Cesarean Section

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The document discusses various risks associated with cesarean delivery for both mother and baby, as well as factors that may help reduce cesarean section rates and techniques used during the procedure.

The document notes that cesarean delivery is associated with increased risks of maternal morbidity and mortality compared to vaginal delivery. It can also increase risks during a subsequent delivery. Uterine rupture primarily occurs in women with a history of cesarean.

The document mentions that interventions like mandatory second opinions, nurse-led relaxation classes and birth preparation classes may help reduce cesarean section rates. Delaying elective c-sections to 39 weeks of gestation may also help reduce neonatal risks.

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Cesarean section
Updated 2012 May 17 01:40:00 PM: no randomized trials found evaluating planned cesarean section for non-medical indications at term (Cochrane Database Syst Rev 2012 Mar 14) view update Show more updates

Related Summaries: Trial of vaginal birth after cesarean (VBAC) Overview of labor and delivery Surgical Safety Checklist Medicare/Joint Commission National Hospital Inpatient Quality Measures Overview: risks of cesarean delivery maternal risks cesarean delivery associated with increased risk of maternal morbidity and mortality (level 2 [mid-level] evidence) planned cesarean delivery may be associated with increased postpartum risks compared with planned vaginal delivery (level 2 [mid-level] evidence) cesarean delivery of rst pregnancy associated with increased risks during labor in second delivery (level 2 [mid-level] evidence) uterine rupture occurs primarily in women with history of cesarean delivery (level 2 [mid-level] evidence) neonatal risks cesarean section associated with higher neonatal mortality than vaginal delivery in women with "no indicated risk" (level 2 [mid-level] evidence) elective cesarean delivery associated with increased mortality compared to planned vaginal delivery and similar mortality compared to emergency cesarean delivery (level 2 [mid-level] evidence) elective cesarean delivery associated with higher risk of respiratory morbidity than vaginal delivery (level 2 [mid-level] evidence) timing of emergent cesarean sections decision-to-incision time > 30 minutes not associated with adverse neonatal outcomes (level 2 [mid-level] evidence) decision to delivery interval > 75 minutes may be harmful but decision to delivery interval 16-75 minutes no worse than interval 15 minutes or less (level 2 [mid-level] evidence)

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elective cesarean sections interventions which may reduce rates of cesarean section include mandatory second opinion, nurse-led relaxation classes and birth preparation classes (level 2 [mid-level] evidence) delay of elective cesarean section to 39 weeks of gestation may be associated with lower risk of neonatal respiratory and other morbidity (level 2 [mid-level] evidence) periprocedural management prophylactic antibiotics for women having elective or non-elective cesarean section may improve maternal outcomes (reduced febrile mortality, wound infection and endometritis) (level 2 [mid-level] evidence) prophylactic betamethasone before elective cesarean section at term may reduce admission to neonatal special care units for respiratory complications (level 2 [mid-level] evidence) anesthesia insufcient evidence on benets and harms comparing regional anesthesia with general anesthesia spinal anesthesia and epidural anesthesia both effective, spinal anesthesia has shorter onset but increased risk of treatment of hypotension (level 1 [likely reliable] evidence) postoperative analgesia morphine may be associated with better pain control and higher breastfeeding rates than meperidine for post-cesarean section pain (level 2 [mid-level] evidence) oral analgesia may be associated with better pain control than patientcontrolled analgesia device (level 2 [mid-level] evidence) no evidence to justify withholding oral uids or food after uncomplicated cesarean section venous thromboembolism prophylaxis may be considered in women with risk factors procedural management Joel-Cohen incision has less postoperative morbidity than Pfannenstiel incision (level 1 [likely reliable] evidence) insufcient evidence to recommend most appropriate surgical technique for uterine incision during cesarean section manual removal of placenta at cesarean section associated with higher complication rate (level 2 [mid-level] evidence) insufcient data to support or refute routine use of uterine exteriorization for repair compared to intra-abdominal repair of uterine incision different approaches for uterine incision closure, peritoneum closure and subrectus sheath drain use have similar rates of maternal infectious morbidity (level 1 [likely reliable] evidence) subcutaneous fat closure may reduce wound complications, but otherwise

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insufcient evidence to guide abdominal wall closure after cesarean section prophylactic subcutaneous drainage does not appear effective in reducing wound complications after cesarean delivery (level 2 [mid-level] evidence) staples for skin closure associated with increased risk of wound infection or separation compared to subcuticular sutures, but no differences in pain or cosmetic outcome (level 2 [mid-level] evidence) Indications for Cesarean Delivery indications for cesarean delivery(1) emergent - immediate threat to life of woman or fetus other indications maternal or fetal compromise that is not immediately life-threatening failure to progress in labor placenta previa morbidly adherent placenta in women with previous cesarean delivery, Doppler ultrasound may be used for initial diagnosis; magnetic resonance imaging may help conrm diagnosis intervention options for women with morbidly adherent placenta include cross-matching blood and planned cesarean delivery with consultant obstetrician, anesthesiologist, and pediatrician present, and senior hematologist on call breech presentation multiple pregnancy cephalopelvic disproportion in labor mother to child transmission of maternal infections HIV if mother not receiving antiretroviral therapy or has viral load ! 400 copies per mL with any antiretroviral therapy hepatitis C if mother has co-infection with HIV primary genital herpes simplex in third trimester maternal request after discussion about risks and benets and offer of support (including perinatal mental health support for women with anxiety about vaginal delivery) other indications may include malpresentation other than breech cord prolapse prolonged pregnancy dystocia non-reassuring fetal heart rate Reference - American Academy of Family Physicians (AAFP) position paper on cesarean delivery in family medicine (AAFP) Incidence

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incidence of cesarean deliveries varies widely globally retrospective analysis of population-based surveys in 42 developing countries proportion of deliveries which were cesarean ranged from 0.28% in Chad to 36.35% in Brazil, 6 countries had proportions < 1% proportion of deliveries which were cesarean in poorest quintiles ranged from 0% in Chad to 18.6% in Dominican Republic, 20 countries had proportions < 1% proportion of deliveries which were cesarean in richest quintiles ranged from 0.83% in Chad to 67.6% in Brazil Reference - Lancet 2006 Oct 28;368(9546):1516 EBSCOhost Full Text, editorial can be found in Lancet 2006 Oct 28;368(9546):1472 EBSCOhost Full Text increasing incidence of primary cesarean deliveries in parous women with singleton gestations in the United States from 1990 to 2003 7.1% in 1990 6.6% in 1996 9.3% in 2003 Reference - Obstet Gynecol 2008 Dec;112(6):1235 rate of cesarean births in United States increased from 20.7% in 1996 to 31.1% in 2006 (Clin Perinatol 2008 Jun;35(2):293) 23.8% of 620,604 singleton births delivered by cesarean birth in England in 2008 (BMJ 2010 Oct 6;341:c5065 full-text), editorial can be found in BMJ 2010 Oct 6;341:c5255 27.6% of births in United States were cesarean sections in 2003, the highest percentage ever reported in United States (MMWR Morb Mortal Wkly Rep 2005 Jan 21;54(2):46) 26% of births in United States were cesarean sections in 2002 (Pediatrics 2003 Dec;112(6):1215 full-text) increasing interbirth interval associated with increased risk of cesarean delivery in women with previous vaginal delivery (level 2 [mid-level] evidence) based on retrospective cohort study 2,528 multiparous women with history of vaginal delivery presenting to labor and delivery unit classied by interbirth interval cesarean delivery in 2.6% increasing interbirth interval (compared with interbirth interval < 5 years) associated with increased risk of cesarean delivery 5-9 years (adjusted odds ratio [OR] 2.1, 95% CI 1.12-3.92) 10-14 years (adjusted OR 3.2, 95% CI 1.17-8.63) ! 15 years (adjusted OR 7.2, 95% CI 1.47-35.53) Reference - Obstet Gynecol 2011 Jul;118(1):39 Risks

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Maternal mortality and morbidity: cesarean delivery associated with increased risk of maternal morbidity and mortality (level 2 [mid-level] evidence) based on prospective study of 106,546 deliveries from 120 health facilities in Latin America over 3 months multiple births, emergency cesarean deliveries and women with incomplete delivery data were excluded among 94,307 deliveries analyzed, 31,821 (34%) were cesarean deliveries (58.5% intrapartum, 41.5% elective) and 62,486 (66%) were vaginal deliveries maternal morbidity and mortality dened as any of blood transfusion, hysterectomy, maternal admission to intensive care unit (ICU), maternal death, or maternal hospital stay > 7 days comparing elective cesarean delivery vs. vaginal delivery 5.5% vs. 1.8% maternal morbidity and mortality overall (NNH 27) 0.04% vs. 0.01% death (NNH 3,333) 2.72% vs. 0.54% admission to ICU (NNH 45) 0.98% vs. 0.44% blood transfusion (NNH 185) 0.35% vs. 0.05% hysterectomy (NNH 333) 2.55% vs. 0.88% required hospitalization > 7 days (NNH 59) 62% vs. 24.6% required antibiotics after delivery (NNH 2) 0.18% vs. 0.77% had 3rd or 4th degree perineal laceration and/or postpartum stula (NNT 170) comparing intrapartum cesarean delivery vs. vaginal delivery 4% vs. 1.8% maternal morbidity and mortality overall (NNH 45) 0.06% vs. 0.01% death (NNH 2,000) 1.42% vs. 0.54% admission to ICU (NNH 113) 0.71% vs. 0.44% blood transfusion (NNH 370) 0.29% vs. 0.05% hysterectomy (NNH 416) 2.18% vs. 0.88% required hospitalization > 7 days (NNH 77) 70% vs. 24.6% required antibiotics after delivery (NNH 2) 0.12% vs. 0.77% had 3rd or 4th degree perineal laceration and/or postpartum stula (NNT 154) Reference - BMJ 2007 Nov 17;335(7628):1025 full-text, editorial can be found in BMJ 2007 Nov 17;335(7628):1003, commentary can be found in BMJ 2007 Dec 15;335(7632):1226 cesarean delivery associated with greater maternal mortality and morbidity except when indicated by breech presentation based on data from 107,950 deliveries from World Health Organization global survey cesarean section in 27.3% and operative vaginal delivery in 3.2% risk of maternal mortality and morbidity signicantly increased with operative vaginal delivery and any type of cesarean section

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cesarean section (antepartum or intrapartum) for breech presentation signicantly associated with improved perinatal outcomes (and increased risk of stay in neonatal ICU) Reference - Lancet 2010 Feb 6;375(9713):490, correction can be found in Lancet 2010 Dec 4;376(9756):1902, editorial can be found in Lancet 2010 Feb 6;375(9713):440, commentary can be found in Lancet 2010 Apr 24;375(9724):1435 cesarean section associated with increased maternal mortality (level 2 [mid-level] evidence) based on case-control study with 65 postpartum deaths and 10,244 controls compared with vaginal delivery, cesarean delivery had odds ratio (OR) 3.64 (95% CI 2.15-6.19) for postpartum death Reference - Obstet Gynecol 2006 Sep;108(3 Pt 1):541, commentary can be found in ACOG News Release 2006 Aug 31 anesthesia-related maternal mortality rate 1.2 per million live births from 1991 to 2002 (level 2 [mid-level] evidence) based on retrospective cohort study of all anesthesia-related maternal mortalities (24 abortion deaths, 3 ectopic deaths, 56 deaths resulting in live birth or stillbirth and 3 maternal deaths with unknown outcomes) in United States from 1991 to 2002 86% of deaths resulting in live or stillbirths were from complications of anesthesia during cesarean delivery anesthesia-related maternal mortality 1.2 per million live births (1.6% of all pregnancy-related mortalities, 59% decrease in mortality from 1979 to 1990) no known maternal mortality associated with vaginal delivery Reference - Obstet Gynecol 2011 Jan;117(1):69 maternal morbidity may increase progressively with increasing number of cesarean sections (level 2 [mid-level] evidence) prospective study of 83,754 women with cesarean delivery in 19 academic centers in United Kingdom only 30,132 women with cesarean delivery without labor, data available for previous pregnancies and detailed outcome data on study pregnancy were analyzed Prospective Study of Women with Cesarean Delivery: Number of Cesarean Sections First (primary) Second Third Fourth Sample Size 6,201 15,808 6,324 1,452 Hysterectomy Rate 0.65% 0.42% 0.9% 2.41% Placenta Accreta Rate 0.24% 0.31% 0.57% 2.13%

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Number of Cesarean Sections Fifth Sixth or more

Sample Size 258 89

Hysterectomy Rate 3.49% 8.99%

Placenta Accreta Rate 2.33% 6.74%

Reference - Obstet Gynecol 2006 Jun;107(6):1226 similar conclusions reported in retrospective study of 491 women with second cesarean delivery and 277 women with third or more cesarean delivery (Obstet Gynecol 2006 Jul;108(1):21) cesarean section associated with 21.4% rate of complications prospective study of 2,751 cesarean deliveries in Norway 21.4% of women had 1 or more complications dened as intraoperative complications, blood loss, wound infection, cystitis, endometritis, hematoma, and reoperation risk factors for complications were higher degree of cervical dilation, general anesthesia, low gestational age, and fetal macrosomia complication rate was 16.8% for operations performed at 0 cm cervical dilation and 32.6% at 9-10 cm cervical dilation Reference - Am J Obstet Gynecol 2004 Feb;190(2):428 planned cesarean delivery appears to be associated with increased postpartum risks planned cesarean delivery may be associated with increased postpartum risks compared with planned vaginal delivery (level 2 [mid-level] evidence) based on retrospective population-based cohort study of all women in Canada (excluding Quebec and Manitoba) during 1991-2005 46,766 healthy women had planned primary cesarean delivery for breech presentation, compared to 2,292,420 women who had planned vaginal delivery overall rates of severe morbidity were 27.3 per 1,000 with planned cesarean vs. 9 per 1,000 with planned vaginal delivery planned cesarean compared with vaginal delivery had increased postpartum risks of cardiac arrest wound hematoma hysterectomy major puerperal infection anesthetic complications venous thromboembolism hemorrhage requiring hysterectomy longer stay in hospital planned cesarean compared with vaginal delivery had decreased postpartum risk of hemorrhage requiring blood transfusion

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Reference - CMAJ 2007 Feb 13;176(4):455 EBSCOhost Full Text full-text, commentary can be found in CMAJ 2007 Oct 9;177(8):899 EBSCOhost Full Text full-text planned cesarean delivery appears associated with increased rehospitalization risks compared with planned vaginal delivery (level 2 [mid-level] evidence) based on retrospective cohort study of 244,088 women with no prior cesarean section and no documented prenatal risks in Massachusetts 3,334 women had planned primary cesarean deliveries, compared to 240,754 women who had labor and planned vaginal deliveries (including women who had vaginal or cesarean delivery) rate of rehospitalization within 30 days was 19.2 per 1,000 women with planned cesarean delivery vs. 7.5 per 1,000 women with planned vaginal delivery Reference - Obstet Gynecol 2007 Mar;109(3):669 cesarean delivery associated with pregnancy-related death in case-control study 118 pregnancy-related deaths after live birth compared to 3,697 randomly selected pregnancies, adjusted OR for pregnancy-related death with cesarean delivery 3.9 (95% CI 2.5-6.1) estimated risk of pregnancy-related death 9.2 per 100,000 following vaginal delivery and 35.9 per 100,000 following cesarean delivery Reference - Obstet Gynecol 2003 Aug;102(2):273 cesarean and assisted vaginal deliveries associated with increased risk of rehospitalization within 60 days compared with spontaneous vaginal deliveries, especially for infectious morbidities retrospective cohort study of 256,795 primiparous deliveries, 1.2% women rehospitalized within 60 days cesarean delivery associated with relative risk (RR) of 1.8 for rehospitalization (95% CI 1.6-1.9) related to uterine infection, obstetrical surgical wound complications, and cardiopulmonary and thromboembolic conditions assisted vaginal delivery rehospitalizations (RR 1.3, 95% CI 1.2-1.4) related to postpartum hemorrhage, obstetrical surgical wound complications, and pelvic injury Reference - JAMA 2000 May 10;283(18):2411 cesarean delivery may be associated with increased risk for postpartum maternal stroke based on retrospective record review data from 987,010 women with singleton deliveries 1998-2002 in Taiwan National Health Insurance Research Database 33.9% were cesarean deliveries cesarean delivery associated with increased risk for stroke compared to vaginal delivery

