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Background: Unintentional extension of uterine incision is a known complication during cesarean delivery estimated to occur in 4-8% of cesarean deliveries. The aim of this study was to examine risk factors associated with unintentional uterine incision extension and to assess which of them are independent risk factors for this condition., Study Design: We conducted a retrospective cohort study at a large public university tertiary referral center between 2003 and 2017. Included were women who underwent cesarean delivery during this time period. Demographic, medical, obstetrical and surgical data were collected. The primary outcome was the presence of uterine incision extension during cesarean delivery. Secondary outcomes included detection of risk factors associated with uterine incision extension. A multivariate analysis was additionally performed to identify general and labor related risk factors for unintentional extension of uterine incision among patients that underwent cesarean delivery during second stage of labor., Results: During the study period, 25,879 cesarean deliveries performed in our medical center were assessed. Out of them, 731 (2.8%) cases of unintended uterine incision extension were identified. Women in this group had high rates of full cervical dilatation and increased maternal hemorrhage. Assessment of incision extension direction revealed that two-thirds of extensions were lateral, mostly unilateral. Median size of the extension was 2.7 ± 1.2 cm.Independent parameters associated with unintended uterine incision extension included nulliparity, vertex presentation, epidural anesthesia and cesarean section indication. Further analysis including cesarean deliveries performed during the second stage of labor revealed 397 (15.3%) cesarean deliveries in which incision extension was noted and 2205 (84.7%) cesarean deliveries without incision extension. Following multivariate analysis performed in women who underwent cesarean delivery during second stage of labor, two independent parameters associated with unintended uterine incision extension remained significant - past cesarean delivery and failed vacuum attempt., Conclusions: Vacuum extraction attempt and previous cesarean delivery are independent risk factors for uterine incision extension in women undergoing cesarean delivery during the second stage of labor. We also showed the majority of these extensions to be lateral.

