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Randomized study of nonclosure or closure of the peritoneum at cesarean delivery in 123 women: The impact of the interval to the next pregnancy
S126 SMFM Abstracts 427 RANDOMIZED STUDY OF NONCLOSURE OR CLOSURE OF THE PERITONEUM AT CESAREAN DELIVERY IN 123 WOMEN: THE IMPACT OF THE INTERVAL TO THE NEXT PREGNANCY YOSHIKO KOMOTO1, SHIMOYA KOICHIRO1, SHIMIZU TAKASHI2, SON MIHYON1, KINUGASA YUKIKO1, TSUBOUCHI HIROAKI1, HAYASHI SHUSAKU1, MARI TOMIIE3, FUKUDA HIROTSUGU1, WASADA KENSHI1, MURATA YUJI1, 1Osaka University, Obstetrics and Gynecology, Suita, Osaka, Japan, 2Shimizu womens’ clinic, Takarazuka, Japan, 3Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan OBJECTIVE: Cesarean delivery is the most common intraperitoneal surgical procedure. Nonclosure of the peritoneum at cesarean delivery has attained widespread use. We conducted this study to evaluate the effect of nonclosure of peritoneum at cesarean delivery on the interval to the next pregnancy. STUDY DESIGN: Between 1995 and 2000, 123 women who were to undergo cesarean delivery were randomized to one of two categories after informed consent. Group assignment was based on the last digit of the patient’s medical record. 123 women scheduled for low transverse cervical cesarean were randomized to either closure of both the visceral and parietal peritoneum with absorbable suture (N = 70) or no both peritoneal closure (N = 53). RESULTS: There was no significant difference between the groups in characteristics, such as maternal age, parity, gestational age, maternal body weight, and neonatal weight. There was significant difference in the average operating time (closure group; 41.7G6.9 min.; nonclosure group; 35.3G5.9 min.; p!0.001) and the number of analgesic doses after operation (closure group; 2.4G1.1; nonclosure group; 2.0G0.9; p!0.05). There was no significant difference in the incidence of febrile morbidity, urinary tract infection and cystitis, endometritis, wound problems, pneumonia, ileus, anemia, and number of patients receiving therapeutic antibiotics. The time interval from cesarean section to the next pregnancy in the nonclosure group was significantly shorter than that in the closure group. CONCLUSION: We conclude that nonclosure of visceral and parietal peritoneum at cesarean delivery appears to have no adverse effect on immediate postoperative recovery, decrease the number of analgesic doses and shorten operating time and may be more likely to desire to achieve a next pregnancy.
429 THE MFMU CESAREAN REGISTRY: COMPLICATIONS OF PRIMARY CESAREAN SECTION IN MULTIPLE GESTATIONS MONIQUE LIN (F)1, 1for the NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To assess maternal intra- and post-operative morbidities in women with multifetal gestations undergoing a primary prelabor cesarean. STUDY DESIGN: Between January 1, 1999 and December 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at thirteen university centers. For this secondary analysis, maternal intra- and post-operative morbidities were compared among women with singletons, twins, and triplets who underwent a primary prelabor cesarean. RESULTS: 5142 women, of which 87.6% had singletons, 11.0% twins and 1.4% triplets, underwent a primary cesarean prior to labor. Except for atony requiring medical treatment, which increased with increasing fetal number (Table), other intra- (cystotomy, ureteral or bowel injury, hysterectomy) and post-operative complications (transfusion, thromboembolism, ileus, wound complications) were similar between women with singletons and multiples. In a logistic regression, which controlled for demographic characteristics associated with mutifetal pregnancies (gestational age at delivery, maternal age, smoking status, race) and the medical indications for primary cesarean, medically treated atony (p!0.0001) remained associated with increasing fetal number.
428 SHOULD WE RENOUNCE FORCEPS AND EPISIOTOMY TO PROTECT THE SEAN BLACKWELL1, GENE NULLIPAROUS PERINEUM? BELA KUDISH1, MCNEELEY1, EMMANUEL BUJOLD2, MICHAEL KRUGER1, SUSAN HENDRIX1, ROBERT SOKOL1, 1Wayne State University, Obstetrics & Gynecology, Detroit, Michigan, 2Universite´ de Montreal, Obstetrique-Gynecologie, Montreal, Quebec, Canada OBJECTIVE: Conflicting opinions exist in the literature and clinical care on the future role of operative vaginal delivery (OVD) and episiotomy in obstetrical practice. The purpose of this study is to determine the impact of these modalities, alone and in combination, on the rate of severe perineal lacerations in nulliparas. STUDY DESIGN: Using a prospectively collected computerized perinatal database of a tertiary care institution, we examined maternal and obstetric factors, including maternal age (MA), race, epidural anesthesia, birth weight (BW), newborn head circumference (HC) and length, midline episiotomy, OVD type, and forceps type (mid, low, outlet) for all singleton, term (R37 weeks), vertex nulliparous live vaginal births between 1/1996 and 1/2003. The primary outcome measure was the development of severe perineal injury (3rd or 4th ( perineal laceration). Data were analyzed with stepwise logistic regression. RESULTS: Over the 6-year study period, there were 12,063 deliveries meeting inclusion criteria. 8.0% of women had a 3rd or 4th ( perineal laceration (n = 969). Controlling for MA, race, BW & HC, evaluation of the main effects and interaction of episiotomy and delivery method revealed that episiotomy and forceps consistently increased the rate of severe perineal trauma. CONCLUSION: Given the exceedingly high rate of severe perineal laceration with any use of OVD and/or midline episiotomy and the reported substantial long-term adverse consequences for anal function, one must wonder if these techniques may be approaching obsolescence for nulliparous delivery.