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adjusted hazard ratio (HR) 1.67 (95% CI 1.29-2.16) within 3 months of delivery adjusted HR 1.61 (95% CI 1.31-1.98) within 6 months of delivery adjusted HR 1.49 (95% CI 1.27-1.76) within 12 months of delivery patients having cesarean delivery were more likely to be older (mean 29.1 vs. mean 27.5 years) and to have pregnancy complications Reference - Am J Obstet Gynecol 2008 Apr;198(4):391e1 primary cesarean section during second stage of labor may have slightly increased maternal morbidity than during rst stage of labor (level 2 [mid-level] evidence) based on prospective observational study of 11,981 primary cesarean deliveries 9,265 cesarean sections performed during rst stage of labor 2,716 cesarean sections performed during second stage of labor second stage cesarean deliveries associated with longer operative time epidural analgesia chorioamnionitis higher birth weight slightly increased maternal composite morbidity due to uterine atony uterine incision extension incidental cystotomy no signicant difference in neonatal composite morbidity Reference - Obstet Gynecol 2007 Apr;109(4):917 cesarean delivery in setting of active phase arrest of labor associated with increased risk of maternal complications compared with vaginal delivery (level 2 [mid-level] evidence) based on retrospective cohort study 1,014 women with term, singleton, cephalic-presenting pregnancies diagnosed with active phase arrest of labor (no cervical change for 2 hours despite adequate contractions) evaluated 33% patients delivered vaginally 67% patients had cesarean delivery cesarean delivery in active phase arrest of labor associated with increased risk of chorioamnionitis (adjusted OR 3.37, p < 0.05) endometritis (adjusted OR 48.41, p < 0.05) postpartum hemorrhage (adjusted OR 5.18, p < 0.05) severe postpartum hemorrhage (adjusted OR 14.97, p < 0.05) no signicant difference in adverse neonatal outcomes among vaginal or cesarean deliveries in arrest of delivery vaginal deliveries with active phase arrest of labor, deliveries in setting of arrest

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of labor associated with increased risk of chorioamnionitis (adjusted OR 2.7, p < 0.05) shoulder dystocia (adjusted OR 2.37, p < 0.05) no signicant difference in adverse neonatal outcomes among vaginal deliveries with or without active phase arrest of labor Reference - Obstet Gynecol 2008 Nov;112(5):1109 no association between cesarean section and postpartum depression found in systematic review of 24 studies (Psychosom Med 2006 Mar-Apr;68(2):321) intractable pain after cesarean delivery or hysterectomy may be due to neuroma formation 7 cases of intractable pain > 6 months after cesarean delivery or hysterectomy and not due to gynecologic disease or other obvious pathology neuromas of ilioinguinal, iliohypogastric and/or genitofemoral nerves conrmed intraoperatively all patients had complete pain relief after neuroma resection Reference - Obstet Gynecol 2006 Jul;108(1):27 Pfannenstiel incision reported to result in chronic pain in some women (level 3 [lacking direct] evidence) based on uncontrolled cohort study 886 women who had Pfannenstiel incisions for cesarean delivery or abdominal hysterectomy were sent questionnaire > 2 years after surgery 690 (80%) responded 223 (32%) reported chronic pain at incision site 7% reported moderate to severe pain 8.9% reported pain impaired daily activities risk factors for pain were numbness, recurrent Pfannenstiel surgery and emergency cesarean delivery Reference - Obstet Gynecol 2008 Apr;111(4):839 2%-3% rate of blood transfusion 3.2% rate of blood transfusion in 23,486 primary cesarean deliveries 2.2% rate of blood transfusion in 33,683 repeat cesarean deliveries Reference - Obstet Gynecol 2006 Oct;108(4):891, correction can be found in Obstet Gynecol 2006 Dec;108(6):1556 HIV infection associated with increased risk of morbidity and mortality after cesarean delivery (level 2 [mid-level] evidence) based on cohort study of 378 women with HIV and 54,281 women without HIV who had singleton gestations and cesarean delivery comparing women with HIV vs. without HIV 11.6% vs. 5.8% had postpartum endometritis (p < 0.001) 4% vs. 2% had postpartum blood transfusion (p = 0.02) 1.1% vs. 0.2% had maternal sepsis (p < 0.001) 1.3% vs. 0.3% treated for pneumonia (p = 0.001) 0.8% vs. 0.1% maternal death (p < 0.001)

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Reference - Obstet Gynecol 2007 Aug;110(2 Pt 1):385 vernix caseosa peritonitis following cesarean section in case report (Lancet 2010 Aug 14;376(9740):564) puerperal septic pelvic thrombophlebitis suspect diagnosis when patient continues febrile despite antibiotics for endometritis computed tomography (CT) and magnetic resonance imaging (MRI) may conrm diagnosis but treatment can be empiric based on clinical presentation puerperal septic pelvic thrombophlebitis incidence 1 in 3,000 deliveries incidence 1 in 9,000 vaginal deliveries incidence 1 in 800 cesarean deliveries based on cohort of 44,922 women with cesarean deliveries in 19% 69 woman had postpartum fever with 15 (22%) due to pelvic thrombophlebitis cesarean delivery in 73% with pelvic thrombophlebitis no signicant difference in outcomes comparing antimicrobial therapy alone vs. with heparin Reference - Am J Obstet Gynecol 1999 Jul;181(1):143 treatment recommendations based on case series (level 3 [lacking direct] evidence) symptomatic right ovarian vein thrombosis conrmed on CT treated with antibiotics for 7 days and enoxaparin (1 mg/kg twice daily), then warfarin for 3 months with negative CT symptomatic pelvic branch vein thrombosis conrmed on CT treated with antibiotics for 7 days and enoxaparin (1 mg/kg twice daily) for 2 weeks symptomatic pelvic vein thrombosis with negative imaging treated with antibiotics for 7 days and enoxaparin (1 mg/kg twice daily) for 1 week Reference - Infect Dis Obstet Gynecol 2006;2006:15614 Full Text full-text Reference - Obstet Gynecol Surv 2007 Jun;62(6):400 EBSCOhost

Risks during subsequent pregnancies: inconsistent evidence for association between previous cesarean section and risk of stillbirth in second pregnancy no overall association between cesarean history and subsequent stillbirth, but cesarean delivery may increase risk for subsequent stillbirth among black mothers study of 396,441 women with information on rst and second pregnancies 71,950 (18.1%) had cesarean delivery for rst pregnancy 324,491 (81.9%) had vaginal birth delivery for rst pregnancy rates of stillbirth in second pregnancy for women with vs. without cesarean delivery 4.4 vs. 4.1 per 1,000 births (p = 0.2)

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among white women, 3.7 vs. 3.6 per 1,000 births (odds ratio [OR] 1, 95% CI 0.9-1.2) among black women, 9.3 vs. 6.8 per 1,000 births (OR 1.4, 95% CI 1.1-1.7) Reference - Obstet Gynecol 2006 Feb;107(2):383 previous cesarean section may not be associated with antepartum stillbirth in second pregnancy based on retrospective cohort study 158,502 second births (19% with previous cesarean section) were analyzed comparing second births with vs. without previous cesarean antepartum stillbirth in 0.3% vs. 0.27% (not signicant) unexplained antepartum stillbirth in 0.21% vs. 0.16% (not signicant) Reference - BJOG 2008 May;115(6):726 EBSCOhost Full Text previous cesarean section might be associated with increased risk of stillbirth in second pregnancy study of 120,633 singleton second births antepartum stillbirth occurred in 68 of 17,754 women (0.383%) previously delivered by cesarean section vs. 244 of 102,879 women (0.237%) previously delivered vaginally (p < 0.001, NNH 685) unexplained antepartum stillbirth occurred in 43 (0.242%) vs. 163 (0.158%) (p = 0.004, NNH 1,190) risk not attenuated by adjustment for maternal characteristics or outcome of rst pregnancy Reference - Lancet 2003 Nov 29;362(9398):1779 EBSCOhost Full Text, editorial can be found in Lancet 2003 Nov 29;362(9398):1774 EBSCOhost Full Text, commentary can be found in Lancet 2004 Jan 31;363(9406):402 EBSCOhost Full Text DynaMed commentary -- 16,391 women (13.6%) did not have adequate records to determine mode of rst delivery but appear to be counted as "no previous cesarean", so results may not be accurate cesarean delivery may be associated with increased risk of stillbirth in subsequent pregnancy based on retrospective cohort study with linked statistical data for 81,784 singleton deliveries in Oxfordshire and West Berkshire 1968-1989 signicant associations were still present but no longer statistically signicant after adjusting for other risk factors Reference - BJOG 2007 Mar;114(3):264 EBSCOhost Full Text cesarean delivery of rst pregnancy associated with increased risks during labor in second delivery (level 2 [mid-level] evidence) based on 3 cohort studies in cohort of 637,497 women with ! 2 singleton pregnancies, and 242,812

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women with ! 3 singleton pregnancies women with actual complication in previous pregnancy/birth excluded in second delivery, cesarean delivery at rst birth (compared to vaginal delivery) associated with increased risk of bleeding in pregnancy (adjusted odds ratio [OR] 1.1, p = 0.04) preeclampsia (adjusted OR 1.7, p < 0.01) small for gestational age (adjusted OR 1.3, p < 0.01) placenta previa (adjusted OR 1.4, p < 0.01) placenta accreta (adjusted OR 1.9 p = 0.01) placental abruption (adjusted OR 1.7, p < 0.01) uterine rupture (adjusted OR 37.2, p < 0.01) similar results for complications in third delivery after one or two previous cesarean deliveries compared to vaginal deliveries only placental abruption and uterine rupture lower after two previous cesarean deliveries compared to one previous cesarean delivery Reference - Obstet Gynecol 2008 Jun;111(6):1327 in population-based retrospective cohort study of all singleton, second births in South Australia in 1998-2003 8,275 women had cesarean delivery for rst birth 27,313 women had vaginal rst birth cesarean delivery cohort had increased risks for preterm birth (NNH 134) malpresentation placenta previa prolonged labor emergency cesarean uterine rupture low birth weight small for gestational age stillbirth unexplained stillbirth Reference - Obstet Gynecol 2007 Feb;109(2 Pt 1):270, correction can be found in Obstet Gynecol 2007 May;109(5):1207, commentary can be found in Am Fam Physician 2007 Oct 15;76(8):1210 in 136,101 women with one previous birth who gave birth to singleton infant in New South Wales, Australia 1998-2002 19% had cesarean section in rst pregnancy compared to primary vaginal delivery, primary cesarean section and labor in second delivery associated with increased risks for uterine rupture hysterectomy postpartum hemorrhage following vaginal delivery manual removal of placenta

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infection intensive care unit (ICU) admission Reference - Med J Aust 2005 Nov 21;183(10):515 full-text risk of maternal bladder injury in women with prior cesarean delivery greatest if failing vaginal birth after cesarean (VBAC) trial or if > 1 prior cesarean delivery based on retrospective cohort study 25,005 patients with ! 1 prior cesarean delivery evaluated for delivery mode-specic bladder injury in subsequent deliveries bladder injury in 0.43% risk of bladder injury 0.44% with VBAC vs. 0.42% with elective repeat cesarean delivery (not signicant) absolute risk of bladder injury 0.2% with successful VBAC 0.3% with elective repeat cesarean 0.7% with elective repeat cesarean after > 1 previous cesarean 1.1% with failed VBAC increased risk of bladder injury with failed VBAC compared to successful VBAC (adjusted OR 4.6, P < 0.01) increased risk of bladder injury with > 1 prior cesarean compared to women with 1 prior cesarean delivery (adjusted OR 2.4, P < 0.01) Reference - Obstet Gynecol 2008 Jul;112(1):116 increased risk of uterine rupture in subsequent pregnancies with previous preterm cesarean delivery compared to term cesarean delivery based on prospective cohort study of 41,367 women with prior cesarean delivery uterine ruptures occurred in 0.33% uterine rupture occurred in 0.58% of women with prior preterm cesarean vs. 0.28% of women with prior term cesarean deliveries (p < 0.001) Reference - Obstet Gynecol 2008 Mar;111(3):648 history of ! 3 cesarean deliveries associated with increased risk of accreta and hysterectomy in women with placenta previa based on systematic review of 21 observational studies with 2,282,922 deliveries incidence of placenta previa 10 per 1,000 deliveries in women with 1 previous cesarean delivery 28 per 1,000 deliveries in women with ! 3 cesarean deliveries comparing no prior cesarean delivery vs. ! 3 cesarean deliveries in women with placenta previa accreta in 3.3%-4% vs. 50%-67% (p < 0.05) hysterectomy in 0.7%-4% vs. 50%-67% (p < 0.05) Reference - Am J Obstet Gynecol 2011 Sep;205(3):262.e1 large defects of hysterotomy scar associated with increased risk of uterine

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rupture or dehiscence in subsequent pregnancy based on cohort study 162 women had transvaginal ultrasound of hysterotomy scar 6-9 months after last cesarean delivery subsequent pregnancy in 43% uterine rupture or dehiscence in 5.3% (1 of 19) with intact or small scar vs. 42.9% (3 of 7) with large defect (p = 0.047) Reference - Obstet Gynecol 2011 Mar;117(3):525 history of prior cesarean section associated with increased risk for peripartum hysterectomy based on estimated 18,339 peripartum hysterectomies in United States 1998-2003 Reference - Obstet Gynecol 2006 Dec;108(6):1486 cesarean delivery associated with peripartum hysterectomy based on population-based case-control study in United Kingdom 318 women having peripartum hysterectomy compared to 614 matched controls increased risk of peripartum hysterectomy associated with cesarean delivery rst cesarean delivery in current pregnancy (OR 7.13, 95% CI 3.71-13.7) any previous cesarean delivery (OR 3.52, 95% CI 2.35-5.26) 1 previous cesarean delivery (OR 2.14, 95% CI 1.37-3.33) ! 2 previous cesarean delivery (OR 18.6, 95% CI 7.67-45.4) Reference - Obstet Gynecol 2008 Jan;111(1):97 cesarean delivery of rst pregnancy associated with increased risk of placenta previa and placental abruption in second delivery retrospective study of 156,475 women with rst 2 and 31,102 women with rst 3 consecutive singleton pregnancies in Missouri placenta previa occurred in 694 (0.44%) live births, and was more common in pregnancy after cesarean delivery (0.63%) than pregnancy after vaginal delivery (0.38%) placental abruption occurred in 1,243 (0.79%) live births, and was more common in pregnancy after cesarean delivery (0.95%) than pregnancy after vaginal delivery (0.74%) Reference - Obstet Gynecol 2006 Apr;107(4):771, editorial can be found in Obstet Gynecol 2006 Apr;107(4):752, commentary can be found in Obstet Gynecol 2006 Aug;108(2):452 and in Obstet Gynecol 2006 Sep;108(3 Pt 1):693 increasing number of prior cesarean deliveries associated with increasing risk of adverse maternal outcomes in women with placenta previa (level 2 [mid-level] evidence) based on cohort study 868 women with placenta previa and singleton gestation evaluated 488 had no prior cesarean delivery

