Maternal Complications Associated With Multiple Cesarean Deliveries

Adhesion barriers in gynecologic surgeries and cesarean section: An Asia-Pacific expert panel consensus recommendation

Adhesions arising from gynecologic surgeries and cesarean sections pose substantial clinical, social, and economic challenges, leading to issues like pelvic pain, infertility, bowel obstruction, and recurring surgeries. Preventing adhesions is a pressing unmet need, hindered by difficulties in assessing postoperative adhesions and understanding barriers. To bridge adhesion prevention gaps, statements on clinical practices were synthesized to present Asia-Pacific expert perspectives on gynecologic surgery and cesarean section adhesion prevention. An expert panel of eight physicians from various healthcare settings in the Asia-Pacific region was convened and a comprehensive literature search on topics related to adhesion prevention in gynecologic surgeries and cesarean sections was performed. Information from full-text publications was used to develop draft consensus statements, with each statement assigned the highest available evidence level based on a systematic literature review and graded using the Oxford Center for Evidence-based Medicine criteria. A modified Delphi process, involving two rounds of online voting and discussions with an extended group of 109 experts, was employed to reach a consensus on six topics related to adhesion barriers. A set of 15 consensus statements were synthesized. Key topics include adhesion incidence in Asia, cesarean section complications, barrier application status, adhesion formation and prevention, absorbable barriers' effectiveness, recommendations, and future considerations. The statements provide guidance for healthcare professionals, especially in the Asia-Pacific region, to tackle the challenges posed by postoperative adhesions and improve patient outcomes. Further research is needed to enhance understanding and prevention of adhesions in this region.

Comparison between extraperitoneal and transperitoneal cesarean section: Retrospective case-control study

INTRODUCTION

  The main advantage of extraperitoneal cesarean section (EXPCS) is not only less pain, faster recovery, and less potential for infection but also a possible lack of intraperitoneal adhesions.

METHODS

  In a 3-year period from 2019 to 2022, 88 EXPCSs were performed. A comparison was made with 90 patients who underwent a standard transperitoneal cesarean section (TPCS). For both groups, the inclusion criterion was uterine inertia and prolonged labor as an indication for cesarean section. Only pregnant women from 37 to 42 weeks were included. After this, 51 patients remained in the EXPCS arm, and 49 remained in the TPCS arm.

RESULTS

  No statistical difference was found in gestational weeks, newborn weight, Apgar score, erythrocyte (Er), hemoglobin (Hgb), and hematocrit (Htc) values and duration of operative time between the EXPCS and TPCS groups. Leukocytes, C-reactive protein (CRP) with fever higher than >38°C on the third postoperative day were found statistically significantly (p=0.005) higher in the TPCS group. The usage of tramadol + metamizole at 3, 6, and 9 hours after delivery and diclofenac at 6, 12, and 18 hours after surgery was statistically significantly (p<0.05) higher in the TPCS group. On the visual analog scale (VAS) 24 hours after surgery, a statistically significant difference was found (p = 0.001) between the two groups. In the small group of patients who underwent a TPCS section after an EXPCS, intraperitoneal adhesions were not found; in another group of patients who underwent a TPCS twice, adhesions were found in 12 patients; Fisher's exact test (p=0.04).

CONCLUSION

  The protective effect of EXPCS for infection could be proven in prolonged delivery. EXPCS could be a good solution in the fight against adhesions and infection in women who undergo second, third, or even fourth cesarean sections.

Optimal Timing of Cesarean Section Following Two or More Prior Cesareans: An Investigation Into Maternal and Neonatal Outcomes (a Two-Center Study)

Objective This study aimed to determine the optimal timing of elective cesarean sections for women with two or more prior cesarean deliveries by investigating maternal and neonatal outcomes across different gestational ages (37 weeks, 38 weeks, and 39 weeks). Methods A retrospective cohort study was conducted at Tawam and Kanad Hospitals in Al Ain, United Arab Emirates, including 435 women with previous cesarean deliveries. Data were collected on patient demographics, obstetric history, maternal complications, and neonatal outcomes, such as birth weight, appearance, pulse, grimace, activity, and respiration (APGAR) scores, neonatal intensive care unit (NICU) admissions, and length of NICU stay. The patients were divided into two groups: those with two prior cesareans and those with three or more. Outcomes were analyzed based on gestational age at delivery. Results Elective cesarean sections constituted 81.0% of the procedures, with no significant difference in the distribution of elective versus emergency cesareans across the studied gestational weeks (P = 0.073). Neonatal outcomes indicated healthy birth weights and low NICU admissions. For women with two prior cesareans, the NICU admission rates were 23.53% for deliveries at 37 weeks, 8.11% at 38 weeks, and 4.35% for deliveries beyond 39 weeks. For women with three or more prior cesareans, NICU admission rates were 18.18% for 37 weeks, 20.00% for 38 weeks, and 10.00% for 39 weeks. The average birth weight increased with gestational age, and NICU stays were longer for earlier deliveries (P = 0.0065 for stays > 5 days). Conclusion The findings suggest that the optimal timing for elective cesarean sections in women with two or more prior cesareans is 39 weeks of gestation. This timing is associated with the best neonatal outcomes, including lower NICU admission rates and healthy birth weights while minimizing the risks associated with earlier deliveries. Scheduling elective cesarean sections at 39 weeks will improve maternal and neonatal health benefits.

Delivery mode and fetal outcome in attempted vaginal deliveries after previous cesarean section: a nationwide register-based cohort study in Finland

PURPOSE

Even though the risks and advantages of repeat Cesarean sections (CSs) and vaginal births after cesarean section (VBACs) are well studied, there is a scarcity of information on the effects of previous CS on maternal and fetal outcomes during subsequent deliveries. The aim of this study is to evaluate delivery mode and fetal outcomes in a trial of labor after cesarean section (TOLAC).

METHODS

In this nationwide retrospective cohort study, data from the National Medical Birth Register (MBR) were used to evaluate the outcomes of TOLACs. TOLACs were compared to the outcomes of the trial of labor after previous successful vaginal delivery. A multivariable logistic regression model was used to assess the primary outcomes (delivery mode, neonatal intensive care unit, and perinatal/neonatal mortality). Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used for comparison.

RESULTS

A total of 29 352 (77.0%) women attempted vaginal delivery in the TOLAC group. In the control group, 169 377 (97.2%) women attempted vaginal delivery. The adjusted odds for urgent CS (aOR 13.05, CI 12.59-13.65) and emergency CS (aOR 3.65, CI 3.26-4.08) were notably higher in the TOLAC group when compared to the control group. The odds for neonatal intensive care unit treatment (aOR 2.05, CI 1.98-2.14), perinatal mortality (aOR 2.15, CI 1.79-2.57), and neonatal mortality (aOR 1.75, CI 1.20-2.49) were higher in the TOLAC group.

CONCLUSIONS

The odds for emergency CS were higher among women who underwent TOLAC. The odds for neonatal intensive care and perinatal mortality were also higher, and further research is needed to identify those expecting women who are better suited for TOLAC to minimize the risk for a neonate. The results of this study should be acknowledged by the mother and the clinician when considering the possibility of vaginal births after cesarean section.

The rates of vaginal births after cesarean section have increased during the last decades: a nationwide register-based cohort study in Finland

PURPOSE

Epidemiological studies assessing the effects of previous cesarean section (CS) on subsequent delivery mode using large nationwide study populations. This study aims to calculate the incidence rates of trial of labors after cesarean section (TOLACs) and evaluate the annual rates of vaginal births after cesarean section (VBAC) during the last decades in Finland.

METHODS

Data from the National Medical Birth Register (MBR) were used to evaluate incidence rates of VABC in the Finnish population (1998-2018). All nulliparous women having their first and second pregnancy during our study period, and with the mode of delivery identified in both of these pregnancies were included in this study. Absolute annual numbers and incidence rates for TOLACs, elective CS, and VBAC were calculated.

RESULTS

The absolute number of TOLACs had an increasing trend during our study period, increasing up to 2118 TOLACs in 2016. The incidence rates for elective CS after the first CS had a decreasing trend, decreasing from 45% in 1999, to 28% in 2018. The absolute number of VBACs had an increasing trend during our study period, peaking in 2016 (1466 VBACs). The rates for VBAC remained relatively constant, ranging between 38 and 52%, but a slightly increasing trend at the end of the study period was seen.

