS).What do the results of this study add? In singleton-term breech presentation, EmCS in tertiary care setting was not associated with an increase in serious maternal and neonatal morbidity compared with EICS. Cord prolapse as an indication for emergency caesarean section was significantly associated with adverse outcomes while advanced cervical dilation ≥7 cm or low foetal station ≥+1 did not have an impact on maternal and neonatal complications.What are the implications of these findings for clinical practice and/or further research? Mean gestational age in both the ElCS and EmCS groups was approximately 38 weeks and 5 d; there were no neonatal cases with respiratory distress syndrome. Our findings suggest further prospective study in planned caesarean section scheduled for 38-39 weeks in patients with term breech presentation. The results of such a study could yield lower rates of both EmCS and potential adverse outcomes.

The impacted foetal head at caesarean section: incidence and techniques used in a single UK institution

An impaction of the foetal head at caesarean section is a topical concern in modern obstetric practice. The management options for this problem are well described but the incidence or even definition of impaction, is unknown. The primary aim of this study was to ascertain the incidence of impacted foetal head at CS in labour. This prospective study used data from all women undergoing CS during a 12-month period in a single unit. Following completion of all CS, the surgeon completed a questionnaire covering: cervical dilation at time of CS; if the surgeon felt there was a difficulty in delivering the foetal head as an indicator of impaction, as well as the other techniques utilised. Of 440 EMCS in labour, 18% (n = 81) reported a difficulty delivering the head, which was most common at cervical dilation ≥8 cm (n = 124, 48%). A difficulty with the delivery of the foetal head was associated with 36% increased measured blood loss. Impact statement What is already known on this subject? Impaction of the foetal head at a caesarean section is a recognised complication of CS in late labour but there are no reliable data on the incidence of the problem. It is poorly defined and yet many techniques and devices have been described to overcome this problem, however, optimal management remains uncertain. What do the results of this study add? The primary aim of this study was to determine the incidence of the impacted foetal head during CS in labour as determined by whether the surgeon experienced difficulty with delivery of the head. We report that at least some difficulty in delivering the foetal head at CS is common, and most often encountered when cervical dilation is ≥8 cm. When additional manoeuvres were required, the 'push' technique was exclusively adopted with implications for training. A difficulty in delivering the foetal head was associated with a 36% increase in the measured maternal blood loss. What are the implications of these findings for clinical practice and/or further research? Further multi-centre investigation is required to ascertain incidence of this obstetric problem with predicting factors determined. This work will inform decisions about the optimal management.

Practical approaches to managing postpartum haemorrhage with limited resources

Mortality from postpartum haemorrhage (PPH) is higher in low resource settings due to increased incidence, higher case fatality rates and poor general health of the population. The challenges of managing PPH with limited resources are presented. Feasible interventions for preventing and treating PPH for home births are described. Given that maternity care is organised around levels of care in low resource settings, guidance is provided for what measures can be performed to manage PPH at different levels of care (clinic, community health centre, district hospital, regional and central hospital); and by which cadre (midwife, clinical officer, general doctor, specialist). Effective management of PPH requires on-going training and emergency drills. Reducing mortality from PPH is not possible without available urgent transport from home to facility and between levels of care. In addition, the essential building blocks of the health system must be functional to enable effective management of PPH.

Maternal and neonatal outcome of reverse breech extraction of an impacted fetal head during caesarean section in advanced stage of labour: a retrospective cohort study

Background

Caesarean section with extraction of a deeply impacted fetal head is technically challenging and is associated with serious maternal and neonatal complications. The purpose of the study was to identify risks and evaluate selected outcome parameters associated with difficult fetal head extraction during caesarean section in advanced labour comparing two different extraction techniques (head pushing vs. reverse breech).

Methods

This retrospective cohort study was conducted at the Division of Obstetrics in a tertiary care hospital in Zurich, Switzerland. 629 women at term with a singleton pregnancy in cephalic presentation during advanced intrapartum caesarean section from December 2012 until December 2016 were evaluated. Primary outcome was the incidence of uterine incision extensions. Secondary outcomes were other selected maternal and neonatal outcome parameters. Data analysis was performed using SPSS with Mann-Whitney U independent sampling test and two-tailed Fisher’s exact test (p < 0.01).

