Cesarean section complications according to degree of emergency during labour

Assessment of colour-code protocol and neonatal outcomes for emergency caesarean sections

CONTEXT

The use of colour codes for emergency caesareans has significantly improved team communication and protocol compliance over time. However, the impact on neonatal prognosis remains to be demonstrated.

OBJECTIVES

Our main objective was to evaluate changes in neonatal morbidity and mortality over time for orange-code (decision-delivery interval ≤ 30 mins) and red-code caesareans (decision-delivery interval ≤ 15 mins), since the introduction of the colour-code protocol. The secondary objectives were to describe maternal complications and types of anaesthesia.

METHODS

This retrospective single-centre observational study was carried out in the maternity ward of the Rennes University Hospital and included all patients for whom an emergency caesarean was performed with an orange or red code between 1st January 2015 and 31st December 2021. A composite endpoint of neonatal morbidity and mortality was defined as the primary outcome. A sample of 1301 patients and 1346 newborns was analysed.

RESULTS

Compliance with the colour-code protocol increased significantly during the study period to reach in 2021 97.8 % usage of appropriate colour codes according to the indication (p < 0.0001) and 92.1 % concordance between the colour code and the decision-delivery interval (p < 0.0001). In contrast, changes in neonatal outcomes were minimal and not statistically significant (p = 0.5873). However, the risk of maternal complications did not increase and there was no difference in the rate of general anaesthesia (p = 0.2002).

CONCLUSION

The colour-code protocol did not show significant changes in neonatal outcomes but remains a relevant reference tool to coordinate the labour ward teams.

Prediction of intrapartum cesarean delivery among women with obesity: A retrospective cohort study

OBJECTIVE

To determine risk factors and design a clinically based predictive model for the risk of intrapartum cesarean delivery (CD) in women with obesity.

METHODS

A retrospective cohort study was conducted in a single tertiary medical center between 2012 and 2022 and included all consecutive women with a pre-gestational body mass index (BMI) ≥30 who planned a trial of labor. Uni- and multivariate analyses compared maternal and neonatal characteristics of women who delivered vaginally to those who underwent intrapartum CD. A specific risk prediction score was developed in accordance with the relative risk to predict the need for intrapartum CD.

RESULTS

Of the 5663 women with obesity included in the study cohort, 424 (7.5%) underwent intrapartum CD and 5239 (92.5%) delivered vaginally. The independent risk factors for CD were maternal age >35 years, pre-gestational BMI category (BMI 35-40 and BMI >40), nulliparity, epidural anesthesia, induction of labor, antibiotic administration during labor, multiple gestation, previous uterine scar, and pre-eclampsia. The intrapartum CD prediction score model demonstrated predictive performance with 85% sensitivity and 70% specificity.

CONCLUSION

Score model for intrapartum CD can be used by caregivers to offer a more informed consultation to women with obesity facing the decision of mode of delivery.

Risk factors for re-hospitalization following cesarean delivery at term

OBJECTIVE

To identify the key risk factors contributing to re-hospitalization after term cesarean delivery (CD).

METHODS

This retrospective cohort study included women who underwent CD at term at a university-affiliated tertiary medical center (January 2021 to March 2023). The primary outcome was risk factors for re-hospitalization within 30 days post-discharge. Data on selected maternal demographic, pregnancy-related and delivery variables were extracted from electronic medical records. A multivariable logistic regression analysis was conducted to identify independent risk factors for re-hospitalization. Logistic regression analysis was used to determine the odds ratios (ORs) and 95% confidence intervals (CIs) for various independent risk factors.

RESULTS

A total of 2878 women were included in the study, of whom 76 required re-hospitalization (2.6%). The rates of high-risk pregnancies were more prevalent among those who were re-hospitalized (41 [62.1%] vs. 1148 [49.1%], P = 0.043). Furthermore, the rates of emergency CDs (42 [56%] vs. 1040 [37.8%], P = 0.001), prolonged surgery duration (17 [22.4%] vs. 292 [10.4%], P = 0.001) and hospitalization duration (14 (18.4%) vs. 273 (9.7%), P = 0.015) were significantly higher in the re-hospitalized group. Emergency CD (OR 1.90, 95% CI 1.06-3.42, P = 0.030) and prolonged surgery duration (OR 2.44, 95% CI 1.25-4.77, P = 0.016) remained significant risk factors of re-hospitalization in the multivariate analysis.

