[2 or more cesarean sections--elective repeat cesarean or vaginal delivery?]

Cesarean section rates have been steadily increasing over the past two decades in most countries of the Western world. The review of the literature suggests that a trial of labor in patients with more than one previous cesarean delivery is appropriate, and that these women should be treated no differently from those who have had only one cesarean delivery. Obstetric management should be individualized after thorough patient counseling. If women are carefully selected for a trial of labor and supervised closely, the risk of serious complications can be minimized and a successful outcome achieved. Epidural anesthesia is safe, effective and justified. Similarly, if oxytocin administration is considered medically necessary either to augment or to induce labor, it should be given. It would appear from the present data, that the use of prostaglandins for priming and induction of labor is also safe and effective under consistent supervision. Rupture of the uterine scare is a rare but catastrophic complication (0-2.8%); fetal bradycardia may be the only diagnostic sign. Prompt intervention is necessary to minimize both maternal and neonatal complications. The maternal and fetal outcomes in women who have had multiple previous sections do not differ from those in women after ordinary cesarean section. At present there is no sufficiently predictive method to identify those women most likely to benefit from an elective repeat cesarean delivery.

[Trial of labor after 2 cesarean sections. Prospective study of 130 cases]

The mode of delivery in the parturient women with two prior cesarean is controversial. Based on a prospective analysis of 130 cases, we tried to assess the outcome of trial of labor after two cesarean sections. Among 167 patients with two uterine scars, 130 (77.8%) were selected for a trial of labor that was successful in 65 cases (50%). The overall rate of vaginal birth and cesarean section was 39% and 61%, respectively. There were 4 scar dehiscences and 2 uterine ruptures among the women who underwent trial of labor, but no case of perinatal death or morbidity related to these complications was observed. In the majority of the cases, these scar separations were due to poor obstetrical conditions. Trial of vaginal delivery after two prior cesarean sections seems to us a reasonable attitude if it is well indicated and supervised correctly.

Hematological complications of Gaucher's disease in pregnancy

A case is presented of a 31-year-old Filipino female, gravida 5 para 2, at 38 weeks plus 5 days gestation, with known type I Gaucher's disease who underwent repeat cesarean delivery. After cesarean delivery, the patient developed disseminated intravascular coagulation and required transfusion of eight 6-packs of platelets, 6 units of fresh frozen plasma, two 10-packs of cryoprecipitate, and 6 units of packed red blood cells. Pregnancy is generally well tolerated in patients with type I Gaucher's disease, an autosomal recessive lysosomal storage disorder in which lipid deposits accumulate in the liver, spleen, and bone marrow. Hemorrhagic problems secondary to severe thrombocytopenia may develop postpartum in pregnancies complicated by Gaucher's disease, requiring significant support with blood and blood products.

Vaginal birth after cesarean

Vaginal birth or trial of labor after previous cesarean delivery represents one of the most significant changes in obstetric practice. There are numerous reasons that influence the decision to proceed with either a trial of labor after previous cesarean delivery or elective repeat cesarean delivery. For the majority of women with a previous cesarean delivery, a trial of labor should be encouraged. There are few absolute contraindications. Women with a previous classical uterine incision should not undergo a trial of labor and should be delivered once fetal lung maturity is documented. An attempted trial of labor should not be discouraged in women with a previous low vertical uterine incision, although the patient should be counseled that the evidence as to the risks and benefits of a trial of labor is limited. In those situations where the previous uterine incision is unknown, but suggestive of a classical uterine incision, an argument can be made for elective repeat cesarean delivery once fetal lung maturity is documented. When the history of a uterine incision is unknown and unlikely to be classical, a trial of labor can be attempted after counseling. Close intrapartum management is warranted in this situation. The optimal management of labor in women with a previous low transverse uterine incision who desire a trial of labor with a breech presentation, multiple gestation, orin whom induction of labor is necessary is uncertain; the evidence as to the risks and benefits of a trial of labor is limited and obstetric management should be individualized after counseling. Uterine rupture represents the most catastrophic complication of a trial of labor after previous cesarean delivery. In women suspected of having a uterine scar injury, prompt intervention is necessary to minimize both maternal and neonatal complications. Women who are not successful with a trial of labor require repeat cesarean delivery and appear to be at greatest risk for maternal complications. Identifying those women most likely to be successful with an attempted trial of labor after previous cesarean while also incurring the least maternal and perinatal morbidity and mortality would be ideal. At present, however, there is no sufficiently predictive method to identify those women most likely to benefit from an elective repeat cesarean delivery. The management of labor in women with a previous uterine scar is not low risk. As the number of women who attempt vaginal birth after previous cesarean delivery increases, we should focus on trying to develop reliable methods of identifying women who should and should not undertake a trial of labor after cesarean delivery.