Results

Difficult fetal head extractions are associated with significantly elevated maternal and neonatal risks. When performed by reverse breech technique, significant lower rates of extensions of the uterine incision, shorter operation times and less operative blood loss were identified compared to the head pushing method. No statistically significant differences for the neonatal outcomes were described so far. However, among the group of difficult fetal delivery with the head pushing method two neonates had perinatal skull fractures, with one of those resulting in neonatal death.

Conclusions

The head pushing method is associated with higher maternal morbidity than the reverse breech method for extraction of a deeply engaged fetus during intrapartum caesarean section in advanced stage of labour.

Comparison of 'push method' with 'Patwardhan's method' on maternal and perinatal outcomes in women undergoing caesarean section in second stage

A deeply impacted foetal head in a second stage caesarean section is associated with an increased risk of maternal and neonatal complications. For the present study, we compared the maternal and neonatal outcomes during the use of the 'Push method' and of 'Patwardhan's method' for a foetal head delivery in a second-stage caesarean section. This was a retrospective observational study involving 298 women who underwent a second stage caesarean section with a foetal head at or below the level of their ischial spines and was conducted in a tertiary teaching hospital in South India. The rates of uterine incision extension and other maternal complications were similar in both methods (24.9% vs. 26.0%, p = .850). The rates of neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. Although the maternal complications were similar, the use of Patwardhan's method resulted in higher rates of neonatal complications compared to the Push method during a second stage caesarean section. Future randomised, controlled studies comparing these two methods are needed to confirm their safety and benefits, prior to its routine use in second stage caesarean sections. Impact statement What is already known on this subject? Use of a second-stage caesarean section increases the risk of maternal and neonatal complications. A deeply engaged foetal head, along with the stretching and thinning of the lower uterine segment predisposes to these complications. The recent literature mainly compares the complication rates of the Push method to a Reverse breech extraction, with only small studies reporting the use of Patwardhan's technique for the delivery of a deeply engaged foetal head. What do the results of this study add? This study suggests that the use of either the Push method or of Patwardhan's method results in similar maternal complications such as extension of a uterine incision or postpartum haemorrhage. But neonatal complications such as neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. What are the implications of these findings for clinical practice and/or further research? The extension of uterine incision is similar in both methods; however, the neonatal complications were noted to be higher in those delivered with Patwardhan's technique. A future, randomised controlled trial comparing these two techniques is required to confirm the findings, before either of the methods are used in routine practice.

Simulation-based educational package to improve delivery of the deeply impacted fetal head at caesarean section

Deeply impacted fetal head at caesarean section at full dilation is a rare obstetric emergency, and exposure for trainees can be limited. We aimed to pilot and evaluate a hospital-based training program incorporating mastery learning principles for trainees performing caesarean section at full dilation. We demonstrated improvements in knowledge, skills and self-confidence, and feel that this educational package shows promise as an important component of obstetric training, and warrants further exploration in the future.

"Strategies to increase the accuracy and safety of OVD" (Clinical assessment skills and role of ultrasound, simulation training and new technologies to enhance instrument application)

Operative vaginal delivery (OVD) is commonly performed in the UK and Ireland. With skillful practice, the risks to mothers and babies are low. Caesarean section at full dilatation, particularly after failed OVD, can be more hazardous for mothers and babies. It is important to maintain and develop skills in OVD in order to provide it as a safe delivery option when the benefits outweigh the risks. As ultrasound machines have become more readily available on the labour ward, ultrasound assessment has been used to help clinicians diagnose the fetal head position and station, and also to try predict the success of the delivery. Simulation training has successfully been used in the setting of obstetric emergencies and is being developed to teach both technical and communication skills in OVD in order to improve maternal and neonatal outcomes. In this chapter we will discuss strategies to improve the accuracy and safety of OVD in more details.