CONCLUSIONS

The need for emergency CD and prolonged surgery duration were found as independent risk factors for re-hospitalization after CD at term.

Maternal and perinatal outcomes following code red cesarean delivery performed among hospitals with different level of care

INTRODUCTION

Code red cesarean delivery (CD) is performed in the presence of an impending danger to maternal or fetal life. The indications, times, and procedures in this setting remain ambiguous. The aim of this study was to evaluate in a cohort of code red CD the impact of the level of care of Obstetric Units, indications, and decision to delivery interval CD on maternal and perinatal outcomes.

METHODS

This was a multicenter retrospective study conducted at four maternal units (two level-2 University Hospitals and two level-1 Community Hospitals) on a cohort of women who underwent code red CD between 2018 and 2021. An independent team of experts performed retrospective audits to assess the appropriateness of indications.

RESULTS

A cohort of 168 code red CDs were included. The most frequent indications were severely abnormal fetal heart rate patterns (41.7 %) and sentinel events (38.1 %). Decision to delivery interval (DDI) was similar between different level of care (20.7 vs 21.4 min, p = 0.66) and didn't affect adverse perinatal outcome. Rates of appropriate indications were higher in the level-2 than level-1 hospitals (80.2 % vs 65 %, p = 0.036), with worse adverse perinatal outcome in the former than the latter (43.4 % vs 21.1 %, p = 0.002).At multivariate analysis, worse perinatal outcomes were independently associated with indications for code red CD (P = 0.01) and level-2 units (P = 0.005).

CONCLUSIONS

Level-1 hospitals guarantee a promptness of response comparable to that of level-2 centers in dealing with emergency in CD, however with lower rates of appropriate indications. Indications for code red CD but not DDI are associated with worse perinatal outcomes.

Re-exploration following caesarean birth: a prospective national case-control study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system

BACKGROUND

Re-exploration following caesarean birth and the associated maternal morbidity has not been investigated in the UK. Our aims were to determine the national incidence and identify the associated risk factors.

METHODS

We conducted a prospective observational case-control study across 194 UK consultant-led maternity units in women whose caesarean birth was complicated by a re-exploration. Independent factors for re-exploration were analysed using multivariable multi-level mixed effects logistic regression.

RESULTS

Over the study period (1 June 2021 and 31 May 2022) 238,423 caesarean births were recorded across the UK of which 187 women underwent re-exploration, giving an incidence of one re-exploration per 1282 caesarean births (95%CI 1:1099-1:1471). Haemorrhage (124/187, 66.3%) and sepsis (31/187, 16.6%) were the most common findings at re-exploration. Median (IQR [range]) time interval to re-exploration following the caesarean birth was 1 (0-4 [0-28]) day. Mechanical ventilation was required in 34 (18.6%) women, cardiac arrest was reported in 5 (2.7%) and 3 (1.6%) women died. Independent preceding factors associated with a re-exploration included: receipt of blood transfusion (adjusted OR (95%CI) 8.25 (2.66-25.61)); use of a general anaesthetic (adjusted OR (95%CI) 3.33 (1.61-6.88)); pre-eclampsia (adjusted OR (95%CI) 3.27 (1.55-6.91)); black ethnicity (adjusted OR (95%CI) 3.14 (1.39-7.11)); postpartum haemorrhage (adjusted OR (95%CI) 2.82 (1.81-4.37)); use of anticoagulants or antiplatelet drugs pre-caesarean birth (adjusted OR (95%CI) 2.26 (1.35-3.81)); and emergency caesarean birth (adjusted OR (95%CI) 1.89 (1.01-3.57)).

CONCLUSION

Re-exploration following caesarean birth in the UK is uncommon but is associated with significant maternal morbidity and mortality. These study findings will help guide informed consent and encourage appropriate surveillance of high-risk women postpartum.

Establishing a risk score for prediction of intrapartum cesarean delivery among older women: A retrospective cohort study

OBJECTIVE

To determine risk factors and to develop a risk prediction score for intrapartum cesarean delivery (CD) in women over 40 years old.

