Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. Prolonging passive second stage beyond 2 hours did not increase the risk of hysterotomy extension during cesareans

2. Surgeon’s level of experience and forceps use during cesarean were associated with hysterotomy extensions

Evidence Rating Level: 2 (Good)

Approximately 3-8% of cesareans result in hysterotomy extension which can result in increased postpartum hemorrhage and subsequent pregnancy complications. Previous studies have suggested that during the second stage of labour, at full dilation, women are at a higher risk of extension of the incision. The goal of this study was to better understand the factors associated with second-stage labour and hysterotomy extensions. This 5-year retrospective cohort study included 747 women at the Port Royal maternity hospital in Paris. Women were included if they had a cesarean delivery during the second stage of labor at term (37 weeks gestation or later). Data were collected on all hysterotomies requiring a suture including lateral, inferior, and superior extensions. Analyses were included for operative time, hemorrhage, maternal, and neonatal complications. Of the 747 second-stage cesareans, there were 83 (11.1%) hysterotomy extensions, with only 2 being intentional in order to extract the fetus. Overall, the occurrence of hysterotomy extension was more frequent among obese women, those with hypertensive conditions, and multiparous women. However, the rate of extensions did not change based on duration of the passive second-stage, the position of the fetal head, nor fetal station. Additionally, birth weight and head circumference did not make a significant difference in hysterotomy extension either. Factors that were found to be associated with hysterotomy extension included the supervising surgeon’s experience and the use of forceps. Therefore, a limitation of the study is that it may suggest that forceps use is dangerous. However, situations when forceps are used are typically higher risk regardless and they are required in order to safely and efficiently deliver the fetus. Conversely, a strength of this study was the large amount of data analyzed covering a large cohort of births in their many stages and the factors associated with varying cesarean experiences. Overall, this study can give reassurance to women in labour and obstetrical health care providers that prolonged second stage and delayed pushing does not lead to greater risk of extended hysterotomy when cesarean delivery is performed.

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