CONCLUSION

Despite the increasing annual total number of deliveries with CS in the first pregnancy, the absolute numbers and rates for VBACs have increased towards the end of the study period in Finland. The epidemiology of TOLACs and VBACs should be better studied around the world, as with the rapidly increasing rate of CSs, these events are becoming more common challenges in health care.

Preoperative anemia and associated factors in women undergoing cesarean section at a comprehensive specialized referral hospital in Ethiopia

Background

Anemia is a common public health burden during pregnancy. Severe maternal and fetal complications have been associated with anemia. Despite many studies on anemia during pregnancy have been conducted in Ethiopia at any time of antenatal care visits, the prevalence of preoperative anemia among women awaiting cesarean delivery and its contributing factors have not been determined. The aim of this study was to determine the prevalence and associated factors of preoperative anemia in women awaiting cesarean section at a comprehensive specialized hospital in Ethiopia.

Methods

An institution-based cross-sectional study was done from April to June 2022 to determine preoperative anemia in women undergoing cesarean delivery. Data were obtained using a standardized questionnaire that included the women's background characteristics. Bi-variable and multi-variable logistic regression analyses were performed to identify variables related to preoperative anemia. With a 95% confidence level, the estimated crude odds ratio and adjusted odds ratio were calculated. In a multivariate analysis, variables were considered statistically significant if their p-value was less than 0.05.

Results

A total of 424 pregnant women with a 100% response rate were included in this study. The prevalence of preoperative anemia among women awaiting cesarean delivery was 28.3% (95% CI: 23.8-32.5%). Previous history of abortion, lack of iron supplementation, human immunodeficiency virus infection, previous cesarean section, and American Society of Anesthesiology class III were significantly associated with preoperative anemia among women awaiting cesarean section.

Conclusion and recommendation

Preoperative anemia was diagnosed in a significant proportion of women awaiting cesarean-delivery. Anemia was linked to a lack of iron supplementation, American Society of Anesthesiology class III, previous history of abortion, human immunodeficiency virus infection, and previous cesarean section. Therefore, early detection of high-risk pregnancies, iron supplementation, prevention of HIV infection and due attention to people living with HIV/AIDs are paramount.

External validation of vaginal birth after cesarean delivery calculator in Israeli cohort of parturients and construction of an improved model

OBJECTIVE

To validate the Maternal Fetal Medicine Unit's (MFMU) vaginal birth after cesarean delivery (VBAC) calculator in an Israeli cohort, and to detect other variables associated with VBAC and construct an improved VBAC calculator.

METHODS

A retrospective cohort study was performed at a single university-affiliated medical center. Women carrying a singleton, term, cephalic-presenting fetus, with previous one low transverse cesarean delivery who opted for trial of VBAC were included. Demographic and obstetric characteristics were incorporated into the MFMU's calculator, to predict probabilities of VBAC and compare prediction performance with the original publication utilizing receiver operating characteristic (ROC) statistics. Logistic regression analysis was used to investigate other variables and construct an improved model for success of VBAC.

RESULTS

Of 490 parturients, 396 (80.8%) had a successful vaginal delivery. Compared to the original publication, the MFMU's calculator underperformed: area under the ROC curve (AUC) was 0.709 (95% confidence interval [CI] 0.652-0.766, P < 0.001). Sensitivity, specificity, positive and negative predictive values, and overall accuracy were 67.42%, 65.96%, 89.30%, 32.46%, and 32.46%, respectively. An improved model that included previous VBAC, prior vaginal delivery, spontaneous onset of delivery, and maternal diabetes resulted in improved prediction performance with an AUC of 0.771 (95% CI 0.723-0.82, P < 0.001).

CONCLUSION

MFMU's VBAC calculator needs to be validated in different populations before implementation.

Prolonged operative time of cesarean is a risk marker for subsequent cesarean maternal complications

PURPOSE

Prolonged cesarean operative time (OT) is a well-established proxy for post-operative maternal complications. We aimed to study whether prolonged OT may serve as a proxy for maternal complications in the subsequent cesarean delivery.

METHODS

A retrospective cohort study of women who underwent cesarean delivery between 2005 and 2019. Parturients who had two subsequent cesarean deliveries were included and those with Placenta Accreta Syndrome (PAS) were excluded. Prolonged operative time was defined as the duration of cesarean delivery above 60 min. Univariate analyses were followed by multivariate analysis (adjusted Odds Ratio (aORs); [95% Confidence Interval]).

RESULTS

A total of 5163 women met the inclusion and exclusion criteria of which 360 (7%) had prolonged operative time. Prolonged operative time of a cesarean section in the index pregnancy was significantly associated in the subsequent cesarean delivery with the following: Prolonged operative time, intra-operative blood loss > 1000 ml, postpartum hemorrhage, blood products transfusion, injuries to the urinary system in the subsequent delivery, and hysterectomy. Multivariate analysis revealed that prolonged OT in the index delivery was associated with composite adverse maternal outcome (aOR 1.46 [1.09-1.95]; P = 0.01) and blood products transfusion (aOR 2.93 [1.90-4.52]; P < 0.01) in the subsequent delivery.

CONCLUSION

Prolonged operative may serve as a proxy for adverse maternal outcomes, mostly blood products transfusion, in the subsequent cesarean delivery among women undergoing repeat cesarean delivery.

Incidence and risk factors of bladder injury during cesarean delivery: a cohort study

PURPOSE

To identify risk factors associated with bladder injury during cesarean delivery, and to determine the frequency of associated morbidities.

METHODS

Data obtained from the United States' Health Care Cost and Utilization Project-Nationwide Inpatient Sample were used to conduct a retrospective population-wide cohort study. ICD-9 codes were used to identify women who underwent a cesarean delivery between 1999 and 2015. Subsequently, women were classified based on whether or not they experienced a bladder injury during delivery. Multivariate logistic regression was used to determine predictors of bladder injury in cesarean deliveries and to examine the associated morbidities while adjusting for baseline maternal demographics and clinical characteristics.

RESULTS

Of 4,169,681 cesarean deliveries identified, there were 7,627 (0.2%) bladder injuries for an overall incidence of 18 per 10,000. Women ≥ 35 years were at greater risk of bladder injury 1.5 (1.4-1.6), as were women with endometriosis 2.0 (1.5-2.7) and Crohn's disease 2.7 (1.7-4.2). Risk of bladder injury increased if the cesarean delivery was associated with placenta previa 2.2 (1.9-2.4), previous cesarean delivery 4.3 (4.1-4.6), failed instrumental delivery 4.1 (3.5-4.8), fetal distress 1.7 (1.6-1.8), failed trial of labor after cesarean delivery 1.3 (1.2-1.4), and labor dystocia 1.7 (1.6-1.8). Cesarean hysterectomies presented the greatest risk for bladder injury 37.0 (33.7-40.6). Bladder injury was associated with an increased frequency of sepsis, venous thromboembolism, peritonitis, blood transfusions and longer hospital stays.

CONCLUSION

Bladder injury during cesarean deliveries is a rare outcome but it is more common among women with certain demographic and clinical characteristics. Among these cases, strategies to prevent sepsis and venous thromboembolism should be considered.

Average maternal hemoglobin decline after first elective cesarean section compared to higher order cesarean sections

INTRODUCTION

Lower uterine segment scarring after cesarean section can decrease intraoperative bleeding during subsequent surgery. We examined whether first elective cesarean section is associated with greater average blood loss compared to repeated surgery.

METHODS

Decrease in maternal hemoglobin and hematocrit after surgery was retrospectively compared between three study groups, women in their first, second and third or more cesarean section. Surgery length and need for blood transfusion were also compared.

RESULTS

Out of 9401 cases reviewed between January 2010 November 2020, 3917 had a first cesarean section, 3159 s cesarean section and 2325 had a third or more cesarean section. Hemoglobin and hematocrit drops were highest after first cesarean section (1.1 vs 1.0 vs 1.0 mg/dL, P < 0.001 and 3.3 vs 3.0, vs 2.9%, P < 0.001, respectively). Surgery length was significantly longer and more patients after third cesarean section required blood transfusions (2.5% vs 1.4% vs. 0.8%, P < 0.001). First cesarean section, younger age and BMI >35 were associated with increased hemoglobin drop in univariate and multivariate analysis.