STUDY DESIGN

A retrospective cohort study, in a single university-affiliated tertiary medical center. All women aged 40 years or more who planned a trial of labor between 2012 and 2022. Women who opted for an elective CD and those with non-viable fetuses were excluded. Maternal and neonatal characteristics of women who delivered vaginally were compared to those who underwent an intrapartum CD. Risk factors were examined using univariate and multivariate analysis. A score was developed to predict the need for intrapartum CD. We assessed a receiver operating characteristic curve to evaluate the performance of our model.

MAIN OUTCOME MEASURE

An unplanned intrapartum cesarean section.

RESULTS

During the study period, 122,583 women delivered at our center, of whom 6122 (4.9 %) aged 40 years or more attempted a trial of labor. Of them, 428 (7 %) underwent intrapartum CD. Several independent risk factors were identified, including nulliparity, regional anesthesia, induction of labor, use of antibiotics during labor, multiple gestation, previous cesarean delivery, and the presence of gestational diabetes or preeclampsia. A risk score model, employing a cut-off of 7, demonstrated successful prediction of intrapartum CD, with an area under the curve of 0.86.

CONCLUSION

The score model for intrapartum CD can be used by caregivers to offer a more informed consultation to women aged 40 years or more deciding on the mode of delivery.

A prediction tool for mode of delivery in twin pregnancies-a secondary analysis of the Twin Birth Study

BACKGROUND

One of the controversies regarding the management of twin gestations relates to the mode of delivery. Currently, counseling regarding the mode of delivery and the chance of successful vaginal twin delivery is based on the average risk for intrapartum cesarean delivery in the general population of twin pregnancies. Decision support tools that provide an individualized risk for intrapartum cesarean delivery based on the unique characteristics of each patient can improve counseling and decision-making regarding the choice of mode of delivery in twin pregnancies.

OBJECTIVE

This study aimed to develop and validate a prediction model to determine the risk for intrapartum cesarean delivery in twin pregnancies.

STUDY DESIGN

In this secondary analysis of the Twin Birth Study, a multicenter randomized controlled trial, we considered the subgroup of individuals who underwent a trial of vaginal delivery. Candidate predictors included maternal age, parity, previous cesarean delivery, conception method, chorionicity, diabetes and hypertension in pregnancy, gestational age at birth, the onset of labor, presentation of the second twin, sonographic fetal weight estimation, and fetal sex. The co-primary outcomes were overall intrapartum cesarean delivery and cesarean delivery of the second twin. Multivariable logistic regression models were used to estimate the probability of the study outcomes. Model performance was evaluated using measures of discrimination (the area under the receiver operating characteristic curve), calibration, and predictive accuracy. Internal validation was performed using the bootstrap resampling technique.

RESULTS

A total of 1221 individuals met the study criteria. The rate of overall intrapartum cesarean delivery and cesarean delivery for the second twin was 25.4% and 5.7%, respectively. The most contributory predictor variables were nulliparity, term birth (≥37 weeks), a noncephalic presentation of the second twin, previous cesarean delivery, and labor induction. The models for overall intrapartum cesarean delivery and cesarean delivery of the second twin had good overall discriminatory accuracy (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.688-0.752 and 0.736; 95% confidence interval, 0.669-0.803, respectively) and calibration (as illustrated by the calibration plot and Brier scores of 0.168; 95% confidence interval, 0.156-0.180 and 0.051; 95% confidence interval, 0.040-0.061, respectively). The models achieved good specificity (66.7% and 81.6%, respectively), high negative predictive value (86.0% and 96.9%, respectively), and moderate sensitivity (68.1% and 57.1%, respectively).

CONCLUSION

The prediction models developed in this study may assist care providers in counseling individuals regarding the optimal timing and mode of delivery in twin pregnancies by providing individualized estimates of the risk for intrapartum cesarean delivery.

The association between indications for cesarean delivery and surgery time

OBJECTIVE

We aimed to determine risk factors for prolonged surgery time of cesarean delivery (CD).

METHODS

We conducted a retrospective cohort study in a single tertiary university-affiliated medical center (2011-2022). The study group consisted of all women who underwent CD that lasted >90 min (representing the 95th percentile of CD length in our cohort). Data were compared with CDs with an operation time of <90 min. Demographic, obstetric, and surgical characteristics, as well as indications for surgery and urgency (in labor vs. elective surgery), were compared.

