Carbetocin vs Oxytocin in Emergency Cesarean Delivery: Bleeding Outcomes Within 24 Hours

Carbetocin vs Oxytocin in Emergency Cesarean Delivery: Bleeding Outcomes Within 24 Hours | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Carbetocin vs Oxytocin in Emergency Cesarean Delivery: Bleeding Outcomes Within 24 Hours Tahir Eryılmaz, Tuğba Kolomuç Gayretli, Selver Özge Şefik, Ayşe Sena Küçükkayıcı, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9337147/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Postpartum hemorrhage remains a major cause of maternal morbidity, and cesarean delivery is associated with greater blood loss than vaginal birth. This study compared prophylactic oxytocin and carbetocin for bleeding-related outcomes within 24 hours after NICE Category 1–2 emergency cesarean delivery in antenatally low-risk women and identified intrapartum factors associated with additional uterotonic use. Methods This prospective observational comparative study was conducted between October 2024 and August 2025. Antenatally low-risk women admitted for intended vaginal birth who subsequently required NICE Category 1–2 emergency cesarean delivery received oxytocin 10 IU IV or carbetocin 100 µg IV immediately after delivery. The primary outcome was any additional uterotonic use within 24 hours. Secondary outcomes were tranexamic acid use, hemoglobin decrease ≥ 2 g/dL at 24 hours, absolute hemoglobin change (ΔHb), and postoperative hemoglobin < 8 g/dL. Multivariable logistic regression was performed for the primary outcome. Results A total of 300 women were included, with 150 in each group. Additional uterotonic use occurred in 24.0% (36/150) of the carbetocin group and 33.3% (50/150) of the oxytocin group (p = 0.074). Tranexamic acid use was similar between groups (18.7% vs 16.0%, p = 0.542). Hemoglobin decrease ≥ 2 g/dL occurred in 68.0% and 60.0%, respectively (p = 0.149). Mean ΔHb was 2.49 ± 1.13 g/dL in the carbetocin group and 2.38 ± 1.03 g/dL in the oxytocin group (p = 0.388). Postoperative hemoglobin < 8 g/dL occurred in 11.3% and 12.0%, respectively (p = 0.981). In multivariable analysis, induction/augmentation (adjusted OR 1.92, 95% CI 1.07–3.42, p = 0.028) and longer duration of membrane rupture (adjusted OR 1.23 per doubling, 95% CI 1.06–1.43, p = 0.006) were independently associated with additional uterotonic use, whereas uterotonic group was not (adjusted OR for oxytocin vs carbetocin 1.51, 95% CI 0.90–2.54, p = 0.122). Conclusions In antenatally low-risk women who underwent emergency cesarean delivery, prophylactic carbetocin and oxytocin showed comparable bleeding-related outcomes within 24 hours. Additional uterotonic use was numerically lower with carbetocin, but the difference was not statistically significant. Induction/augmentation and longer duration of membrane rupture were independently associated with higher odds of additional uterotonic use. Trial registration: ClinicalTrials.gov (NCT07380529), first submitted on 18 January 2026. Retrospectively registered. emergency cesarean delivery carbetocin oxytocin additional uterotonic use postpartum hemorrhage Synopsis In antenatally low-risk women who underwent emergency cesarean delivery, carbetocin and oxytocin showed comparable bleeding-related outcomes within 24 hours, while induction/augmentation and longer duration of membrane rupture were independently associated with additional uterotonic use. Introduction Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality worldwide 1 . In 2023, an estimated 260,000 women died from pregnancy- or childbirth-related causes, underscoring the continued global burden of preventable obstetric complications 2 . Cesarean delivery is associated with a higher hemorrhage risk than vaginal birth, and emergency cesarean delivery has been reported to carry greater rates of severe blood loss compared with planned procedures in population-based data 3 . These patterns highlight the need for reliable prophylaxis and standardized perioperative prevention pathways in time-critical emergency cesarean settings. Prophylactic uterotonics are the cornerstone of PPH prevention. The World Health Organization (WHO) recommends oxytocin (10 IU IM/IV) as the uterotonic of choice for PPH prevention and also supports carbetocin (100 µg IM/IV) as an effective alternative; heat-stable carbetocin is particularly relevant in contexts where oxytocin is unavailable or of unreliable quality and where cost is comparable to other effective uterotonics. 4 , 5 Although randomized trials and meta-analyses have evaluated oxytocin versus carbetocin in cesarean delivery, many cohorts include mixed elective and non-elective cases, and comparative evidence focused specifically on time-critical emergency cesarean delivery remains limited 3 , 6 . This study aimed to compare prophylactic oxytocin and carbetocin with respect to bleeding-related outcomes within 24 hours after NICE Category 1–2 emergency cesarean delivery. A secondary aim was to identify intrapartum factors independently associated with additional uterotonic use. Materials and Methods Study design This was a prospective observational comparative study conducted at Ankara Etlik City Hospital (Ankara, Türkiye) from October 2024 to August 2025. We enrolled antenatally low-risk women who were admitted for intrapartum care with an intention of vaginal birth and subsequently required emergency cesarean delivery (NICE Category 1–2). Participants were categorized according to the prophylactic uterotonic agent administered immediately after delivery (carbetocin or oxytocin). The study protocol was approved by the institutional ethics committee (Approval No. AEŞH-2024-0025). A study record exists at ClinicalTrials.gov (NCT07380529; first submitted 18 Jan 2026). Participants and eligibility We enrolled antenatally low-risk women admitted for intrapartum care with an intention of vaginal birth who subsequently required NICE Category 1–2 emergency cesarean delivery. Antenatal “low-risk” status was defined by the absence of major hemorrhage risk factors identified before labor. Inclusion criteria were age ≥ 18 years, singleton pregnancy, no previous uterine surgery (including prior cesarean delivery or myomectomy), and ability to provide informed consent. Written informed consent was obtained during intrapartum admission, before any decision for emergency cesarean delivery. Exclusion criteria were planned/elective cesarean delivery or NICE Category 3–4 urgency; multiple gestation; placenta previa or placenta accreta spectrum diagnosed antenatally; known bleeding disorder or therapeutic anticoagulation; known hypersensitivity to oxytocin or carbetocin; and any condition judged by the investigator to preclude safe participation. Interventions Prophylactic uterotonic management was recorded prospectively according to routine clinical care. Women received either oxytocin 10 IU IV or carbetocin 100 µg IV immediately after delivery, as documented in the clinical record. All other intrapartum and postoperative care followed local standards. Additional uterotonics (methylergonovine and/or misoprostol) and tranexamic acid were permitted as clinically indicated