Article

Timing of Elective Repeat Cesarean Delivery at Term.

New England Journal of Medicine (Impact Factor: 54.42). 05/2009; 360(15):1570; author reply 1570-1. DOI: 10.1056/NEJMc090206
Source: PubMed
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    ABSTRACT: This report aims to summarize the evidence around early-term elective repeat cesarean section (ERCS) to help inform evidence-based guidelines and advance practice in the province of Ontario. Key Messages • Early-term ERCS (37-38 weeks) has consistently been associated with increased risks to the neonate, including respiratory morbidity, NICU admission and lengthier hospital stays when compared with ERCS at 39-40 weeks; • Empirical studies, guideline-producing bodies and expert consensus unanimously agree that delaying ERCS to ≥39 weeks significantly reduces these risks; • Studies addressing the timing of ERCS at term are limited and generally of lower quality; most studies examining ERCS compare maternal and neonatal outcomes between VBAC and ERCS; • Current rates of ERCS <39 weeks in Ontario exceed what is expected would be necessary and reasons for this are not well defined; • Ensuring adherence to guidelines dictating the timing of uncomplicated, term ERCS may pose specific challenges to clinicians, health policy and decision makers.
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    ABSTRACT: Abstract OBJECTIVE: To assess the effect of the scheduled gestational age for a repeat planned cesarean section (CS) on the risk for adverse pregnancy outcome in women with two or more previous CS. A retrospective cohort study of all women after ≥ 2 previous CS who were scheduled for a repeat planned CS. Women were divided into two groups at which the planned CS was scheduled: 38-week group or 39-week group. Overall, 377 were enrolled, 264 (70.0%) and 113 (30.0%) in the 38-week and the 39-week groups, respectively. The rate of an unplanned CS was significantly higher in the 39-week vs. the 38-week group (23.0% vs. 13.3%, p=0.02). A repeat planned CS scheduled to week 39 was associated with an increased risk of maternal adverse outcome (31.9% vs. 21.6%, p=0.03). There was no significant difference in the rate of adverse neonatal outcome between the two groups (20.8% vs. 23.0%, p=0.5). The lowest rate of any adverse outcome (maternal and/or neonatal) was observed when CS was scheduled to 38+1 weeks of gestation. In women after 2 cesarean sections, scheduling a planned CS at around 39 weeks compared with at around 38 weeks is associated with an increased risk for maternal adverse outcome with no apparent advantage in terms of neonatal outcome.
    The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 06/2013; 27(5). DOI:10.3109/14767058.2013.818130 · 1.21 Impact Factor
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    ABSTRACT: OBJECTIVE:: To compare the maternal and neonatal risks of elective repeat cesarean delivery compared with pregnancy continuation at different gestational ages, starting from 37 weeks. METHODS:: We analyzed the composite maternal and neonatal outcomes of repeat cesarean deliveries studied prospectively over 4 years at 19 U.S. centers. Maternal outcome was a composite of pulmonary edema, cesarean hysterectomy, pelvic abscess, thromboembolism, pneumonia, transfusion, or death. Composite neonatal outcome consisted of respiratory distress, transient tachypnea, necrotizing enterocolitis, sepsis, ventilation, seizure, hypoxic-ischemic encephalopathy, neonatal intensive care unit admission, 5-minute Apgar of 3 or lower, or death. Outcomes after elective repeat cesarean delivery without labor at each specific gestational age were compared with outcomes for all who were delivered later as a result of labor onset, specific obstetric indications, or both. RESULTS:: Twenty-three thousand seven hundred ninety-four repeat cesarean deliveries were included. Elective delivery at 37 weeks of gestation had significantly higher risks of adverse maternal outcome (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.06-2.31), whereas elective delivery at 39 weeks of gestation was associated with better maternal outcome when compared with pregnancy continuation (OR 0.51, 95% CI 0.36-0.72). Elective repeat cesarean deliveries at 37 and 38 weeks of gestation had significantly higher risks of adverse neonatal outcome (37 weeks OR 2.02, 95% CI 1.73-2.36; 38 weeks OR 1.39 95% CI 1.24-1.56), whereas delivery at 39 and 40 weeks of gestation presented better neonatal outcome as opposed to pregnancy continuation (39 weeks OR 0.79, 95% CI 0.68-0.92; 40 weeks OR 0.57, 95% CI 0.43-0.75). CONCLUSION:: In women with prior cesarean delivery, 39 weeks of gestation is the optimal time for repeat cesarean delivery for both mother and neonate. LEVEL OF EVIDENCE:: II.
    Obstetrics and Gynecology 03/2013; 121(3):561-569. DOI:10.1097/AOG.0b013e3182822193 · 4.37 Impact Factor