RESULTS

Overall, during the study period, 31 660 CDs were performed in our center. Of them, 1397 (4.4%) lasted >90 min. After applying a multivariate analysis, abnormal placentation (relative risk [RR] 1.5 [95% confidence interval (CI), 1.3-1.8]), previous uterine scar (RR, 2.15 [95% CI, 1.5-3.0]), general anesthesia (RR, 3.5 [95% CI, 2.9-4.4]) and preterm delivery (RR, 2.06 [95% CI, 1.78-2.4]) were found to be associated with prolonged surgical time. CD due to malpresentation (RR, 0.57 [95% CI, 0.46-0.7]), multiple gestations (RR, 0.72 [95% CI, 0.6-0.9]), and patient request (RR, 0.56 [95% CI, 0.38-0.84]) were found to be protective factors.

CONCLUSION

The main risk factors associated with additional surgery time in CD are general anesthesia, abnormal placentation, previous uterine scar, and preterm delivery.

Singleton pregnancy using in vitro fertilization or intracytoplasmic sperm injection does not increase risk of bleeding in cesarean delivery: a retrospective cohort study

PURPOSE

Several studies indicate that assisted reproductive technology (ART) including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancies carries increased risk of complications including postpartum hemorrhage (PPH). However, the association between IVF/ICSI and the bleeding risk particularly in cesarean delivery has not been systematically assessed. The aim of this study was to evaluate bleeding risk during and after cesarean delivery in parturients who conceived using IVF or ICSI.

METHODS

This is a retrospective observational study analyzing data from 310 parturients who underwent cesarean delivery: 155 who had conceived using IVF or ICSI (IVF/ICSI group) and 155 age and year of delivery matched controls who had conceived spontaneously (control group). The primary outcome measure was the amount of blood lost during and within 24 h after cesarean delivery. Secondary outcome measure was the incidence of severe PPH. With 132 parturients in each group, we had 90% power to detect a 200 mL difference in the bleeding amount, at a 0.05 two-sided significance level.

RESULTS

The amount of bleeding in the IVF/ICSI group was 1234 ± 669 mL, which was 124 mL (11.2%) greater than that in the control group (95% CI - 34 to 282; p = 0.12). The incidence of severe PPH in the IVF/ICSI group and in the control group was 23.9% and 16.8%, respectively (p = 0.16), and the unadjusted odds ratio was 1.6 (95% CI, 0.9-2.7; p = 0.12). No significant independent effect of IVF/ICSI on the bleeding amount and the incidence of severe PPH was observed in multivariable regression analyses (p = 0.22, p = 0.16).

CONCLUSION

In this study, IVF and ICSI were not associated with increasing risk of bleeding in cesarean delivery.

["Red code" C-sections: A new tool developed with Delphi method is enabling analysis of practices]

OBJECTIVE

In France, C-sections are classified through a color code according to their degree of urgency. A red-classified C-section is triggered when life of mother or fetus is immediately threatened These cases happen very rarely and represent less than 1% of total deliveries. Many French maternity hospitals are above this rate. This risky procedure should remain an exception. The main purpose of this study is to develop a new tool enabling to determine the relevance of red C-sections in order to improve obstetrical practices.

METHODS

Eleven national obstetrical experts were submitted with relevant-estimated indications of red C-sections. A two-round Delphi methodology was then used to reach a consensus on a new table of relevance.

RESULTS

Five different groups of indications were proposed to the panel of experts. After two rounds, four groups achieved a consensus by being qualified "very relevant" or "relevant" by more than 80% of the 11 experts.

CONCLUSION

The aim of this new consensual table of relevance is to improve quality of care. It allows to evaluate the relevance of red C-sections and determine when red C-sections are non-relevant but it particularly helps teams to identify ways of improvements. Finally, this tool enables a reproductible analysis that can be further intra- or inter-hospitals developed towards harmonization of practices.

Evaluation of decision to delivery interval and its effect on feto-maternal outcomes in Category-I emergency cesarean section deliveries in Phuentsholing General Hospital, 2020: A retrospective cross-sectional study

Background and Aims

When there is an immediate threat to maternal or fetal life, it is recommended to deliver within 30 min of the decision to have favorable perinatal outcomes. However, there is no data on the delivery intervals for Category-I emergency cesarean section in Bhutan. The study evaluated the decision to delivery interval (DDI) and its effect on perinatal and maternal outcomes in Category-I emergency cesarean section.