and were prospectively recorded; tranexamic acid was not classified as an additional uterotonic. Outcomes The primary outcome was the use of any additional uterotonic within 24 hours after emergency cesarean delivery, defined as administration of methylergonovine and/or misoprostol. Tranexamic acid was not classified as an additional uterotonic. Secondary outcomes were tranexamic acid (TXA) use within 24 hours; hemoglobin decrease ≥ 2 g/dL at 24 hours; absolute hemoglobin change (ΔHb, g/dL) at 24 hours; and postoperative hemoglobin < 8 g/dL at 24 hours. ΔHb was defined as the difference between the preoperative hemoglobin and the 24-hour postoperative hemoglobin (preoperative minus 24-hour value); hemoglobin decrease ≥ 2 g/dL was defined as ΔHb ≥ 2 g/dL.Perioperative vital signs (SBP, DBP, and HR) were recorded preoperatively, intraoperatively at 1 minute after uterotonic administration, and postoperatively at 1 hour, and are summarized in Supplementary Table S1 . Statistical analysis Analyses were performed according to the prophylactic uterotonic received. Categorical variables were summarized as n (%) and compared using the chi-square test or Fisher’s exact test, as appropriate. Continuous variables were assessed for distributional assumptions and compared using the independent-samples t test or Mann–Whitney U test, as appropriate, and are presented as mean (SD) or median (IQR). The primary outcome, additional uterotonic use within 24 hours, was evaluated using logistic regression and is reported as odds ratios (ORs) with 95% confidence intervals (CIs). Candidate variables included BMI, parity, induction/augmentation, active-phase duration > 4 hours, and ROM duration. Multivariable logistic regression was then used to estimate adjusted ORs for the association between uterotonic group and additional uterotonic use, including selected covariates based on clinical relevance, crude associations, and model parsimony to reduce the risk of overfitting. The final multivariable model included uterotonic group, induction/augmentation, and log2-transformed membrane rupture duration(log2[ROM duration + 1]). Secondary outcomes were analyzed descriptively and by between-group comparison as appropriate. Hemoglobin-based outcomes were treated as bleeding-related hematologic measures rather than direct clinical definitions of postpartum hemorrhage. Perioperative vital signs were summarized descriptively. A two-sided p value < 0.05 was considered statistically significant. There were no missing data for the primary outcome; other analyses used complete-case data. Analyses were performed using IBM SPSS Statistics v23. Results A total of 300 women were included in the analysis. Data for the primary outcome were available for all participants. Maternal and obstetric baseline characteristics were comparable between the two uterotonic groups (Table 1 ). Table 1 Maternal and obstetric baseline characteristics Variable Carbetocin (n = 150) Oxytocin (n = 150) p Maternal age (years) 26 (23–31) 26 (23–30) 0.675 Primigravida, n (%) 104 (69.3%) 99 (66.0%) 0.537 Nulliparous, n (%) 114 (76.0%) 115 (76.7%) 0.892 Body mass index (kg/m²) 30 (26–33) 29 (27–32.2) 0.876 Gestational age (weeks) 39.86 (39–40.6) 39.43 (38.5–40.4) 0.104 Preoperative hemoglobin (g/dL) 12.25 (11.4–13) 11.90 (11–12.8) 0.314 Data are presented as median (Q1–Q3) or n (%). Mann–Whitney U and chi-square tests were used, as appropriate. BMI, body mass index. Intrapartum characteristics are summarized in Table 2 . The distribution of emergency cesarean indications did not differ between groups (p = 0.278), and active-phase duration categories were also similar (p = 0.188). Across both groups, the most common indication for emergency cesarean delivery was fetal distress. Perioperative vital signs were comparable and are summarized in Supplementary Table S1 . Table 2 Intrapartum Characteristics Variable Carbetocin (n = 150) Oxytocin (n = 150) p Indication for emergency cesarean delivery, n (%): 0.278ᶜ Fetal distress 62 (41.3%) 72 (48.0%) Cephalopelvic disproportion 46 (30.7%) 30 (20.0%) Failed induction 14 (9.3%) 15 (10.0%) Arrested labor 17 (11.3%) 15 (10.0%) Other indications* 11 (7.4%) 18 (12.0%) Intrapartum risk factors, n (%) : 0.481ᶜ None 131 (87.3%) 121 (80.7%) Present 19 (12.7%) 29 (19.3%) Membrane rupture, n (%) : 0.197ᶜ No 67 (44.7%) 56 (37.3%) Yes 83 (55.3%) 94 (62.7%) Active phase duration, n (%) : 0.188ᶜ 0 h 80 (53.3%) 83 (55.3%) 1–4 h 40 (26.7%) 28 (18.7%) >4 h 30 (20.0%) 39 (26.0%) Cervical ripening performed, n (%) : 0.633ᶜ No 96 (64.0%) 92 (61.3%) Yes 54 (36.0%) 58 (38.7%) Induction or augmentation performed, n (%) : 1.000ᶜ No 55 (36.7%) 55 (36.7%) Yes 95 (63.3%) 95 (63.3%) ᶜ Chi-square test. Other indications include cord prolapse, placental abruption, chorioamnionitis, or maternal indications. Bleeding-related outcomes within 24 hours are presented in Table 3 . The primary outcome, additional uterotonic use, occurred in 24.0% (36/150) of the carbetocin group and 33.3% (50/150) of the oxytocin group (p = 0.074). Tranexamic acid use was similar between groups (18.7% vs 16.0%, p = 0.542). Hemoglobin decrease ≥ 2 g/dL occurred in 68.0% and 60.0% of women in the carbetocin and oxytocin groups, respectively (p = 0.149). Mean ΔHb was 2.49 ± 1.13 g/dL in the carbetocin group and 2.38 ± 1.03 g/dL in the oxytocin group (p = 0.388). At 24 hours, postoperative hemoglobin < 8 g/dL occurred in 11.3% and 12.0% of women, respectively (p = 0.981). Table 3 Bleeding-related outcomes within 24 hours by uterotonic group Outcome Carbetocin (n = 150) Oxytocin (n = 150) p value Additional uterotonic use, n (%) 36 (24.0) 50 (33.3) 0.074ᵇ Tranexamic acid (TXA) use, n (%) 28 (18.7) 24 (16.0) 0.542ᵇ Hemoglobin decrease ≥ 2 g/dL, n (%) 102 (68.0) 90 (60.0) 0.149ᵇ ΔHb g/dL (mean ± SD) 2.49 ± 1.13 2.38 ± 1.03 0.388ᵃ Postoperative Hb < 8 g/dL, n (%) 17 (11.3) 18 (12.0) 0.981ᵇ Logistic regression analyses for the primary outcome are shown in Table 4 . In univariable analyses, induction/augmentation (OR 2.20, 95% CI 1.26–3.87, p = 0.006), active-phase duration > 4 h (OR 1.72, 95% CI 0.98–3.04, p = 0.061), and ROM duration (OR 1.28, 95% CI 1.11–1.48, p = 0.001) were associated with higher odds of additional uterotonic use, whereas BMI and parity were not. In the multivariable model, induction/augmentation (aOR 1.92, 95% CI 1.07–3.42, p = 0.028) and longer ROM duration (aOR 1.23 per doubling, 95% CI 1.06–1.43, p = 0.006) remained independently associated with additional uterotonic use. Uterotonic group was not independently associated with the primary outcome (aOR for oxytocin vs carbetocin 1.51, 95% CI 0.90–2.54, p = 0.122). Table 4 Univariable and multivariable logistic regression analyses for additional uterotonic use within 24 hours Variable Unadjusted OR 95% CI p value Adjusted OR 95% CI p value Uterotonic group 1.58 0.96–2.63 0.075 1.51 0.90–2.54 0.122 BMI 1.04 0.99–1.10 0.106 — — — Parity 0.97 0.54–1.75 0.915 — — — Induction/augmentation 2.20 1.26–3.87 0.006 1.92 1.07–3.42 0.028 Active-phase duration >4h 1.72 0.98–3.04 0.061 — — — ROM duration 1.28 1.11–1.48 0.001 1.23 1.06–1.43 0.006 OR , odds ratio; CI , confidence interval; ROM , rupture of