Postpartum Hemorrhagic Morbidity with Scheduled versus Unscheduled Cesarean Delivery at Term

Rachel L. Wiley; Suneet P. Chauhan; Emily A. Johnson; Ipsita Ghose; Hailie N. Ciomperlik; Hector Mendez-Figueroa

doi:10.1055/a-2437-0759

American Journal of Perinatology, Table of Contents

Am J Perinatol 2025; 42(07): 883-890
DOI: 10.1055/a-2437-0759

Original Article

Postpartum Hemorrhagic Morbidity with Scheduled versus Unscheduled Cesarean Delivery at Term

Authors

Rachel L. Wiley

¹Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, California
Suneet P. Chauhan

²Delaware Center of Maternal-Fetal Medicine at ChristianaCare, Newark, Delaware
Emily A. Johnson

³Department of Obstetrics and Gynecology, Baylor School of Medicine, Houston, Texas
Ipsita Ghose

³Department of Obstetrics and Gynecology, Baylor School of Medicine, Houston, Texas
Hailie N. Ciomperlik

²Delaware Center of Maternal-Fetal Medicine at ChristianaCare, Newark, Delaware
Hector Mendez-Figueroa

⁴Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas

Abstract

Objective

This study aimed to compare the composite maternal hemorrhagic outcomes (CMHOs) among term (≥37 weeks) singletons who had scheduled versus unscheduled cesarean deliveries (CDs). A subgroup analysis was done for those without prior uterine surgeries.

Study Design

Retrospectively, we identified all singletons at term who had CDs. The unscheduled CDs included individuals admitted with a plan for vaginal delivery with at least 1 hour of attempted labor. CMHOs included any of the following: estimated blood loss of ≥1,000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to intensive care unit, or maternal death. Multivariable Poisson regression models with robust error variance were used to estimate adjusted relative risks (aRRs) with 95% confidence intervals (CIs).

Results

Of 8,623 deliveries in the study period, 2,691 (31.2%) had CDs at term, with 1,709 (67.3%) scheduled CDs, and 983 (36.5%) unscheduled CDs. Overall, the rate of CMHO was 23.3%, and the rate of blood transfusion was 4.1%. CMHOs were two-fold higher among unscheduled (34.5%) than scheduled CDs (16.9%; aRR = 2.18; 95% CI: 1.81–2.63). The aRRs for blood transfusion and surgical interventions to manage postpartum hemorrhage were three times higher with unscheduled than scheduled CDs. The subgroup analysis indicated that among the cohorts without prior uterine surgery, the rate of the CMHOs was significantly higher when the CD was unscheduled versus scheduled (aRR = 1.85; 95% CI: 1.45–2.37).

Conclusion

Compared to scheduled CDs, the composite hemorrhagic adverse outcomes were significantly higher with unscheduled CDs.

Key Points

Unscheduled cesareans are at higher risk of hemorrhage.
Unscheduled cesareans are at higher risk of transfusion.
Atony treatment is higher in unscheduled cesareans.