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252 had 1 prior cesarean delivery 76 had 2 prior cesarean deliveries 52 had ! 3 prior cesarean deliveries maternal morbidity outcome (composite of transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death) associated with 1 prior cesarean delivery (adjusted odds ratio [OR] 1.9, 95% CI 1.2-2.9) 2 prior cesarean deliveries (adjusted OR 9.6, 95% CI 5.2-17.8) ! 3 prior cesarean deliveries (adjusted OR 33.6, 95% CI 14.6-77.4) risk of any maternal morbidity outcome 15% with no prior cesarean delivery and 23% with 1 prior cesarean delivery prior cesarean delivery (any number) not associated with gestational age at delivery or adverse perinatal outcome (composite of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3 or 4, seizures, or death) Reference - Obstet Gynecol 2007 Dec;110(6):1249 recurrent ectopic pregnancy in cesarean scar in case report (Obstet Gynecol 2008 Feb;111(2 Pt 2):541) Risk of uterine rupture in subsequent pregnancies: uterine rupture occurs primarily in women with history of cesarean delivery (level 2 [mid-level] evidence) based on cohort study of 114,933 deliveries over 10 years 39 cases of uterine rupture with 18 complete ruptures and 21 incomplete ruptures (dehiscence) 36 (92%) ruptures associated with previous cesarean delivery among 4,516 women undergoing trial of vaginal delivery after previous cesarean delivery, rate of complete rupture 2.4 per 1,000 and rate of uterine dehiscence 2.4 per 1,000 uterine dehiscence not associated with signicant morbidity or mortality complete uterine rupture associated with 44% rate of blood transfusion and 2 perinatal deaths Reference - Obstet Gynecol 2002 Oct;100(4):749, commentary can be found in BMJ 2003 Feb 8;326(7384) case reports of uterine rupture in primigravid women uterine rupture in unscarred primigravid uterus reported with oxytocin in case report (Obstet Gynecol 2006 Sep;108(3 Pt 2):723) case report of spontaneous uterine rupture in nonlaboring primigravid with no known risk factors can be found in Obstet Gynecol 2006 Sep;108(3 Pt 2):725, patient subsequently determined to have Ehlers-Danlos syndrome (Obstet Gynecol 2007 Feb;109(2 Pt 1):455) uterine rupture rare, with an estimated 370 elective cesarean deliveries required to prevent 1 symptomatic uterine rupture (level 2 [mid-level]

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evidence) systematic review of 21 articles (no controlled trials, 17 cohort studies, 2 case-control studies, and 2 case series with at least 10 cases) comparing uterine rupture rates and sequelae between trial of labor or elective repeat cesarean delivery in women with cesarean scar (low transverse or unclassied) rates of symptomatic uterine rupture ranged from 0% to 0.78% of trials of labor in 10 observational studies with pooled rate of 0.38% (95% CI 0.13% to 0.62%) only 2 studies provided comparative data for elective repeat cesarean and estimated absolute additional risk of symptomatic uterine rupture with trial of labor was 0.27% (95% CI 0.073% to 0.473%, NNT 370, 95% CI 213 to 1,370) no maternal deaths related to uterine rupture additional risk of perinatal death from uterine rupture was 1.4 per 10,000 (NNH 7,143) and additional risk of hysterectomy was 3.4 per 10,000 (NNH 2,941) rates of asymptomatic uterine rupture (dehiscence) ranged from 0.5% to 2% (weighted mean 1.3%) with trial of labor and did not differ signicantly from elective repeat cesarean Reference - BMJ 2004 Jul 3;329(7456):19 full-text, commentary can be found in BMJ 2004 Aug 14;329(7462):403, commentary can be found in Am Fam Physician 2004 Nov 1;70(9):1761 trial of labor associated with increased (but very low) risk of uterine rupture (level 2 [mid-level] evidence) based on 2 cohort studies 17,898 women who had trial of labor compared with 15,801 women with elective repeat cesarean section in prospective study 0.7% vs. 0% had symptomatic uterine rupture (NNH 144) 0.07% vs. 0% had infants with hypoxic-ischemic encephalopathy (NNH 1,491) 2.9% vs. 1.8% had endometritis (NNH 91) 1.7% vs. 1% had blood transfusion (NNH 143) no signicant difference rates of hysterectomy (0.2% vs. 0.3%) maternal mortality (0.02% vs. 0.04%) neonatal mortality (0.01% vs. 0%) Reference - N Engl J Med 2004 Dec 16;351(25):2581 EBSCOhost Full Text full-text, editorial can be found in N Engl J Med 2004 Dec 16;351(25):2647 EBSCOhost Full Text, commentary can be found in Am Fam Physician 2005 Apr 1;71(7):1389, and in N Engl J Med 2005 Apr 21;352(16):1718 EBSCOhost Full Text (correction can be found in N Engl J Med 2005 Jun 2;352(22):2362) 39,117 women with term singleton gestation and prior cesarean delivery

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0.32% overall uterine rupture risk 0.74% uterine rupture in women with trial of labor (114 of 15,323 women) 0.12% uterine rupture risk in women with indicated repeat cesarean delivery (with or without labor) (7 of 6,080 women) 0.02% uterine rupture risk for elective (no indication) repeat cesarean delivery (with or without labor) (4 of 17,714 women), risk of uterine rupture in this group limited to women with labor (4 of 2,721 [0.15%]) Reference - Obstet Gynecol 2007 Oct;110(4):801 risk factors for uterine rupture, mainly labor induction use of prostaglandins or oxytocin during vaginal birth after cesarean section associated with increase risk of uterine rupture (level 2 [mid-level] evidence) based on retrospective cohort study of 29,008 women having a second birth after a prior cesarean for their rst birth in Australia from 1998-2000 uterine rupture rates 0.02% in 18,050 women having elective cesarean section (odds ratio [OR] 0.11, 95% CI 0.04-0.34) for spontaneous labor 0.19% in 8,221 women with spontaneous labor with no oxytocin augmentation (OR 1) 1.91% in 628 women with spontaneous labor augmented with oxytocin (OR 9.99, 95% CI 4.7-21.2) for labor induction 0.63% in 320 women with labor induced without prostaglandins or oxytocin (OR 3.23, 95% CI 0.7-14.1 0.82% in 735 women with labor induced with oxytocin only (OR 4.22, 95% CI 1.7-10.8) 0.68% in 586 women with labor induced with prostaglandins only (OR 3.52, 95% CI 1.2-10.6) 1.77% in 226 women with labor induced with oxytocin and prostaglandins (OR 9.24, 95% CI 3.1-27.9) Reference - BJOG 2010 Oct;117(11):1358 EBSCOhost Full Text risk of uterine rupture increased with labor induction, especially with prostaglandin based on retrospective study of 20,095 women who delivered live singleton infant by cesarean section and subsequent singleton infant between 1987 and 1996 in Washington State uterine rupture occurred in 0.16% women with repeat cesarean delivery without labor 0.52% women with spontaneous onset of labor (relative risk [RR] 3.3) 0.77% women with labor induction without prostaglandins (RR 4.9) 2.45% women with prostaglandin-induced labor (RR 15.6)

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Reference - N Engl J Med 2001 Jul 5;345(1):3

EBSCOhost Full Text,

editorial can be found in N Engl J Med 2001 Jul 5;345(1):54 EBSCOhost Full Text, commentary can be found in N Engl J Med 2002 Jan 10;346(2):134 EBSCOhost Full Text, summary can be found in Am Fam Physician 2002 Feb 15;65(4):678 risk of uterine rupture 0.35% and increased with no previous vaginal delivery and labor induction with prostaglandin based on retrospective study of 35,854 women with previous cesarean section and delivery by means other than planned repeat cesarean section Reference - BMJ 2004 Aug 14;329(7462):375, editorial can be found in BMJ 2004 Aug 14;329(7462):359 risk of uterine rupture 0.71% and increased with labor induction with prostaglandin E2 gel based on retrospective study of 2,119 trials of labor after cesarean delivery 15 (0.71%) had uterine rupture rates of uterine rupture 0.45% for spontaneous labor 0.74% for labor inductions other than with prostaglandin E2 2.9% for labor inductions with prostaglandin E2 gel Reference - Am J Obstet Gynecol 2000 Nov;183(5):1176 risk of uterine rupture reduced if history of previous vaginal delivery; retrospective study of 3,783 trials of labor after cesarean delivery, 1,021 (27%) with previous vaginal delivery had 0.2% rate of uterine rupture, women without prior vaginal delivery had 1.1% rate of uterine rupture (Am J Obstet Gynecol 2000 Nov;183(5):1184) risk of uterine rupture may be increased with history of post-cesarean fever, but small absolute risk (0.48%) and borderline statistical signicance limit clinical application; case-control study compared 12 cases of uterine rupture and 84 controls among women who had trial of labor after cesarean, 38% cases vs. 15% controls had fever following prior cesarean (OR 4, 95% CI 1-15.5) (Obstet Gynecol 2003 Jan;101(1):136) risk factors associated with uterine rupture based on cohort study of 300,200 women attempting vaginal birth in second singleton delivery in Sweden risk factors associated with increased risk of uterine rupture cesarean delivery compared with vaginal delivery in rst birth (adjusted OR 41.79, 95% CI 29.73-57) induction of labor high birth weight (! 4,000 g) postterm birth (! 42 weeks) high maternal age (! 35 years old) short maternal stature (" 164 cm [64.6 inches])

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Reference - BJOG 2007 Oct;114(10):1208 EBSCOhost Full Text interpregnancy interval < 6 months associated with increased risk of uterine rupture and other morbidities in women having vaginal birth after cesarean (VBAC) based on secondary analysis of retrospective cohort study 13,331 pregnant women attempting VBAC 1995-2000 in United States 128 (0.9%) had uterine rupture 286 (2.2%) had interpregnancy interval (time between prior delivery and conception) < 6 months risks increased with interpregnancy interval < 6 months uterine rupture (adjusted OR 2.66 [95% CI 1.21-5.82]) major morbidity (adjusted OR 1.95 [95% CI 1.04-3.65]) blood transfusion (adjusted OR 3.14 [95% CI 1.42-6.95]) long interpregnancy interval (! 60 months) not associated with increased major morbidity Reference - Obstet Gynecol 2007 Nov;110(5):1075 interdelivery interval < 18 months associated with increased risk of uterine rupture in women attempting term VBAC based on retrospective cohort study 1,768 women with singleton gestation attempting term trial of labor immediately following single prior cesarean delivery successful VBAC in 71% compared with interdelivery interval (time between previous cesarean delivery and trial of labor) of ! 24 months, interdelivery interval < 18 months associated with increased risk of uterine rupture (adjusted OR 3, 95% CI 1.3-7.2) Reference - Obstet Gynecol 2010 May;115(5):1003 single-layer uterine closure in previous cesarean delivery associated with higher risk of uterine rupture than double-layer closure based on case-control study 96 women who had complete uterine rupture during trial of labor were matched with 288 women without uterine rupture during trial of labor all women had a single prior low-transverse cesarean delivery single-layer closure in 36% of cases vs. 20% of controls (p < 0.01) increased risk of uterine rupture for prior single-layer uterine closure (OR 2.69, 95% CI 1.37-5.28) birth weight > 3,500 g (OR 2.03, 95% CI 1.21-3.38) prior vaginal birth associated with decreased risk of uterine rupture (OR 0.47, 95% CI 0.24-0.93) Reference - Obstet Gynecol 2010 Jul;116(1):43 case report of discrepancy between full thickness and myometrial layers on sonographic evaluation of the lower uterine segment at 36 weeks of gestation in 31-year-old patient with prior low transverse cesarean delivery with subsequent

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uterine rupture during term trial of labor in (Obstet Gynecol 2009 Feb;113(2 Pt 2):520), editorial can be found in Obstet Gynecol 2009 Jun;113(6):1371 Neonatal risks: cesarean section associated with higher neonatal mortality than vaginal delivery in women with "no indicated risk" (level 2 [mid-level] evidence) based on observational data 1998-2001 birth cohort in the United States included 5,762,037 live births and 11,897 infant deaths analysis limited to women with no indicated medical risk for complications and singleton full term (37-41 weeks' gestation) delivery neonatal mortality was 1.77 per 1,000 live births for infants delivered by cesarean section delivery vs. 0.62 per 1,000 live births for infants delivered vaginally (NNH 869) Reference - Birth 2006 Sep;33(3):175 primary cesarean section associated with increased risk of neonatal mortality and morbidity in late preterm births based on cohort of 422,001 live births adjusted for infant size, medical conditions, complications in labor, maternal demographics, and gravidity 60% of births included in analysis (gestational age 32-36 weeks) Reference - Birth 2009 Mar;36(1):26 cesarean section without labor complications or procedures associated with higher neonatal mortality than planned vaginal birth (including those resulting in ceserean section) (level 2 [mid-level] evidence) based on observational data 1999-2002 birth cohorts in United States included 8,026,415 live births and 17,412 infant deaths neonatal mortality 0.72 per 1,000 all planned vaginal deliveries 0.63 per 1,000 completed vaginal deliveries 1.69 per 1,000 cesarean deliveries with labor complications or procedures neonatal mortality 1.73 per 1,000 cesarean section deliveries without labor complications or procedures (p < 0.05 compared to planned vaginal delivery, NNH 909) Reference - Birth 2008 Mar;35(1):3 cesarean delivery associated with decreased fetal morbidity and mortality in breech presentation (level 2 [mid-level] evidence) based on prospective study of 106,546 deliveries from 120 health facilities in Latin America over 3 months multiple births, emergency cesarean deliveries and women with incomplete delivery data were excluded among 94,307 deliveries analyzed, 31,821 (34%) were cesarean deliveries (58.5% intrapartum, 41.5% elective) and 62,486 (66%) were vaginal deliveries comparing elective cesarean delivery vs. vaginal delivery in newborns with

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cephalic presentation 0.31% vs. 0.39% fetal death (NNT 1,250) 5% vs. 1.9% required neonatal intensive care unit (ICU) stay (NNH 32) 0.77% vs. 0.38% neonatal mortality up to hospital discharge (NNH 256) comparing elective cesarean delivery vs. vaginal delivery in newborns with breech and other presentations 0.96% vs. 9.7% fetal death (NNT 12) 6.8% vs. 13% required neonatal ICU stay (NNT 16) 1.79% vs. 8.55% neonatal mortality up to hospital discharge (NNT 15) comparing intrapartum cesarean delivery vs. vaginal delivery in newborns with cephalic presentation 0.44% vs. 0.39% fetal death (not signicant) 3.5% vs. 1.9% required neonatal ICU stay (NNH 62) 0.65% vs. 0.38% neonatal mortality up to hospital discharge (NNH 370) comparing intrapartum cesarean delivery vs. vaginal delivery in newborns with breech and other presentations 0.69% vs. 9.7% fetal death (NNT 11) 7% vs. 13% required neonatal ICU stay (NNT 17) 1.63% vs. 8.55% neonatal mortality up to hospital discharge (NNT 15) Reference - BMJ 2007 Nov 17;335(7628):1025 full-text, editorial can be found in BMJ 2007 Nov 17;335(7628):1003, commentary can be found in BMJ 2007 Dec 15;335(7632):1226 increased rate of intracranial hemorrhage among infants delivered by vacuum extraction, forceps or cesarean section during labor (1 in 664-907) than by spontaneous vaginal delivery or cesarean section without labor (1 in 1,900-2,750) (N Engl J Med 1999 Dec 2;341(23):1709 EBSCOhost Full Text), editorial can EBSCOhost Full Text, be found in N Engl J Med 1999 Dec 2;341(23):1758

commentary can be found in N Engl J Med 2000 Mar 23;342(12):892 EBSCOhost Full Text 1.1% overall rate of fetal injury based on prospective cohort of 37,110 cesarean deliveries most common injury was skin laceration, occurring in 0.7% deliveries other injuries included cephalohematoma (0.2%), clavicular fracture (0.03%), facial nerve palsy (0.03%), brachial plexus injury (0.024%) and skull fracture (0.016%) Reference - Obstet Gynecol 2006 Oct;108(4):885, commentary can be found in Obstet Gynecol 2007 Feb;109(2 Pt 1):453 and Obstet Gynecol 2007 Mar;109(3):783 elective cesarean delivery associated with higher risk of respiratory morbidity than vaginal delivery (level 2 [mid-level] evidence) based on 2 observational cohort studies 34,458 liveborn infants at gestational ages 37-41 weeks without malformations