membranes. ROM duration was entered as a log2-transformed variable. Adjusted estimates were obtained from a multivariable logistic regression model including uterotonic group, induction/augmentation, and ROM duration. Discussion In this prospective observational comparative study of antenatally low-risk women undergoing NICE Category 1–2 emergency cesarean delivery, prophylactic carbetocin and oxytocin were associated with broadly comparable bleeding-related outcomes within 24 hours. The primary outcome, additional uterotonic use, was numerically lower in the carbetocin group, although this difference did not reach statistical significance. Hemoglobin-based secondary outcomes were also similar between groups. In multivariable analysis, induction/augmentation and longer membrane rupture duration were independently associated with higher odds of additional uterotonic use, while no independent association was observed between uterotonic group and the primary outcome. Evidence on additional uterotonic requirement in emergency or non-elective cesarean delivery remains limited. Razali et al. reported a significantly lower requirement for additional uterotonics with carbetocin in emergency cesarean delivery 7 . In a broader cesarean population that also included emergency cases, Attilakos et al. likewise found fewer additional pharmacological oxytocic interventions with carbetocin 8 . Other emergency or non-elective cesarean studies have reported either no statistically significant difference between the two agents or lower additional uterotonic use with carbetocin 9 , 10 . A systematic review restricted to non-elective cesarean delivery also found lower additional uterotonic use with carbetocin, although heterogeneity across studies was high 11 . In this context, the numerically lower but statistically non-significant rate observed in our cohort is not inconsistent with the available literature, while the overall evidence in emergency cesarean settings remains limited and heterogeneous. Hemoglobin-based secondary outcomes were also similar between groups, consistent with previous non-elective cesarean studies and meta-analytic data showing no significant between-group difference in hemoglobin decrease 9 , 11 . A more recent meta-analysis in high-risk cesarean delivery reported a smaller postoperative hemoglobin drop with carbetocin, although heterogeneity was high 12 . In multivariable analysis, induction/augmentation and longer membrane rupture duration were independently associated with higher odds of additional uterotonic use. This pattern is broadly compatible with literature suggesting that a more complex intrapartum course may be associated with greater bleeding burden and a higher likelihood of requiring additional uterotonic treatment. In a large population-based study, induction of labor was associated with severe postpartum hemorrhage, and the highest risk was observed in emergency cesarean delivery after induction 13 . A registry-based cesarean study likewise reported that, beyond shared cesarean risk factors, emergency cesarean delivery carried additional delivery-related risk factors for severe blood loss 3 . In a comparative cesarean cohort, labor duration and intrapartum oxytocin use were also treated as key hemorrhage-related intrapartum factors in adjusted analyses 14 . Direct evidence specifically addressing membrane rupture duration in emergency cesarean delivery remains limited; therefore, this finding should be interpreted cautiously and may reflect a more prolonged and complex intrapartum course rather than an isolated exposure. This study has several strengths, including prospective data collection and a clinically relevant cohort restricted to antenatally low-risk women undergoing NICE Category 1–2 emergency cesarean delivery. These features allowed a focused comparison in a time-critical setting that remains underrepresented in the literature. However, several limitations should be acknowledged. First, the observational design limits causal inference and leaves the possibility of residual confounding. Second, the study was conducted at a single center, which may limit generalizability across different clinical settings and uterotonic protocols. Third, the primary outcome was based on the use of additional uterotonics, which reflects clinical decision-making and may therefore vary according to provider thresholds. Finally, hemoglobin-based secondary outcomes were assessed as bleeding-related hematologic measures rather than direct measures of quantified blood loss and may have been influenced by perioperative fluid shifts. Larger multicenter studies are needed to confirm these findings in emergency cesarean populations. Conclusion In this prospective observational comparative study of antenatally low-risk women undergoing NICE Category 1–2 emergency cesarean delivery, prophylactic carbetocin and oxytocin were associated with broadly comparable bleeding-related outcomes within 24 hours. Additional uterotonic use was numerically lower with carbetocin, but the difference was not statistically significant. Induction/augmentation and longer membrane rupture duration were independently associated with higher odds of additional uterotonic use. Larger multicenter studies are needed to confirm these findings in emergency cesarean populations. Declarations Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Ankara Etlik City Hospital (Approval No. AEŞH-2024-0025) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before study participation. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This study received no external funding. Author Contribution T.E.: Conception and design; data analysis and interpretation; drafting of the manuscript; critical revision for important intellectual content; statistical analysis; corresponding author.T.K.G.: Data analysis and interpretation; drafting of the manuscript.S.Ö.Ş.: Conception and design; critical revision of the manuscript.A.S.K.: Data analysis and interpretation.H.L.K.: Critical revision of the manuscript; supervision.All authors approved the final version of the manuscript. Acknowledgements Not applicable. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Organization WH. A roadmap to combat postpartum haemorrhage between 2023 and 2030. World Health Organization; 2023. Organization WH. Trends in maternal mortality 2000 to 2023: estimates by WHO. UNICEF, UNFPA, World Bank Group and UNDESA/Population Division; 2025. Skjeldestad FE, Øian P. Blood loss after cesarean delivery: a registry-based study in Norway, 1999–2008. Am J Obstet Gynecol. 2012;206(1):76. e71-76. e77. Organization WH. WHO recommendations Uterotonics for the prevention of postpartum haemorrhage. World Health Organization; 2018. Tran NT, Schulte-Hillen C, Bar-Zeev S, et al. How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health. 2022;7(4):e008913. Vogel JP, Williams M, Gallos I et al. WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one? BMJ Specialist Journals 2019:e001466. Razali N, Latar ILM, Chan YK, et al. Carbetocin compared to oxytocin in emergency cesarean section: a randomized trial. Eur J Obstet Gynecol Reproductive Biology. 