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Muraca GM, Peled T, Kirubarajan A, Weiss A, Sela HY, Grisaru-Granovsky S, Rottenstreich M. The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth. Am J Obstet Gynecol MFM 2024; 6:101326. [PMID: 38447679 DOI: 10.1016/j.ajogmf.2024.101326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth. OBJECTIVE We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. STUDY DESIGN We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. RESULTS A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42). CONCLUSION Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.
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Affiliation(s)
- Giulia M Muraca
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University (Dr Muraca), Hamilton, Canada; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet (Dr Muraca), Stockholm, Sweden.
| | - Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada; Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
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Kirubarajan A, Thangavelu N, Rottenstreich M, Muraca GM. Operative delivery in the second stage of labor and preterm birth in a subsequent pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:295-307.e2. [PMID: 37673234 DOI: 10.1016/j.ajog.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/18/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy. DATA SOURCES MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023. STUDY ELIGIBILITY CRITERIA All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included. METHODS Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool. RESULTS After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57-2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries. CONCLUSION Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution.
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Affiliation(s)
- Abirami Kirubarajan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.
| | - Nila Thangavelu
- Bachelor of Health Sciences Program, McMaster University, Hamilton, Canada
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada; Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada; Faculty of Health Sciences, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institute, Stockholm Sweden
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Hung MWC, Lee LTL, Chiu CPH, Ma MKT, Chan YYY, Kwong LT, Wong EJ, Lai THT, Chan OK, So PL, Lau WL, Leung TY. The use of bubble charts in analyzing second stage cesarean delivery rates. Am J Obstet Gynecol 2024:S0002-9378(24)00363-6. [PMID: 38408623 DOI: 10.1016/j.ajog.2024.02.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
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.
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Affiliation(s)
| | - Lin Tai Linus Lee
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Christopher Pak Hey Chiu
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Man Kee Teresa Ma
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - Yuen Yee Yannie Chan
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Lee Ting Kwong
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Eunice Joanna Wong
- Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong
| | - Theodora Hei Tung Lai
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Oi Ka Chan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Wai Lam Lau
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, New Territories, Hong Kong.
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Lee LTL, Chiu CPH, Ma MKT, Kwong LT, Hung MWC, Chan YYY, Wong EJ, Lai THT, Chan OK, So PL, Lau WL, Leung TY. The use of bubble charts in analyzing the global second-stage cesarean delivery rates: a systematic review. AJOG GLOBAL REPORTS 2024; 4:100312. [PMID: 38380079 PMCID: PMC10877423 DOI: 10.1016/j.xagr.2024.100312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
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).
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Affiliation(s)
- Lin Tai Linus Lee
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong (Dr Lee)
| | - Christopher Pak Hey Chiu
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
| | - Man Kee Teresa Ma
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong (Dr Ma)
| | - Lee Ting Kwong
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
| | - Man Wai Catherine Hung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong (Drs Hung and Lau)
| | - Yuen Yee Yannie Chan
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Lai Chi Kok, Hong Kong (Dr Chan)
| | - Eunice Joanna Wong
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
- Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong (Dr Wong)
| | - Theodora Hei Tung Lai
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Pok Fu Lam, Hong Kong (Dr Lai)
| | - Oi Ka Chan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Lai Chi Kok, Hong Kong (Dr Chan)
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
| | - Wai Lam Lau
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong (Drs Hung and Lau)
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong (Dr Lee)
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
| | - Hong Kong College of Obstetricians and Gynaecologists Research Group
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong (Dr Lee)
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong (Dr Ma)
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong (Drs Hung and Lau)
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Lai Chi Kok, Hong Kong (Dr Chan)
- Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong (Dr Wong)
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Pok Fu Lam, Hong Kong (Dr Lai)
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Glazewska-Hallin A, Rosen O'Sullivan H, Shennan A. Emergency caesareans are associated with an increased risk of recurrent early preterm birth: a commentary. BJOG 2024; 131:1-4. [PMID: 35938502 DOI: 10.1111/1471-0528.17271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
Abstract
This article includes Author Insights, a video abstract available at: https://vimeo.com/733549553.
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Affiliation(s)
| | - Hannah Rosen O'Sullivan
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
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