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1998-2006 in birth cohort in Denmark 2,687 (7.8%) infants delivered by elective cesarean delivery respiratory morbidity included 289 infants with transitory tachypnea of newborn, 303 infants with RDS and 36 with persistent pulmonary hypertension of newborn serious respiratory morbidity included oxygen therapy for > 2 days, nasal continuous positive airway pressure and need for mechanical ventilation comparing cesarean delivery vs. intended vaginal delivery respiratory morbidity in 4.2% vs. 1.5% (NNH 37) respiratory morbidity at 37 weeks gestation in 10% vs. 2.8% (NNH 13) respiratory morbidity at 38 weeks gestation in 5.1% vs. 1.7% (NNH 29) respiratory morbidity at 39 weeks gestation in 2.1% vs. 1.1% (NNH 100) serious respiratory morbidity at 37 weeks gestation in 1.9% vs. 0.4% (NNH 66) serious respiratory morbidity at 38 weeks gestation in 0.9% vs. 0.2% (NNH 142) serious respiratory morbidity at 39 weeks gestation in 0.2% vs. 0.1% (not signicant) no signicant differences at 40-41 weeks gestation similar results after exclusion of pregnancies complicated by diabetes, preeclampsia, intrauterine growth retardation or by breech presentation Reference - BMJ 2008 Jan 12;336(7635):85 full-text 672 women with one prior cesarean delivery and subsequent singleton pregnancy at ! 37 weeks gestation having intended elective repeat cesarean delivery or intended vaginal birth after cesarean (VBAC) 26% failure rate of intended VBAC deliveries comparing neonates delivered by cesarean section vs. intended VBAC oxygen required during delivery room resuscitation in 41.5% vs. 23.2% (p < 0.001) neonatal intensive care unit (NICU) admission rate 9.3% vs. 4.9% (p = 0.025) oxygen required in NICU in 5.8% vs. 2.4% (p = 0.028) admission for hypoglycemia in 3.5% vs. 0.9% (p = 0.03) VBAC associated with lower cost of hospital stay (p < 0.001 for total cost for mother, infant and total cost of birth), but failed VBAC was most expensive birth experience Reference - Obstet Gynecol 2009 Jun;113(6):1231 elective cesarean delivery associated with increased mortality compared to planned vaginal delivery and similar mortality compared to emergency cesarean delivery (level 2 [mid-level] evidence) based on retrospective review of cohort study

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54,549 infants born at ! 34 weeks gestational age were evaluated for neonatal outcome according to type of delivery comparing elective cesarean delivery vs. planned vaginal delivery or emergency cesarean delivery birth depression dened as arterial cord blood pH " 7.10 and/or venous cord blood pH " 7.15 and/or 5 minute Apgar score < 7 respiratory morbidity dened as any respiratory disease requiring medical support for > 30 minutes and special care admission Elective Cesarean Delivery vs. Planned Vaginal Delivery or Emergency Cesarean Delivery: Elective Cesarean Delivery Mortality 0.54% Planned Vaginal Delivery 0.14% (p = 0.031, NNH 250) 20.5% (not signicant) 6.7% (p < 0.0001, NNH 12) Emergency Cesarean Delivery 0.58% (not signicant)

Birth depression 21.4%

30.9% (p < 0.001) 15.4 % (p < 0.002)

Admission to special care unit

14.7%

Respiratory morbidity

5.5%

2.1% (p < 5.9% (not 0.001, NNH 29) signicant)

lowest incidence of neonatal complications occurred after 39 weeks for elective cesarean delivery and planned vaginal delivery 41 weeks for emergency cesarean delivery Reference - Pediatrics 2009 Jun;123(6):e1064 cesarean delivery of full-term singleton infants before onset of labor might be associated with higher risk of admission to neonatal ICU than vaginal delivery (level 2 [mid-level] evidence) based on record review of 481,362 low-risk women Reference - Birth 2007 Dec;34(4):301 Childhood risks: cesarean section associated with increased risk of asthma in children based on cohort study 1,756,700 singletons from birth registry in Norway followed for 18 years evaluating risk of asthma and association to delivery type cumulative incidence of asthma 4 per 1,000 delivery types included

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spontaneous vaginal delivery instrumental vaginal delivery planned cesarean section emergency cesarean section cesarean section associated with risk of asthma compared with spontaneous vaginal delivery (adjusted hazard ratio [HR] 1.52) emergency cesarean section (HR 1.59) planned cesarean section (HR 1.42) Reference - J Pediatr 2008 Jul;153(1):112, commentary can be found in J Pediatr 2009 Jan;154(1):154 cesarean section may increase risk of celiac disease in preterm infants based on retrospective case-control study 1,088 children born prematurely with current gastrointestinal (GI) disease including Crohn's disease, ulcerative colitis, and celiac disease were compared to 862 children without known GI disease birth by cesarean section more common in children with celiac disease compared to controls (p = 0.014) cesarean section not associated with increased risk of Crohn's disease or ulcerative colitis Reference - Pediatrics 2010 Jun;125(6):e1433 Timing of Emergent Cesarean Sections National Institute for Health and Clinical Excellence (NICE) recommendations(1) perform cesarean section as soon as possible after decision, especially if immediate threat to life of woman or fetus perform cesarean section within 75 minutes of decision if maternal or fetal compromise not immediately life-threatening consider health of woman and fetus when considering rapid delivery (may be harmful in some circumstances) failure to achieve emergent cesarean section within 30 minutes not shown to be harmful decision-to-incision time > 30 minutes not associated with adverse neonatal outcomes (level 2 [mid-level] evidence) prospective cohort of 2,808 primary cesarean deliveries done for emergency indication, mostly for nonreassuring heart rate tracings 1,814 (65%) started within 30 minutes of decision to operate decision-to-incision interval not associated with maternal complication rates including endometritis, wound infection or operative injury cesarean delivery within 30 minutes associated with increase rate of newborn compromise (umbilical artery pH < 7, intubation in delivery room), likely related to need for expedited delivery Reference - Obstet Gynecol 2006 Jul;108(1):6, editorial can be found in

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Obstet Gynecol 2006 Jul;108(1):2, commentary can be found in Obstet Gynecol 2006 Nov;108(5):1297 failure to achieve emergent cesarean section within 30 minutes occurred in > 50% of prospective study of 415 women, median time from decision to delivery 34 minutes, prolonged time to deliver associated with better cord blood pH values (BMJ 2001 Jun 2;322(7298):1334 full-text), editorial can be found in BMJ 2001 Jun 2;322(7298):1316 full-text, commentary can be found in BMJ 2001 Oct 20;323(7318):930 full-text failure to achieve urgent cesarean section within 30 minutes occurred in 34% of series of 721 women, but did not affect neonatal outcomes (BMJ 2001 Jun 2;322(7298):1330 full-text), editorial can be found in BMJ 2001 Jun 2;322(7298):1316 full-text, commentary can be found in BMJ 2001 Oct 20;323(7318):930 full-text decision to delivery interval > 75 minutes may be harmful but decision to delivery interval 16-75 minutes no worse than interval 15 minutes or less (level 2 [mid-level] evidence) national United Kingdom cross-sectional study of 17,780 emergency cesarean sections in England and Wales compared with babies delivered within 15 minutes, no difference in maternal or baby outcome for decision to delivery interval between 16 and 75 minutes, but interval > 75 minutes had signicantly increased risk of 5-minute Apgar score < 7 (adjusted odds ratio 1.7, 95% CI 1.2-2.4) and additional special care for mothers (adjusted odds ratio 1.5, 95% CI 1.2-1.8) Reference - BMJ 2004 Mar 20;328(7441):665 full-text rural maternity care unit without surgical facilities can safely offer obstetric care as part of an integrated perinatal network, based on study of 1,131 women (J Fam Pract 2002 Feb;51(2):129 EBSCOhost Full Text), commentary can be found in EBSCOhost Full Text J Fam Pract 2002 Jul;51(7):646 Elective Cesarean Sections Lowering cesarean section rates: interventions which may reduce rates of cesarean section include mandatory second opinion, nurse-led relaxation classes and birth preparation classes (level 2 [mid-level] evidence) based on Cochrane review of observational studies and moderate-quality randomized trials systematic review of 16 studies evaluating nonclinical interventions for reducing unnecessary cesarean sections 5 cluster-randomized trials 6 randomized trials 5 interrupted time series analyses (observational studies) 6 studies targeted pregnant women

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4 trials did not nd signicant differences in cesarean or vaginal birth after cesarean (VBAC) rates prenatal VBAC education and support program not associated with signicant differences in cesarean or VBAC rates compared to educational pamphlets in 1 trial with 1,275 women decision aids not associated with signicant differences in VBAC rates compared to control in 1 trial with 742 women decision analysis not associated with signicant differences in VBAC rates compared to information program or usual care in 1 trial (number of patients not reported) intensive group therapy not associated with signicant difference in requests for cesarean sections compared to conventional therapy in 1 trial with 176 patients nurse-led relaxation associated with reduced cesarean sections (15.4%) compared to control (40.4%, p = 0.001, NNT 4) in 1 trial with 104 women birth preparation class associated with reduced cesarean sections (3%) compared to control (10%, p = 0.044, NNT 15) in 1 trial with 200 patients 10 studies targeted health professionals uptake of mandatory second opinion associated with reduction in cesarean sections (p = 0.044) in 1 cluster-randomized trial with 34 hospitals (described below) audit and feedback and local opinion leaders associated with increased VBAC rate (p value not stated) in 1 cluster-randomized trial with 76 physicians in 16 hospitals peer review program with pre-cesarean consultation and mandatory second opinion not associated with reduced cesarean rates at 12 months in 1 observational study (number of participants not stated) implementation of labor management and cesarean delivery guidelines associated with reduced cesarean deliveries (p " 0.05) in 1 observational study with 12,912 deliveries nancial interventions associated with reduced cesarean section rates in 1 observational study with 11,767 deliveries included equalizing physician fees for vaginal and cesarean deliveries (no p value reported) insurance reform increasing physician fees for VBAC (p " 0.05) but insurance reform increasing physician fees for vaginal deliveries not associated with reduced cesareans in this study peer review programs not associated with reduced cesareans in 1 clusterrandomized trial (number of clusters not stated) and in 1 clusterrandomized trial with 366,246 live births implementation of legislative guidelines not associated with change in cesareans in 1 observational study with 706,196 deliveries Reference - Cochrane Database Syst Rev 2011 Jun 15;(6):CD005528

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mandatory secondary opinions for nonemergent cesarean sections may safely reduce rates of unnecessary cesarean sections (level 2 [mid-level] evidence) 36 hospitals in Latin America were randomized (in matched pairs) to intervention vs. control, all physicians in intervention hospitals electing for nonemergency cesarean section had to follow policy of mandatory second opinion 34 hospitals with 149,276 deliveries completed the study protocol comparing intervention vs. control mean rates of cesarean section over 6 months (starting 1 month after randomization) was 24.7% vs. 24.9% (not signicant) overall change was statistically signicant because baseline rates (the 6 months before randomization) were 26.3% vs. 24.6% no signicant differences in maternal or neonatal morbidity or mortality Reference - Lancet 2004 Jun 12;363(9425):1934 EBSCOhost Full Text cesarean section rates can be lowered dramatically without worsening perinatal outcomes (Obstet Gynecol 1985 Mar;65(3):307, N Engl J Med 1988 Dec 8;319(23):1511, Am J Obstet Gynecol 1990 Sep;163(3):1081) insufcient evidence regarding patient information interventions to reduce cesarean section rates based on Cochrane review systematic review of 2 randomized trials with 1,451 women did not nd signicant differences in rates of cesarean section or attempted vaginal delivery Reference - systematic review last updated 2003 Aug 30 (Cochrane Library 2004 Issue 1:CD003858) later admission in labor (delayed until cervical dilation at least 4 cm) and collaborative care associated with reduced cesarean delivery rate study of 2,196 low-income, low-risk pregnant women in obstetric practice admitted for delivery during spontaneous labor women managed by collaborative team of certied nurse midwife and obstetrician (compared to traditional obstetric care) had lower risk of admission with dilation < 4 cm, fewer admissions directly upon presentation, and more spontaneous vaginal deliveries women admitted earlier in labor had fewer spontaneous deliveries Reference - J Obstet Gynecol Neonatal Nurs 2003 Mar-Apr;32(2):147 in AHRQ Research Activities 2003 Aug;276:10 Timing of elective cesarean sections: elective cesarean section generally not recommended before 39 weeks due to increased risk of respiratory morbidity(1) delay of elective cesarean section to 39 weeks of gestation may be associated

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with lower risk of neonatal respiratory and other morbidity (level 2 [mid-level] evidence) based on 2 cohort studies 9-year prospective cohort of 33,289 deliveries at or after 37 weeks gestation rate of neonatal respiratory morbidity (respiratory distress syndrome or transient tachypnea) signicantly higher for cesarean section before onset of labor (35.5 per 1,000 live births) than for cesarean section during labor (12.2 per 1,000 live births) or of vaginal delivery (5.3 per 1,000 live births) among infants delivered by cesarean section before onset of labor, relative risk (RR) of neonatal respiratory morbidity higher during 38 weeks gestation than 39 weeks gestation (RR 2.4) and higher during 37 week than 38 weeks (RR 1.74) Reference - Br J Obstet Gynaecol 1995 Feb;102(2):101 prospective cohort of 13,258 low-risk elective cesarean deliveries between 37-39 weeks gestation 35.8% performed at ! 37 weeks but < 39 weeks gestation (6.3% at 37 weeks and 29.5% at 38 weeks) 1 neonatal death occurred in infant born at 39 weeks comparing birth at 37 vs. 38 vs. 39 weeks (p for trend < 0.001) respiratory distress syndrome in 3.7% vs. 1.9% vs. 0.9% transient tachypnea of newborn in 4.8% vs. 3.9% vs. 2.7% treated hypoglycemia in 2.4% vs. 0.9% vs. 0.7% suspected or proven sepsis in 7% vs. 4% vs. 2.5% admission to neonatal intensive care unit (ICU) in 12.8% vs. 8.1% vs. 5.9% hospitalization ! 5 days in 9.1% vs. 5.7% vs. 3.6% Reference - N Engl J Med 2009 Jan 8;360(2):111 EBSCOhost Full Text, editorial can be found in N Engl J Med 2009 Jan 8;360(2):183 EBSCOhost Full Text, commentary can be found in N Engl J Med 2009 Apr 9;360(15):1570 EBSCOhost Full Text delay of elective cesarean section to after 39 weeks gestation associated with less neonatal respiratory distress (level 2 [mid-level] evidence) 998 women electing to have cesarean section after 37 weeks gestation were randomized to betamethasone (2 doses of 12 mg intramuscularly 24 hours apart) vs. usual treatment, 942 babies analyzed 86 infants (9%) born at 37 weeks gestation, 434 (46%) born at 38 weeks gestation, 357 (38%) born at 39 weeks gestation among 467 infants who received antenatal betamethasone, predicted probability of admission to special baby care unit for respiratory distress was 5.2% at 37 weeks gestation 2.8% at 38 weeks gestation 0.6% at 39 weeks gestation

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among 475 infants who did not receive antenatal betamethasone, predicted probability of admission to special baby care unit for respiratory distress was 11.4% at 37 weeks gestation 6.2% at 38 weeks gestation 1.5% at 39 weeks gestation Reference - BMJ 2005 Sep 24;331(7518):662 full-text, editorial can be found in BMJ 2005 Sep 24;331(7518):645, commentary can be found in BMJ 2005 Dec 17;331(7530):1475, commentary can be found in Am Fam Physician 2006 Feb 15;73(4):694 Cesarean delivery on maternal request: National Institute for Health and Clinical Excellence (NICE) recommends discussion of risks and benets, and referral to counseling for women with anxiety about vaginal delivery, with planned cesarean delivery on further request(1) insufcient evidence comparing cesarean delivery on maternal request with planned vaginal delivery (AHRQ Evidence Report on Cesarean Delivery on Maternal Request 2006:133) NIH consensus conference 2006 Mar 27-29 on cesarean delivery on maternal request can be found in NIH Consens State Sci Statements 2006 Mar 27-29;23(1):1 PDF, also published in Obstet Gynecol 2006 Jun;107(6):1386, commentary can be found in Obstet Gynecol 2007 Feb;109(2 Pt 1):457 systematic review of 54 studies reporting maternal and infant outcomes found evidence base inadequate because most studies evaluated actual routes of delivery instead of planned routes of delivery (Obstet Gynecol 2006 Dec;108(6):1517) of 86 women with fear of birth and request for planned cesarean who were referred for counseling, 86% became prepared to give birth vaginally (Birth 2006 Sep;33(3):221) no randomized trials found evaluating planned cesarean section for nonmedical indications at term based on Cochrane review Reference - Cochrane Database Syst Rev 2012 Mar 14;(3):CD004660 Periprocedural Management Preoperative preparation and testing: National Institute for Health and Clinical Excellence (NICE) recommendations(1) preoperative testing hemoglobin assessment to identify women with anemia tests not recommended for healthy women with uncomplicated pregnancies grouping and saving serum cross-matching blood clotting screen