Objective: Maternal age is an established determinant of successful trial of labor after cesarean (TOLAC). While an increasing proportion of parturients are aged 40 years and older, and previously underwent a cesarean section, little data regarding TOLAC success for this age group is available. This study assessed TOLAC success, and its associated characteristics, among women >40 years who never delivered vaginally., Study Design: A retrospective case-control study of all women who never delivered vaginally aged ≥40 years with a history of previous cesarean delivery, who delivered at our hospital during 2006-2017. Maternal, neonatal, and delivery characteristics were compared between women with successful and unsuccessful TOLAC., Results: Of 335 older women who never delivered vaginally with a history of one cesarean delivery, 61 (18.2 %) elected TOLAC (18.2 %); the median age was 41[40-42] years and the inter-delivery interval 34 [25-50] months. Overall, 38/61 (62.3 %) had a successful TOLAC. Women with successful TOLAC had a higher rate of a non-recurrent indication for cesarean delivery in their previous cesarean delivery (42.1 % vs. 13.0 %, P = 0.01), whereas dysfunctional labor at previous delivery was more common in the failed TOLAC group (47.8 % vs. 15.8 %, P = 0.007). Failed TOLAC was associated with the presence of gestational diabetes (13.0 % vs. 0 %, P = 0.02) and having a comorbidity (47.8 % vs. 21.0 %, P = 0.02). Induction of labor at TOLAC was more common in the failed TOLAC group (34.8 % vs. 2.6 %, P < 0.001). Birthweight was higher in the failed TOLAC group (3330 vs. 3107 g, P = 0.04), as well as the birthweight difference between deliveries (212 g vs. 82 g, P = 0.03). Neonatal and maternal outcomes were comparable between groups, except for longer length of stay (5 vs. 4 days, P = 0.04) in the failed TOLAC group. In a multivariable logistic regression analysis, only two factors were independently associated with TOLAC failure: previous cesarean delivery due to dysfunctional labor (OR [95 % CI]: 13.40 (1.29, 138.71), P = 0.03) and higher inter-delivery birthweight difference (OR [95 % CI]: 1.18 (1.11, 1.39), P = 0.02)., Conclusions: TOLAC in older women who never delivered vaginally is associated with a moderate success rate. The indication for cesarean delivery at the first delivery and inter-delivery birthweight difference were identified as having strong predictive value for TOLAC outcome., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To examine the laboratory anticoagulant effect of two thromboprophylactic low-molecular weight heparin (LMWH) regimens in post-cesarean obese patients., Methods: A prospective cohort study, performed during 2017-2018 at a university hospital, of post-cesarean obese (>90 kg) patients receiving 40 mg/day (n = 30) or 60 mg/day (n = 30) enoxaparin, and a control group of non-obese (n = 30) post-cesarean patients receiving 40 mg/day enoxaparin. Thrombin generation and anti-Xa were measured twice on the third postoperative day: prior to and 3.5-4 h following the third LMWH dose., Results: Age, parity, weight and body mass index were comparable between the obese study groups. Compared to the control non-obese group, the 40 mg obese and 60 mg obese groups showed increased baseline thrombin generation: medians 491, 581, 571 nM, respectively (P = 0.001 and P = 0.04, respectively). At peak LMWH activity, thrombin generation was higher in the 40 mg than in the 60 mg obese and control groups: medians 2599, 2391, 2229 nM, respectively (P = 0.01 and P < 0.0001, respectively); and thrombin generation was comparable between the 60 mg obese and the control groups (P = 0.58). Similarly, a significantly lower proportion of patients in the 40 mg obese group (10%) had anti-Xa levels within the recommended prophylactic range (0.2-0.5 IU/mL) than in the other groups (P < 0.0001 for both comparisons)., Conclusion: As determined by thrombin generation and anti-Xa testing, post-cesarean obese patients have an increased procoagulant potential, which was diminished only in those receiving higher dosages of LMWH. These findings support the need for clinical evaluation of LMWH dose adjustment in this setting., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: To determine whether induction of labor (IOL) after successful external cephalic version (ECV) is associated with an increased risk of cesarean delivery (CD) compared with IOL with spontaneous cephalic presentation., Methods: Retrospective case-control study. All women having IOL after successful ECV were eligible. Each woman in the study group was matched for parity, age and indication for induction with two consecutive controls having IOL and spontaneous cephalic presentation. The primary outcome measure was CD. Secondary outcomes measures were operative vaginal delivery, perineal tear/episiotomy and post-partum hemorrhage., Results: 79 women enrolled in the study group were matched with 158 controls. The overall incidence of CD was significantly higher in the study group compared with the control group (20.3 vs. 10.1 %; OR 2.25, 95 % CI 1.06-4.79, P = 0.03). After dividing the groups according to parity, the difference in the CD rate remained statistically significant for nulliparous women (36.7 vs. 15 %; OR 3.28, 95 % CI 1.17-9.16, P = 0.02), but not for multiparous women (10.2 vs. 7.1 %; OR 1.48, 95 % CI 0.44-4.92, P = 0.53). There was no significant difference in adjusted odds ratios for secondary outcomes., Conclusion: Induction of labor after successful ECV in nulliparous women increased the risk of CD compared with IOL with spontaneous cephalic presentation.

Background: Subfebrile intrapartum maternal temperature is very common, yet there is sparse evidence regarding its causes or its effects on perinatal outcomes. We examined whether mild temperature elevation during labour is a risk marker for adverse obstetric and neonatal outcomes., Methods: A retrospective cohort analysis including 42 601 term, singleton live-births in two medical centres between 2003 and 2010 was performed. This study compared women who experienced a maximal intrapartum temperature of ≤37°C with women who experienced subfebrile intrapartum temperature (37.1-37.9°C). Adjusted risks for adverse obstetric and neonatal outcomes were calculated by using multivariable logistic regression models., Results: Compared with maternal temperature ≤ 37°C, subfebrile temperature was associated with higher rates of primary caesarean deliveries {adjusted odds ratios [aOR] = 1.36 [95% confidence interval (CI) 1.25, 1.49])} and assisted vaginal deliveries (aOR = 1.20 [95% CI 1.11, 1.30]), as well as with greater risks of early neonatal sepsis (aOR = 2.66 [95% CI 1.88, 3.77]), neonatal intensive care unit admissions (aOR = 1.40 [95% CI 1.08, 1.83]), and neonatal asphyxia or seizures (aOR = 3.18 [95% CI 1.51, 6.70]). Mildly elevated maternal intrapartum temperature (37.1-37.5°C) was also associated with adverse outcomes., Conclusions: Maternal intrapartum subfebrile temperature may be an indicator of operative delivery and neonatal morbidity. Further research is needed to confirm these findings and to reveal underlying mechanisms., (© 2013 John Wiley & Sons Ltd.)