Global perspectives on operative vaginal deliveries

Operative vaginal delivery (OVD) refers to the use of an instrument (forceps or vacuum device) to assist with the delivery of the fetus from the vagina. This can help improve maternal and fetal outcomes and has to be weighed up against the risks and benefits of performing second-stage cesarean deliveries. OVD forms an integral part of basic emergency obstetric care and a skilled birth attendant's duties. Outlet forceps and vacuum extraction should be used to shorten the second stage of labor and to improve maternal and fetal outcomes associated with delayed second stage. Despite the known benefit of OVD, available data on the use of OVDs in low- and middle-income countries show very low rates, mostly due to the lack of skilled healthcare workers and equipment shortages. Increased use of OVD can safely reduce the number of second-stage cesarean deliveries with its associated morbidity and mortality. We recommend implementing training programs to increase the number of skilled healthcare workers and strengthening health systems to provide birthing facilities with the equipment required to perform OVD.

Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study

INTRODUCTION

The aim of the study was to investigate fetal head rotation during vacuum extraction.

MATERIAL AND METHODS

We conducted a prospective cohort study from November 2013 to July 2016 in seven European hospitals. Fetal head position was determined with transabdominal or transperineal ultrasound and categorized as occiput anterior (OA), occiput transverse (OT) or occiput posterior (OP) position. Main outcome was the proportion of fetuses rotating during vacuum extraction. Secondary outcomes were conversion of delivery method, duration of vacuum extraction, umbilical artery pH <7.10 and agreement between clinical and ultrasound assessments.

RESULTS

The study population comprised 165 women. During vacuum extraction 117/119 (98%) remained in OA and two fetuses rotated to OP position. Rotation from OT to OA position occurred in 14/19 (74%) and to OP position in 5/19 (26%). Rotation from OP to OA position occurred in 15/25 (60%), and 10/25 (40%) fetuses remained in OP position. Delivery information was missing in two cases. The conversion rate from vacuum extraction to cesarean section or forceps was 10% in the OA group vs. 23% in the non-OA group; p < 0.05. The estimated duration of vacuum extraction was significantly shorter in OA fetuses, 7 min vs. 10 min (log rank test p < 0.01). There was no significant difference in umbilical artery pH < 7.10 between OA and non-OA position. Cohens Kappa of agreement between clinical and ultrasound assessments was 0.42 (95% CI 0.26-0.57).

CONCLUSION

Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.

A case-control study about foetal trauma during caesarean delivery

OBJECTIVE

The caesarean section rate is gradually increasing in most countries. The frequency of occurrence of foetal injury per birth is estimated to 1%. The majority of these injuries presents a low functional impact, but remains responsible for a significant neonatal morbidity. Even though the foetal risk factors are well documented in cases of vaginal birth, they have not been accurately identified for caesarean section. The aim of this study is to identify the risk factors for neonatal fracture during caesarean section.

METHODS

We conducted a retrospective case-control study comparing complicated caesarean sections foetal fracture with uncomplicated caesarean sections in a tertiary teaching hospital. We collected all the caesarean sections carried out between 1st January 2003 and 1st September 2015 and selected those the medical files of which presented a foetal fracture diagnosis.

RESULTS

We identified 10 fractures during the study period, including four skull fractures, three long bone fractures, three clavicle fractures. In all these cases there were no complications with a median perspective of six years (median=6, IQR=4). The push method, which is performed during a caesarean section at the second stage of labour, is identified as a risk factor for foetal trauma in our study (OR: 20.2 [2.8-116.85], p<0.01). A significant correlation was found between transverse lie and foetal trauma (OR: 16.67, CI [1.39; 123.18], p=0.0137).

CONCLUSION

Foetal trauma during caesarean delivery is a rare event for which the prognosis is most often favourable. Data in the literature on the subject are minimal. This study highlighted transverse lie and the push method as risks factors for foetal fractures during caesarean sections. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Prospective cohort study comparing outcomes between vacuum extraction and second-stage cesarean delivery at a Ugandan tertiary referral hospital

OBJECTIVE

To compare maternal and perinatal outcomes between vacuum extraction and second-stage cesarean delivery (SSCD).