Methods

A retrospective cross-sectional study was conducted at the Phuentsholing General Hospital, Bhutan, from January 1, 2020 to December 31, 2020. Mothers who underwent Category-I emergency cesarean section were included. The demographic variables, patient transfer time, anesthesia time, operation time, DDI, and maternal and perinatal outcomes were recorded in a standard proforma. The data were analyzed using SPSS version 23.

Results

Of 78 Category-I emergency cesarean sections, only 23 (29.5%) of the cases were able to perform within 30 min of the DDI. The median (interquartile range) DDI was 37 (30-44) min. More time was taken by anesthetists to administer anesthesia (20 [15-8] min). Fetal distress (40, 51.3%) was the commonest indication. The longest DDI was around 39 min for prolonged labor, and the shortest was 26 min for failed instrumental delivery. Over half of the newborns delivered more than 30 min of DDI had low APGAR scores (25, 32.1%) at 1 min and meconium was present (23, 29.5%). Intensive care was required in 11 (14.1%), of which there was 1 (1.3%) neonatal death.

Conclusion

The Category-I emergency cesarean sections performed within recommended DDI of 30 min were much less. The main delay was due to the longer time taken for the patient transfer and time taken by the anesthetists to administer anesthesia. Perinatal outcomes were favorable when the deliveries were conducted within 30 min of DDI.

Types of intrapartum hypoxia in the newborn at term with metabolic acidemia: A retrospective study

INTRODUCTION

In the most recent recommendations of the International Federation of Gynecology and Obstetrics (FIGO), a chapter was dedicated to the physiological approach and to the description of fetal mechanisms developed to respond to hypoxia. Our objective was to classify the type of hypoxia in the case of metabolic acidemia and to describe the order of appearance of fetal heart rate abnormalities in cases of gradually evolving hypoxia.

MATERIAL AND METHODS

132 neonates born between 2018 and 2020 with acidemia were included. We excluded preterm birth, fetuses with congenital anomaly and twin pregnancies. Intrapartum cardiotocography traces were assigned to one of these four types of labor hypoxia: acute, subacute, gradually evolving and chronic hypoxia. For gradually evolving hypoxia, fetal heart rate abnormalities were described according to the FIGO classification.

RESULTS

36 cardiotocography traces (27.3%) were classified as acute hypoxia, 14 (10.6%) as subacute hypoxia, and 3 (3.2%) as chronic hypoxia; gradually evolving hypoxia occurred in 62 cases (47%). In 77.4% of cases of gradually evolving hypoxia, deceleration was the first anomaly to appear, with loss of variability and bradycardia appearing later. Increased fetal heart rate was observed immediately after late deceleration in 46.8% of cases and was followed by a loss of variability or saltatory rhythm in 37.1% of cases.

CONCLUSIONS

In cases of metabolic acidemia at term, the most frequent situation observed was gradually evolving hypoxia, with an initial occurrence of decelerations. The sequence of fetal heart rate modifications was variable.

Risk factors for postpartum depression in women undergoing elective cesarean section: A prospective cohort study

Background

Postpartum depression (PPD) has adverse effects on maternal and child health. Cesarean section (CS) is suggested to be associated with PPD, but no study has examined the risk factors for PPD in women who underwent CS. Therefore, this study aimed to investigate this association.

Methods

A prospective observational study was conducted between December 2020 and September 2021. In total, 590 women who underwent elective CS participated in this study. Data were collected using a questionnaire through a face-to-face interview at three time points: 32nd week of gestation, 2 days postpartum, and 6 weeks postpartum. PPD was defined by an Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 11 at 6 weeks postpartum. Multivariate logistic regression analysis was performed to identify the risk factors for PPD.

Results

Among the 590 women, 25.4% had PPD (142/590). After adjustment for the confounding factors, high antenatal self-rating anxiety scale score (OR = 1.10, 95% CI = 1.04–1.16), PPD symptoms (EPDS ≥ 11) at 2 days postpartum (OR = 6.17, 95% CI = 1.35–28.31), and pain at 6 weeks postpartum (OR = 2.14, 95% CI = 1.24–3.69) were independently associated with PPD.