430 THE MFMU CESAREAN REGISTRY: COMPLICATIONS OF PRIMARY PRELABOR CESAREAN IN OBESE GRAVIDAS MONIQUE LIN (F)1, 1for the NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To assess the effect of body mass index (BMI, kg/m2) on the maternal intra- and postoperative morbidities in women undergoing primary pre-labor cesarean. STUDY DESIGN: Between January 1, 1999 and December 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at thirteen university centers. For this secondary analysis, maternal intra- and postoperative morbidities were compared among women with singletons that were normal weight (BMI R18 to !25), overweight (BMI R 25 to !30), obese (BMI R30 to !40) and morbidly obese (BMIR40) undergoing a primary prelabor cesarean. BMI was assessed perioperatively. RESULTS: Of the 4258 women with a primary prelabor cesarean, 13.4% were normal weight, 33.3% overweight, 40.9% obese and 12.4% morbidly obese. Except for vertical hysterotomy and wound infection, which increased with increasing BMI, and postpartum transfusion, which decreased with increasing BMI (Table), the incidence of other intra- (i.e. transfusion, cystotomy, ureteral or bowel injury, hysterectomy) and post-operative complications (i.e. thromboembolism, ileus, other wound complications) did not differ by BMI. In a logistic regression, which controlled for demographic characteristics associated with obesity and the outcome of interest, wound infection (p!0.0001), vertical hysterotomy (p!0.0001) and postpartum transfusion (p=0.007) remained associated with BMI.
Delivery method
Rate of severe lacerations
OR
95% CI
SVD SVD with episiotomy Vacuum Vacuum with episiotomy Forceps Forceps with episiotomy
3.0% 14.7% 10.2% 34.6% 21.4% 42.7%
1.0 4.6 3.1 13.7 8.6 21.1
3.8-5.6 1.9-4.8 10.1-18.6 6.5-11.4 16.7-26.8
(260/8628) (283/1929) (26/256) (92/266) (95/444) (213/499)
Complication
Singletons n = 4501
Twins n = 567
Triplets n = 74
Test of trend (p)
Medically treated atony Cesarean hysterectomy Intrapartum transfusion Postpartum endometritis Wound infection
2.7% 0.7% 1.4% 4.8% 0.8%
6.4% 0.2% 0.2% 5.7% 0.7%
12.2% 0% 6.8% 2.7% 0%
!0.0001 0.12 0.75 0.80 0.56
CONCLUSION: As the number of fetuses increases, the rate of medically treated uterine atony increases. Other intra- and post-operative complications are not significantly increased with increasing fetal number.
Complication
Normal n = 572
Overweight n = 1417
Obese n = 1742
Morbidly obese n = 527
p value
Vertical hysterotomy Wound infection Postpartum transfusion Uterine atony Postpartum endometritis
8.2% 0.2% 3.7% 3.7% 5.8%
7.0% 0.4% 2.8% 4.4% 3.5%
7.7% 1.0% 2.8% 4.1% 4.4%
11.8% 1.5% 1.1% 2.9% 6.6%
0.01 0.001 0.02 0.39 0.19
CONCLUSION: As BMI increases, vertical hysterotomy and wound infection rates increase, while the rate of postpartum transfusion decreases. Other intraand post-operative complications are not affected by perioperative BMI.
429 THE MFMU CESAREAN REGISTRY: COMPLICATIONS OF PRIMARY CESAREAN SECTION IN MULTIPLE GESTATIONS MONIQUE LIN (F)1, 1for the NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To assess maternal intra- and post-operative morbidities in women with multifetal gestations undergoing a primary prelabor cesarean. STUDY DESIGN: Between January 1, 1999 and December 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at thirteen university centers. For this secondary analysis, maternal intra- and post-operative morbidities were compared among women with singletons, twins, and triplets who underwent a primary prelabor cesarean. RESULTS: 5142 women, of which 87.6% had singletons, 11.0% twins and 1.4% triplets, underwent a primary cesarean prior to labor. Except for atony requiring medical treatment, which increased with increasing fetal number (Table), other intra- (cystotomy, ureteral or bowel injury, hysterectomy) and post-operative complications (transfusion, thromboembolism, ileus, wound complications) were similar between women with singletons and multiples. In a logistic regression, which controlled for demographic characteristics associated with mutifetal pregnancies (gestational age at delivery, maternal age, smoking status, race) and the medical indications for primary cesarean, medically treated atony (p!0.0001) remained associated with increasing fetal number.