Risk factors and morbidity in patients with placenta previa accreta compared to placenta previa non-accreta

BACKGROUND

Placenta accreta is associated with high morbidity and most cases occur with placenta previa. This study was carried out in an attempt to define risk factors for placenta accreta in cases of placenta previa and to quantify the increased morbidity of placenta previa accreta in comparison to placenta previa alone.

METHODS

The records of all patients delivered by cesarean section (CS) for placenta previa and accreta during the seven-year period from 1990 to 1996, inclusive, were reviewed. Data regarding the demographic features, previous CS, the incidence of hysterectomy and postpartum morbidity were analyzed.

RESULTS

Out of 23070 deliveries 110 (0.48%) had placenta previa, twelve (0.05%) of whom had placenta previa accreta. There was no significant difference in age and parity. Patients with a history of previous CS showed a significant increase in the incidence of placenta previa accreta (p=0.001). The percentage of accreta increased linearly from 4.1% in patients with no CS to 60% in patients who had had three or more CS. Postpartum hemorrhage and emergency hysterectomy were significantly higher among the previa accreta patients compared with the previa patients alone (p<0.001; p<0.001, respectively).

CONCLUSION

In the presence of a previous history of CS, patients with antepartum diagnosis of placenta previa are considered to be at a greater risk for having placenta accreta. The risk increases with the increase in the number of previous CS. Patients with placenta previa accreta have a significantly higher incidence of PPH and are more likely to undergo emergency hysterectomy.

Laparoscopic cholecystectomy at cesarean section. A new surgical option

A 29-year-old woman with recurrent cholelithiasis in pregnancy and a history of previous cesarean section underwent elective repeat abdominal delivery combined with laparoscopic cholecystectomy under general anesthetic. A transverse suprapubic incision was employed for fetal extraction and for facilitating the placement of three upper abdominal laparoscopic cannulas. After closure of the laparotomy incision, a pneumoperitoneum was established, and the gallbladder was removed laparoscopically. The surgery was uneventful, and the patient was discharged on the third postoperative day.

Once a cesarean, always a controversy

For most of this century, "once a cesarean, always a cesarean" was the rule in the United States. In the 1980s, vaginal birth after cesarean grew in popularity and the pendulum began to swing away from routine repeat cesarean delivery. Recently, the wisdom of this transition has been questioned. As the 20th century comes to a close, the treatment of the patient with a prior cesarean delivery remains controversial.

Pattern of cervical dilatation in previous lower segment caesarean section patients

The pattern of cervical dilatation during labour in 100 patients with previous lower segment caesarean section (LSCS) was determined in a prospective partographic study. Eighty-four subjects delivered successfully by vaginal route. The mean initial dilatation rate (IDR) and average dilatation rate (ADR) were 0.884 cm/hour and 1.255 cm/hour respectively. The mean IDR and ADR of the patients who delivered vaginally were 0.96 cm/hour and 1.41 cm/hour respectively, while of those who required repeat LSCS mean IDR was 0.44 cm/hour and mean ADR was 0.42 cm/hour. Hence ADR in cases who required repeat LSCS was significantly slower as compared to those who delivered vaginally (p < 0.01). Most (87.5%) of the cases who required repeat LSCS crossed the alert line as compared to 34.5% of patients who delivered vaginally. The mean admission delivery interval (ADI) was 9.45 +/- 4.29 hours in patients with no previous vaginal delivery and 8.02 +/- 4.83 hours in patients with previous vaginal delivery. The mean durations of 1st and 2nd stages of labour were 11.8 +/- 5.35 hours and 29.4 +/- 27.3 minutes respectively. It is concluded that partographic evaluation is an important aspect in management of labour of such patients.

Vaginal delivery in the grand multipara following previous lower segment cesarian section

OBJECTIVE

To examine the effect of attempting vaginal birth after cesarian section in the grand multipara with one previous cesarian section scar in the uterus.

METHOD

Over 5-year period (1990-1994) mothers with 6 or more previous deliveries and with a previous section scar in the uterus were identified. The outcome in these patients who attempted vaginal birth was reviewed.

RESULTS

Of the 85 patients with the combination of both grand multiparity and a previous cesarian section scar in the uterus, 45 attempted a trial of labor. Twenty-seven patients (60%) achieved successful uncomplicated vaginal delivery. There was a relatively high incidence of serious complications.

CONCLUSION

Vaginal birth after cesarian section can be achieved in some grand multiparas with a previous scar in the uterus. There is an increased risk of serious complications. The labor should be very closely supervised and early intervention arranged if there is not smooth rapid progress.

Inflammatory cytokine mRNA in human gestational tissues: implications for term and preterm labor

OBJECTIVE

To determine if inflammatory cytokine mRNA in gestational tissues is present only in the setting of infection-associated preterm labor or under several other clinical conditions.