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preoperative ultrasound for localization of placenta (not associated with improved morbidity outcomes) before cesarean section inform women of risk of fetal laceration (about 2%) offer antacids and drugs (for example, H2 receptor antagonists or proton pump inhibitors) that reduce gastric volumes and acidity to reduce risk of aspiration pneumonitis offer antiemetics (pharmacologic or acupressure) to reduce nausea and vomiting during cesarean section perform cesarean section at maternity unit with on-site blood transfusion services if cesarean section being performed for antepartum hemorrhage, abruption, uterine rupture, or placenta previa (increased risk of blood loss > 1,000 mL) indwelling urinary catheter required for women having regional anesthesia due to risk of bladder over-distension (anesthetic block can interfere with bladder function) Prophylactic antibiotics: American College of Obstetricians and Gynecologists (ACOG) recommends antimicrobial prophylaxis for all cesarean deliveries (if patient has not already received adequate antibiotics) antibiotics administered " 60 minutes prior to start of cesarean delivery Reference - ACOG Committee Opinion 465 (Obstet Gynecol 2010 Sep;116(3):791), commentary can be found in ACOG News Release 2010 Aug 23 National Institute for Health and Clinical Excellence (NICE) recommends(1) antibiotics before incision for all cesarean deliveries (reduces risk of maternal infection more than antibiotics after incision) choosing antibiotics effective against endometritis, urinary tract infections, and wound infections avoiding co-amoxiclav when administering antibiotics before incision prophylactic antibiotics for women having elective or non-elective cesarean section may improve maternal outcomes (level 2 [mid-level] evidence), no evidence available to assess effects on infant based on Cochrane review without high-quality trials systematic review of 86 randomized and quasi-randomized trials comparing prophylactic antibiotics vs. no treatment in > 13,000 women having cesarean section prophylactic antibiotics associated with reduced febrile mortality in analysis of 50 trials with 8,141 women risk ratio (RR) 0.45 (95% CI 0.39-0.51), results limited by heterogeneity (p = 0.00048) NNT 6-7 for control event rate 29%

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reduced wound infection in analysis of 77 trials with 11,961 women RR 0.39 (95% CI 0.32-0.48), results limited by heterogeneity (p = 0.04) NNT 15-20 for control event rate 10% reduced endometritis in analysis of 79 trials with 12,142 women RR 0.38 (95% CI 0.34-0.42) NNT 9-11 for control event rate 17% reduced serious maternal infectious complications in analysis of 31 trials with 5,047 women RR 0.31 (95% CI 0.19-0.48) NNT 42-64 for control event rate 3% trend toward increased risk of maternal adverse effects (RR 2.43, 95% CI 1-5.9) in analysis of 13 trials with 2,131 women similar results in elective and non-elective cesarean groups and in administration before or after cord clamping no trials reported on infant adverse outcomes Reference - Cochrane Database Syst Rev 2010 Jan 20;(1):CD007482 prophylactic penicillins have similar maternal clinical outcomes compared to cephalosporins for elective or non-elective cesarean section (level 2 [mid-level] evidence), no evidence available to assess effects on infant based on Cochrane review of low quality trials systematic review of 25 randomized trials evaluating different classes of antibiotics in 6,328 women delivering by elective or non-elective cesarean section cephalosporins compared to penicillins in 22 trials with 5,949 women no signicant differences comparing cephalosporins to penicillins in maternal clinical outcomes for either elective or non-elective cesarean section or in timing of antibiotic administration (before or after cord clamping) sepsis in analysis of 3 trials with 421 women endometritis in analysis of 16 trials with 4,167 women fever in analysis of 13 trials with 2,465 women wound infection in analysis of 14 trials with 2,104 women urinary tract infection in analysis of 11 trials with 1,564 women infection rates after discharge out to 10 weeks in 1 trial with 283 women and to 6 weeks in 2 trials with 305 women adverse events (composite includes vomiting and rash) in analysis of 5 trials with 2,313 women cephalosporins associated with increased risk of endometritis compared to extended spectrum penicillins in analysis of 2 trials of rst generation cephalosporins with 814 women risk ratio (RR) 2.18 (95% CI 1.3-3.66) NNH 6-52 assuming 6.5% endometritis in extended spectrum penicillins group

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in 1 trial of third generation cephalosporins with 300 women (RR 2.14 [95%CI 1.14-4], NNH 11) comparing third generation cephalosporins to aminopenicillins signicant reduction in maternal wound infection in analysis of 5 trials with 810 women RR 0.31 (95%CI 0.13-0.76) NNT 24-87 assuming 5% wound infection in aminopenicillins group Reference - Cochrane Database Syst Rev 2010 Oct 6;(10):CD008726 ampicillin-sulbactam and cefuroxime appear similar for prevention of infection in women having cesarean delivery (level 2 [mid-level] evidence) based on randomized trial without blinding of outcome assessors 176 women (mean age 28 years) having cesarean delivery randomized to ampicillin-sulbactam 3 g IV vs. cefuroxime 1.5 g IV in single-dose after umbilical cord clamping postoperative infection in 5.9% with cefuroxime vs. 8.8% with ampicillinsulbactam (not signicant) Reference - BMC Infect Dis 2010 Nov 30;10:341 EBSCOhost Full Text full-text prophylactic antibiotics at cesarean delivery associated with decreased risk of postpartum endometritis and wound infection (level 2 [mid-level] evidence) based on secondary analysis of cohort of 9,432 women having cesarean delivery 64% of patients received prophylactic antibiotics results adjusted for smoking, payer status, gestational age and body mass index at delivery, race, diabetes, antepartum infections, anemia, operative time, number of cesarean deliveries and center comparing prophylactic antibiotics vs. no prophylactic antibiotics postpartum endometritis in 2% vs. 2.6% (adjusted odds ratio [OR] 0.4, p < 0.05, NNT 167) wound infection in 0.52% vs. 0.96% (adjusted OR 0.49, p < 0.05, NNT 228) Reference - Obstet Gynecol 2009 Oct;114(4):752 antibiotic prophylaxis prior to cesarean delivery associated with decreased incidence of postpartum endometritis and total infectious morbidity compared to prophylaxis given at cord clamp (level 2 [mid-level] evidence) based on systematic review without quality assessment of included trials systematic review of 3 randomized trials with 749 patients evaluating prophylactic antibiotic for cesarean delivery given preoperatively vs. at cord clamp preoperative administration associated with decreased postpartum endometritis (RR 0.47 [95% CI 0.26-0.85], p = 0.012) decreased total infectious morbidity (RR 0.5 [95% CI 0.33-0.78], p =

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0.002) no signicant difference in maternal wound infection suspected neonatal sepsis requiring workup proven neonatal sepsis no signicant difference in neonatal intensive care unit (ICU) admissions in 2 randomized trials with 681 patients Reference - Am J Obstet Gynecol 2008 Sep;199(3):301e1 cefazolin prior to incision may signicantly reduce maternal infection compared with cefazolin administered after cord clamp (level 2 [mid-level] evidence) based on systematic review without quality assessment systematic review without meta-analysis of 15 studies evaluating timing of antibiotic administration or use of extended-spectrum prophylaxis in cesarean sections and review of 9 reports on national recommendations or technical reviews in support of current antibiotic prophylaxis guidelines 50% reduction in postoperative infection with antibiotic prophylaxis given prior to incision compared with after cord clamp in 3 randomized trials and 1 retrospective cohort study Reference - Obstet Gynecol 2009 Mar;113(3):675 cefazolin 2 g prior to incision may not provide adequate antimicrobial coverage in obese women (level 3 [lacking direct] evidence) based on small cohort study without clinical outcomes 29 women having cesarean delivery stratied by body mass index, received cefazolin 2 g 30-40 minutes prior to skin incision and had evaluation of cefazolin concentrations within adipose samples obese (30-39.9 kg/m2) or extremely obese (! 40 kg/m2) classication in 66% minimal inhibitory cefazolin concentration (> 4 mcg/g) for gram-negative rods not achieved in 20% at skin incision and 20% at skin closure among obese patients 33.3% at skin incision and 44.4% at skin closure among extremely obese patients Reference - Obstet Gynecol 2011 Apr;117(4):877 extended-spectrum combination antibiotics may further reduce risk of infections endometritis dened as fever 100.4 degrees F (38 degrees C) or higher plus any of maternal tachycardia (> 100 beats/minute twice at least 30 minutes apart), foul-smelling or purulent lochia, severe uterine tenderness, or maternal leukocytosis (> 12,000/mm 3 ) 597 women undergoing cesarean section randomized to cefotetan 2 g IV after cord clamping plus placebos vs. cefotetan 2 g IV and doxycycline 100 mg IV after cord clamping and azithromycin 1 g orally 6-12 hours after delivery comparing cefotetan vs. combination antibiotics, 24.7% vs. 16.9% had

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postpartum endometritis (NNT 13), 3.6% vs. 0.8% had wound infections (NNT 36), mean length of stay 104 vs. 95 hours Reference - Obstet Gynecol 2003 Jun;101(6):1183 in J Watch Online 2003 Jun 27, summary can be found in Am Fam Physician 2004 Feb 1;69(3):642 Antenatal steroids: prophylactic betamethasone before elective cesarean section at term may reduce admission to neonatal special care units for respiratory complications (level 2 [mid-level] evidence) based on Cochrane review of 1 trial without blinding systematic review of randomized and quasi-randomized trials comparing prophylactic antenatal corticosteroid administration vs. placebo or no treatment, given before elective cesarean section at term (! 37 weeks of gestation) 1 trial evaluating intramuscular betamethasone (2 doses administered within 48 hours before cesarean section) in 942 women met inclusion criteria comparing intramuscular betamethasone vs. usual care admission to neonatal intensive care unit (NICU) for respiratory distress in 0.4% vs. 2.9% (p = 0.01, NNT 40) no signicant differences in RDS, need for mechanical ventilation, or length of NICU stay no reports of neonatal sepsis, perinatal death or maternal trauma infection Reference - Cochrane Database Syst Rev 2009 Oct 7;(4):CD006614 delaying cesarean section to 39 weeks gestation appears to have larger impact than antenatal betamethasone in this trial (level 2 [mid-level] evidence) 998 women electing to have cesarean section after 37 weeks gestation were randomized to betamethasone (2 doses of 12 mg intramuscularly 24 hours apart) vs. usual treatment, 942 babies analyzed 86 infants (9%) born at 37 weeks gestation, 434 (46%) born at 38 weeks gestation, 357 (38%) born at 39 weeks gestation comparing 467 infants who received antenatal betamethasone vs. 475 control infants estimated rates of admission to special baby care unit for respiratory distress in overall analysis 2.4% vs. 5.1% (NNT 37) at 37 weeks gestation 5.2% vs. 11.4% (NNT 16) at 38 weeks gestation 2.8% vs. 6.2% (NNT 30) at 39 weeks gestation 0.6% vs. 1.5% (NNT 111) respiratory distress syndrome in 0.2% vs. 1.1% (NNT 111) transient tachypnea of newborn in 2.1% vs. 4% (NNT 53) Reference - BMJ 2005 Sep 24;331(7518):662 full-text, editorial can be found in BMJ 2005 Sep 24;331(7518):645

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Anesthesia: National Institute for Health and Clinical Excellence (NICE) recommendations(1) offer regional anesthesia due to association with less maternal and neonatal morbidity compared to general anesthesia (including women with placenta previa) women having induction of regional anesthesia for cesarean section should be cared for in theater (does not increase women's anxiety) general anesthesia for unplanned cesarean section should include preoxygenation, cricoid pressure, and rapid sequence induction to reduce risk of aspiration to reduce risk of hypotension during cesarean section offer IV ephedrine or phenylephrine to women having cesarean section under regional anesthesia volume pre-loading with crystalloid or colloid can reduce risk of hypotension operating table should have lateral tilt of 15 degrees to reduce maternal hypotension IV ephedrine or phenylephrine should be used to manage hypotension during cesarean section insufcient evidence on benets and harms comparing regional anesthesia with general anesthesia based on Cochrane review systematic review of 16 randomized or quasi-randomized trials comparing regional (spinal or epidural) anesthesia vs. general anesthesia in 1,586 women having cesarean section for any reason regional anesthesia associated with less blood loss, shivering, nausea and vomiting regional anesthesia preferred by patients based on 1 trial insufcient evidence to assess pain outcomes, mortality, or other major complications no trials evaluated recovery times, effects on breastfeeding, or effects on mother-child relationship Reference - systematic review last updated 2006 Aug 15 (Cochrane Library 2006 Issue 4:CD004350) general anesthesia associated with increased rates of neonatal adverse outcomes compared with spinal or epidural anesthesia based on cohort study 50,806 cesarean sections (planned repeat, failure to progress and fetal distress indications) risk of adverse neonatal outcomes greater with general anesthesia for all delivery indications compared with spinal or epidural anesthesia

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largest absolute risk for infant morbidity associated with general anesthesia use in unplanned cesarean sections Reference - BMC Med 2009 Apr 29;7(1):20 EBSCOhost Full Text, PDF spinal anesthesia and epidural anesthesia both effective, spinal anesthesia has shorter onset but increased risk of treatment of hypotension (level 1 [likely reliable] evidence) systematic review of 10 randomized trials of spinal vs. epidural anesthesia in 751 women undergoing cesarean section no signicant differences in failure rates, need for additional intraoperative analgesia, conversion to general anesthesia, maternal satisfaction, need for postoperative pain relief, or neonatal intervention spinal anesthesia associated with shorter time from anesthesia to operation (by 8 minutes, based on 4 trials) and increased need for treatment of hypotension (based on 6 trials) Reference - systematic review last updated 2004 Jan 21 (Cochrane Library 2004 Issue 2:CD003765) epidural anesthesia associated with higher 1-minute Apgar scores and earlier breastfeeding than general anesthesia in randomized trial of 30 women undergoing cesarean section (Gynecol Obstet Invest 2003;55(1):41) when converting from epidural labor analgesia to anesthesia for emergency cesarean section, top up bolus of lidocaine plus epinephrine may have faster onset than bolus of ropivacaine, bupivacaine or levobupivacaine (level 2 [mid-level] evidence) based on systematic review limited by clinical heterogeneity systematic review of 11 randomized trials evaluating conversion of epidural analgesia during labor to surgical anaesthesia in 779 women having emergency cesarean section clinical heterogeneity due to differences in epidural top up solutions, protocols, and endpoints epidural solutions categorized into 3 groups for analyses 2% lidocaine plus epinephrine (with or without addition of fentanyl) 0.75% ropivacaine 0.5% bupivacaine or 0.5% levobupivacaine comparing lidocaine plus epinephrine to all other solutions, lidocaine plus epinephrine associated with reduced time to surgical block (weighted mean reduction 1.66 minutes, p < 0.0001) in analysis of 5 trials with 346 patients comparing bupivacaine or levobupivacaine to ropivacaine, bupivacaine or levobupivacaine associated with increased need for intraoperative anaesthesia supplementation (risk ratio 3.23, 95% CI 1.26-8.33) in analysis of 3 trials with 162 patients Reference - Br J Anaesth 2011 Nov;107(5):668 regional anesthesia successful in most women undergoing cesarean section delivery

