Is Foley Catheter Use during a Trial of Labor after Cesarean Associated with Uterine Rupture?

OBJECTIVE: We sought to assess the safety of transcervical Foley catheter (TCF) placement for cervical ripening in women undergoing induction of labor (IOL) after prior cesarean by evaluating the risk of uterine rupture. STUDY DESIGN: We performed a secondary analysis of the Maternal-Fetal Medicine Unit's Cesarean Section Registry, a prospective observational cohort study. We included women with a history of ≤2 low-transverse cesarean deliveries who underwent IOL at ≥24 weeks of gestational age with a live singleton fetus without major anomalies. We excluded those who received prostaglandins or laminaria. We performed multinomial logistic regression to calculate adjusted odds ratios (aORs) for uterine rupture and dehiscence. Relevant confounders included prior vaginal delivery, pregnancy-induced hypertension, chorioamnionitis, and cervical effacement and dilation on admission. RESULTS: A total of 2,564 women were eligible. Unadjusted analysis demonstrated no increased risk of uterine rupture with TCF (1.9 vs. 0.9%; p = 0.10) but an increased risk of uterine dehiscence (1.9 vs. 0.6%; p = 0.02). After adjustment, TCF was not associated with an increased risk of uterine rupture (aOR: 2.02; 95% confidence interval [CI]: 0.71-5.78) or uterine scar dehiscence (aOR: 1.32; 95% CI: 0.37-4.72). CONCLUSION: Foley catheter is a safe tool for mechanical dilation in women undergoing IOL after prior cesarean.

Same-Day Discharge After Laparoscopic Hysterectomy for Endometrial Cancer.

PURPOSE: The aim of this study was to investigate the relationship between same-day discharge (SDD) and postoperative complications within 30 days of laparoscopic hysterectomy for endometrial cancer and endometrial intraepithelial neoplasia (EIN). METHODS: This single-institution retrospective cohort included all patients who underwent conventional and robotic-assisted laparoscopic hysterectomy for endometrial cancer or EIN in a large teaching hospital between 2011 and 2013. Temporal trends in frequency of SDD and rates of postoperative complications were investigated to assess whether adoption of routine SDD was associated with increased postoperative complications. Associations between SDD and postoperative complications were also investigated in univariate and multivariate models. RESULTS: Overall, 696 patients underwent laparoscopic hysterectomy. Of these, 37.1 % had pelvic lymphadenectomy, 3.0 % had para-aortic lymphadenectomy, and 9.3 % underwent omentectomy. The rate of SDD increased from 3.9 to 69.6 % during the study period (p < 0.001), and the frequency of postoperative readmission, unscheduled surgery, infection, and composite complications within 30 days of hysterectomy did not differ during the study period. The composite complication rate did not differ significantly between patients who underwent surgery before and after the adoption of routine SDD (rate ratio 0.7, 95 % CI 0.4-1.2, p = 0.24). After controlling for demographic, intraoperative, and comorbid factors, patients who underwent SDD were not at increased risk for postoperative complications. CONCLUSIONS: Adoption of routine SDD after laparoscopic surgery for endometrial cancer and EIN did not result in increased complication rates within our institution. A larger prospective study is required to definitively establish the safety of this approach.

Institutional prevalence of class III obesity modifies risk of adverse obstetrical outcomes.