CONCLUSIONS

Although repeated cesarean section is associated with longer surgery and higher need for blood transfusion, average hemoglobin drop after first cesarean section is higher. Scarring of the lower uterine segment can explain this paradoxical finding.

Complete Cervicouterine Dissociation After Repeat Cesarean Sections: A Case Report

INTRODUCTION

The number of cesarean deliveries (CDs) has extremely increased in the last decades. Although it is a common and relatively safe surgical procedure, there are several potential complications. To the best of our knowledge, complete cervicouterine dissociation after several CDs has not been reported before in the medical literature.

CASE REPORT

A 28-year-old woman with a history of 6 CDs presented with abdominal pain and vaginal bleeding. The patient's most recent CD happened three weeks before the current presentation. Transabdominal ultrasonography examination and magnetic resonance imaging revealed the absence of continuity with the uterine cervix and corpus with associated pelvic hematoma. Laparotomy findings confirmed the imaging findings, and the displaced uterine corpus was removed with the evacuation of the associating pelvic hematoma.

CONCLUSION

Uterine dehiscence and rupture are among the relatively common complications of CD. Uterine rupture and dehiscence are focal disorders, and complete cervicouterine dissociation has not been seen before. Multiple CDs are among the risk factors for complete cervicouterine dissociation, and abnormal uterine bleeding is the most common symptom. Imaging findings allow a quick and definitive diagnosis, and surgical intervention may be planned accordingly based on the imaging findings.

A retrospective analysis of maternal complications and newborn outcomes of general anesthesia for cesarean delivery in a single tertiary hospital in China

Background

Either neuraxial anesthesia or general anesthesia can be performed for cesarean delivery. Generally, neuraxial anesthesia is the first choice with the risk and benefit balance for both the mother and fetus. However, general anesthesia is also applicable most commonly in the emergent setting. This study analyzed maternal complications associated with general anesthesia for cesarean delivery and suggested lowering pregnancy-related maternal and newborn adverse outcomes.

Methods

With the approval of the Institutional Ethics Review Board (No: 2017016), data on cesarean delivery and related anesthesia were collected from the Electronic Health Record System from 1/1/2013 to 12/31/2016. Statistical software STATA version 15.1 was used for data analyses. All statistical tests were two-sided, and a level significance of 0.05 was assumed.

Results

The rate of general anesthesia for cesarean delivery increased steadily during 2013–2016, 3.71% in 2013 to 10.23% in 2016 (p < 0.001). Repeat cesarean delivery among general anesthesia group increased significantly from 16.22% in 2013 to 54.14% in 2016 (p < 0.001). Morbidly adherent placenta (MAP) was the first reason among pregnancy-related complications, which accounted for 33% in total in general anesthesia group (38% in 2013 to 44% in 2016). The laryngeal mask airway (LMA) was used in airway management, and the proportion of LMA increased from 28.38% in 2013 to 92.99% in 2016 (p < 0.001). There were significant differences in newborn outcomes between general anesthesia and neuraxial anesthesia groups, including newborn weight, newborn Apgar score at 1 min and 5 min and newborn admission to the NICU (p < 0.001).

Conclusions

The growing incidence of general anesthesia was consistent with the trend of rising repeat cesarean delivery and MAP. low newborn Apgar score and high newborn admission to the NICU in general anesthesia group compared with neuraxial anesthesia group. The LMA was performed safely for airway management with enough fasting and careful gastric volume evaluation.

Intra-abdominal Adhesions among Patients Undergoing Repeat Caesarean Section in Department of Obstetrics and Gynaecology of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Adhesions are one of the common complications encountered after caesarean section whose risk increases with the number of caesarean deliveries. This study aimed to find out the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted on 74 pregnant women undergoing repeat caesarean section in the Department of Obstetrics and Gynaecology of a tertiary care centre from July, 2021 to December, 2021 after receiving the ethical approval from the Institutional Review Committee (Reference number: 2107202103). Pregnant women who met the eligibility criteria were included in the study. Convenience sampling was done. The severity of the adhesions was classified using the Tulandi and Lyell classification. Data were analysed using the Statistical Package for the Social Sciences version 26.0 software. Point estimate at 90% Confidence Interval was calculated along with frequency and percentage for binary data along with mean and standard deviation for continuous data.

Results

Out of 74 women undergoing repeat caesarean section, 55 (74.32%) (65.99-82.65 at 90% Confidence Interval) had developed intra-abdominal adhesions.

Conclusions

Our study showed that the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section was higher when compared to similar studies conducted in similar settings.

Keywords

postoperative complications; repeat caesarean section; surgical adhesions.

Geographic and socioeconomic inequalities in cesarean birth rates in Peru: A comparison between 2009 and 2018

BACKGROUND

There is a global concern about the high rates of cesarean birth (CB). This study aimed to investigate the geographic and socioeconomic inequalities in CB rates in the Peruvian population.

METHODS

We conducted a population-based study using the Peruvian Demographic and Family Health Surveys (ENDES, the Spanish acronym for Encuesta Demográfica y de Salud Familiar) between 2009 and 2018. ENDES reported data from births registered in the five years preceding survey execution. For the years 2009 (n = 10 289) and 2018 (n = 23 077), we calculated the weighted rates of CB among variables such as natural geographic domain (Coast, Andean, or Amazon), area of residence (rural or urban), wealth index quintile (quintile 1 is poorest, and quintile 5 is richest), and educational level. To assess inequalities, we calculated the concentration index (CIs), the slope index of inequality (SII), and the relative index of inequality (RII).

RESULTS

The CB rates by year were 21.4% (95% confidence interval [CI]: 20.0-22.9) in 2009 and 34.5% (95% CI: 33.4-35.5) in 2018. Women living in urban and coastal regions and with a higher education level had the highest CB rates. All the CIs were positive, reflecting a prowealthy inequality in CB rates, and both SII and RII were positive, indicating a gap between the use of cesarean in women in the higher wealth quintile compared with those in the lower quintile.

CONCLUSIONS

Cesarean birth rates have increased by 60% during the last decade in Peru. The richest wealth quintiles had the highest CB rates during the study years, which were well above global recommendations.

The Association Between Number of Repeat Cesarean Deliveries and Adverse Outcomes among Low-Risk Pregnancies

OBJECTIVE

To investigate maternal and neonatal adverse outcomes among low-risk pregnancies delivered at ≥ 37 weeks by repeat cesarean deliveries (RCD).

METHODS

A population-based, retrospective-study using the U.S. vital statistics datasets (2014-2018) evaluating low-risk pregnancies with a non-anomalous singleton non-laboring RCD from 37 to 41 weeks. People with hypertensive disorders or diabetes were excluded. Primary outcome was composite maternal adverse outcome (CMAO). Secondary outcome was composite neonatal adverse outcome (CNAO). Multivariable Poisson regression models were used to estimate the association between number of RCD and outcomes (using adjusted relative risks [aRR] and 95% confidence interval [CI]).

RESULTS

Of the 19,623,195 live births, 1,747,610 (8.9%) met inclusion criteria and among them, 1,144,186 (65.5%) had 1 prior CD, 454,817 (26.0%) had 2 prior CD, 119,087 (6.8%) had 3 prior CD, and 29,520 (1.7%) had ≥4 prior CD. Compared with individuals with 1 prior CD, the risk of CMAO was higher in individuals with 2 (aRR=1.41, 95% CI= 1.34-1.48), 3 (1.96, 1.83-2.10), and ≥4 (2.98, 2.69-3.29) prior CD. An increased risk of CNAO was also found with an increasing number of RCD CONCLUSION: Among low-risk pregnancies undergoing RCD, increasing number of prior CD was associated with a higher risk of adverse outcomes.

Laparotomy for Abdominal Adhesion and Removal of Intrauterine Device from Anatomically Distorted Uterus due to Adhesion in a 43-Year-Old Woman with 3 Previous Cesarean Sections

Patient: Female, 43-year-old

Final Diagnosis: Uterine adhesion to abdominal wall

Symptoms: Chronic pelvic pain

Medication: —

Clinical Procedure: Laparotomy

Specialty: Obstetrics and Gynecology

Skin Color May Predict Intra-Abdominal Adhesions During Repeated Caesarean Section Deliveries

OBJECTIVE

Caesarean rates have increased rapidly for various reasons recently. One of the important reasons among these is medicolegal problems. Our aim with this study was to preoperatively predict abdominal adhesion density by combining the scar tissue morphology formed in the post-caesarean Pfannenstiel incision line and the skin color scoring of the patients.