METHODS

The present observational cohort study was conducted among women with term vertex singleton pregnancies who underwent vacuum extraction or SSCD at Mulago National Referral Hospital, Kampala, Uganda, between November 25, 2014, and July 8, 2015. Severe maternal outcomes (mortality, uterine rupture, hysterectomy, re-laparotomy) and perinatal outcomes (mortality, trauma, low Apgar score, convulsions) were compared between initial delivery mode.

RESULTS

Among 13 152 deliveries, 358 women who underwent vacuum extraction and 425 women who underwent SSCD were enrolled in the study. No maternal deaths occurred after vacuum extraction versus five deaths from complications of SSCD. Vacuum extraction was associated with less severe maternal outcomes compared with SSCD (3 [0.8%] vs 18 [4.2%]; adjusted odds ratio [aOR] 0.24, 95% confidence interval [CI] 0.07-0.84). Fetal death during the decision-to-delivery interval was also less common in the vacuum extraction group (3 [0.9%] vs 18 [4.4%]; aOR 0.24, 95% CI 0.07-0.84); however, the perinatal mortality rate did not differ between the vacuum extraction and SSCD groups (29 [8.4%] vs 45 [11.0%], respectively; aOR 0.83, 95% CI 0.49-1.41). One infant in each group exhibited neurodevelopmental anomalies at 6 months.

CONCLUSION

Vacuum extraction had better maternal outcomes and equivalent perinatal outcomes compared with SSCD. These findings encourage re-introduction of vacuum extraction.

Caesarean delivery-related blood transfusion: correlates in a tertiary hospital in Southwest Nigeria

BACKGROUND

Caesarean delivery carries a risk of major intra-operative blood loss and its performance is often delayed by non-availability of blood and blood products. Unnecessary cross-matching and reservation of blood lead to apparent scarcity in centres with limited supply. This study set out to identify the risk factors for blood transfusion in women who underwent caesarean delivery at a tertiary obstetric unit with a view to ensuring efficient blood utilization.

METHODS

A prospective cohort analysis of 906 women who had caesarean deliveries at the Lagos State University Teaching Hospital, Nigeria between January and December, 2011. A comparison was made between 188 women who underwent blood transfusion and 718 who did not. Data were obtained on a daily basis by investigators from patients, clinical notes and referral letters using structured pre-tested data collecting form. Socio-demographic characteristics; antenatal, perioperative and intraoperative details; blood loss; transfusion; and puerperal observations were recorded. EPI-Info statistical software version 3.5.3 was used for multivariable analysis to determine independent risk factors for blood transfusion.

RESULTS

Of the 2134 deliveries during the study period, 906 (42.5%) had caesarean deliveries and of which 188 (20.8%) were transfused. The modal unit of blood transfused was 3 pints (41.3%). The most common indication for caesarean section was cephalo-pelvic disproportion (25.7%).The independent risk factors for blood transfusion at caesarean section were second stage Caesarean Section (aOR = 76.14, 95% CI = 1.25-4622.06, p = 0.04), placenta previa (aOR = 32.57, 95% CI = 2.22-476.26, p = 0.01), placental abruption (aOR = 25.35, 95% CI = 3.06-211.02, p < 0.001), pre-operative anaemia (aOR = 12.15, 95% = CI 4.02-36.71, p < 0.001), prolonged operation time (aOR = 10.72 95% CI = 1.37-36.02, p < 0.001), co-morbidities like previous uterine scar (aOR = 7.02, 95% CI = 1.37-36.02, p = 0.02) and hypertensive disorders in pregnancy (aOR = 5.19, 95% CI = 1.84-14.68, p < 0.001). Obesity reduced the risk for blood transfusion (aOR = 0.24, 95% CI = 0.09-0.61, p = 0.0024).

CONCLUSION

The overall risk of blood transfusion in cesarean delivery is high. Paturients with the second stage Caesarean section, placenta previa, abruptio placentae and preoperative maternal anaemia have an increased risk of blood transfusion. Hence, adequate peri-operative preparations for blood transfusion are essential in these situations. Optimizing maternal hemoglobin concentration during antenatal period may reduce the incidence of caesarean-associated blood transfusion.