2016;198:35–9. Attilakos G, Psaroudakis D, Ash J, et al. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG: Int J Obstet Gynecol. 2010;117(8):929–36. Whigham C-A, Gorelik A, Loughnan TE, et al. Carbetocin versus oxytocin to reduce additional uterotonic use at non-elective caesarean section: a double-blind, randomised trial. J Maternal-Fetal Neonatal Med. 2016;29(23):3866–9. Al Zubaidi S, Alhaidari T. Heat stable carbetocin vs. oxytocin for the prevention of post-partum hemorrhage in emergency caesarean delivery: a randomized controlled trial. J Perinat Med. 2022;50(2):150–6. Onwochei DN, Owolabi A, Singh PM, et al. Carbetocin compared with oxytocin in non-elective Cesarean delivery: a systematic review, meta-analysis, and trial sequential analysis of randomized-controlled trials. Can J Anesthesia/Journal canadien d'anesthésie. 2020;67(11):1524–34. El-Goly NA, Maged AM, Kamal WM, et al. Carbetocin versus oxytocin in prevention of postpartum hemorrhage after cesarean delivery in high-risk women. A systematic review and meta-analysis. Arch Gynecol Obstet. 2025;312(2):291–309. Al-Zirqi I, Vangen S, Forsén L, et al. Effects of onset of labor and mode of delivery on severe postpartum hemorrhage. Am J Obstet Gynecol. 2009;201(3):273. e271-273. e279. Delorme P, Kayem G, Legardeur H, et al. Carbetocin versus oxytocin for the prevention of postpartum hemorrhage in cesarean deliveries: a retrospective study of two consecutive periods. Am J Perinatol Rep. 2020;10(03):e241–6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9337147","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633775313,"identity":"84df14ee-2850-49a4-92fa-95661c21e2f0","order_by":0,"name":"Tahir Eryılmaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYFACHoYDYJqZuQFI2iSAOQkF+DTAtTCCtKQlMLCBtBjg1wIFYC2HIVoY8GixZz978HAFg02+wXHG1g0//pzP45fvTvzwwIBBnl/sAHZbePISDp5hSLPccJix7WYPz+1iyTbezRJAhxnOnJ2Aw2E5BgcbGA4bGAC13OCRuJ244RjvBpCWBIPbOLTwvwFp+Q/WcvOPwTmQls0/8GqRANtyAKzlNk/CAZCWbfhtuQG2JdlAEqRF5kBy4sy23G0WCQYSOP3C3p9j/LGBwc6A7/zhYzff/LFL7Gc+u/nmjwobeX5p7FrAgPEfA4PCAVQxCdzKYUC+gbCaUTAKRsEoGKEAANxGYhCtZbFGAAAAAElFTkSuQmCC","orcid":"","institution":"Etlik City Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tahir","middleName":"","lastName":"Eryılmaz","suffix":""},{"id":633775314,"identity":"1faac382-f0c5-47d0-9c9c-10eeb7e187cd","order_by":1,"name":"Tuğba Kolomuç Gayretli","email":"","orcid":"","institution":"Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tuğba","middleName":"Kolomuç","lastName":"Gayretli","suffix":""},{"id":633775315,"identity":"ee88b327-d8a4-4ef3-9671-c9aee18e8280","order_by":2,"name":"Selver Özge Şefik","email":"","orcid":"","institution":"Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Selver","middleName":"Özge","lastName":"Şefik","suffix":""},{"id":633775316,"identity":"7b92db2d-a4f4-4f9e-bafb-2b29c5387b98","order_by":3,"name":"Ayşe Sena Küçükkayıcı","email":"","orcid":"","institution":"Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ayşe","middleName":"Sena","lastName":"Küçükkayıcı","suffix":""},{"id":633775317,"identity":"e3d049c6-6767-4f8f-a156-191c4c538e33","order_by":4,"name":"Hüseyin Levent Keskin","email":"","orcid":"","institution":"Ufuk University","correspondingAuthor":false,"prefix":"","firstName":"Hüseyin","middleName":"Levent","lastName":"Keskin","suffix":""}],"badges":[],"createdAt":"2026-04-06 20:38:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9337147/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9337147/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108803721,"identity":"d3c6e708-9911-4ec2-b81c-96b774a1bf8d","added_by":"auto","created_at":"2026-05-08 15:04:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":282722,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9337147/v1/48c6518d-a4d4-41f9-aa34-0db9b4b316c4.pdf"},{"id":108387231,"identity":"fe2be086-e7d2-4b08-9513-3b0f266f63a6","added_by":"auto","created_at":"2026-05-04 06:28:41","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16120,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9337147/v1/e0d755fc02d3768638414ac5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Carbetocin vs Oxytocin in Emergency Cesarean Delivery: Bleeding Outcomes Within 24 Hours","fulltext":[{"header":"Synopsis","content":"\u003cp\u003eIn antenatally low-risk women who underwent emergency cesarean delivery, carbetocin and oxytocin showed comparable bleeding-related outcomes within 24 hours, while induction/augmentation and longer duration of membrane rupture were independently associated with additional uterotonic use.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePostpartum hemorrhage (PPH) remains a leading cause of maternal mortality worldwide\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In 2023, an estimated 260,000 women died from pregnancy- or childbirth-related causes, underscoring the continued global burden of preventable obstetric complications\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Cesarean delivery is associated with a higher hemorrhage risk than vaginal birth, and emergency cesarean delivery has been reported to carry greater rates of severe blood loss compared with planned procedures in population-based data\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. These patterns highlight the need for reliable prophylaxis and standardized perioperative prevention pathways in time-critical emergency cesarean settings.\u003c/p\u003e \u003cp\u003eProphylactic uterotonics are the cornerstone of PPH prevention. The World Health Organization (WHO) recommends oxytocin (10 IU IM/IV) as the uterotonic of choice for PPH prevention and also supports carbetocin (100 \u0026micro;g IM/IV) as an effective alternative; heat-stable carbetocin is particularly relevant in contexts where oxytocin is unavailable or of unreliable quality and where cost is comparable to other effective uterotonics.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Although randomized trials and meta-analyses have evaluated oxytocin versus carbetocin in cesarean delivery, many cohorts include mixed elective and non-elective cases, and comparative evidence focused specifically on \u003cem\u003etime-critical\u003c/em\u003e emergency cesarean delivery remains limited\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aimed to compare prophylactic oxytocin and carbetocin with respect to bleeding-related outcomes within 24 hours after NICE Category 1\u0026ndash;2 emergency cesarean delivery. A secondary aim was to identify intrapartum factors independently associated with additional uterotonic use.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a prospective observational comparative study conducted at Ankara Etlik City Hospital (Ankara, T\u0026uuml;rkiye) from October 2024 to August 2025. We enrolled antenatally low-risk women who were admitted for intrapartum care with an intention of vaginal birth and subsequently required emergency cesarean delivery (NICE Category 1\u0026ndash;2). Participants were categorized according to the prophylactic uterotonic agent administered immediately after delivery (carbetocin or oxytocin). The study protocol was approved by the institutional ethics committee (Approval No. AEŞH-2024-0025). A study record exists at ClinicalTrials.gov (NCT07380529; first submitted 18 Jan 2026).