MATERIAL AND METHODS

Patients who had undergone one caesarean section previously, completed their terms (37-39 weeks) and were under 35 years old were included in the study. Skin color scoring of the patients was performed using the Fitzpatrick skin color scale. Intra-abdominal adhesion scoring of the participant patients was performed using Nair's adhesion scoring system.

RESULTS

The change in abdominal adhesion scores was evaluated based on the Fitzpatrick color scale. Adhesion scores per the Nair intra-abdominal adhesion scoring system were found to be 0.04±0.209 in the FP1 group, 0.35±0.662 in the FP2 group, 1.58±0.923 in the FP3 group, and 2.33±0.577 in the FP4 group (p<0.05). These results showed a significant increase in adhesion density with increasing skin color darkness. Based on these results, it was observed that the abdominal adhesion scores and the frequency of depressed skin scar were significantly increased with increasing Fitzpatrick scores (p<0.05).

CONCLUSION

The aim of this study was to increase the prediction rates by adding the skin color scoring to the scar tissue characteristics, which have been used in previous studies. The results of this study indicate that the combination of these two parameters may be more effective in predicting intra-abdominal adhesions. Nevertheless, there is a need for studies with a much higher number of patients and multiple parameters to be able to predict intra-abdominal adhesion density preoperatively with greater accuracy.

Risk factors for postpartum hemorrhage following cesarean delivery

OBJECTIVE

To identify risk factors for postpartum hemorrhage (PPH) following cesarean delivery (CD).

METHODS

A retrospective study of all women who underwent CD in a university-affiliated tertiary hospital (2014-15). PPH was defined as any of the following: clinical PPH (≥1000 ml estimated blood loss), hemoglobin (Hb) drop ≥3 g/dl (the difference between pre-CD Hb level within a 24 h prior to the delivery) and post-CD (nadir level during the first 72 h after CD)) or the need for blood products transfusion. The characteristics of women with PPH following CD were compared to a control group of those with CD without PPH.

RESULTS

Of the 15,564 deliveries during the study period, 3208 (20.6%) women met inclusion criteria, of them, 307 (9.6%) had PPH and 2901 (90.4%) served as controls. Women in the PPH group were younger (32.6 ± 5.3 vs. 33.5 ± 5.4, p = .006) and more often nulliparous (45.9% vs. 33.3%, p<.001) compared to the controls. However, there were no differences between the groups regarding the rate of multiple gestations, maternal diabetes mellitus, hypertensive disorders, polyhydramnios, and macrosomia. The rates of induction of labor (16.3% vs. 8.6%, p<.001) and urgent CD (47.9% vs. 32.0%, p<.001) were higher in the PPH group compared to the controls. In multivariate logistic regression, predictors for PPH following CD were (odds ratio, 95% confidence interval) urgent CS (1.57, 1.78-2.11, p = .002), CD duration (1.02, 1.01-1.03, p<.001), and the number of previous CDs (0.74, 0.62-0.90, p = .003).

CONCLUSIONS

In women undergoing cesarean section, urgent CD, the duration of the surgery, and the number of the previous CD are associated with the risk of PPH and should be taken into consideration during the postpartum assessment.

Cesarean Section Complications Followed by Bladder Cystotomy and Gross Hematuria Due to Unknown Dense Scar Tissue

Adhesions formed from previous Cesarean section (C-section) are a significant risk factor for bladder injury. We present a case of a 43-year-old pregnant woman who underwent a C-section and experienced severe complications due to adhesions and incisional dehiscence from a previous Cesarean delivery 11 years earlier. Several surgical and non-surgical interventions as radiologic tests, cystotomy, blood transfusion, cystogram, and others were necessary to resolve the issues followed by the Cesarean delivery. It is important for clinicians caring for women undergoing both primary and subsequent Cesarean sections to consider and mitigate risk factors for adhesion development.

Maternal Hypertension, Advanced Doppler Haemodynamics and Therapeutic Precision: Principles and Illustrative Cases

PURPOSE OF REVIEW

Maternal hypertension is a common and serious condition associated with increased maternal and foetal morbidity and mortality, with early detection and management improving outcomes.

RECENT FINDINGS

Blood pressure (BP) changes of pre-eclampsia are defined after 20 gestational weeks, while haemodynamic changes can be detected at 5-11 weeks using a specialised non-invasive Doppler stroke volume (SV) monitor. Thus, advanced haemodynamic monitoring allows for physiologically precise identification of circulatory abnormalities, and implementation of appropriate therapy within the first trimester. We measured the oscillometric BP and advanced haemodynamics (USCOM 1A) of 3 unselected women with singleton pregnancies, consecutively listed for therapeutic induction for maternal hypertension at 32-41 weeks gestational age. While the BP's of the patients varied, it was the haemodynamics, particularly SV, cardiac output, systemic vascular resistance, Smith Madigan Inotropy Index, and oxygen deliver, that identified differing patterns of circulatory dysfunction, therapeutic objectives, and predicted post-partum complications of the mother and child. First trimester screening of maternal haemodynamics may allow for earlier detection of circulatory derangements, selection of patient precise interventions, and improved maternal-foetal outcomes.

Determinants of cesarean-related complications: high number of repeat cesarean, operation type or placental pathologies?

Background: Cesarean delivery (CD) is one of the most common operations worldwide. Vaginal birth after cesarean (VBAC) could be a solution to decrease increased CD rates. On the other hand, risks of VBAC on maternal and neonatal outcomes drifts physicians and patients to a scheduled CD. Successive CDs, especially after the 3rd operation, increase complications for the fetus and the mother. Operation type (emergency or elective CD) could be a risk factor of increased morbidities, like placental implantation anomalies. Evaluation of these conditions related to complications and morbidities were investigated. Material and methods: Women who underwent the fourth and more repeat CD in Bursa Yuksek Ihtisas Training Research Hospital between March 2016 and December 2019 were retrospectively reviewed. Pre-operative characteristics, per-operative and post-operative complications were reviewed. Patients were separated into groups as operational type, repeat cesarean number, and major morbidities. A comparison between groups was evaluated. Results: A total of 46.048 women gave birth, of which 17,721 underwent CDs with a rate of 38%. The rate of primary CD was 18%. The number of the fourth or more CD performed was 854. The number of patients who underwent fourth and fifth or more CD and of these operational data could be accessed was 599 and 145, respectively. The overall complications were detected as severe adhesions (n: 220), preterm delivery (n: 91), stillbirth (n: 9), admission to NICU (n: 98), bladder injury (n: 10), uterine scar dehiscence (n: 6), uterine rupture (n: 6), uterine atony (n: 26), blood transfusion requirement (n: 68), preterm delivery (n: 91), placenta previa totalis (n: 24), morbidly adherent placenta (n: 14), hysterectomy (n: 12), partial uterine resection (n: 2), uterus-conserving interventions (n: 26). The number of patients with major morbidity was 105. Emergency cesarean performed in 339 of 744 patients. A comparison of the emergency cesarean group with elective repeat cesarean group revealed no significant difference in operative adverse outcomes. Comparing patients between 4th repeat CD with 5th and more CD revealed a significant difference in severe adhesion, morbidly adherent placenta and hysterectomy. Previa totalis were detected in 24 patients. All of them experienced major morbidity with 12 of them underwent hysterectomy. The rest of them performed Uterus-conserving treatments (B-Lynch Suture, Bacri Balloon, Hypogastric artery ligation ) and a total of 51 units of packed red blood cells and 32 units of Fresh Frozen Plasma were transfused to 9 (37%) of 24 patients. Conclusion: The major risk factor of the morbidity is placenta previa whose incidence has dramatically increased after 3rd cesarean. Emergency cesarean did not increase the complication rate in the present study. Fourth and more repeat CDs ought to be performed by experienced obstetricians in high-equipped tertiary hospitals.

The use of absorbable adhesion barriers to reduce the incidence of intraperitoneal adhesions at repeat cesarean delivery

PURPOSE

We aimed to evaluate the effect of an absorbable adhesion barrier (oxidized regenerated cellulose) for the prevention of peritoneal adhesions in women undergoing repeat cesarean delivery (CD).

