Objective-To estimate the frequency, indications, and complications of cesarean hysterectomy.Methods-This was a prospective, 2-year observational study at 13 academic medical centers conducted between January 1, 1999 and December 31, 2000 on all women who underwent a hysterectomy at the time of cesarean delivery. Data was abstracted from the medical record by study nurses. The outcomes included procedure frequency, indications, and complications.Results-A total of 186 cesarean hysterectomies (0.5%) were performed from a cohort of 39,244 women who underwent cesarean delivery. The leading indications for hysterectomy were placenta accreta (38%) and uterine atony (34%). Of the hysterectomy cases with a diagnosis recorded as accreta, 18% accompanied a primary cesarean delivery while 82% had a prior procedure (p<0.001). Of the hysterectomy cases with atony recorded as a diagnosis, 59% complicated primary cesarean delivery whereas 41% had a prior cesarean (p< 0.001). Major maternal complications of cesarean hysterectomy included transfusion of red blood cells (84%) and other blood products (34%), fever (11%), subsequent laparotomy (4%), ureteral injury (3%), and death (1.6%). Accreta hysterectomy cases were more likely than atony hysterectomy cases to require ureteral stents (14% versus 3%, p=0.03) and to instill sterile milk into the bladder (23% versus 8%, p=0.02).Conclusion-The rate of cesarean hysterectomy has declined modestly in the last decade. In spite of the use of effective therapies and procedures to control hemorrhage at cesarean delivery, a small proportion of women continue to require hysterectomy to control hemorrhage from both uterine atony and placenta accreta.

Regional anesthesia is associated with fetal acidemia, occasionally severe, and has features of an acute respiratory type of acidemia. Fetal acidemia is less frequent with epidural anesthesia compared to subarachnoid techniques.

No abstract

No abstract

Objective-To compare maternal and neonatal outcomes in women undergoing a second stage cesarean after a trial of operative vaginal delivery with women undergoing a second stage cesarean without such an attempt.Methods-This study is a secondary analysis of the women who underwent second stage cesarean. .The maternal outcomes examined included blood transfusion, endometritis, wound complication, anesthesia use, and maternal death. Infant outcomes examined included umbilical artery pH < 7.0, Apgar of 3 or less at 5 minutes, seizures within 24 hours of birth, hypoxic ischemic encephalopathy (HIE), stillbirth, skull fracture, and neonatal death.Results-Of 3189 women who underwent second stage cesarean, operative vaginal delivery was attempted in 640. Labor characteristics were similar in the two groups with the exception of the admission to delivery time and cesarean indication. Those with an attempted operative vaginal delivery were more likely to undergo cesarean delivery for a non-reassuring fetal heart rate tracing (18.0% vs 13.9%, p=.01), have a wound complication (2.7% vs 1.0%; OR 2.65 95% CI 1.43-4.91), and require general anesthesia (8.0% vs 4.1%, OR 2.05 95% CI 1.44-2.91). Neonatal outcomes including umbilical artery pH less than 7.0, Apgar at or below 3 at 5 minutes, and hypoxic ischemic encephalopathy were more common for those with an attempted operative vaginal delivery. This was not significant when cases with a non-reassuring fetal heart rate tracing were removed. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. * For a list of other members of the NICHD MFMU, see the Appendix online at http://links.lww.com/xxx. Conclusion-Cesarean delivery after an attempt at operative vaginal delivery was not associated with adverse neonatal outcomes in the absence of a non-reassuring fetal heart rate tracing. NIH Public Access

Objective-Elective repeat cesarean delivery at 37 or 38 weeks compared to 39 completed weeks' gestation is associated with adverse neonatal outcomes. We assessed whether delivery prior to 39 weeks is justifiable on the basis of decreased adverse maternal outcomes.Methods-We conducted a cohort study of women with live singleton pregnancies delivered by prelabor elective repeat cesarean from 1999 through 2002 at 19 U.S. academic centers. Gestational age was examined by completed weeks (e.g., 37 completed weeks = 37 0/7 to 37 6/7 weeks). Maternal outcomes included a primary composite of death, hysterectomy, uterine rupture or dehiscence, blood transfusion, uterine atony, thromboembolic complications, anesthetic complications, surgical injury or need for arterial ligation, intensive care unit admission, wound complications, or endometritis.Results-Of 13,258 elective repeat cesareans performed at 37 weeks of gestation or later, 11,255 (84.9%) were between 37 0/7 and 39 6/7 weeks (6.3% at 37, 29.5% at 38, and 49.1% at 39 completed weeks), and 15.1% were at 40 0/7 weeks or more. The primary outcome occurred in 7.43% at 37 weeks, 7.47% at 38 weeks and 6.56% at 39 weeks (p-value for trend test = 0.09). Delivery prior to 39 weeks was not associated with a decrease in the primary outcome when compared with delivery at 39 weeks (adjusted OR 1.16; 95% CI 1.00-1.34). Early delivery was associated with increased maternal hospitalization of 5 days or more [1.96 (1.54, 2.49)] but not with a composite of death or hysterectomy or with individual maternal morbidities. Conclusion-Electiverepeat cesarean delivery at 37 or 38 weeks is not associated with decreased maternal morbidity.

No abstract

No abstract