Keywords

postpartum hemorrhage - cesarean delivery - transfusion - uterotonics

Full Text

References

References
1 Hamilton BE, Martin JA, Osterman MJK. Births: Provisional data for 2022. NCHS Vital Statistics Rapid Release; no 28. Hyattsville, MD: CDC | National Center for Health Statistics; . June 2023
2 Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum hemorrhage. Obstet Gynecol 2017; 130 (04) e168-e186
3 Sentilhes L, Sénat MV, Le Lous M. et al; Groupe de Recherche en Obstétrique et Gynécologie. Tranexamic acid for the prevention of blood loss after cesarean delivery. N Engl J Med 2021; 384 (17) 1623-1634
4 Pacheco LD, Clifton RG, Saade GR. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Tranexamic acid to prevent obstetrical hemorrhage after cesarean delivery. N Engl J Med 2023; 388 (15) 1365-1375
5 Backley S, Chen HY, Sibai BM, Chauhan SP, Fishel Bartal M. The association between number of repeat cesarean deliveries and adverse outcomes among low-risk pregnancies. Int J Gynaecol Obstet 2022; 159 (01) 246-253
6 Magann EF, Evans S, Hutchinson M, Collins R, Lanneau G, Morrison JC. Postpartum hemorrhage after cesarean delivery: an analysis of risk factors. South Med J 2005; 98 (07) 681-685
7 Cerra C, Morelli R, Di Mascio D. et al. Maternal outcomes of cesarean delivery performed at early gestational ages: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2021; 3 (04) 100360
8 Harper LM, Caughey AB, Roehl KA, Odibo AO, Cahill AG. Defining an abnormal first stage of labor based on maternal and neonatal outcomes. Am J Obstet Gynecol 2014; 210 (06) 536.e1-536.e7
9 Blankenship SA, Raghuraman N, Delhi A. et al. Association of abnormal first stage of labor duration and maternal and neonatal morbidity. Am J Obstet Gynecol 2020; 223 (03) 445.e1-445.e15
10 Goetzl L. Maternal fever in labor: etiologies, consequences, and clinical management. Am J Obstet Gynecol 2023; 228 (5S): S1274-S1282
11 Conde-Agudelo A, Romero R, Jung EJ, Garcia Sánchez ÁJ. Management of clinical chorioamnionitis: an evidence-based approach. Am J Obstet Gynecol 2020; 223 (06) 848-869
12 Gimovsky AC, Pham A, Ahmadzia HK, Sparks AD, Petersen SM. Risks associated with cesarean delivery during prolonged second stage of labor. Am J Obstet Gynecol MFM 2021; 3 (01) 100276
13 Cheng YW, Hopkins LM, Caughey AB. How long is too long: does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?. Am J Obstet Gynecol 2004; 191 (03) 933-938
14 Ghose I, Wiley RL, Ciomperlik HN. et al. Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage. Am J Obstet Gynecol MFM 2023; 5 (10) 101106
15 Schwartzenburg C, Wiley RL, Ghose I, Ciomperlik HN, Chauhan SP, Mendez-Figueroa H. Postpartum hemorrhage risk stratification: association of adverse outcomes with and without documentation. Am J Obstet Gynecol MFM 2024; 6 (04) 101262
16 Mendez-Figueroa H, Chauhan SP, Pedroza C, Refuerzo JS, Dahlke JD, Rouse DJ. Preterm cesarean delivery for nonreassuring fetal heart rate: neonatal and neurologic morbidity. Obstet Gynecol 2015; 125 (03) 636-642
17 Silver RM, Landon MB, Rouse DJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
18 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 2014; 12 (12) 1495-1499
19 Fink DA, Kilday D, Cao Z. et al. Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations in the United States, 2008 to 2021. JAMA Netw Open 2023; 6 (06) e2317641
20 Rouse DJ, MacPherson C, Landon M. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Blood transfusion and cesarean delivery. Obstet Gynecol 2006; 108 (04) 891-897 Erratum in: Obstet Gynecol 2006;108:1556
21 Cheema HA, Ahmad AB, Ehsan M. et al. Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol MFM 2023; 5 (08) 101049
22 Talati C, Carvalho JCA, Luca A, Balki M. The effect of intermittent oxytocin pretreatment on oxytocin-induced contractility of human myometrium in vitro. Anesth Analg 2019; 128 (04) 671-678
23 Zackler A, Flood P, Dajao R, Maramara L, Goetzl L. Suspected chorioamnionitis and myometrial contractility: mechanisms for increased risk of cesarean delivery and postpartum hemorrhage. Reprod Sci 2019; 26 (02) 178-183
24 Epstein D, Solomon N, Korytny A. et al. Association between ionised calcium and severity of postpartum haemorrhage: a retrospective cohort study. Br J Anaesth 2021; 126 (05) 1022-1028
25 Wright PD, Kanumilli S, Tickle D. et al. A high-throughput electrophysiology assay identifies inhibitors of the inwardly rectifying potassium channel Kir7.1. J Biomol Screen 2015; 20 (06) 739-747
26 Little SE, Clapp MA, Lassey S, Bukowski R, Barth Jr WH, Robinson J. Maternal morbidity in the second stage of labor: analysis to simulate the clinical choice. Am J Perinatol 2022; 41: e312-e317
27 American College of Obstetricians and Gynecologists. Informed Consent and Shared Decision Making in Obstetrics and Gynecology: ACOG Committee Opinion, Number 819. Obstet Gynecol 2021; 137 (02) e34-e41
28 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 761: Cesarean delivery on maternal request. Obstet Gynecol 2019; 133 (01) e73-e77
29 Kabir AA, Steinmann WC, Myers L. et al. Unnecessary cesarean delivery in Louisiana: an analysis of birth certificate data. Am J Obstet Gynecol 2004; 190 (01) 10-19 , discussion 3A
30 Naef III RW, Chauhan SP, Chevalier SP, Roberts WE, Meydrech EF, Morrison JC. Prediction of hemorrhage at cesarean delivery. Obstet Gynecol 1994; 83 (06) 923-926

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