METHODS

This is a retrospective, single center study that included all women who underwent two consecutive CDs, 2011-2018. Women in whom an absorbable adhesion barrier (oxidized regenerated cellulose) was placed at the time of the initial CD (index CD) were compared to women in whom no such barrier was placed. The association between absorbable adhesion barrier placement at index CD and the presence of intraperitoneal adhesions at subsequent CD was assessed. Factors evaluated included intraperitoneal adhesion severity, time from skin incision to newborn delivery and total duration of surgery.

RESULTS

We identified 2125 women that met the inclusion criteria. They were divided into two groups; those in whom an absorbable adhesion barrier was placed at index CD and those in whom no such absorbable barrier was placed. 161 (7.6%) had an absorbable adhesion barrier placed at index CD. At the time of index CD, the rate of intra-peritoneal adhesions was 34.8% in the absorbable adhesion barrier group vs 26.5% in the group without the absorbable adhesion barrier (p = 0.02). At the time of subsequent CD, the rate of intraperitoneal adhesions was 39.8% in the absorbable adhesion barrier group vs 46% in the group without the absorbable adhesion barrier (p = 0.13). Notably, the use of an absorbable adhesion barrier lowered the mean increase in adhesions rate 0.05 ± 0.55 vs 0.20 ± 0.55 (p < 0.01). Absorbable adhesion barrier placement at index CD was found to be independently associated with a lower rate of intraperitoneal adhesions at subsequent CD, aOR 0.67 (0.47-0.96). Overall, absorbable adhesion barrier placement at index CD was associated with a shorter mean duration of subsequent surgery (min), 37.7 ± 18.9 vs. 42.7 ± 27.1 (p = 0.02).

CONCLUSION

Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.

Labor patterns in Chinese women in Fuzhou attempting vaginal birth after previous cesarean delivery: a retrospective cohort study

Objective

To investigate the characteristics of labor in Chinese women who successfully have vaginal birth after cesarean section (VBAC).

Methods

A retrospective cohort study was conducted in a hospital with 1000 beds between January 1 2015 and December 31 2017. A total 657 parturients with VBAC were selected. Women were divided into two groups according to previous cesarean section with or without trial of labor. Labor curves were analyzed and interval-censored regression was used to estimate the duration of labor.

Results

The 95th percentile for the first stage of labor in VBAC was 13.03 hours, and labor accelerated after 4 cm of cervical dilation in both groups. The dilation rate in the trial of labor group was superior to that in the non-trial of labor group at 6–10 cm of dilation. After 6 cm, labor accelerated much faster in the trial of labor group than in the non-trial of labor group.

Conclusions

Management of labor in parturients with VBAC whose cervical dilation is >6 cm should be treated differently according to previous cesarean section with or without trial of labor. If there is trial of labor in a previous delivery, the duration of labor should be shortened.

ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Maternal and fetal outcomes of cesarean delivery and factors associated with its unfavorable management outcomes; in Ayder Specialized Comprehensive Hospital, Mekelle, Tigray, Ethiopia, 2017

Objectives

This study aimed to determine the unfavorable outcomes and to assess factors contribute to the unfavorable management outcomes after cesarean deliveries in Ayder Specialized Comprehensive Hospital, Mekelle, Tigray, Ethiopia, 2017.

Results

The unfavorable maternal management outcomes were Adhesion 28 (8.3%), excessive blood loss and blood transfusion 19 (5.6%), cesarean hysterectomy 10 (3%), relaparotomy 5 (1.5%), wound infection and wound dehiscence 23 (6.8%). Unfavorable fetal outcomes were were stillbirth 9 (2.6%), early neonatal death 8 (2.4%), low birth weight 58 (17.2%). women who did not book for Antenatal Care and having a history of previous cesarean delivery were found to be associated with unfavorable maternal outcomes and indications of cesarean delivery as obstructed labor was associated with unfavorable fetal outcomes.

Prediction of pelvic adhesions at repeat cesarean delivery through assessment of striae gravidarum score: A cross-sectional study

OBJECTIVE

To investigate the predictive value of the Davey Score for striae gravidarum (SG) on the presence of pelvic adhesions at repeat cesarean delivery (CD).

MATERIALS AND METHODS

The current study was a cross-sectional study conducted in a tertiary university hospital between November 2016 and March 2018. All women scheduled for elective CD were included if they had at least previous one CD with pregnancy in term fetus (37-40 weeks gestation. Preoperative evaluation of SG severity using Davey score, which is a validated scoring system, was done on the examination bed. Patients with no/mild striae (score 0-2) were classified as group (I) and women with severe striae (score 3-8) were classified as group (II). During surgery, pelvic adhesions were evaluated and classified according to the Nair's scoring system. The primary outcome was the difference in the rate of pelvic adhesions between both groups.

RESULTS

The study included 300 women; group I included 114 women and group II included 186 women. About 90% of women with severe striae versus 82.5% of women with no/mild striae were found to have adhesions (p = 0.035). Dense adhesions were significantly present in severe striae group (57.4%) versus (41.5%) in no/mild striae group (p = 0.022). The mean Davey score in women in group (II) was significantly higher than group (I) (4.25 ± 3.36 vs. 3.09 ± 2.95, p = 0.03). Nair's score had a significant positive moderate correlation with Davey score (r = 0.541, p = 0.016). According to the results of multivariate regression analysis, Davey score >2 was the only variable associated with increased risk of pelvic adhesions (p = 0.010).

CONCLUSION

Assessment of SG score in women with previous CD using Davey score might help to predict pelvic adhesions status before planning a new surgery.

Complications associated with higher order compared to lower order cesarean sections

Background: The rate of multiple cesarean sections is persistently on the rise because of cultural demands for large families, and multiple cesarean sections are an important cause of maternal morbidity and mortality.Objectives: This study was designed to detect the complications associated with higher order compared to lower order cesarean sections.Materials and methods: The hospitals record of women who had a cesarean section performed after three or more previous cesarean sections, and those who had a cesarean section for the second time over 2 years reviewed. Women with ≥3 cesarean sections admitted for elective cesarean section after 38 weeks' gestation, and those with ≥3 cesarean sections admitted in labor for emergency cesarean section were included in group 1. Women with history of previous one lower segment cesarean section (LSCS), who refused trial of labor and women with one LSCS who had an emergency cesarean section after failed trial of labor (TOL) were included in group 2. Antenatal, intraoperative, and postoperative data were reviewed. Statistical analysis done using SPSS version 20 (Chicago, Illinois, USA), to detect the complications associated with higher order compared to lower order cesarean sections. Primary outcome measures; complications associated with higher order compared to lower order cesarean sections. Secondary outcome measures; intraoperative, and postoperative complications.Results: Four hundred and fifty (450) women undergoing repeat cesarean section studied; 32.2% (145/450) had ≥3 previous cesarean sections (group 1), and 67.8% (305/450) had previous one cesarean section (group 2). In group 1, 77.2% (112/145) had previous three cesarean sections, 12.4% (18/145) had previous four cesarean sections, 9% (13/145) had previous five cesarean sections, and 1.4% (2/145) had previous six cesarean sections. The proportion of unbooked admission, and emergency cesarean sections were significantly high in group 2 compared to group 1 (11.1% (34/305) and 73.1% (223/305) versus 4.83% (7/145) and 40.7% (59/145); respectively) (p<.05, 95% CI; 0.1-0.2) and p<.01, 95% CI; 0.4-11.4; respectively. The risk of dense omental adhesions, and bladder injuries were significantly high in group 1 compared to group 2 (4.14% (6/145) and 1.38% (2/145) versus 0.66% (2/305) and 0% (0/305); respectively), (p=.01 (95% CI; 0.6-1.6) and p=.01 (95% CI; 0.5-5.5); respectively). Logistic regression analysis showed that the bladder injury was 5 times more (odds ratio 5.0 (95% CI; 0.035-711.8)) and the blood transfusion was 4.7 times more (odds ratio 4.7 (95% CI; 0.147-151.5)) in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference p=.52 and .38; respectively).Conclusion: The risk of dense omental adhesions and bladder injury was significantly high in women with previous ≥3 cesarean sections compared to women with previous one cesarean section. Logistic regression analysis showed that the bladder injury was five times more and the blood transfusion was 4.7 times more in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference).

Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications

Background

Repeat cesarean delivery (CD) accounts for approximately 15% of all annual deliveries in the US with an estimated 656,250 operations per year. We aimed to study whether prolonged operative time (OT; skin incision to closure) is a risk marker for post-operative maternal complications among women undergoing repeat CD.

Methods

We conducted a cross-sectional retrospective study in a single tertiary center including all women who underwent repeat CD but excluding those with cesarean hysterectomy. Prolonged OT was defined as duration of CD longer than the 90th percentile duration on record for each specific surgeon in order to correct for technique differences between surgeons. Bi-variate analysis was used to study the association of prolonged OT with each one of the following maternal complications: post-operative blood transfusion, prolonged maternal hospitalization (defined as hospitalization duration longer than 1 week post-CD), infection necessitating antibiotics, re-laparotomy within 7 days post-CD, and re-admission within 42 days post-CD. A multivariate regression analysis was performed controlling for maternal age, ethnicity, parity, number of fetus, gestational age at delivery, trial of labor after cesarean, anesthesia, and number of previous CDs. The adjusted odd ratio was calculated for each complication independently and for a composite adverse maternal outcome defined as any one of the above.

Results

A total of 6507 repeat CDs were included; prolonged OT was highly associated (P value < 0.000) with: post-operative blood transfusion (4.4% vs. 1.5%), prolonged hospitalization (8.4% vs. 4.0%), infection necessitating antibiotics (2% vs. 1%), and readmission (1.8% vs. 0.8%) when compared to control. The composite adverse maternal outcome was also associated with prolonged OT (20.2% vs. 11.2%, p < 0.000). These correlations remained statistically significant in the multivariate regression analysis when controlling for confounders.

Conclusions

Among women undergoing repeat CD, prolonged OT (reflecting CD duration greater than 90th percentile for the specific surgeon) is a risk marker for post-operative maternal complications.

Risk factors for relaparotomy after cesarean delivery and related maternal near-miss event due to bleeding

Aim: To define the risk factors for relaparotomy after cesarean delivery (RLACD) and related maternal near-miss event due to bleeding.Methods: In this retrospective descriptive case-control study, women who underwent RLACD (n = 46) only for bleeding between 2012 and 2017 were reviewed. Factors that could predict relaparotomy and related near-miss event were evaluated. Maternal characteristics, laboratory findings and surgical features were compared with a control group (n = 230) that included noncomplicated cesarean deliveries (CD). Logistic regression analysis was used to identify independent factors for relaparotomy.Results: RLACD for bleeding was required in 0.26% of patients and the incidence increased gradually over years (0.16% in 2013 versus 0.44% in 2017). Mean interval between CD and subsequent relaparotomy was 15.7 ± 3.2 hours. The sources of bleeding in descending order of frequency included; uterine fundus and placental bed (39.1%), cervix (21.7%), undetermined (17.3%), superior epigastric artery (13%), superficial epigastric artery (8.1%). Longer duration of CD (adjusted odd ratio (aOR) 1.82, 95% CI 1.02-2.53), increased number of prior CDs (aOR 2.51, 95% CI 1.09-5.78), preeclampsia (aOR 3.48, 95% CI 1.21-7.19) were found to be independent risk indicators for RLACD. Moreover, longer duration of interval between CD and relaparotomy (p = .005), longer relaparotomy duration (p = .012) and greater drop in hemoglobin level (p = .001) were found to be the predictors of maternal near-miss event.Conclusions: Patients with identified risk factors should be managed properly in order to prevent relaparotomy and near-miss event after CD. Also, urgent decision of surgical intervention might reduce the risk of maternal near-miss event.

Effect of Cesarean Delivery on Long-term Risk of Small Bowel Obstruction

OBJECTIVE

To evaluate the association of cesarean deliveries on the incidence of small bowel obstruction.

METHODS

We formed a population-based cohort of all women with a first live birth between 1998 and 2007 using the U.K. Clinical Practice Research Datalink. Women were followed until 2015, the occurrence of a small bowel obstruction, or loss to follow-up. Cesarean delivery was identified from the Hospital Episode Statistics and small bowel obstruction events were identified using the Classification of Interventions and Procedures and International Classification of Diseases, 10th Revision codes. Cox proportional hazard models, with cesarean delivery defined as a time-dependent exposure, estimated the adjusted hazard ratios and 95% CIs of small bowel obstruction associated with cesarean delivery.

RESULTS

The cohort included 81,480 women with a median follow-up of 8.0 years (range 6 months to 16.6 years), during which 575 new small bowel obstructions occurred (incidence 9.1/10,000 person-years). Risk of small bowel obstruction was higher among women with a cesarean delivery compared with women without (16.3 vs 6.4 patients/10,000 person-years, odds ratio [OR] 2.54, 95% CI 2.15-3.00). Increasing number of cesarean deliveries was associated with an increasing risk of small bowel obstruction (OR 1.61, 95% CI 1.46-1.78, per additional cesarean delivery). Repeated small bowel obstructions were more common among women with a cesarean delivery and the association remained when restricting to small bowel obstruction requiring surgical management.

CONCLUSION

Although rare, small bowel obstructions are increased among women who have undergone a cesarean delivery. With increasing rates of cesarean deliveries worldwide, small bowel obstructions and related morbidities may become a more prevalent women's health concern.

Caesarean section audit to improve quality of care in a rural referral hospital in Tanzania

Background

Caesarean section (CS) is often a life-saving procedure, but can also lead to serious complications, even more so in low-resource settings. Therefore unnecessary CS should be avoided and optimal circumstances for vaginal delivery should be created. In this study, we aim to audit indications for Caesarean sections and improve decision-making and obstetric management.

Methods

Audit of all cases of CS performed from January to August 2013 was performed in a rural referral hospital in Tanzania. The study period was divided in three audit blocks; retrospective (before auditing), prospective 1 and prospective 2. A local audit panel (LP) and an external auditor (EA) judged if obstetric management was adequate and indications were appropriate or if CS could have been prevented and yet retain good pregnancy outcome. Furthermore, changes in modes of deliveries, overall pregnancy outcome and decision-to-delivery interval were monitored.

Results

During the study period there were 1868 deliveries. Of these, 403 (21.6%) were Caesarean sections. The proportions of unjustified CS prior to introduction of audit were as high as 34 and 75%, according to the respective judgments of LP and EA. Following introduction of audit, the proportions of unjustified CS decreased to 23% (p = 0.29) and 52% (p = 0.01) according to LP and EA respectively. However, CS rate did not change (20.2 to 21.7%), assisted vacuum delivery rate did not increase (3.9 to 1.8%) and median decision-to-delivery interval was 83 min (range 10 - 390 min).

Conclusions

Although this is a single center study, these findings suggest that unnecessary Caesarean sections exist at an alarming rate even in referral hospitals and suggest that a vast number can be averted by introducing a focused CS audit system. Our findings indicate that CS audit is a useful tool and, if well implemented, can enhance rational use of resources, improve decision-making and harmonise practice among care providers.

Suture Compared With Staple Closure of Skin Incision for High-Order Cesarean Deliveries

OBJECTIVE

To compare wound complication rates in tertiary or higher-order cesarean delivery based on wound closure technique.

METHODS

We performed a retrospective cohort study of all tertiary or higher-order cesarean deliveries performed by one group practice in a large academic medical center from 2005 to 2017. We excluded patients with a vertical skin incision. Although the study was not randomized, wound closure type was relatively uniform in this practice and based on time period: before 2011, the preferred closure was staple closure; after 2011, subcuticular suture closure was preferred. All patients received preoperative antibiotics and closure of subcutaneous tissue 2 cm deep or greater. The primary outcome was a wound complication, defined as a wound infection requiring antibiotics or a wound separation requiring wound packing or reclosure any time up to 6 weeks after delivery. Regression analysis was used to control for any significant differences at baseline between the groups.

RESULTS

There were 551 patients with tertiary or higher-order cesarean delivery, 192 (34.8%) of whom had staple closure and 359 (65.2%) of whom had suture closure. Suture closure was associated with a significantly lower rate of wound complication (4.7% [17/359, 95% CI 3.0%-7.5%] vs 11.5% [22/192, 95% CI 7.7%-16.7%], P=.003). On regression analysis controlling for the number of prior cesarean deliveries and the participation of a resident in the closure, suture closure remained independently associated with a lower risk of a wound complication (adjusted odds ratio 0.44, 95% CI 0.23-0.86).