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and eligibility\u003c/h3\u003e\n\u003cp\u003eWe enrolled antenatally low-risk women admitted for intrapartum care with an intention of vaginal birth who subsequently required NICE Category 1\u0026ndash;2 emergency cesarean delivery. Antenatal \u0026ldquo;low-risk\u0026rdquo; status was defined by the absence of major hemorrhage risk factors identified before labor. Inclusion criteria were age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, singleton pregnancy, no previous uterine surgery (including prior cesarean delivery or myomectomy), and ability to provide informed consent. Written informed consent was obtained during intrapartum admission, before any decision for emergency cesarean delivery. Exclusion criteria were planned/elective cesarean delivery or NICE Category 3\u0026ndash;4 urgency; multiple gestation; placenta previa or placenta accreta spectrum diagnosed antenatally; known bleeding disorder or therapeutic anticoagulation; known hypersensitivity to oxytocin or carbetocin; and any condition judged by the investigator to preclude safe participation.\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eProphylactic uterotonic management was recorded prospectively according to routine clinical care. Women received either oxytocin 10 IU IV or carbetocin 100 \u0026micro;g IV immediately after delivery, as documented in the clinical record. All other intrapartum and postoperative care followed local standards. Additional uterotonics (methylergonovine and/or misoprostol) and tranexamic acid were permitted as clinically indicated and were prospectively recorded; tranexamic acid was not classified as an additional uterotonic.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the use of any additional uterotonic within 24 hours after emergency cesarean delivery, defined as administration of methylergonovine and/or misoprostol. Tranexamic acid was not classified as an additional uterotonic.\u003c/p\u003e \u003cp\u003eSecondary outcomes were tranexamic acid (TXA) use within 24 hours; hemoglobin decrease\u0026thinsp;\u0026ge;\u0026thinsp;2 g/dL at 24 hours; absolute hemoglobin change (ΔHb, g/dL) at 24 hours; and postoperative hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;8 g/dL at 24 hours. ΔHb was defined as the difference between the preoperative hemoglobin and the 24-hour postoperative hemoglobin (preoperative minus 24-hour value); hemoglobin decrease\u0026thinsp;\u0026ge;\u0026thinsp;2 g/dL was defined as ΔHb\u0026thinsp;\u0026ge;\u0026thinsp;2 g/dL.Perioperative vital signs (SBP, DBP, and HR) were recorded preoperatively, intraoperatively at 1 minute after uterotonic administration, and postoperatively at 1 hour, and are summarized in Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were performed according to the prophylactic uterotonic received. Categorical variables were summarized as n (%) and compared using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. Continuous variables were assessed for distributional assumptions and compared using the independent-samples t test or Mann\u0026ndash;Whitney U test, as appropriate, and are presented as mean (SD) or median (IQR).\u003c/p\u003e \u003cp\u003eThe primary outcome, additional uterotonic use within 24 hours, was evaluated using logistic regression and is reported as odds ratios (ORs) with 95% confidence intervals (CIs). Candidate variables included BMI, parity, induction/augmentation, active-phase duration\u0026thinsp;\u0026gt;\u0026thinsp;4 hours, and ROM duration. Multivariable logistic regression was then used to estimate adjusted ORs for the association between uterotonic group and additional uterotonic use, including selected covariates based on clinical relevance, crude associations, and model parsimony to reduce the risk of overfitting. The final multivariable model included uterotonic group, induction/augmentation, and log2-transformed membrane rupture duration(log2[ROM duration\u0026thinsp;+\u0026thinsp;1]).\u003c/p\u003e \u003cp\u003eSecondary outcomes were analyzed descriptively and by between-group comparison as appropriate. Hemoglobin-based outcomes were treated as bleeding-related hematologic measures rather than direct clinical definitions of postpartum hemorrhage. Perioperative vital signs were summarized descriptively. A two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. There were no missing data for the primary outcome; other analyses used complete-case data. Analyses were performed using IBM SPSS Statistics v23.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 300 women were included in the analysis. Data for the primary outcome were available for all participants. Maternal and obstetric baseline characteristics were comparable between the two uterotonic groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal and obstetric baseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarbetocin (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOxytocin (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal age (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (23\u0026ndash;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (23\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.675\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimigravida, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (69.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (66.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNulliparous, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (76.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (76.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (26\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (27\u0026ndash;32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational age (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.86 (39\u0026ndash;40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.43 (38.5\u0026ndash;40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative hemoglobin (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.25 (11.4\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.90 (11\u0026ndash;12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as median (Q1\u0026ndash;Q3) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMann\u0026ndash;Whitney U and chi-square tests were used, as appropriate. BMI, body mass index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntrapartum characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The distribution of emergency cesarean indications did not differ between groups (p\u0026thinsp;=\u0026thinsp;0.278), and active-phase duration categories were also similar (p\u0026thinsp;=\u0026thinsp;0.188). Across both groups, the most common indication for emergency cesarean delivery was fetal distress. Perioperative vital signs were comparable and are summarized in Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntrapartum Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarbetocin (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOxytocin (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for emergency cesarean delivery, n (%):\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.278ᶜ\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFetal distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62 (41.