Conclusion

Prenatal anxiety, PPD symptoms occurring at an early postoperative stage, and pain at 6 weeks postpartum may be associated with an increased risk of PPD among women who undergo CS.

The risk factors and nursing countermeasures of sepsis after cesarean section: a retrospective analysis

Background

Sepsis is a very serious complication of cesarean section, understanding the influencing factors is important to the prevention and management of sepsis. We aimed to analyze the associated risk factors of sepsis of cesarean section, to provide evidences into the clinical management and nursing care of cesarean section.

Methods

Patients who underwent cesarean section surgery from January 1, 2017 to June 30, 2021 in our hospital were included. The characteristics of patients were collected and analyzed. Logistic regression analyses were conducted to analyze the influencing factors of sepsis of cesarean section.

Results

A total of 3819 patients undergoing cesarean section were included, the incidence of sepsis in patients undergoing cesarean section was 0.84%. There were significant differences in the age, vaginal delivery attempt, premature rupture of membranes, preoperative hemoglobin, estimated blood loss during surgery and postoperative urinary tube implacement between sepsis and no sepsis patients (all p < 0.05). Logistic regression analyses found that age ≥ 35y(OR3.22, 95%CI1.20 ~ 5.15), gestational diabetes(OR2.64, 95%CI1.91 ~ 4.15), vaginal delivery attempt(OR2.05, 95%CI1.70 ~ 4.42), premature rupture of membranes(OR2.42, 95%CI1.02 ~ 4.20), preoperative hemoglobin ≤ 105 g/L(OR4.39, 95%CI1.02 ~ 7.88), estimated blood loss during surgery ≥ 400 ml(OR1.81, 95%CI1.35 ~ 3.01), postoperative urinary tube implacement(OR2.19, 95%CI1.27 ~ 2.50) were the risk factors of sepsis in patients undergoing cesarean section(all p < 0.05). Escherichia Coli(46.15%), Enterococcus faecalis(17.95%) and Pseudomonas aeruginosa(12.83%) were the most commonly-seen bacteria in sepsis patients.

Conclusion

In clinical practice, medical workers should carry out strict management and early prevention of related risk factors during the perioperative period of pregnant women, to effectively reduce the occurrence of sepsis after cesarean section.

Prediction model for prolonged hospitalization following cesarean delivery

INTRODUCTION

A rise in the rate of cesarean delivery (CD) has been found to be associated with a higher length of hospital stay, making it a public health concern. We aimed to evaluate risk factors for prolonged hospitalization following CD.

METHODS

A retrospective cohort study, in a single tertiary medical center, was conducted (2011-2019). Cesarean deliveries were categorized into three groups according to the postpartum length of stay (a) up to 3 days (the routine post cesarean hospital stay in our center, reference group) (b) 4-9 days, and (c) 10 days or above (prolonged hospitalization). Risk factors were examined using univariate analysis as well as multivariate logistic regression. A specific risk prediction score was developed to predict the need for prolonged hospitalization and ROC curve was assessed utilizing the performance of our model.

RESULTS

Overall, 87,424 deliveries occurred during the study period. Of them, 19,732 (22.5%) were cesarean deliveries. Hospitalization period was distributed as follows: 10,971 (55.6%) women were hospitalized for up to 3 days, 7,576 (38.4%) stayed for 4-9 days and 1,185 (6%) had a prolonged hospitalization period (≥10 days). Using multivariate analysis, multiple pregnancy (OR = 1.29, 95%CI 1.05-1.58), preterm delivery < 37 weeks (OR = 8.32, 95%CI 6.7-10.2), Apgar score < 7 (OR = 1.41, 95%CI 1.11-1.78) and non-elective CD (OR = 1.44, 95%CI 1.15-1.8) were identified as independent risk factors for prolonged hospitalization. Antenatal thrombocytopenia (PLT < 100 K) was found to be a protective factor (OR = 0.51, 95%CI 0.28-0.92). Our score model included antenatal risk factors and was found to be predicting the outcome, with an AUC of 0.845 (95%CI 0.83-0.86, p-value < 0.001).

CONCLUSION

A prediction score model for prolonged hospitalization after CD may be beneficial for risk assessment and post-partum management.