CONCLUSION

For women undergoing their third or higher-order cesarean delivery, suture closure is associated with a lower rate of wound complications.

MRI findings of complications related to previous uterine scars

Although the World Health Organization suggests 10–15% as the adequate cesarean delivery rate to assure optimal prognosis for mother and children, cesarean rates have continuously increased worldwide over the last three decades, even in primiparous women. Moreover, uterine scars after myomectomies, complications of obstetrical interventions and more recently, after fetal surgery, are often observed. This review article describes the most commonly seen complications related to prior uterine scars and discusses their imaging findings, with emphasis on the increasing role of Magnetic Resonance Imaging for diagnosis.

Antiepileptic drug use among women from the Taiwanese Registry of Epilepsy and Pregnancy: Obstetric complications and fetal malformation outcomes

To investigate antiepileptic drugs (AEDs) prescription and pregnancy outcomes in pregnancies with epilepsy in Taiwan between 2004 and 2015. We retrospectively reviewed data from the Taiwanese Registry of Epilepsy and Pregnancy (TREP). The TREP registry is a voluntary prospective cohort registry, which tracks pregnant women with epilepsy and AED prescription throughout pregnancy, delivery, and early childhood development. All TREP pregnancies (n = 318) that had completed questionnaires up until delivery or had had an unsuccessful pregnancy were analyzed. Over 94.7% of women had been prescribed AEDs during pregnancy, with 69.0% and 25.7% having received monotherapy, or polytherapy, respectively. Among live births, 12 (3.9%) reported malformation. Cesarean section rate was reported higher than usual (54.5%). In 2004, 73.3% of AEDs prescribed were 1st generation, with 1st generation prescription rates falling to only 8.3% of total prescribed in 2015. AED polytherapy also fell during the study period (40.0% to 20.0%). Cesarean sections were found to be higher for women over 35 years, who had generalized epilepsy, or had experienced an obstetric complication during pregnancy term. Binary logistic regression revealed that Cesarean section was associated with maternal complications (OR = 5.11, CI 95% = 1.11-23.51, p = 0.036), while malformations were associated with obstetric complication (OR = 20.46, CI 95% = 4.80-87.21, p<0.001). Both AED risk types were not associated with complications or malformations. Our sample provides a unique insight into the women with epilepsy with AED use during pregnancy. Cesarean section rate was observed to be higher than usual, but malformation rates remained low. Results indicate a decrease in both 1st generation AEDs and proportion of patients receiving polytherapy over the study period. Obstetric complications were associated with Cesarean section. Fetal malformations were significantly associated with obstetric complications. AED risk factors were not significantly associated with either complications or malformations.

Prevalence of adhesions and associated postoperative complications after cesarean section in Ghana: a prospective cohort study

BACKGROUND

The global increase in Cesarean section rate is associated with short- and long-term complications, including adhesions with potential serious maternal and fetal consequences. This study investigated the prevalence of adhesions and association between adhesions and postoperative complications in a tertiary referral hospital in Accra, Ghana.

METHODS

In this prospective cohort study, 335 women scheduled for cesarean section at Korle-Bu Teaching Hospital in Accra, Ghana were included from June to December 2015. Presence or absence of adhesions was recorded and the severity of the adhesions was scored using a classification system. Associations between presence and severity of adhesions, postoperative complications, and maternal and infant outcomes at discharge and 6 weeks postpartum were assessed using multivariate logistic and linear regression analysis.

RESULTS

Of the participating women, 128 (38%) had adhesions and 207 (62%) did not. Prevalence of adhesions increased with history of caesarean section; 2.8% with no CS but may have had an abdominal surgery, 51% with one previous CS, 62% with >1 CS). Adhesions significantly increased operation time (mean 39.2 (±15.1) minutes, absolute adjusted difference with presence of adhesions 9.6 min, 95%CI 6.4-12.8), infant delivery time (mean 5.4 (±4.8) minutes, adjusted difference 2.4 min, 95%CI 1.3-3.4), and blood loss for women with severe adhesions (mean blood loss 418.8 ml (±140.6), adjusted difference 57.6 ml (95%CI 12.1-103.0). No differences for other outcomes were observed.

CONCLUSION

With cesarean section rates rising globally, intra-abdominal adhesions occur more frequently. Risks of adhesions and associated complications should be considered in counseling patients for cesarean section.

Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Prediction of vaginal birth after one ceasarean delivery for non-progressive labor

PURPOSE

A model exists that predicts the probability of vaginal birth after cesarean (VBAC). That model is not stratified by indication at first cesarean. The aim of the study was to identify factors that may predict successful VBAC in patients operated for arrest of dilatation or descent at their first cesarean.

METHODS

Retrospective analysis of all women with trials of labor after one cesarean (TOLAC) for non-progressive labor between November 2008 and October 2015 was performed (n = 231). A multivariate logistic regression analysis was carried out to generate a prediction model for VBAC at hospital admission for planned TOLAC.

RESULTS

During the study period, we had 231 parturient women who chose to undergo TOLAC following one previous cesarean delivery for non-progressive labor. Successful VBAC occurred in 155 (67.0%) parturient women. A model consisting of previous successful VBAC, lower head station on decision at previous cesarean delivery, lower newborn weight at previous cesarean delivery and larger cervical effacement on admission at delivery planned for TOLAC correctly classified 75.3% of cases (R ² = 0.324, AUC 0.80, 95% CI 0.70-0.89, p < 0.001).

CONCLUSION

A predictive model, which incorporates four variables available at hospital admission for the planned TOLAC, has been developed that allows the determination of likelihood of successful VBAC following one cesarean delivery for non-progressive labor.

Stage of labor at admission among Ugandan women with a prior cesarean, and its impact on management and delivery outcomes

OBJECTIVE

To describe stage of labor at admission among women with a prior cesarean, and examine its impact on intrapartum management and delivery mode.

METHODS

In a prospective cohort study, women admitted to Mbarara Regional Referral Hospital, Uganda, for delivery were enrolled between March and June 2015. Rates of vaginal delivery (VBAC) and in-hospital trial of labor (TOL) were compared between early (<4 cm dilation) and late (≥4 cm) presenters. Women were interviewed after delivery about decision making and labor preferences.

RESULTS

Overall, 188 women comprised the study sample; 98 (52.1%) and 65 (34.6%) women presented at ≥4 cm and ≥6 cm, respectively, and 18 (9.6%) were fully dilated. In-hospital TOL and VBAC rates were 25.5% (42/165) and 9.6% (18/188), respectively. Compared with early presenters, late presenters were significantly more likely to undergo TOL (28/88 [31.8%] vs 14/77 [18.2%]; odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-5.0), and achieve VBAC (16/98 [16.3%] vs 2/90 [2.2%]; OR 7.6, 95% CI 1.7-35.1).

CONCLUSION

Most women arrived in active labor, but most had a repeat cesarean. Work is needed to understand the clinical decision making and provider management driving low TOL and VBAC rates.

Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study

OBJECTIVE

The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS).

DESIGN

Longitudinal population-based register study.

SETTING

Sweden.

POPULATION

Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000-2014, with a previous delivery during 1973-2013 (n = 15 479).

METHODS

Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers.

MAIN OUTCOME MEASURES

Adhesions.

RESULTS

In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70-5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (P < 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05-1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49-2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05-2.30) increased the risk of adhesions.

CONCLUSIONS

Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence.

TWEETABLE ABSTRACT

Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.

National Rates of Uterine Rupture are not Associated with Rates of Previous Caesarean Delivery: Results from the Nordic Obstetric Surveillance Study

BACKGROUND

Previous caesarean delivery and intended mode of delivery after caesarean are well-known individual risk factors for uterine rupture. We examined if different national rates of uterine rupture are associated with differences in national rates of previous caesarean delivery and intended mode of delivery after a previous caesarean delivery.

METHODS

This study is an ecological study based on data from a retrospective cohort in the Nordic countries. Data on uterine rupture were collected prospectively in each country as part of the Nordic obstetric surveillance study and included 91% of all Nordic deliveries. Information on the comparison population was retrieved from the national medical birth registers. Incidence rate ratios by previous caesarean delivery and intended mode of delivery after caesarean were modelled using Poisson regression.