METHODS

Human gestational tissues were collected from 51 women experiencing 1) term cesarean delivery without labor, 2) normal term vaginal delivery, 3) preterm cesarean delivery without labor, 4) preterm vaginal delivery without chorioamnionitis, and 5) preterm vaginal delivery with concomitant chorioamnionitis. Decidua, chorion, and amnion were isolated, total RNA from each tissue was extracted, and the presence of inflammatory cytokine mRNA was determined by polymerase chain reaction. Interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor-alpha mRNA was detected using specific oligonucleotide primers.

RESULTS

Interleukin-1 beta mRNA was rarely found in tissues preterm without labor but was readily detected in both maternal and fetal tissues after labor, regardless of gestational age. Interleukin-6 mRNA was rare in tissues from the nonlaboring patient but was found in almost all tissues after labor. Interleukin-8 mRNA was detected in all tissues at term, both in nonlaboring and laboring patients. Tumor necrosis factor-alpha mRNA was detected in only 20-50% of tissues after labor, and was rarely detected in the absence of labor.

CONCLUSIONS

Inflammatory cytokine mRNA is commonly expressed in human gestational tissues after normal labor and preterm labor with or without associated intrauterine infection. There was no difference in the pattern of expression of mRNA inflammatory cytokine in women who did or did not have clinically evident intrauterine infection.

Outcome of unplanned vaginal deliveries after two previous caesarean sections

Once a caesarean section always a caesarean section may not stand true any more but twice a caesarean section always a caesarean section still stays put because of its high maternal and foetal complications. Jinnah Postgraduate Medical Centre is large tertiary care hospital and has a caesarean section rate of over 18%, 10 patients (3.9%) were picked up in a retrospective study who had vaginal delivery after 2 previous caesarean sections in 2 years. They were admitted late in labour. Only one patient had dehiscence of scar. The aim of the study was to evaluate the outcome and safety of vaginal deliveries after 2 previous caesarean sections even when the trial was not conducted at the hospital.

Vaginal birth after cesarean section: current opinion

Although the current literature attests to the merits of a trial of labor in the patient with a prior cesarean section, some controversies remain. For example, can women with two or more sections be allowed a trial of labor and can patients who undergo a trial of labor receive oxytocin or prostaglandins for induction? Also, do certain indications for previous cesarean section such as relative cephalopelvic disproportion/failure to progress or the diagnosis of breech or twins in the present pregnancy constitute an indication for elective repeat cesarean delivery? These questions along with some other controversies are discussed in the light of newly accumulated data in the English literature and our own experience over the last decade in a major university-based tertiary medical center.

Predictors of repeat cesarean delivery after trial of labor: do any exist?

BACKGROUND

We evaluated the predictive value of risk factors for repeat cesarean delivery identified in retrospective studies.

STUDY DESIGN

We identified 175 consecutive patients who underwent trial of labor (TOL) and compared detailed admission, intrapartum, and postpartum characteristics of those who required repeat cesarean delivery with those who had vaginal births. We calculated relative risks, positive predictive values, and sensitivities for potentially predictive admission characteristics. We also performed multiple logistic regression and classification analyses.

RESULTS

Ninety-five percent of eligible patients underwent a TOL, and 85 percent of them delivered vaginally. Patients who had labor induced and patients with high fetal station on admission were significantly more likely to require repeat cesarean section (relative risk [RR]=2.9 and 2.1; 95 percent confidence interval [CI]=1.5 to 5.3, 1.1 to 4.2, respectively), but even these patients had high rates of vaginal birth (67 percent and 75 percent, respectively). A subgroup of patients who underwent labor induction and had large fetuses (estimated weight 3,800 g or more) had a 75 percent risk of cesarean delivery (RR=2.5, 95 percent CI=0.9 to 7.5). Multivariate models using different combinations of admission characteristics could not correctly identify which patients would require repeat cesarean delivery.

CONCLUSIONS

Admission characteristics with statistically significant risk ratios have low predictive values because of the extremely low rate of repeat cesarean delivery in this population. A larger series is needed to study TOL outcomes in patients with large fetuses who are being induced. We conclude that until risk factors with high predictive value for repeat cesarean delivery are identified, all eligible patients should be encouraged to undergo a TOL.

Vaginal delivery after Caesarean section: factors influencing success rates

In a retrospective review of 333 pregnancies in women who had 1 previous Caesarean section, 244 (73.3%) underwent a trial of scar, and 89 (26.7%) had an elective Caesarean section. In the trial of scar group 197 (80.7%) had a vaginal delivery and 47 (19.3%) required an emergency Caesarean section. The success of the trial was favourably influenced by a nonrecurring indication for the original Caesarean section, a previous vaginal delivery, and a smaller baby. Maternal morbidity was greater in the groups requiring a Caesarean section, whether elective or emergency. Those patients delivered vaginally spent significantly less time in hospital. In 2 of the 244 patients (0.8%) who underwent a trial of scar the previous lower segment scar was found at Caesarean section to have dehisced or ruptured.