Objective: To estimate the association between time of delivery after external cephalic version at term and the risk for cesarean delivery., Methods: This retrospective cohort study included all successful external cephalic versions performed in a tertiary center between January 1997 and January 2010. Stepwise logistic regression was used to calculate the odds ratio (OR) for cesarean delivery., Results: We included 483 external cephalic versions in this study, representing 53.1% of all external cephalic version attempts. The incidence of cesarean delivery for 139 women (29%) who gave birth less than 96 hours from external cephalic version was 16.5%; for 344 women (71%) who gave birth greater than 96 hours from external cephalic version, the incidence of cesarean delivery was 7.8% (P = .004). The adjusted OR for cesarean delivery was 2.541 (95% confidence interval 1.36-4.72). When stratified by parity, the risk for cesarean delivery when delivery occurred less than 96 hours after external cephalic version was 2.97 and 2.28 for nulliparous and multiparous women, respectively., Conclusion: Delivery at less than 96 hours after successful external cephalic version was associated with an increased risk for cesarean delivery., Level of Evidence: III.

Objective: To evaluate the success and morbidity rates for attempted external cephalic version (ECV) in patients with one previous cesarean delivery (CD) and a breech-presenting fetus at term., Study Design: This is a retrospective study of outcomes of ECV at our institution for all women with one previous CD and a breech-presenting fetus at term between January 1997 and June 2005. A literature review was also performed as a Medline search (1966-2006)., Results: ECV was attempted for 42 women with a breech-presenting fetus and previous CD. The success rate of ECV was 74.0%, and 84% of women with successful ECV delivered vaginally. All fetal and maternal outcomes were favorable. Only four Medline reports met our inclusion criteria, representing a total of 124 patients and a mean ECV success rate of 76.6%. Thus we assessed 166 cases of attempted ECV and find an average ECV success rate of 76.5% and favorable fetal and maternal outcomes., Conclusions: Women with a breech-presenting fetus at term and previous CD, who desire a trial of labor, should be counseled regarding the accumulating evidence about the efficacy and apparently safety of this procedure and may be offered an ECV attempt.

Objective: Umbilical cord prolapse in a parturient is an emergency, where the need for immediate fetal delivery may conflict with maternal anesthetic risk factors. We describe the anesthetic management of a parturient who was rushed to the operating room, in the knee-chest prone position, because of cord prolapse with variable decelerations of fetal heart rate., Clinical Features: A 28-yr-old multiparous patient presented at 37 weeks gestation. Her co-morbidities included morbid obesity and asthma. She had a Mallampati class IV airway. She required emergency Cesarean delivery, in view of umbilical cord prolapse, with evidence of fetal compromise. In light of the airway concerns, the urgency to proceed with delivery, and the presence of a palpable umbilical cord pulse in this position, we performed a spinal anesthetic in the knee-chest prone position, and immediately thereafter turned the patient supine, with lateral uterine displacement. Fetal heart rate was monitored throughout the procedure. The spinal anesthetic required less than five minutes to perform, from the time of skin preparation, until readiness for surgery. The subsequent surgical and anesthetic course was unremarkable., Conclusions: Performing spinal anesthesia in the knee-chest prone position served as an innovative solution for emergency Cesarean delivery in this case. Both the head-down lateral, and the head-down knee-chest prone positions, are compatible with spinal anesthesia, and the maternal position that achieves relief of cord compression, determined by the presence of a palpable umbilical cord pulse, may be the most important factor to determine the optimal approach to spinal anesthesia.