428 SHOULD WE RENOUNCE FORCEPS AND EPISIOTOMY TO PROTECT THE SEAN BLACKWELL1, GENE NULLIPAROUS PERINEUM? BELA KUDISH1, MCNEELEY1, EMMANUEL BUJOLD2, MICHAEL KRUGER1, SUSAN HENDRIX1, ROBERT SOKOL1, 1Wayne State University, Obstetrics & Gynecology, Detroit, Michigan, 2Universite´ de Montreal, Obstetrique-Gynecologie, Montreal, Quebec, Canada OBJECTIVE: Conflicting opinions exist in the literature and clinical care on the future role of operative vaginal delivery (OVD) and episiotomy in obstetrical practice. The purpose of this study is to determine the impact of these modalities, alone and in combination, on the rate of severe perineal lacerations in nulliparas. STUDY DESIGN: Using a prospectively collected computerized perinatal database of a tertiary care institution, we examined maternal and obstetric factors, including maternal age (MA), race, epidural anesthesia, birth weight (BW), newborn head circumference (HC) and length, midline episiotomy, OVD type, and forceps type (mid, low, outlet) for all singleton, term (R37 weeks), vertex nulliparous live vaginal births between 1/1996 and 1/2003. The primary outcome measure was the development of severe perineal injury (3rd or 4th ( perineal laceration). Data were analyzed with stepwise logistic regression. RESULTS: Over the 6-year study period, there were 12,063 deliveries meeting inclusion criteria. 8.0% of women had a 3rd or 4th ( perineal laceration (n = 969). Controlling for MA, race, BW & HC, evaluation of the main effects and interaction of episiotomy and delivery method revealed that episiotomy and forceps consistently increased the rate of severe perineal trauma. CONCLUSION: Given the exceedingly high rate of severe perineal laceration with any use of OVD and/or midline episiotomy and the reported substantial long-term adverse consequences for anal function, one must wonder if these techniques may be approaching obsolescence for nulliparous delivery.
430 THE MFMU CESAREAN REGISTRY: COMPLICATIONS OF PRIMARY PRELABOR CESAREAN IN OBESE GRAVIDAS MONIQUE LIN (F)1, 1for the NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To assess the effect of body mass index (BMI, kg/m2) on the maternal intra- and postoperative morbidities in women undergoing primary pre-labor cesarean. STUDY DESIGN: Between January 1, 1999 and December 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at thirteen university centers. For this secondary analysis, maternal intra- and postoperative morbidities were compared among women with singletons that were normal weight (BMI R18 to !25), overweight (BMI R 25 to !30), obese (BMI R30 to !40) and morbidly obese (BMIR40) undergoing a primary prelabor cesarean. BMI was assessed perioperatively. RESULTS: Of the 4258 women with a primary prelabor cesarean, 13.4% were normal weight, 33.3% overweight, 40.9% obese and 12.4% morbidly obese. Except for vertical hysterotomy and wound infection, which increased with increasing BMI, and postpartum transfusion, which decreased with increasing BMI (Table), the incidence of other intra- (i.e. transfusion, cystotomy, ureteral or bowel injury, hysterectomy) and post-operative complications (i.e. thromboembolism, ileus, other wound complications) did not differ by BMI. In a logistic regression, which controlled for demographic characteristics associated with obesity and the outcome of interest, wound infection (p!0.0001), vertical hysterotomy (p!0.0001) and postpartum transfusion (p=0.007) remained associated with BMI.
Delivery method
Rate of severe lacerations
OR
95% CI
SVD SVD with episiotomy Vacuum Vacuum with episiotomy Forceps Forceps with episiotomy
3.0% 14.7% 10.2% 34.6% 21.4% 42.7%
1.0 4.6 3.1 13.7 8.6 21.1
3.8-5.6 1.9-4.8 10.1-18.6 6.5-11.4 16.7-26.8
(260/8628) (283/1929) (26/256) (92/266) (95/444) (213/499)
Complication
Singletons n = 4501
Twins n = 567
Triplets n = 74
Test of trend (p)
Medically treated atony Cesarean hysterectomy Intrapartum transfusion Postpartum endometritis Wound infection
2.7% 0.7% 1.4% 4.8% 0.8%
6.4% 0.2% 0.2% 5.7% 0.7%
12.2% 0% 6.8% 2.7% 0%
!0.0001 0.12 0.75 0.80 0.56
CONCLUSION: As the number of fetuses increases, the rate of medically treated uterine atony increases. Other intra- and post-operative complications are not significantly increased with increasing fetal number.
Complication
Normal n = 572
Overweight n = 1417
Obese n = 1742
Morbidly obese n = 527
p value
Vertical hysterotomy Wound infection Postpartum transfusion Uterine atony Postpartum endometritis
8.2% 0.2% 3.7% 3.7% 5.8%
7.0% 0.4% 2.8% 4.4% 3.5%
7.7% 1.0% 2.8% 4.1% 4.4%
11.8% 1.5% 1.1% 2.9% 6.6%
0.01 0.001 0.02 0.39 0.19
CONCLUSION: As BMI increases, vertical hysterotomy and wound infection rates increase, while the rate of postpartum transfusion decreases. Other intraand post-operative complications are not affected by perioperative BMI.