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72 (48.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCephalopelvic disproportion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (30.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailed induction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrested labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther indications*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntrapartum risk factors, n (%)\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.481ᶜ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131 (87.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121 (80.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (12.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (19.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMembrane rupture, n (%)\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.197ᶜ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67 (44.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (37.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83 (55.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94 (62.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eActive phase duration, n (%)\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.188ᶜ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83 (55.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (18.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;4 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (26.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCervical ripening performed, n (%)\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.633ᶜ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e96 (64.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (61.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (38.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInduction or augmentation performed, n (%)\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.000ᶜ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eᶜ\u003c/b\u003e Chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOther indications include cord prolapse, placental abruption, chorioamnionitis, or maternal indications.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBleeding-related outcomes within 24 hours are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The primary outcome, additional uterotonic use, occurred in 24.0% (36/150) of the carbetocin group and 33.3% (50/150) of the oxytocin group (p\u0026thinsp;=\u0026thinsp;0.074). Tranexamic acid use was similar between groups (18.7% vs 16.0%, p\u0026thinsp;=\u0026thinsp;0.542). Hemoglobin decrease\u0026thinsp;\u0026ge;\u0026thinsp;2 g/dL occurred in 68.0% and 60.0% of women in the carbetocin and oxytocin groups, respectively (p\u0026thinsp;=\u0026thinsp;0.149). Mean ΔHb was 2.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13 g/dL in the carbetocin group and 2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03 g/dL in the oxytocin group (p\u0026thinsp;=\u0026thinsp;0.388). At 24 hours, postoperative hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;8 g/dL occurred in 11.3% and 12.0% of women, respectively (p\u0026thinsp;=\u0026thinsp;0.981).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBleeding-related outcomes within 24 hours by uterotonic group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarbetocin (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOxytocin (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdditional uterotonic use, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.074ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTranexamic acid (TXA) use, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.542ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin decrease\u0026thinsp;\u0026ge;\u0026thinsp;2 g/dL, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.149ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔHb g/dL (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.388ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Hb\u0026thinsp;\u0026lt;\u0026thinsp;8 g/dL, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.981ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLogistic regression analyses for the primary outcome are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In univariable analyses, induction/augmentation (OR 2.20, 95% CI 1.26\u0026ndash;3.87, p\u0026thinsp;=\u0026thinsp;0.006), active-phase duration\u0026thinsp;\u0026gt;\u0026thinsp;4 h (OR 1.72, 95% CI 0.98\u0026ndash;3.04, p\u0026thinsp;=\u0026thinsp;0.061), and ROM duration (OR 1.28, 95% CI 1.11\u0026ndash;1.48, p\u0026thinsp;=\u0026thinsp;0.001) were associated with higher odds of additional uterotonic use, whereas BMI and parity were not. In the multivariable model, induction/augmentation (aOR 1.92, 95% CI 1.07\u0026ndash;3.42, p\u0026thinsp;=\u0026thinsp;0.028) and longer ROM duration (aOR 1.23 per doubling, 95% CI 1.06\u0026ndash;1.43, p\u0026thinsp;=\u0026thinsp;0.006) remained independently associated with additional uterotonic use. Uterotonic group was not independently associated with the primary outcome (aOR for oxytocin vs carbetocin 1.51, 95% CI 0.90\u0026ndash;2.54, p\u0026thinsp;=\u0026thinsp;0.122).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariable and multivariable logistic regression analyses for additional uterotonic use within 24 hours\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnadjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterotonic group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.96\u0026ndash;2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.075\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.90\u0026ndash;2.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.122\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.99\u0026ndash;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.106\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.54\u0026ndash;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.915\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInduction/augmentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.26\u0026ndash;3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.07\u0026ndash;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive-phase duration \u0026gt;4h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.98\u0026ndash;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.061\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.11\u0026ndash;1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.06\u0026ndash;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eOR\u003c/b\u003e, odds ratio; \u003cb\u003eCI\u003c/b\u003e, confidence interval; \u003cb\u003eROM\u003c/b\u003e, rupture of membranes. ROM duration was entered as a log2-transformed variable. Adjusted estimates were obtained from a multivariable logistic regression model including uterotonic group, induction/augmentation, and ROM duration.