BACKGROUND: Women with prepregnancy class III obesity (body mass index ≥40 kg/m2) are at an increased risk of perinatal complications and adverse obstetrical outcomes. Estimates of the magnitude of risk that these women face vary widely, which may reflect differences in institutional experience caring for women with obesity. OBJECTIVE: We sought to characterize the relationship between institutional prevalence of prepregnancy class III obesity and the risk of adverse perinatal outcomes among these women, hypothesizing that higher-prevalence institutions would have lower rates of adverse maternal and perinatal outcomes among this population. STUDY DESIGN: We conducted a retrospective cohort study using chart-abstracted data on births in Washington state from Jan. 1, 2012, to Dec. 31, 2017. The analysis was restricted to hospitals that delivered at least 1 patient per month with prepregnancy class III obesity. Institutional prevalence of prepregnancy class III obesity was calculated, and hospitals were classified as either high or low prevalence. We included nulliparous women with vertex-presenting singleton pregnancies at ≥37 weeks of gestation. We excluded births with missing initial body mass index. The primary outcome was the incidence of cesarean delivery. Secondary outcomes were induction of labor, postpartum complications, postpartum readmission, and neonatal intensive care unit admissions. We compared outcomes between women with prepregnancy class III and all obesity at high- and low-prevalence hospitals using the χ2 test or the Fishers exact test as appropriate. Binary logistic regression was performed to compare outcomes at high- and low-prevalence hospitals. A hospital-adjusted multivariable regression model that controlled for baseline institutional rates of each outcome and compared outcomes between high- and low-prevalence hospitals was developed. A final multivariable logistic regression that controlled for both baseline institutional variation as well as potential clinical confounders was performed. RESULTS: A total of 20,556 women at 6 hospitals were eligible for inclusion; the prevalence of prepregnancy class III obesity was 6.2% and 2.1% in high- and low-prevalence hospitals, respectively. Obese women, including those with class III obesity in a high-prevalence hospital, were more likely to be Latina and less likely to be of advanced maternal age and carry private insurance. After adjusting for the institutional cesarean delivery rate, women with prepregnancy class III obesity had significantly increased odds of cesarean delivery (odds ratio, 1.53, 95% confidence interval, 1.12-2.10); however, after adjusting for significant covariates, the association no longer achieved significance (odds ratio, 1.68, 95% confidence interval, 0.97-2.94). The hospital-adjusted odds of postpartum readmission were significantly increased for women with prepregnancy class III obesity when delivering in low-prevalence institutions (odds ratio, 6.61, 95% confidence interval, 1.93-22.56), and the association was further strengthened after controlling for significant covariates (odds ratio, 15.20, 95% confidence interval, 2.32-99.53). None of the models demonstrated significantly different odds of induction of labor, postpartum complications, or neonatal intensive care unit admission by institutional prevalence of prepregnancy class III obesity. CONCLUSION: Even after controlling for underlying hospital and subject characteristics, women with prepregnancy class III obesity had significantly increased odds of postpartum readmission, and a trend toward increased odds of cesarean delivery, when delivering in institutions with less experience caring for women with obesity.

Cesarean Delivery in Adolescents.

STUDY OBJECTIVE: To examine the effect of maternal age on indication for primary cesarean delivery in low-risk nulliparous women. DESIGN: Retrospective cohort study. SETTING: Urban academic tertiary care center. PARTICIPANTS: Nulliparous women younger than 35 years of age delivering vertex-presenting singletons at term. INTERVENTIONS: Participants underwent spontaneous, operative or cesarean delivery. MAIN OUTCOME MEASURES: Mode of delivery, indication, and timing of cesarean delivery. RESULTS: Adolescents were half as likely to undergo cesarean delivery overall (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.43-0.54), and more than one-third less likely to undergo cesarean delivery in labor (OR, 0.59; 95% CI, 0.53-0.66). Adjustment for potential confounders did not alter the strength of these associations. Adolescents were half as likely to undergo cesarean delivery for failure to progress (OR, 0.49; 95% CI, 0.43-0.54). There was no difference in the odds of cesarean delivery for nonreassuring fetal status (OR, 0.91; 95% CI, 0.77-1.06), or genital herpes (OR, 1.44; 95% CI, 0.57-3.68). Induction, macrosomia, oxytocin augmentation, and any labor complication were all associated with increased risk of cesarean delivery. There was no difference in the duration of second stage for adolescents who delivered by cesarean delivery compared with adults (240.0 vs 237.7 minutes; P = .84), but adolescents who delivered vaginally had a second stage that was one-third shorter than adults (62.5 vs 100.3 minutes; P < .001). CONCLUSION: Adolescents are half as likely to undergo primary cesarean delivery overall, and 40% less likely to undergo a primary cesarean delivery in labor, even after adjustment for multiple maternal, neonatal, and labor characteristics. This difference is not explained by differences in the duration of the second stage of labor.