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prospective observational study of 37,142 women with singleton gestations undergoing cesarean section delivery in multiple university-based hospitals in US, 34,615 (93%) received regional anesthesia 1,114 (3%) regional procedures failed, maternal morbidity rare risk factors for failed regional procedure increased maternal size higher preoperative risk rapid decision-to-incision interval placement later in labor Reference - Obstet Gynecol 2005 Aug;106(2):281 intrathecal bupivacaine plus clonidine or sufentanil or sufentanil-clonidine associated with similar post-operative pain at 48 hours (level 2 [mid-level] evidence) based on randomized trial with inadequate statistical power 96 women having elective cesarean delivery receiving intrathecal bupivacaine randomized to additional sufentanil (BS group) vs. sufentanil-clonidine 75 microg (BSC group) vs. clonidine 150 microg (BC group) among groups, at 48 hours postoperatively the BS group demonstrated reduced area of perincisional hyperalgesia (p = 0.02) incidence of hyperalgesia (p = 0.03) no signicant difference among group in postoperative morphine consumption pain scores incidence and intensity of residual pain Reference - Anesth Analg 2008 Sep;107(3):948 subarachnoid morphine may reduce need for postoperative analgesia but increase risk of adverse events compared to transversus abdominis plane block (level 2 [mid-level] evidence) based on small randomized trial 57 patients having elective cesarean section randomized to subarachnoid morphine (bupivacaine spinal anesthesia combined with morphine 0.2 mg ) vs. transversus abdominis plane block (bupivacaine 0.375% plus epinephrine 5 mcg/mL) postoperative analgesia included scheduled rectal diclofenac and IV paracetamol with IV tramadol as rescue medication comparing subarachnoid morphine vs. transversus abdominis plane block median time to rst analgesic request 8 hours vs. 4 hours (p = 0.005) median (range) tramadol doses in 0-12 hours 0 (0-1) vs. 0 (0-2) (p = 0.03) moderate-to-severe nausea in 46% vs. 17% (p = 0.02, NNH 4) pruritus in 39% vs. 0% (p < 0.001, NNH 3) no signicant difference in rescue medication use from 13-48 hours Reference - Anesth Analg 2010 Aug;111(2):475 single-shot spinal anesthesia may be as effective as spinal-epidural

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anesthesia for sensory blockage (level 2 [mid-level] evidence) based on randomized trial of 30 women having elective cesarean section Reference - Anesth Analg 2009 Jan;108(1):240 local anesthetic wound inltration with or without abdominal nerves block may reduce postoperative opioid use based on Cochrane review systematic review of 20 randomized trials evaluating local anesthetic wound inltration and/or abdominal nerve blocks to reduce postoperative pain in 1,150 women having cesarean section signicantly reduced opioid consumption associated with wound inltration with local anesthetic compared to control (mean difference -1.7 mg) in analysis of 3 trials with 126 women local anesthetic plus abdominal nerves block compared to control (mean difference -25.8 mg) in analysis of 4 trials with 175 women Reference - Cochrane Database Syst Rev 2009 Jul 8;(3):CD006954 hypotension with spinal anesthesia for cesarean section no intervention has been shown to prevent need for treating hypotension associated with spinal anesthesia for cesarean section based on Cochrane review interventions shown to reduce risk for hypotension include colloid or crystalloid preloading, parenteral ephedrine administration and lower limb compression ephedrine associated with dose-related maternal hypertension and tachycardia and fetal acidosis Reference - systematic review of 25 trials with 1,477 patients last updated 2002 May 23 (Cochrane Library 2002 Issue 3:CD002251 colloid administration before or during spinal anesthesia associated with similar rates of hypotension (level 2 [mid-level] evidence) based on randomized trial without clinical outcomes 178 women having spinal anesthesia for elective cesarean delivery were randomized to preload of hydroxyethyl starch 500 mL 15-20 minutes before initiation of spinal anesthesia vs. coload starting at time of identication of cerebrospinal uid no signicant difference between groups in incidence of hypotension or severe hypotension doses of ephedrine and phenylephrine number of vasopressor unit doses incidence of nausea or vomiting neonatal outcome Reference - Anesth Analg 2009 Oct;109(4):1219 colloid and crystalloid preloading associated with similar hypotension rates in women having spinal anesthesia for planned cesarean delivery (level 2 [mid-level] evidence)

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based on small randomized trial 60 healthy term women scheduled for planned cesarean delivery under spinal anesthesia randomized to 1 of 3 uid preload regimens over 15 minutes crystalloid (Hartman's solution) 1.5 L 6% hydroxyethyl starch (HES) solution 0.5 L 6% HES solution 1 L no signicant differences in hypotension rates 70% with Hartman's solution 35% with HES solution 0.5 L 65% with HES solution 1 L no signicant differences in mean ephedrine dose maternal cardiac output and corrected ow time increased in all groups (p < 0.005) but only maintained with HES solution 1 L after anesthesia (p < 0.005) Reference - Anesth Analg 2009 Dec;109(6):1916 Postoperative analgesia: National Institute for Health and Clinical Excellence (NICE) recommendations(1) inform women of different types of postoperative analgesia so as to nd one best suited to their needs offer diamorphine (0.3-0.4 mg intrathecally) for intra-and postoperative analgesia, epidural diamorphine (2.5-5 mg) as alternative offer patient-controlled analgesia with opioid analgesic to improve pain relief if no contraindication, offer nonsteroidal anti-inammatory drugs as adjunct to other analgesics (can reduce need for opioids) morphine may be associated with better pain control and higher breastfeeding rates than meperidine for post-cesarean section pain (level 2 [mid-level] evidence) 1,256 women delivering via cesarean section were assigned to morphine vs. meperidine and analgesia via intramuscular vs. patient-controlled IV routes morphine groups had fewer time points when patients rated pain as moderate or worse, but no signicant differences in patient satisfaction with pain management patient-controlled IV meperidine more effective than intramuscular meperidine; morphine use associated with higher breastfeeding and rooming-in rates Reference - Am J Obstet Gynecol 2004 May;190(5):1341 in Am Fam Physician 2005 Feb 15;71(4):802 oral analgesia may be associated with better pain control than patientcontrolled analgesia device (level 2 [mid-level] evidence) 93 patients with scheduled cesarean delivery randomized to oral analgesia with oxycodone/acetaminophen vs. morphine patient-controlled analgesia device

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at 6 hours, oral analgesia associated with less pain, less nausea, and less drowsiness at 24 hours, oral analgesia associated with less pain but slightly more nausea Reference - Am J Obstet Gynecol 2006 Apr;194(4):967 ketorolac tromethamine reduces postoperative pain after cesarean section 44 women who had cesarean section randomized to ketorolac tromethamine vs. placebo, all had patient-controlled analgesia (PCA) pain scores were signicantly reduced with ketorolac at 2, 3, 4, 6, 12 and 24 hours; ketorolac reduced overall narcotic dosage no signicant differences in blood loss, hours of PCA use, number of PCA attempts or time to discharge Reference - Am J Obstet Gynecol 2003 Dec;189(6):1559 in Am Fam Physician 2004 Jul 1;70(1):191 lidocaine may decrease persistent postcesarean pain in women with peritoneal closure based on randomized trial 370 women with cesarean section including closure of parietal peritoneum randomized to intraperitoneal injection of lidocaine 200 mg vs. sterile saline persistent postcesarean pain decreased from 20.8% at 2 weeks to 10.8% at 8 months with lidocaine (p < 0.001) Reference - Clin J Pain 2010 Feb;26(2):121 preoperative gabapentin may decrease pain with movement after Cesarean section (level 2 [mid-level] evidence) based on small randomized trial 46 patients having Cesarean section randomized to preoperative gabapentin 600 mg vs. placebo in addition to spinal anesthesia during Cesarean section and standard postoperative analgesics (diclofenac, acetaminophen, and morphine) gabapentin associated with signicant improvement in pain with movement score and patient satisfaction severe maternal sedation in 0% with gabapentin vs. 19% with placebo (p = 0.04, NNT 6) no signicant differences in opioid consumption, neonatal complications or maternal pain at 3 months Reference - Anesth Analg 2011 Jan;112(1):167 wound infusion below the fascia with ropivacaine and ketoprofen may reduce pain and morphine use compared to infusion above the fascia (level 2 [mid-level] evidence) based on small randomized trial 56 women having elective cesarean delivery under spinal anesthesia were randomized to postoperative continuous wound infusion with ropivacaine and ketoprofen below vs. above the fascia for 48 hours no additional systemic analgesics used except patient-controlled rescue IV

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morphine infusion below the fascia associated with reduced pain at rest (p < 0.05) postoperative morphine consumption (p < 0.05) Reference - Obstet Gynecol 2010 Oct;116(4):893 postoperative acupuncture and electro-acupuncture each associated with reduced pain within 2 hours and less frequent analgesia use within 24 hours in women having cesarean section (level 2 [mid-level] evidence) based on small randomized trial 60 women having cesarean section (with spinal anesthesia) randomized to 1 of 3 groups and followed for 24 hours after delivery postoperative acupuncture postoperative electro-acupuncture control all women had patient-controlled analgesia IV after surgery acupuncture and electro-acupuncture each signicantly associated with (vs. control) reduced pain scores within rst 2 hours (signicant effect did not persist > 2 hours) less frequent analgesia use within rst 24 hours (30%-35% decrease) delayed rst request for analgesia (10-11 minute difference) no signicant difference between acupuncture and electro-acupuncture Reference - Chin Med J (Engl) 2009 Aug 5;122(15):1743 full-text Early oral intake after cesarean section: women recovering well and without complications post-cesarean section can eat and drink when they feel ready(1) no evidence to justify withholding oral uids or food after uncomplicated cesarean section early oral uids or food associated with reduced time to rst food intake, bowel sounds and hospital discharge no signicant differences in nausea, vomiting, passing of atus or bowel movements, paralytic ileus or analgesic use Reference - systematic review of 6 trials last updated 2002 May 20 (Cochrane Library 2002 Issue 3:CD003516) clear uids and solid food within 8 hours of cesarean delivery may be associated with higher maternal satisfaction and may not increase postoperative complications based on randomized trial with 179 women having rst or repeated cesarean delivery randomized to early feeding within 8 hours vs. feeding at 8-12 hours after delivery Reference - Acta Obstet Gynecol Scand 2008;87(1):68 Text EBSCOhost Full

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early feeding (maternal intake of solid food) after cesarean section well tolerated in randomized trial of 120 women postoperative feeding restrictions (nothing orally for 1 day, clear liquids only on second day, waiting for passage of atus or stool to start solid foods) are not warranted Reference - Obstet Gynecol 2001 Jul;98(1):113 in Am Fam Physician 2002 Feb 15;65(4): 681 gum chewing may stimulate early return of bowel motility and reduce hospital stay after cesarean section based on randomized trial 200 pregnant women who delivered by elective cesarean section under general anesthesia were randomized to sugarless gum chewing orally for 15 minutes every 2 hours after surgery vs. traditional management and were followed until discharged mean times comparing gum chewing vs. traditional management time to rst hearing of normal intestinal sounds 10.9 hours vs. 15.6 hours (p < 0.001) passage of atus at 17.9 hours vs. 24.4 hours (p < 0.001) defecation at 21.1 hours vs. 30 hours (p < 0.001) discharge from hospital at 40.8 hours vs. 50.5 hours (p < 0.001) Reference - BJOG 2009 Sep;116(10):1334 EBSCOhost Full Text, EBSCOhost Full commentary can be found in BJOG 2010 Jan;117(1):117 Text

Venous thromboembolism prophylaxis: American College of Chest Physicians (ACCP) 2012 recommendations thrombosis risk assessment suggested for women having cesarean delivery major risk factors (> 3% risk of postpartum venous thromboembolism [VTE] if any are present) immobility (strict bed rest for ! 1 week in antepartum period) postpartum hemorrhage > 1 L with surgery previous VTE preeclampsia with fetal growth restriction antithrombin deciency factor V Leiden mutation (homozygous or heterozygous) prothrombin G20210A mutation (homozygous or heterozygous) systemic lupus erythematosus heart disease sickle cell disease blood transfusion postpartum infection minor risk factors (> 3% risk of postpartum VTE if ! 2 are present) emergency cesarean delivery

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body mass index (BMI) > 30 kg/m2 multiple pregnancy postpartum hemorrhage > 1 L smoking > 10 cigarettes/day fetal growth restriction (birth weight < 25th percentile adjusted for gestational age and gender) protein C deciency protein S deciency preeclampsia if no additional risk factors for VTE (other than pregnancy and cesarean delivery), specic thromboprophylaxis other than early mobilization recommended against (ACCP Grade 1B) if 1 major or ! 2 minor risk factors present, prophylaxis while in hospital suggested (rather than no prophylaxis) with either of (ACCP Grade 2B) prophylactic low-molecular-weight heparin (LMWH) mechanical prophylaxis (elastic stockings or intermittent pneumatic compression [IPC]) if contraindication if very high risk for VTE (multiple additional risk factors that persist in puerperium), combination of prophylactic LMWH plus mechanical prophylaxis (graduated compression stockings and/or IPC) suggested over LMWH alone (ACCP Grade 2C) for selected high-risk women with signicant persistent risk factors following delivery, extended prophylaxis (for up to 6 weeks after delivery) suggested after discharge from hospital (ACCP Grade 2C) Reference - Chest 2012 Feb;141(2 Suppl):e691S National Institute for Health and Clinical Excellence (NICE) recommendations(1) offer thromboprophylaxis to women having cesarean section due to increased risk of venous thromboembolism risk of thromboembolic disease and existing guidelines should inform choice of prophylaxis, and may include graduated stockings hydration early mobilization low molecular weight heparin use of pneumatic compressing stockings reported to be safest approach to thromboprophylaxis after cesarean section in decision analysis (Obstet Gynecol 2005 Oct;106(4):733) use of intermittent pneumatic compression at cesarean delivery reported to be cost-effective in decision analysis (Obstet Gynecol 2006 Sep;108(3 Pt 1):535) Additional information: insufcient evidence to determine ideal maternal position during cesarean

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section based on Cochrane review systematic review of 9 randomized trials comparing different maternal positions during cesarean section most comparisons included only single trials and reported no signicant differences in maternal pulse rate, maternal blood pH, cord blood pH, or 5-minute Apgar scores hypotensive episodes signicantly decreased with manual displacer (compared to left lateral tilt) and right lumbar wedge (compared to right pelvic wedge) and increased with right lateral tilt (compared with left lateral tilt) Reference - Cochrane Database Syst Rev 2010 Jun 16;(6):CD007623 addition of povidone-iodine scrub to standard povidone-iodine paint skin preparation associated with decreased postcesarean infectious complications (level 2 [mid-level] evidence) based on retrospective cohort study 2,143 women with cesarean delivery had povidone-iodine (13%) scrub followed by povidone-iodine (10%) paint protocol vs. povidone-iodine (10%) paint protocol alone comparing scrub plus paint vs. paint alone major puerperal infection in 3.4 vs. 5.4 per 100 deliveries (p = 0.03) composite major puerperal infection and infectious wound complications in 5.5 vs 7.8 per 100 deliveries (p = 0.03) Reference - Obstet Gynecol 2011 May;117(5):1123 preoperative vaginal cleansing with povidone iodine vaginal preparation with povidone iodine may reduce postoperative endometritis, particularly in women with ruptured membranes (level 2 [mid-level] evidence) based on Cochrane review of trials with methodologic limitations systematic review of 4 randomized trials comparing preoperative vaginal antiseptic cleansing vs. placebo or standard care for prevention of postoperative morbidities with 1,361 women all trials use povidone-iodine for cleansing methodologic limitations included unclear allocation concealment lack of intention-to-treat analysis early trial termination povidone-iodine associated with reduction in endometritis in analysis of all trials with 1,198 women risk ratio 0.57 (95% CI 0.38-0.87) NNT 18-86 assuming endometritis in 9% of controls reduction in endometritis in subgroup analysis of 148 women with ruptured membranes in 2 trials risk ratio 0.13 (95% CI 0.02-0.66)

