Cesarean section prior to 28 weeks' gestation: which type of uterine incision is optimal?

OBJECTIVE: The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy. METHODS: This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery. RESULTS: There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 - 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03. CONCLUSION: In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.

Preterm prelabor rupture of membranes prior to 33 0/7 weeks: when should rescue corticosteroids be given?

OBJECTIVE: To determine an optimal timing strategy for rescue corticosteroids in gravidas with preterm prelabor rupture of membranes (PPROM) prior to 33 0/7 weeks. METHODS: This was a retrospective cohort analysis of 109 gravidas with a singleton gestation and PPROM between 23 0/7 and 32 6/7 weeks who delivered at a single inner city tertiary care center. The time of the actual first dose of corticosteroids was chosen as Time 0. The date and time of labor onset, chorioamnionitis, heavy bleeding, cord prolapse, or fetal heart rate decelerations warranting delivery were recorded, as well as the date and time of delivery. We then compared hypothetical timing strategies for administration of the rescue course of corticosteroids at either 1, 2, or 3 weeks after the first course if still undelivered, compared to a strategy of withholding the rescue course until the recognition of spontaneous labor or the need for delivery. For each strategy, we calculated the percentage of gravidas who would have delivered within the optimal window after rescue course corticosteroids, defined as delivery at 24 h to 7 days from the first rescue dose. RESULTS: The median time from PPROM to delivery among the 109 gravidas was 8.9 days (interquartile range 4.4-17.9 days). Forty-eight (44%) gravidas delivered within the first week after initial corticosteroid administration, leaving 61 (56%) eligible for a rescue dose. In our hypothetical models, the strategy of giving rescue corticosteroids at either 1, 2, or 3 weeks from the first course would have resulted in 34.4%, 23.0%, and 19.7% of infants being born at 24 h to 7 days after the first rescue dose, respectively. These differences among the three groups or between any two groups were not statistically significant. However, all fixed interval strategies were statistically superior to the strategy of waiting for spontaneous labor or the need for delivery, in which only 4.9% would have delivered within the optimal window. CONCLUSION: In gravidas with PPROM prior to 33 0/7 weeks, giving rescue corticosteroids at a fixed interval of either 1, 2, or 3 weeks after the first course would result in a greater percentage of infants being born within the optimal 24 h to 7 day window compared to administering the rescue course at the onset of labor, infection, bleeding, or abnormal fetal heart rate tracing.

Cervical length measurement by translabial sonography in women with preterm premature rupture of membranes: can it be used to predict the latency period or peripartum maternal infection?

OBJECTIVES: To determine the relationship between the translabial cervical length and the latency period or peripartum maternal infection in women with preterm premature rupture of membranes (PPROM). METHODS: Fifty-five women with a singleton gestation and PPROM between 24 and 34 weeks who had a translabial ultrasound performed within 24 hours of membrane rupture were included in the study. Translabial sonography was performed to assess cervical length and funneling. Ultrasound results were not made available to the managing obstetricians. RESULTS: The mean gestational age at PPROM in our cohort was 29.7 +/- 2.8 weeks. The mean translabial cervical length was 2.8 +/- 1.1 cm, and the median latency period was 10 days (interquartile range 4-15 days). There was no statistically significant correlation between cervical length and latency period (r = 0.15, p = 0.28). Additionally, latency periods less than seven days were not associated with cervical length cutoffs of 2.5 cm or 1.5 cm, or the presence of cervical funneling. Similarly, none of these criteria were associated with the development of either chorioamnionitis or postpartum endometritis. CONCLUSIONS: Cervical length by translabial sonography was not associated with duration of the latency period or peripartum maternal infection in women with PPROM.

Does physician attire influence patient satisfaction in an outpatient obstetrics and gynecology setting?

OBJECTIVE: The purpose of our study was to determine whether physician attire played a role in patient satisfaction after a new obstetrician/gynecologist encounter. STUDY DESIGN: Over a 3-month period, 20 physicians were randomly assigned to dress in business attire, casual clothing, or scrub suit each week. One thousand one hundred sixteen patients who had an office visit with a new obstetrician/gynecologist for at least 10 minutes completed a satisfaction survey, which assessed patient comfort as well as perception of the competency and professionalism of the physician. Patients were blinded to the physician attire manipulation. RESULTS: There was no difference in the mean overall satisfaction score among the 3 physician attire groups. No differences existed in satisfaction scores when analyzed by individual survey item or by demographic factors, after controlling for attire. CONCLUSION: Patients are equally satisfied with physicians who dress in business attire, casual clothing, or scrub suit.