RESULTS

The incidence of uterine rupture was 7.8/10 000 in Finland and 4.6/10 000 in Denmark. Rates of caesarean (21.3%) and previous caesarean deliveries (11.5%) were highest in Denmark, while the rate of intended vaginal delivery after caesarean was highest in Finland (72%). National rates of uterine rupture were not associated with the population rates of previous caesarean but increased by 35% per 1% increase in the population rate of intended vaginal delivery and in the subpopulation of women with previous caesarean delivery by 4% per 1% increase in the rate of intended vaginal delivery.

CONCLUSION

National rates of uterine rupture were not associated with national rates of previous caesarean, but increased with rates of intended vaginal delivery after caesarean.

Determinants and materno-fetal outcomes related to cesarean section delivery in private and public hospitals in low- and middle-income countries: a systematic review and meta-analysis protocol

BACKGROUND

Despite the well-established morbidity, mortality, long-term effects, and unnecessary extra-cost burden associated with cesarean section delivery (CSD) worldwide, its rate has grown exponentially. This has become a great topical challenge for the international healthcare community and individual countries. Estimated at three times the acceptable rate as defined by the World Health Organization in 1985, the continued upward trend has been fuelled by higher income countries. Some low- and middle-income countries (LMICs) have now taken the lead, and the factors contributing to this situation are poorly understood. The expansion of the private healthcare sector may be playing a significant role. Distinguishing between the public and private hospitals' role is critical in this investigation as it has not yet been approached. This review aims to systematically synthesize knowledge on the determinants of the CSD rate rise in private and public hospitals in LMICs and to investigate materno-fetal and materno-infant outcomes of CSD in perinatal period, between private and public hospitals.

METHODS/DESIGN

We will include studies published in English, French, Spanish, and Portuguese since 2000, using any experimental design, including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, and interrupted time series. Outcomes of interest are the determinants of CSD and materno-fetal and materno-infant outcomes. We will only include studies carried out in private and public hospitals in LMICs. The literature searches will be conducted in the following databases: MEDLINE, Embase, CINAHL, Cochrane database, LILACS, and HINARI. We will also include unpublished studies in the gray literature (theses and technical reports). Using the two-person approach, two independent review authors will screen eligible articles, extract data, and assess risk of bias. Disagreements will be resolved through discussion with a third author. Results will be presented as structured summaries of the included studies. If possible, a meta-analysis will be conducted and, subsequently, an analysis for heterogeneity will be implemented.

DISCUSSION

The proposed systematic review of the CSD rate rise will provide up-to-date evidence in regard to differences in proportions, determinants, and materno-fetal and materno-infant outcomes in perinatal period, between private and public hospitals in LMICs. We believe that this knowledge synthesis will help to shed light on the evidence and support evidence-informed decision-making with a view to addressing the issue in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016036871.

Sonographic Findings and Diagnostic Pitfalls in Evaluation for Uterine Rupture in a Case of Fetal Demise and Prior Cesarean Delivery of Unknown Type

A 38-week pregnant patient with history of cesarean delivery was admitted to the hospital for induction of labor after diagnosis of fetal demise. When the clinical picture became concerning for uterine scar dehiscence, an ultrasound was ordered. After targeted ultrasound of the lower uterine segment, the sonographer initially reported thin but intact lower uterine segment and normal positioning of the fetus. By keeping a high level of suspicion, the radiologist analyzed the images submitted and found other clues suggesting possible dehiscence or rupture. Additional images were then obtained, ultimately demonstrating uterine rupture with fetus external to uterus.

Trial of labour after caesarean (TOLAC) is associated with increased risk for instrumental delivery

We compared the rates of instrumental delivery in a cohort of nulliparous women at term (n = 19,416), to primiparous women who attempted labour after prior caesarean (TOLAC) (n = 1747). The rate of instrumental deliveries was higher in the TOLAC group compared to nulliparous gravidas (17.3 vs. 15% respectively, p = 0.001). The difference was more prominent for women who eventually had successful vaginal delivery (TOLAC: 23.9% vs.

CONTROLS

17.1%, p < 0.0001 respectively). Based on our results, previous caesarean whether urgent or elective was associated with an increased risk of instrumental delivery in the subsequent pregnancy.

Preoperative Association of Abdominal Striae Gravidarum with Intraabdominal Adhesions in Pregnant Women with a History of Previous Cesarean Section: a Cross-sectional Study

Introduction: Intraabdominal adhesions that develop because of prior abdominal or pelvic surgery may cause problems during surgery. Complications can include difficult intraabdominal entry; injury to the urinary bladder, uterus or small intestine; longer operation times, and increased blood loss. The goal of the present study was to evaluate the association between abdominal striae gravidarum and intraabdominal adhesions in the preoperative period in pregnant women with a history of cesarean section. Materials and Methods: The study included 247 pregnant women at ≥ 37 weeks of gestation admitted to the labor unit for delivery; all had undergone at least one previous cesarean section. Abdominal striae were assessed preoperatively using the Davey scoring system; the severity and intensity of adhesions were subsequently evaluated intraoperatively according to the modified Nair scoring system. Results: No striae were seen in 104 pregnant women; 41 had mild striae and 102 had severe striae. Overall, 113 cases had no adhesions (grade 0), 106 had grade 1-2 adhesions, and 28 had grade 3-4 adhesions. Among patients with grade 0 adhesions, 34 (13.7 %) had no striae, while 79 (31.9 %) had mild-to-severe striae (p < 0.001; sensitivity 55 %; specificity 67 %; positive predictive value 69 %; negative predictive value 52 %). Among women with grade 1-2 adhesions, 48 (19.4 %) had no striae, while 58 (23.4 %) had mild-to-severe striae. Finally, among women with grade 3-4 adhesions, 22 (8.9 %) had no striae, while 6 (2.4 %) had mild-to-severe striae (p < 0.001). A p-value < 0.05 was taken to indicate statistical significance. Conclusions: The abdominal adhesion score dropped as the abdominal striae gravidarum score rose during the preoperative period. Addition of this useful, easy-to-apply, inexpensive, adjunctive, observational, abdominal scoring method to the obstetrical work-up can provide important clues about the intraabdominal adhesion status of pregnant women scheduled for cesarean delivery because of previous cesarean section.

Effectiveness and short-term safety of modified sodium hyaluronic acid-carboxymethylcellulose at cesarean delivery: a randomized trial

BACKGROUND

The rising cesarean birth rate has drawn attention to risks associated with repeat cesarean birth. Prevention of adhesions with adhesion barriers has been promoted as a way to decrease operative difficulty. However, robust data demonstrating effectiveness of such interventions are lacking.

OBJECTIVE

We report data from a multicenter trial designed to evaluate the short-term safety and effectiveness of a modified sodium hyaluronic acid (HA)-carboxymethylcellulose (CMC) absorbable adhesion barrier for reduction of adhesions following cesarean delivery.

STUDY DESIGN

Patients who underwent primary or repeat cesarean delivery were included in this multicenter, single-blinded (patient), randomized controlled trial. Patients were randomized into either HA-CMC (N = 380) or no treatment (N = 373). No other modifications to their treatment were part of the protocol. Short-term safety data were collected following randomization. The location and density of adhesions (primary outcome) were assessed at their subsequent delivery using a validated tool, which can also be used to derive an adhesion score that ranges from 0-12.

RESULTS

No differences in baseline characteristics, postoperative course, or incidence of complications between the groups following randomization were noted. Eighty patients from the HA-CMC group and 92 controls returned for subsequent deliveries. Adhesions in any location were reported in 75.6% of the HA-CMC group and 75.9% of the controls (P = .99). There was no significant difference in the median adhesion score; 2 (range 0-10) for the HA-CMC group vs 2 (range 0-8) for the control group (P = .65). One third of the HA-CMC patients met the definition for severe adhesions (adhesion score >4) compared to 15.5% in the control group (P = .052). There were no significant differences in the time from incision to delivery (P = .56). Uterine dehiscence in the next pregnancy was reported in 2 patients in HA-CMC group vs 1 in the control group (P = .60).

CONCLUSION

Although we did not identify any short-term safety concerns, HA-CMC adhesion barrier applied at cesarean delivery did not reduce adhesion formation at the subsequent cesarean delivery.