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NNT 7-20 assuming endometritis in 15% of controls trend toward reduction in any wound complications in analysis of 2 trials with 730 women risk ratio 0.63 (95% CI 0.37-1.07) no signicant differences in endometritis in subgroup analysis of 312 women with intact membranes in 2 trials postoperative fever in analysis of 3 trials with 1,038 women wound infection in analysis of 3 trials with 668 women Reference - Cochrane Database Syst Rev 2010 Mar 17;(3):CD007892 preoperative vaginal cleansing with povidone iodine not associated with decrease in overall rate of infectious morbidities following cesarean delivery based on randomized trial 300 women having cesarean delivery randomized to preoperative vaginal cleansing with povidone iodine vs. standard care (no vaginal wash) composite outcome of postoperative fever, endometritis, sepsis, readmission, wound infection, or complication in 6.5% cleansing group vs. 11.7% control group (not signicant) Reference - Am J Obstet Gynecol 2010 Mar;202(3):310e1 antacids and H2 antagonists, alone or in combination, might be effective for preventing low gastric pH (level 3 [lacking direct] evidence) based on Cochrane review without clinical outcomes systematic review of 22 randomized trials evaluating interventions to reduce risk of aspiration pneumonitis in 2,658 women having cesarean section interventions effective for reducing risk of intragastric pH < 2.5 at intubation antacids (compared with no treatment or placebo) in analysis of 2 trials with 108 women H2 antagonists (compared with no treatment or placebo) in analysis of 2 trials with 170 women (compared with proton pump inhibitors) in 1 trial with 120 women antacids plus H2 antagonist (compared with placebo) in 1 trial with 89 women (compared with antacid alone) in 1 trial with 119 women proton pump inhibitors (compared with no treatment or placebo) in 1 trial with 80 women inconsistent results comparing antacids vs. H2 antagonists in 4 trials with 175 women Reference - Cochrane Database Syst Rev 2010 Jan 20;(1):CD004943 indwelling catheter during cesarean section associated with increased risk of urinary tract infections (UTIs) (level 2 [mid-level] evidence) based on systematic review with methodologic limitations

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systematic review of 2 randomized trials and 1 non-randomized trial comparing indwelling catheter to no catheter in 1,084 women having cesarean section all trials lacked blinding and allocation concealment not stated in 2 trials incidence of UTIs in patients with catheter vs. without 6% vs. 0.47% (p = 0.02, NNH 18) in 1 randomized trial with 420 patients 6% vs. 0.58% (p = 0.01, NNH 18) in 1 nonrandomized trial with 394 patients group without catheter had less time to ambulation, lower rate of discomfort at rst voiding and less time to rst voiding in single trials no signicant difference in urinary retention or operating time Reference - BJOG 2011 Mar;118(4):400 EBSCOhost Full Text supplemental oxygen does not reduce risk of infectious morbidity after cesarean section (level 1 [likely reliable] evidence) based on randomized trial 585 women with cesarean delivery randomized to supplemental oxygen (10 L/minute by nonrebreather mask intraoperatively and for 2 hours postoperatively) vs. standard care (2 L/minute of oxygen by nasal cannula intraoperatively) and observed for 1 month comparing supplemental oxygen vs. standard care infectious morbidity (composite of endometritis or wound infection) in 12.2% vs. 8.8% (not signicant) endometritis in 2.4% vs. 0.6% (p = 0.08) wound infection in 11.5% vs. 8.8% (not signicant) Reference - Am J Obstet Gynecol 2011 Sep;205(3):267.e1 high-concentration supplemental oxygen does not decrease post-cesarean surgical site infection compared to low-concentration supplemental oxygen (level 1 [likely reliable] evidence) based on randomized trial 143 patients having cesarean section randomized to low vs. high concentration inspired oxygen via nonrebreathing mask intraoperatively and for 2 hours postoperatively surgical site infection dened as administration of antibiotics for postpartum endometritis or wound infection within 14 days of surgery surgical site infection in 24.6% high-concentration oxygen group vs. 13.5% low-concentration group (not signicant) Reference - Obstet Gynecol 2008 Sep;112(3):545, correction can be found in Obstet Gynecol 2008 Dec;112(6):1392 no evidence to support or refute use of tocolytic agents to facilitate delivery at cesarean section based on Cochrane review only 1 randomized trial with 97 women found maternal and infant health outcomes not reported Reference - systematic review last updated 2006 Jul 28 (Cochrane Library

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2006 Issue 4:CD004944) addition of oxytocin infusion to oxytocin bolus reduces need for additional uterotonic agent but does not reduce risk of major obstetric hemorrhage in women having elective cesarean delivery (level 1 [likely reliable] evidence) based on randomized trial 2,069 women with singleton pregnancy having elective cesarean delivery at term randomized to 1 of 2 groups oxytocin bolus plus oxytocin infusion (included oxytocin 5 units bolus IV over 1 minute plus oxytocin 40 units infusion in 0.9% saline solution 500 mL over 4 hours) oxytocin bolus alone (included placebo infusion) major obstetric hemorrhage dened as blood loss > 1,000 mL comparing oxytocin bolus plus oxytocin infusion vs. oxytocin bolus alone major obstetric hemorrhage in 15.7% vs. 16% (not signicant) need for additional uterotonic agent in 12.2% vs. 18.4% (p < 0.001, NNT 16) Reference - BMJ 2011 Aug 1;343:d4661 full-text oxytocin IV bolus prior to infusion does not decrease need for additional uterotonics in women at high risk for atony having cesarean delivery (level 1 [likely reliable] evidence) based on randomized trial 143 women having cesarean delivery with ! 1 risk factor for uterine atony randomized to oxytocin 5 unit bolus vs. normal saline over 30 seconds after umbilical cord clamping all women received infusion of oxytocin 40 units in 500 mL normal saline over 30 minutes, followed by 20 units in 1 L over 8 hours no signicant difference in need for additional uterotonic in rst 24 hours after delivery (29% with oxytocin bolus vs. 40% with saline) side effects Reference - Anesth Analg 2010 Dec;111(6):1460 full-text addition of ergometrine to oxytocin may not affect hematocrit in cesarean section (level 3 [lacking direct] evidence) with more nausea and vomiting (level 2 [mid-level] evidence) based on small randomized trial 48 women having cesarean section for labor arrest randomized to oxytocin 20 units with vs. without ergometrine maleate 0.25 mg immediately following delivery unsatisfactory contractions after delivery treated with additional boluses of allocated drug blood loss estimated from hematocrit before and 48 hours after delivery comparing oxytocin plus ergometrine vs. oxytocin alone estimated blood loss 1,218 ml vs. 1,299 ml (not signicant)

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additional bolus for unsatisfactory contractions in 21% vs. 57% (p < 0.01, NNT 3) nausea in 42% vs. 9% (p < 0.01, NNH 3) vomiting in 25% vs. 4% (p < 0.05, NNH 5) Reference - BJOG 2008 Apr;115(5):579 EBSCOhost Full Text topical Hypericum perforatum reported to improve wound healing and scar formation after cesarean section (level 3 [lacking direct] evidence) based on randomized trial without clinical outcomes 144 women (mean age 23 years) randomized to Hypericum perforatum vs. placebo ointment 3 times daily for 16 vs. no treatment Hypericum perforatum associated with improved wound healing (p < 0.005) and scar formation (p < 0.0001) compared to placebo and control groups Reference - J Altern Complement Med 2010 Jan;16(1):113 music during planned cesarean section under regional anesthesia may improve pulse rate and maternal satisfaction (level 2 [mid-level] evidence) based on Cochrane review of limited, low quality evidence systematic review of randomized trials evaluating addition of music to standard care during cesarean section under regional anesthesia 1 trial with 64 women having planned cesarean section identied signicantly lower pulse rate at all time points in music group birth satisfaction score mean 3.38 points higher (on 35-point scale) in music group (p = 0.00021, 95% CI for mean difference 1.59-5.17 points) no signicant difference between groups in anxiety, blood pressure, SpO2, or respiration rate no data on infant outcomes Reference - Cochrane Database Syst Rev 2009 Apr 15;(2):CD006914 Procedural Management evidence-based recommendations for surgical technique blunt uterine incision expansion prophylactic antibiotics (either ampicillin or rst-generation cephalosporin for just 1 dose) spontaneous placental removal non-closure for both visceral and parietal peritoneum suture closure or drain of subcutaneous tissue when thickness 2 cm or greater Reference - systematic review of randomized trials (Am J Obstet Gynecol 2005 Nov;193(5):1607) Uterine incision: National Institute for Health and Clinical Excellence (NICE) recommendations for abdominal wall incision(1) transverse abdominal incision associated with reduced postoperative pain and improved cosmetic appearance compared to midline incision

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Joel-Cohen incision associated with shorter operating times and reduced postoperative febrile morbidity straight skin incision 3 cm above symphysis pubis subsequent tissue layers opened bluntly and extended with scissors instead of knife if necessary use of separate surgical knives for incision of skin and deeper tissue not recommended (does not decrease risk of wound infection) blunt extension of uterine incision recommended due to reduced blood loss, risk of postpartum hemorrhage, and need for transfusion Joel-Cohen incision has less postoperative morbidity than Pfannenstiel incision (level 1 [likely reliable] evidence) based on 2 Cochrane reviews by same authors Joel-Cohen and Pfannenstiel incisions are transverse lower abdominal skin incisions for cesarean delivery but also used to describe other aspects of surgical technique Joel-Cohen incision is higher than Pfannenstiel incision and with sharp dissection minimized; following initial skin incision, incision is extended by blunt nger dissection resulting in less intraoperative blood loss and less use of suture material systematic review of randomized trials evaluating different techniques for cesarean section compared to Pfannenstiel incision, Joel-Cohen incision associated with less blood loss (WMD -64.5 mL) in analysis of 5 trials with 481 women (p < 0.00001) shorter operating time (WMD -18.7 minutes) in analysis of 5 trials with 581 women (p < 0.00001), quantitative results limited by heterogeneity (p < 0.00001) reduced time to resumption of oral intake postoperatively (WMD -3.92 hours) in analysis of 5 trials with 481 women (p = 0.02), results limited by heterogeneity (p < 0.0001) less fever in analysis of 8 trials with 1,412 women (p = 0.006) shorter duration of postoperative pain (WMD -14.2 hours) in analysis of 2 comparisons from 1 trial with 172 women (p < 0.00001) fewer analgesic injections (WMD -0.92) in analysis of 2 trials with 151 women (p < 0.00001) shorter time from skin incision to birth of baby (WMD -3.84 minutes) in analysis of 5 trials with 575 women (p < 0.00001), results limited by heterogeneity p < 0.0001) Misgav-Ladach method (similar to Joel-Cohen method) associated with reduced blood loss (WMD -93 mL), operating time (WMD -7.3 minutes), time to mobilization (WMD -16.1 hours) and length of maternal postoperative stay (WMD -0.82 days) vs. traditional method (lower midline abdominal incision) in 1 trial with 339 women (p < 0.00001 for all

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comparisons) Misgav-Ladach method associated with longer time from skin incision to birth of baby (WMD 2.1 minutes) vs. modied Misgav-Ladach method in 1 trial with 116 women (p = 0.00004) Reference - systematic review last updated 2007 Nov 6 (Cochrane Library 2008 Issue 1:CD004662) systematic review of 4 randomized trials comparing abdominal incisions for cesarean section comparing Joel-Cohen vs. Pfannenstiel incisions postoperative fever in 3% vs. 8% (p = 0.02, NNT 20) in 2 trials with 411 women mean length of hospital stay 4.4 days vs. 5.9 days (p < 0.00001) in 1 trial with 101 women mean visual analog scale for "long term signicant wound pain" 3.7 vs. 5.6 (p < 0.00001) in 1 trial with 101 women comparing muscle cutting (Mouchel and Maylard) vs. Pfannenstiel incisions in 2 trials with 151 women, no differences found in rates of wound infection, blood transfusion or fever Reference - systematic review last updated 2006 Nov 7 (Cochrane Library 2007 Issue 1:CD004453) insufcient evidence to recommend most appropriate surgical technique for uterine incision during cesarean section based on Cochrane review systematic review of 15 randomized trials comparing various types and closure of uterine incision during cesarean section in 3,972 women compared to double layer uterine closure, single layer uterine closure associated with reduction in mean blood loss in analysis of 3 trials with 527 women (weighted mean difference [WMD] -70.11 mL, 95% CI -101.61 mL to -38.6 mL, p = 0.000013), results may be limited by heterogeneity (p = 0.03) shorter duration of operative procedure in analysis of 4 trials with 645 women (WMD -7.43 minutes, 95% CI -8.41 to -6.46 minutes, p < 0.00001), results may be limited by heterogeneity (p = 0.01) decreased postoperative pain in 1 trial with 158 women (45.8% with single layer vs. 66.7% with double layer, p = 0.0094, NNT 5) comparing sharp dissection vs. blunt dissection at time of uterine incision blunt dissection associated with reduced mean blood loss at the time of procedure in 1 trial with 945 women (mean difference [MD] -43 mL, 95% CI -66.12 mL to -19.88 mL, p = 0.00027) blood transfusion required in 1.9% vs. 0.42% in 1 trial with 945 women (p = 0.052) comparing auto-suture devices vs. traditional hysterotomy no signicant differences in amount of blood loss during procedure in 1

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trial with 200 women auto-suture instrument associated with longer duration of operative procedure in 1 trial with 197 women (MD 3.3 minutes, 95% CI -0.02 to 6.62 minutes, p = 0.052) Reference - Cochrane Database Syst Rev 2008 Jul 16;(3):CD004732 modied Stark's technique (Misgav-Ladach method) for cesarean section associated with fewer adhesions than Stark's or classic lower-segment cesarean section (level 3 [lacking direct] evidence) based on systematic review without clinical outcomes systematic review of 33 retrospective observational studies comparing adhesion formation after Stark's vs. modied Stark's vs. classic lower-segment cesarean section in 4,423 women having repeat cesarean section Stark's (MisgavLadach method) associated with increased adhesion formation compared to modied Stark's cesarean section (odds ratio [OR] 4.69, 95% CI 3.32-6.62) in analysis of 12 studies with 1,167 women modied Stark's cesarean section associated with decreased adhesion formation compared to classic lower-segment cesarean section (OR 0.28, 95% CI 0.10-0.82) in analysis of 2 studies with 295 women, results limited by signicant heterogeneity Stark's cesarean section associated with trend toward increased adhesion formation compared to classic lower-segment cesarean (OR 1.28, 95% CI 0.97-1.68) in analysis of 21 studies with 3,180 patients, results limited by signicant heterogeneity Reference - BJOG 2011 Mar;118(4):410 EBSCOhost Full Text Pfannenstiel incision reported to result in chronic pain in some women (level 3 [lacking direct] evidence) based on uncontrolled cohort study 886 women who had Pfannenstiel incisions for cesarean delivery or abdominal hysterectomy were sent questionnaire > 2 years after surgery 690 (80%) responded 223 (32%) reported chronic pain at incision site 7% reported moderate to severe pain 8.9% reported pain impaired daily activities risk factors for pain were numbness, recurrent Pfannenstiel surgery and emergency cesarean delivery Reference - Obstet Gynecol 2008 Apr;111(4):839 vertical incision associated with higher rate of wound infection than transverse incision in retrospective study of 239 obese women undergoing primary cesarean section (Obstet Gynecol 2003 Nov;102(11):952 in Am Fam Physician 2004 Jun 15;69(12):2918) transverse expansion of uterine incision associated with increased unintended incision extension and more blood loss compared to cephaladcaudad incision expansion (level 3 [lacking direct] evidence)