A parturient (grand multipara) developed arrested labour complicated by severe fetal heart rate decelerations. Senior physicians explained the need for a caesarean section, but she chose to deliver vaginally since rabbinical blessing could not be obtained. Forcing the mother to have a cesarean section without consent is considered "civil battery." The dilemma faced by medical staff and the implications of her refusal for the treating medical staff are described.

The Fontan procedure is performed for patients with a hypoplastic right ventricle, and pregnancies following this palliative surgery are likely to increase. We present a parturient with the Fontan physiology who successfully underwent two consecutive caesarean deliveries; the first under general anaesthesia for emergency surgery and the second under regional anaesthesia for elective surgery. We suggest that pregnancy and delivery do not typically adversely affect maternal cardiac status in these patients. Attention must be paid, however, to fetal loss, prematurity, growth retardation and associated cardiac congenital malformations for which insufficient data exist in the literature in this patient population.

Objective: This study was undertaken to evaluate the attitude of anesthesiologists and gynecologists to the use of blood during cesarean section operation and, on the basis of the results, to ascertain the need for improvement of current transfusion guidelines., Study Design: A scenario-based survey was performed., Results: The response rate was 94% (327/347) among anesthesiologists and 91% (355/391) among gynecologists. The majority of responders selected a hemoglobin threshold ranging from 7.5 to 8.5 g/dL (62%). Threshold hemoglobin concentration differed significantly (P<.001) between anesthesiologists (median, 7.5 g/dL) and gynecologists (median, 8 g/dL). At that threshold, 56% of anesthesiologists compared with 86% of gynecologists administered 2 units of blood (P<.05). When transfusing packed cells, most practitioners would give 2 units regardless of the transfusion threshold., Conclusion: Our findings demonstrate differing approaches to current transfusion protocols. Transfusion consensus recommendations should be improved and unified to enhance red blood cell transfusion practices for relatively young and healthy patients undergoing anesthesia and surgery.

Objective: We compared pregnancy and delivery outcomes between women with cardiac disease versus matched healthy controls. The primary outcome was the frequency of unplanned cesarean delivery. Methods: In this single-center retrospective case-control study, women with cardiac disease were identified and matched (1:2 ratio, according to maternal age, parity, number of prior cesareans, gestational age, delivery onset and fetal presentation) to healthy controls who delivered within the same year. Outcomes were frequency of unplanned cesarean delivery, complications during pregnancy and postpartum course, intensive care unit (ICU) admissions, and length of hospitalization. Results: One hundred and twelve women with cardiac disease (exposed group, 225 deliveries) were identified and matched with 450 healthy women (controls, 2003-2014). The cohort comprised of 103 women (204 deliveries) with acquired heart disease (valve disease [n =69], arrhythmia [n =31], 3 with cardiomyopathy and peri/myocarditis, and 9 women (21 deliveries) with congenital heart disease. The frequency of unplanned cesarean was 14 (7.9%) for the exposed group as compared with 12 (3.4%) in controls with an odds ratio of 2.33 (95% CI =1.0.2–5.32, p =.045). This difference was accentuated in a sub-group of women with severe cardiac disease (15% vs. 4.2% in matched control group, p =.028). Seventy-one (31.6%) exposed women exhibited obstetric and cardiovascular complications during pregnancy as compared with 65 (14.4%) controls, p < .001. Twenty-five (13.9%) exposed women experienced postpartum complications versus 26 (7.5%) in the control group (p =.019). Maternal ICU admission occurred in 13 (7.3%) of the exposed group as compared with only 2 (0.6%) in controls (p < .001). Conclusions: Women with a background cardiac condition, particularly those with severe disease, are at a higher risk for an unplanned cesarean delivery and other peripartum complications as compared with matched healthy controls. [ABSTRACT FROM AUTHOR]