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective observational comparative study of antenatally low-risk women undergoing NICE Category 1\u0026ndash;2 emergency cesarean delivery, prophylactic carbetocin and oxytocin were associated with broadly comparable bleeding-related outcomes within 24 hours. The primary outcome, additional uterotonic use, was numerically lower in the carbetocin group, although this difference did not reach statistical significance. Hemoglobin-based secondary outcomes were also similar between groups. In multivariable analysis, induction/augmentation and longer membrane rupture duration were independently associated with higher odds of additional uterotonic use, while no independent association was observed between uterotonic group and the primary outcome.\u003c/p\u003e \u003cp\u003eEvidence on additional uterotonic requirement in emergency or non-elective cesarean delivery remains limited. Razali et al. reported a significantly lower requirement for additional uterotonics with carbetocin in emergency cesarean delivery\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In a broader cesarean population that also included emergency cases, Attilakos et al. likewise found fewer additional pharmacological oxytocic interventions with carbetocin\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Other emergency or non-elective cesarean studies have reported either no statistically significant difference between the two agents or lower additional uterotonic use with carbetocin\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. A systematic review restricted to non-elective cesarean delivery also found lower additional uterotonic use with carbetocin, although heterogeneity across studies was high\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this context, the numerically lower but statistically non-significant rate observed in our cohort is not inconsistent with the available literature, while the overall evidence in emergency cesarean settings remains limited and heterogeneous.\u003c/p\u003e \u003cp\u003eHemoglobin-based secondary outcomes were also similar between groups, consistent with previous non-elective cesarean studies and meta-analytic data showing no significant between-group difference in hemoglobin decrease\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. A more recent meta-analysis in high-risk cesarean delivery reported a smaller postoperative hemoglobin drop with carbetocin, although heterogeneity was high\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn multivariable analysis, induction/augmentation and longer membrane rupture duration were independently associated with higher odds of additional uterotonic use. This pattern is broadly compatible with literature suggesting that a more complex intrapartum course may be associated with greater bleeding burden and a higher likelihood of requiring additional uterotonic treatment. In a large population-based study, induction of labor was associated with severe postpartum hemorrhage, and the highest risk was observed in emergency cesarean delivery after induction\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. A registry-based cesarean study likewise reported that, beyond shared cesarean risk factors, emergency cesarean delivery carried additional delivery-related risk factors for severe blood loss\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In a comparative cesarean cohort, labor duration and intrapartum oxytocin use were also treated as key hemorrhage-related intrapartum factors in adjusted analyses\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Direct evidence specifically addressing membrane rupture duration in emergency cesarean delivery remains limited; therefore, this finding should be interpreted cautiously and may reflect a more prolonged and complex intrapartum course rather than an isolated exposure.\u003c/p\u003e \u003cp\u003eThis study has several strengths, including prospective data collection and a clinically relevant cohort restricted to antenatally low-risk women undergoing NICE Category 1\u0026ndash;2 emergency cesarean delivery. These features allowed a focused comparison in a time-critical setting that remains underrepresented in the literature. However, several limitations should be acknowledged. First, the observational design limits causal inference and leaves the possibility of residual confounding. Second, the study was conducted at a single center, which may limit generalizability across different clinical settings and uterotonic protocols. Third, the primary outcome was based on the use of additional uterotonics, which reflects clinical decision-making and may therefore vary according to provider thresholds. Finally, hemoglobin-based secondary outcomes were assessed as bleeding-related hematologic measures rather than direct measures of quantified blood loss and may have been influenced by perioperative fluid shifts. Larger multicenter studies are needed to confirm these findings in emergency cesarean populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this prospective observational comparative study of antenatally low-risk women undergoing NICE Category 1\u0026ndash;2 emergency cesarean delivery, prophylactic carbetocin and oxytocin were associated with broadly comparable bleeding-related outcomes within 24 hours. Additional uterotonic use was numerically lower with carbetocin, but the difference was not statistically significant. Induction/augmentation and longer membrane rupture duration were independently associated with higher odds of additional uterotonic use. Larger multicenter studies are needed to confirm these findings in emergency cesarean populations.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study protocol was approved by the Ethics Committee of Ankara Etlik City Hospital (Approval No. AEŞH-2024-0025) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before study participation.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eT.E.: Conception and design; data analysis and interpretation; drafting of the manuscript; critical revision for important intellectual content; statistical analysis; corresponding author.T.K.G.: Data analysis and interpretation; drafting of the manuscript.S.\u0026Ouml;.Ş.: Conception and design; critical revision of the manuscript.A.S.K.: Data analysis and interpretation.H.L.K.: Critical revision of the manuscript; supervision.All authors approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. A roadmap to combat postpartum haemorrhage between 2023 and 2030. World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Trends in maternal mortality 2000 to 2023: estimates by WHO. UNICEF, UNFPA, World Bank Group and UNDESA/Population Division; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkjeldestad FE, \u0026Oslash;ian P. Blood loss after cesarean delivery: a registry-based study in Norway, 1999\u0026ndash;2008. Am J Obstet Gynecol. 