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based on randomized trial without clinical outcomes 811 women who had low-segment transverse cesarean section randomized to blunt expansion of uterine incision in transverse vs. cephalad-caudad direction comparing transverse vs. cephalad-caudad expansion groups unintended extension of incision in 7.4% vs. 3.7% (p = 0.03) estimated blood loss > 1,500 mL in 2.0% vs. 0.2% (p = 0.04) no signicant difference in transfusion (0.7% for both groups) Reference - Am J Obstet Gynecol 2008 Sep;199(3):292.e1 Closure of incisions after delivery: National Institute for Health and Clinical Excellence (NICE) recommendations(1) suture uterine incision with 2 layers (safety and efcacy of single layer closure unknown) closure of visceral and parietal peritoneum not recommended if midline abdominal incision used, mass closure of abdominal wall with slowly absorbable continuous sutures recommended (fewer incision hernias and less dehiscence compared to layered closure) routine closure of subcutaneous tissue space not recommended unless women has > 2 cm subcutaneous fat (does not reduce risk of wound infection) effects of different suture materials or methods for skin closure are uncertain use of blunt suture needles prevents glove perforations and needle stick injuries in surgical staff compared to sharp suture needles (level 1 [likely reliable] evidence) based on Cochrane review systematic review of 10 randomized trials comparing blunt vs. sharp suture needles for prevention of needle stick injuries in surgical staff 4 trials evaluated abdominal closure, and 2 trials each evaluated cesarean section, vaginal repair, and hip replacement use of blunt needles associated with reduced risk of glove perforations (risk ratio [RR] 0.46, 95% CI 0.38-0.54) in analysis of 10 trials fewer self-reported needle stick injuries in analysis of 5 trials with 1,017 patients RR 0.31 (95% CI 0.14-0.68) NNT 24-64 with 4.9% with needle stick injuries in sharp needle group Reference - Cochrane Database Syst Rev 2011 Nov 9;(11):CD009170 different approaches for uterine incision closure, peritoneum closure and subrectus sheath drain use have similar rates of maternal infectious morbidity (level 1 [likely reliable] evidence) based on randomized trial 3,033 women having their rst cesarean section were randomized to 1 of 2 conditions in each of 3 pairs of interventions

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1-layer closure vs. 2-layer closure of uterine incision closure vs. nonclosure of pelvic peritoneum liberal vs. restricted use of subrectus sheath drain maternal infectious morbidity dened as at least 1 of antibiotic use for maternal febrile morbidity during the postnatal hospital stay endometritis wound infection treated with antibiotics maternal infectious morbidity in 16.9% for 1-layer closure vs. 16.9% for 2-layer closure of uterine incision (not signicant) 16.3% for closure vs. 17.7% for nonclosure of pelvic peritoneum (not signicant) 17.9% for liberal vs. 16.6% for restricted use of subrectus sheath drain (not signicant) Reference - BJOG 2010 Oct;117(11):1366 EBSCOhost Full Text closure of uterine incision full-thickness suturing may reduce rate of incomplete healing of uterine incision (level 3 [lacking direct] evidence) based on randomized trial without clinical outcomes 78 term pregnant patients delivered by cesarean section randomized to full-thickness suturing of uterine incision vs. suturing excluding endometrial layer rate of incomplete healing based on ultrasound at 40-42 days was 45% vs. 69% (NNT 5) Reference - Eur J Obstet Gynecol Reprod Biol 2006 Jan 1;124(1):32 1-layer and 2-layer closure associated with similar effects on uterine scar thickness on ultrasound at 6 weeks (level 3 [lacking direct] evidence) based on randomized trial with 30 patients and without clinical outcomes Reference - Obstet Gynecol 2007 Oct;110(4):808, commentary can be found in Obstet Gynecol 2008 Feb;111(2 Pt 1):452 fundal uterine necrosis as a complication of uterine compression sutures in case report (Obstet Gynecol 2008 Aug;112(2 Pt 2):429) peritoneal closure non-closure of peritoneum saves 6-9 minutes of operating time with improved short-term postoperative outcome (less postoperative fever, reduced postoperative stay) based on Cochrane review no signicant differences in analgesic use, wound infection, endometritis, or (based on 1 trial) long-term morbidity Reference - systematic review of 9 controlled trials with 1,811 women last updated 2003 Mar 25 (Cochrane Library 2003 Issue 4:CD000163) parietal peritoneal closure at primary cesarean delivery may be

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associated with fewer adhesions (level 3 [lacking direct] evidence) prospective cohort study of 173 women having rst repeat cesarean delivery surgeons scored severity and location of adhesions patient records abstracted to assess prior surgical techniques, including parietal peritoneal closure outcomes for patients with vs. without prior parietal peritoneal closure 52% vs. 73% had dense and lmy adhesions (p = 0.006, NNT 5) 30% vs. 45% had dense adhesions (p = 0.043, NNT 7) Reference - Obstet Gynecol 2005 Aug;106(2):275 review of adhesion barriers at cesarean delivery can be found in Obstet Gynecol 2011 Jul;118(1):157 subcutaneous fat closure may reduce wound complications, but otherwise insufcient evidence to guide abdominal wall closure after cesarean section systematic review of 7 randomized trials with 2,056 women closure of subcutaneous fat (compared to non-closure) reduced risk of combined outcome of hematoma, seroma, wound infection or wound separation no differences in other short-term outcomes and long-term outcomes not reported no trials found evaluating suture techniques or materials for closure of rectus sheath or subcutaneous fat sharp vs. blunt needled did not affect risk of wound infection in 1 small trial Reference - systematic review last updated 2004 Jul 28 (Cochrane Library 2004 Issue 4:CD004663) skin closure staples associated with increased risk of wound infection or separation compared to subcuticular sutures (level 2 [mid-level] evidence) based on systematic review of mostly moderate quality trials systematic review of 6 studies (5 randomized trials, 1 prospective cohort study) evaluating risk of wound complications with staples vs. subcuticular suture closure of transverse skin incisions after cesarean delivery wound infection or separation in 13.4% with staples vs. 6.6% with sutures (p < 0.05, NNH 14) in analysis of 6 studies no signicant differences in pain, cosmesis or patient satisfaction Reference - Obstet Gynecol 2011 Mar;117(3):682 staples associated with less operative time and small decrease in postoperative pain without difference in incision appearance compared to subcuticular sutures for skin closure (level 1 [likely reliable] evidence) based on randomized trial 101 women having elective cesarean section randomized to skin closure with staples vs. subcuticular sutures comparing staple vs. sutures

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pain at 6 weeks 0.17 vs 0.51 on 0-10 visual analog scale (p = 0.04) operative time 24.6 vs. 32.9 minutes (p < 0.0001) no signicant differences in incision appearance and women's satisfaction Reference - Am J Obstet Gynecol 2009 Mar;200(3):265e1 staples associated with increased rate of wound separation compared to subcuticular sutures for skin closure after cesarean section (level 2 [mid-level] evidence) based on randomized trial with baseline differences 430 women having cesarean section randomized to skin closure with stainless steel staples vs. subcuticular sutures at baseline, staples group had signicantly greater rate of repeat cesarean delivery and chorioamnionitis comparing staples vs. subcuticular sutures median operating time 49 minutes vs. 57 minutes (p < 0.001) wound separation in 17% vs. 5% (p < 0.001, NNH 8) ofce visit before postpartum visit in 36% vs. 11% (p < 0.001) Reference - Am J Obstet Gynecol 2010 Sep;203(3):285.e1 staples and subcuticular sutures for skin closure may result in similar cosmetic appearance following cesarean section (level 2 [mid-level] evidence) based on randomized trial with high dropout rate 180 women having cesarean section randomized to skin closure with staples vs. subcuticular sutures and followed for 6 months 68.3% completed trial no signicant differences in subjective and objective scar ratings at 2 and 6 months Reference - Am J Obstet Gynecol 2010 Jul;203(1):36.e1 earlier Cochrane review found no conclusive evidence to guide skin closure after cesarean section only 1 randomized trial found with 66 women, comparing staples vs. absorbable sub-cuticular suture staples shortened operating time but increased postoperative pain and had worse cosmetic result at postoperative visit Reference - systematic review last updated 2002 Oct 4 (Cochrane Library 2003 Issue 2:CD003577) wound drainage does not appear to reduce risk of infection or complications after cesarean section (level 2 [mid-level] evidence) based on 2 systematic reviews of trials with methodologic limitations wound drainage does not appear to reduce risk of infection or complications after cesarean section (level 2 [mid-level] evidence) based on Cochrane review of trials with blinding of outcome assessor not stated systematic review of 9 randomized trials evaluating wound drainage after

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cesarean section in 2,421 women no signicant differences comparing wound drain vs. no drain in risk of wound infection, other wound complications, febrile morbidity or endometritis 1 trial reported signicant increase in wound infection with subcutaneous drain compared to a sub-sheath drain no signicant difference in outcomes comparing subcutaneous drain vs. subcutaneous suturing in 3 trials Reference - Cochrane Database Syst Rev 2010 Sep 8;(9):CD004549 prophylactic subcutaneous drainage does not appear effective in reducing wound complications after cesarean delivery (level 2 [mid-level] evidence) based on systematic review with methodologic limitations systematic review and meta-analysis of 6 randomized trials of prophylactic subcutaneous drainage compared with no drainage in 1,066 women after cesarean delivery 2 trials did not conduct intention-to-treat analysis no signicant difference in seroma, hematoma, wound infection or wound separation comparing subcutaneous drainage vs. no drainage Reference - Am J Obstet Gynecol 2007 Sep;197(3):229 Additional considerations: National Institute for Health and Clinical Excellence (NICE) recommendations(1) use forceps only if there is difculty delivering baby's head use slow injection of oxytocin 5 units IV to encourage uterine contraction and reduce blood loss remove placenta using controlled cord traction to reduce risk of endometritis compared to manual removal intraperitoneal repair of uterus should be performed, but exteriorization of uterus not recommended supercial wound drains not recommended (no associated decrease in risk of wound infection or hematoma) measure umbilical artery pH after all cesarean sections to assess fetal compromise, review fetal wellbeing, and guide ongoing care of baby manual removal of placenta at cesarean section associated with higher complication rate (level 2 [mid-level] evidence) based on Cochrane review limited by heterogeneity systematic review of 15 randomized trials comparing manual removal vs. cord traction for delivery of placenta at cesarean section in 4,694 women review limited by heterogeneity for duration of surgery, blood loss, and hematologic outcomes comparing manual removal vs. cord traction

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endometritis in 18.4% vs. 11.% in analysis of 13 trials with 4,134 women (p < 0.00001, NNH 14), results may be limited by heterogeneity (p = 0.06) blood loss > 1,000 mL in 34.1% vs. 18.9% in analysis of 2 trials with 872 women (p < 0.00001, NNH 6) manual removal associated with more operative blood loss in analysis of 8 trials with 2,001 women (WMD 94.42 mL, 95% CI 17.2-171.6 mL, p = 0.017), results may be limited by heterogeneity (p < 0.00001) manual removal associated with lower hematocrit after delivery in analysis of 2 trials with 384 women (WMD -1.55, 95% CI -3.09 to -0.01, p = 0.048) manual removal associated with longer hospital stay in analysis of 3 trials with 546 women (WMD 0.39 days, 95% CI 0.17-0.61, p = 0.0005) no signicant differences in feto-maternal hemorrhage, blood transfusion, puerperal fever, but small numbers of women evaluated Reference - Cochrane Database Syst Rev 2008 Jul 16;(3):CD004737 insufcient data to support or refute routine use of uterine exteriorization for repair compared to intra-abdominal repair of uterine incision based on 2 systematic reviews and subsequent randomized trials based on systematic review systematic review of 11 randomized trials evaluating extraabdominal vs. intraabdominal uterine incision repair in 3,183 women no signicant difference among groups in intraoperative complications postoperative complications operative time estimated blood loss length of hospital stay Reference - BECOME study (Am J Obstet Gynecol 2009 Jun;200(6):625e1) Cochrane review systematic review of 6 randomized trials comparing uterine exteriorization with intra-abdominal repair of uterine incision with 1,294 women 1,221 women analyzed no signicant differences in most outcomes extra-abdominal closure of uterine incision associated with less febrile morbidity but increased length of hospital stay (by 0.24 days) Reference - systematic review last updated 2004 Jul 29 (Cochrane Library 2004 Issue 4:CD000085) uterine exteriorization and in situ uterine incision repair appear to have similar clinical outcomes (level 2 [mid-level] evidence) based on randomized trial without blinding of outcome assessment and incomplete follow-up 670 women with indication for cesarean section (emergent or elective) at ! 24 weeks gestation randomized to uterine exteriorization vs. in situ repair

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of uterine incision comparing exteriorization vs. in situ repair surgeries lasting " 45 minutes in 44% vs. 35.3% (p = 0.024, NNT 12, 95% CI 6-100) mean duration of surgery 50.1 vs. 52.5 minutes moderate to severe pain 6 hours postoperatively in 32.6% vs. 23.1% (p = 0.026, NNT 11, 95% CI 6-50) length of hospital stay > 3 days in 56.6% vs. 56.7% (not signicant) comparing exteriorization vs. in situ repair in 581 patients who returned for hospital visit 7-30 days postoperatively surgical site infection in 7.1% vs. 8.7% (not signicant) endometritis in 1.7% vs. 2.1% (not signicant) maternal death in 2 vs. 0 women (not signicant) no signicant difference in nausea, vomiting, intraoperative blood loss, number of postoperative analgesic doses, or days of hospitalization Reference - Obstet Gynecol 2008 Mar;111(3):639, correction can be found in Obstet Gynecol 2008 Jul;112(1):188, commentary can be found in Obstet Gynecol 2008 Jul;112(1):183 uterine exteriorization associated with increased nausea and vomiting and slightly shorter uterine repair time based on randomized trial 80 women having elective cesarean delivery under spinal anesthesia randomized to exteriorized vs. in situ uterine repair comparing exteriorization vs. in situ repair (intraoperatively postdelivery) 38% vs. 18% had nausea or vomiting (p = 0.04, NNH 5) 18% vs. 3% had tachycardia (p = 0.03, NNH 6) 28% vs. 15% had hypotension (not signicant) 26% vs. 13% had pain (not signicant) median duration of uterine repair 10 vs. 11 minutes (p = 0.04) no signicant differences in duration of surgery (median 36 vs. 37 minutes) or estimated blood loss (mean 625 vs. 653 mL) Reference - Obstet Gynecol 2007 Sep;110(3):570 DynaMed commentary -- results consistent with meta-analyses in Cochrane review but might not be sufcient to make overall meta-analyses statistically signicant fetal blood drainage prior to placental delivery appears to reduce risk of feto-maternal transfusion (level 3 [lacking direct] evidence) based on randomized trial without clinical outcomes 86 women aged 15-40 years having cesarean delivery randomized to placental drainage vs. no placental drainage before placental delivery placental drainage dened as cutting and milking umbilical cord until no blood ow occurred all placentas spontaneously expelled

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6.8% (3 of 44) women with placental drainage vs. 33% (14 of 42) without draining had feto-maternal transfusion (p = 0.003, NNT 4) Reference - Obstet Gynecol 2007 Sep;110(3):608 mechanical dilation of cervix may not reduce postoperative morbidity in women having cesarean section (level 2 [mid-level] evidence) based on Cochrane review with wide condence intervals systematic review of 3 randomized trials comparing intraoperative cervical dilation to no dilation in 735 women having elective cesarean section wide condence intervals cannot exclude benet or harm of mechanical dilation no signicant difference between groups in febrile morbidity in analysis of 3 trials wound infection in analysis of 3 trials (no infections reported in 2 trials with 335 women) no trials reported on primary outcome of postpartum hemorrhage Reference - Cochrane Database Syst Rev 2011 Nov 9;(11):CD008019 Quality Improvement Medicare/Joint Commission National Hospital Inpatient Quality Measures: Perinatal Care (PC) measures PC-1 Elective Delivery measured as proportion of patients delivering newborns with 37-39 weeks of gestation completed who have elective deliveries (medical induction of labor or cesarean section) PC-2 Cesarean Section measured as proportion of nulliparous patients delivered of a live term singleton newborn in vertex presentation who have a cesarean section see Medicare/Joint Commission National Hospital Inpatient Quality Measures for additional information Safety checklists: American College of Obstetricians and Gynecologists (ACOG) Patient Safety Checklist 3 on scheduling planned cesarean delivery can be found in Obstet Gynecol 2011 Dec;118(6):1469 ACOG Patient Safety Checklist 4 on preoperative planned cesarean delivery can be found in Obstet Gynecol 2011 Dec;118(6):1471 Guidelines and Resources Patient Information References You are viewing a DynaMed summary. Use of DynaMed indicates acceptance of DynaMed Terms of Use. Limitations of DynaMed are contained in the DynaMed Terms of Use.

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