Stillbirth complicates 1 in 160 deliveries in the United States. Vaginal delivery (VD) is the desirable route of delivery even in the setting of a prior cesarean delivery (CD). ACOG recommends CD only for unusual circumstances because of associated maternal morbidity without any fetal benefit, however some patients prefer CD to avoid the experience of a vaginal birth of a demised fetus. We sought to determine the rate of CD in pregnancies complicated by stillbirth and to identify characteristics associated with CD.METHODS:
Population-based retrospective cohort study of all stillbirths in the United States during the year of 2014. Frequency of CD in stillbirths was stratified by gestational age (16-46 weeks). Maternal, obstetric, and fetal characteristics were compared between women who underwent CD compared to VD. Multivariate logistic regression estimated the relative influence of maternal, obstetric, and fetal factors on the outcome of CD.RESULTS:
There were 17,701 non-laboring women diagnosed with stillbirth during 2014 in the United States in which mode of delivery was recorded. Of the 17,701 stillbirths, 2,951 (16.7%) underwent a CD. Between 20-23, 24-27, 28-31, 32-36, and >36 weeks of gestation, the CD rate was 4.0, 16.2, 23.7, 30.8, and 28.8% respectively. Among this cohort, 1,727 women (58.5%) had a primary CD. Factors associated with CD included obesity (aOR 1.3, 95% CI 1.1-1.5), pre-existing diabetes (aOR 1.6, 95% CI 1.1-2.2), gestational diabetes (aOR 1.6, 95% CI 1.2-2.1), gestational hypertension (aOR 1.7, 95% CI 1.3-2.1), cigarette smoking (aOR 1.5, 95% CI 1.2-1.8), infertility treatment (aOR 1.9, 95% CI 1.2-3.0), diagnosis of stillbirth in 3rd trimester, (aOR 5.0, 95% CI 4.1-6.0), and large for gestational age (>10th%) birthweight (aOR 2.4, 95% CI 0.1.8-3.1). Younger women (<20 yo) and those with small for gestational age birthweight (<10th%) were less likely to have a CD. Women who underwent a CD were more likely to be admitted to an ICU (aOR 6.1, 95% CI 4.1-6.5).CONCLUSION:
Approximately 16% of women diagnosed with a stillbirth in the United States underwent a CD in 2014. The CD rate rose with increasing gestational age and peaked during the 3rd trimester, where more than 1 in 4 women diagnosed with a stillbirth underwent a CD, despite ACOG guidelines. Our findings support that provider education, patient counseling, and adherence to society guidelines are potential areas of focus for perinatal quality improvement efforts.