Attitudes of obstetrics and gynecology residents toward abortion participation: a Philadelphia area survey.

OBJECTIVE: The objective of this study was to evaluate the willingness of Philadelphia obstetrics and gynecology residents to participate in three abortion procedures for various fetal conditions. METHODS: Anonymous questionnaires were distributed to 310 residents from 18 programs. The survey asked the residents whether they would participate in first trimester dilatation and evacuation (D&E), second trimester prostaglandin induction or second trimester D&E for the following conditions: lethal fetal anomaly, nonlethal anomaly with certain long-term functional consequences, possible long-term functional consequences, little or no long-term functional consequences and elective abortion of a normal fetus. RESULTS: Of the 148 respondents, the percentage of residents who would participate in a second trimester D&E for each fetal condition was significantly lower than that for a first trimester D&E (p < or = .001). Additionally, for each abortion procedure, the participation rates consistently fell for lesser degrees of fetal severity. Participation was significantly associated with preferences regarding abortion legislation and personal abortion stance. CONCLUSION: Resident attitudes regarding abortion participation were related to severity of the fetal condition, gestational age and procedure type.

Cervical dilatation thresholds for initiation of group B streptococcus antibiotic prophylaxis for women with spontaneous preterm labor.

OBJECTIVE: To determine the optimal time for initiating group B streptococcus (GBS) antibiotic prophylaxis for women in spontaneous preterm labor. METHODS: In total, 227 women delivering singleton infants after presenting with spontaneous preterm labor and intact membranes at 24 0/7-36 6/7 weeks were evaluated, as well as 150 undelivered women with threatened preterm labor during the same time period. The date and time of each cervical examination throughout labor were recorded. We calculated the percentages who would have correctly received at least 4 h of GBS prophylaxis if antibiotics were routinely initiated for various cervical dilatation thresholds during labor, as well as the percentage of undelivered women who would have received unnecessary antibiotic exposure at each cervical dilatation cutoff. RESULTS: Delaying antibiotics until cervical dilatation reached 2 cm or greater would have resulted in 62.1% receiving four or more hours of antibiotics, compared to 66.5% if antibiotics were started on all women at admission (p = 0.33), while significantly reducing unnecessary antibiotic exposure in undelivered women from 100% to 62.0% (p < 0.001). The 2-cm threshold was applicable regardless of gestational age period or prior vaginal delivery ≥ 20 weeks. CONCLUSIONS: GBS antibiotic prophylaxis may reasonably be withheld for women with suspected preterm labor until the cervix reaches 2 cm or greater at any time during labor.

Small-group discussion versus lecture format for third-year students in obstetrics and gynecology.

OBJECTIVE: To compare lecture and small-group discussion for third-year medical students in obstetrics and gynecology. METHODS: Over a 2-year period, 91 third-year medical students in the obstetrics and gynecology clerkships were given educational sessions on diabetes and hypertension in pregnancy by a single instructor, either in a traditional lecture format or in a small-group discussion. After the instructional sessions, students anonymously completed a 20-question multiple-choice examination on the covered topics. They also completed an evaluation form on the instructional format, using a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). At the completion of each clerkship, students repeated the same multiple-choice examination. RESULTS: There was a significantly higher level of enjoyment (median value 5 versus 4, P <.001) and sense of educational stimulation (median value 5 versus 4, P <.001) in the discussion group, and students in the discussion group were less desirous of the alternate instructional format than those in the lecture group (median value 2 versus 3, P <.001). However, there were no differences in the test scores, either immediately after the instructional sessions or at the end of the clerkships. There was a 90% power to detect a 15% difference in postinstructional test scores. CONCLUSION: Third-year medical students learning about hypertension and diabetes in pregnancy during their obstetrics and gynecology clerkship strongly preferred small-group discussions over traditional lectures. However, this preference did not lead to improved test scores on these subjects.