(1088) Decision-to-delivery time in emergency repeat cesarean deliveries: Every minute counts.

To evaluate the impact of decision-to-delivery time (DDT) on maternal and neonatal morbidity in emergency repeat cesarean deliveries (CD) following failed trial of labor after cesarean (TOLAC) for non-reassuring fetal heart rates.

Study Design:
This retrospective cohort study (2009–2023) included women ≥37 weeks of gestation with singleton pregnancies who underwent emergency CD during labor. Participants were divided into two groups: repeat CD after a prior cesarean (Group 1) and primary emergency CD in nulliparous women (Group 2). DDT was defined as the time (in minutes) from the decision for CD to birth. The primary outcome was a composite of maternal operative complications, including uterine dehiscence or rupture, scar extension, urinary tract injury, inverted T incision, and cesarean hysterectomy.

Results:

Table 1 provides the demographic and secondary clinical characteristics of 2,205 women analyzed. As presented in Figure 1, while the DDT times were similar between groups (12 ± 7 vs. 11 ± 7 minutes, p = 0.11), women in the repeat emergency CD group experienced a significantly higher incidence of composite adverse outcomes compared to those in the primary CD group (14.2% vs. 4.3%, p < 0.001). This difference was primarily driven by significantly higher rates of uterine dehiscence (4.7% vs. 0.1%), uterine rupture (3.1% vs. 0%), and bladder injuries (3.5% vs. 0.8%) in the repeat CD group. A subgroup analysis of repeat emergency CD cases showed significantly more adverse maternal outcomes with a median DDT of 11 minutes compared to 16 minutes (p=0.008). Multivariate analysis revealed that TOLAC itself significantly increased the odds of adverse maternal outcomes (OR=3.64, 95% CI: 2.37-5.60). Neonatal outcomes did not significantly differ between groups.

Conclusion:

Emergency repeat CD for non-reassuring fetal status is associated with a 3.3-fold higher rate of composite adverse maternal morbidity. Future studies should focus on strategies to minimize maternal risks without compromising neonatal outcomes.