2012;206(1):76. e71-76. e77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. WHO recommendations Uterotonics for the prevention of postpartum haemorrhage. World Health Organization; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTran NT, Schulte-Hillen C, Bar-Zeev S, et al. How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health. 2022;7(4):e008913.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVogel JP, Williams M, Gallos I et al. WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one? BMJ Specialist Journals 2019:e001466.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazali N, Latar ILM, Chan YK, et al. Carbetocin compared to oxytocin in emergency cesarean section: a randomized trial. Eur J Obstet Gynecol Reproductive Biology. 2016;198:35\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAttilakos G, Psaroudakis D, Ash J, et al. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG: Int J Obstet Gynecol. 2010;117(8):929\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhigham C-A, Gorelik A, Loughnan TE, et al. Carbetocin versus oxytocin to reduce additional uterotonic use at non-elective caesarean section: a double-blind, randomised trial. J Maternal-Fetal Neonatal Med. 2016;29(23):3866\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Zubaidi S, Alhaidari T. Heat stable carbetocin vs. oxytocin for the prevention of post-partum hemorrhage in emergency caesarean delivery: a randomized controlled trial. J Perinat Med. 2022;50(2):150\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnwochei DN, Owolabi A, Singh PM, et al. Carbetocin compared with oxytocin in non-elective Cesarean delivery: a systematic review, meta-analysis, and trial sequential analysis of randomized-controlled trials. Can J Anesthesia/Journal canadien d'anesth\u0026eacute;sie. 2020;67(11):1524\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Goly NA, Maged AM, Kamal WM, et al. Carbetocin versus oxytocin in prevention of postpartum hemorrhage after cesarean delivery in high-risk women. A systematic review and meta-analysis. Arch Gynecol Obstet. 2025;312(2):291\u0026ndash;309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Zirqi I, Vangen S, Fors\u0026eacute;n L, et al. Effects of onset of labor and mode of delivery on severe postpartum hemorrhage. Am J Obstet Gynecol. 2009;201(3):273. e271-273. e279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelorme P, Kayem G, Legardeur H, et al. Carbetocin versus oxytocin for the prevention of postpartum hemorrhage in cesarean deliveries: a retrospective study of two consecutive periods. Am J Perinatol Rep. 2020;10(03):e241\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"emergency cesarean delivery, carbetocin, oxytocin, additional uterotonic use, postpartum hemorrhage","lastPublishedDoi":"10.21203/rs.3.rs-9337147/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9337147/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostpartum hemorrhage remains a major cause of maternal morbidity, and cesarean delivery is associated with greater blood loss than vaginal birth. This study compared prophylactic oxytocin and carbetocin for bleeding-related outcomes within 24 hours after NICE Category 1–2 emergency cesarean delivery in antenatally low-risk women and identified intrapartum factors associated with additional uterotonic use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective observational comparative study was conducted between October 2024 and August 2025. Antenatally low-risk women admitted for intended vaginal birth who subsequently required NICE Category 1–2 emergency cesarean delivery received oxytocin 10 IU IV or carbetocin 100 µg IV immediately after delivery. The primary outcome was any additional uterotonic use within 24 hours. Secondary outcomes were tranexamic acid use, hemoglobin decrease ≥ 2 g/dL at 24 hours, absolute hemoglobin change (ΔHb), and postoperative hemoglobin \u0026lt; 8 g/dL. Multivariable logistic regression was performed for the primary outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 300 women were included, with 150 in each group. Additional uterotonic use occurred in 24.0% (36/150) of the carbetocin group and 33.3% (50/150) of the oxytocin group (p = 0.074). Tranexamic acid use was similar between groups (18.7% vs 16.0%, p = 0.542). Hemoglobin decrease ≥ 2 g/dL occurred in 68.0% and 60.0%, respectively (p = 0.149). Mean ΔHb was 2.49 ± 1.13 g/dL in the carbetocin group and 2.38 ± 1.03 g/dL in the oxytocin group (p = 0.388). Postoperative hemoglobin \u0026lt; 8 g/dL occurred in 11.3% and 12.0%, respectively (p = 0.981). In multivariable analysis, induction/augmentation (adjusted OR 1.92, 95% CI 1.07–3.42, p = 0.028) and longer duration of membrane rupture (adjusted OR 1.23 per doubling, 95% CI 1.06–1.43, p = 0.006) were independently associated with additional uterotonic use, whereas uterotonic group was not (adjusted OR for oxytocin vs carbetocin 1.51, 95% CI 0.90–2.54, p = 0.122).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn antenatally low-risk women who underwent emergency cesarean delivery, prophylactic carbetocin and oxytocin showed comparable bleeding-related outcomes within 24 hours. Additional uterotonic use was numerically lower with carbetocin, but the difference was not statistically significant. Induction/augmentation and longer duration of membrane rupture were independently associated with higher odds of additional uterotonic use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e ClinicalTrials.gov (NCT07380529), first submitted on 18 January 2026. Retrospectively registered.\u003c/p\u003e","manuscriptTitle":"Carbetocin vs Oxytocin in Emergency Cesarean Delivery: Bleeding Outcomes Within 24 Hours","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 06:28:32","doi":"10.21203/rs.3.rs-9337147/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-05T04:59:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T12:32:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T08:03:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44704629294664961885763676066810296409","date":"2026-05-04T01:33:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21133591070011289569876396987286840490","date":"2026-04-26T22:44:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-22T18:20:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-22T18:18:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-14T03:45:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T12:35:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-04-13T10:05:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4670fb8-2c54-42b2-be6a-297965904682","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-05T04:59:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T12:32:00+00:00","index":83,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T08:03:12+00:00","index":80,"fulltext":""},{"type":"reviewerAgreed","content":"44704629294664961885763676066810296409","date":"2026-05-04T01:33:17+00:00","index":79,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T12:23:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 06:28:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9337147","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9337147","identity":"rs-9337147","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}