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Introduction: Cesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor., Material and Methods: This retrospective cohort study of the four largest delivery units in Stockholm during 2012-2015 included 1150 women with one previous cesarean section with induction of labor., Inclusion Criteria: women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section., Primary Outcome: mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section)., Secondary Outcomes: induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0., Results: Our study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64-17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women., Conclusions: Our study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objectives: To assess the accuracy and utility of transabdominal sonographic paraumbilical and suprapubic sliding signs in predicting intra-abdominal adhesions in women undergoing repeat Cesarean section (CS), and to investigate the association of repeat CS with short-term maternal and neonatal outcomes., Methods: This was a prospective observational study of pregnant women with a history of CS who were scheduled for third-trimester elective or emergency CS at a tertiary referral and teaching hospital between July 2021 and June 2022. In order to evaluate the role of transabdominal sonographic paraumbilical and suprapubic sliding signs in the prediction of intra-abdominal adhesions, participants underwent a high-resolution transabdominal ultrasound scan prior to repeat CS. Free cephalad and caudad gliding of the uterus under the abdominal wall during deep inhalation and exhalation in each area was considered a positive sliding sign, suggesting a low risk of intra-abdominal adhesions. The absence of such movement was considered a negative sliding sign, suggesting a high risk of intra-abdominal adhesions. The presence or absence of intra-abdominal adhesions was then confirmed during surgery by physicians who were blinded to the sonographic sliding-sign findings. The type of adhesion, structures involved, method of adhesiolysis, incision-to-delivery time, 1-min and 5-min Apgar scores, maternal and neonatal injury and other short-term complications were also reported., Results: Of 419 women with a history of at least one previous CS who underwent repeat CS, the preoperative sonographic paraumbilical and suprapubic sliding signs were negative in 173 (41.3%) and 178 (42.5%) women, respectively. On repeat CS, 224 (53.5%) women had intra-abdominal adhesions, of which 165 (39.4%) had dense adhesions and 59 (14.1%) had only filmy adhesions. The sensitivity and specificity of a negative preoperative paraumbilical sliding sign in predicting the presence of dense intra-abdominal adhesions in women undergoing repeat CS were 94.6% (95% CI, 92.4-96.7%) and 93.3% (95% CI, 90.9-95.7%), respectively. A negative suprapubic sliding sign also showed high sensitivity (95.2% (95% CI, 93.1-97.2%)) and specificity (91.7% (95% CI, 89.1-94.4%)). Additionally, a negative sliding sign at both locations in the same patient had robust sensitivity (90.2% (95% CI, 87.3-93.0%)) and specificity (96.3% (95% CI, 94.5-98.1%)). We found that the risk of dense intra-abdominal adhesions increased with parity and the number of previous CS. Dense intra-abdominal adhesions were associated with increased incision-to-delivery time, higher risk of maternal bladder injury, intraoperative bleeding and postpartum hemorrhage., Conclusions: Dense intra-abdominal adhesions are common in women with a history of CS and are associated with delayed delivery of the neonate and increased risk of adverse maternal outcomes. The transabdominal sonographic paraumbilical and suprapubic sliding signs are robust methods for the accurate preoperative prediction of dense intra-abdominal adhesions in patients with a history of CS. As the techniques are easy to learn and perform, the sliding sign should be used more widely for triaging patients at high risk of dense intra-abdominal adhesions for appropriate preoperative planning. © 2024 International Society of Ultrasound in Obstetrics and Gynecology., (© 2024 International Society of Ultrasound in Obstetrics and Gynecology.)

Objective: Each repeat cesarean section (CS) potentially adds surgical complexity. The determination of appropriate anesthesia strategy to meet the surgical challenge is of crucial importance for the maternal and neonatal outcome., Study Design: This prospective cohort study was conducted from 1-Jan-2021 to 31-Dec-2021 at a single large obstetric centre of all repeat CS. We compared the characteristics and the appropriateness of the anesthesia techniques for low-order repeat CS (LOR-CS) (1 or 2 previous CS) and high order repat CS (HOR-CS) group (3 or more repeat CS)., Results: During the study period, 1057 parturients met the study entry criteria, with 821 parturients in the LOR-CS group and 236 parturients in the HOR-CS group. The use of spinal anesthesia was more common for HOR-CS 84.3%. Overall surgical time varied between LOR-CS (38 min, 29-49) and HOR-CS (42 min, 31-57) (p = 0.004).The rate of moderate and severe adhesions was relatively high in HOR-CS and the duration of overall surgical time for cases with mild adhesions was 38 min (29-48), for moderate adhesions was 44 min (34.8-56.5), and for severe adhesions was 56 min (44.8-74.3). There was no significant difference in the Estimated Blood Loss (EBL) between LOR-CS and HOR-CS, with values of 653 ± 292 ml vs. 660 ± 285 ml, respectively., Conclusion: Our data indicate that spinal anesthesia, standard monitoring and regular anesthetic setup are safe and suitable for the majority of HOR-CS, except in cases with high suspicion of placental accreta spectrum., Competing Interests: None., (© 2024 The Authors.)

Background: Cesarean delivery (CD) is associated with increased maternal and neonatal morbidity compared to vaginal delivery, particularly in cases classified as emergency procedures or when there are multiple CDs. This retrospective cohort study aims to examine the incidence of maternal and neonatal complications in women with multiple CDs., Methods: This study used data from a national perinatal database obtained from a single tertiary maternity care hospital. Women who delivered a singleton live birth after 24 weeks of gestation by CD were stratified into five groups based on the number of CDs, with the last group having five or more CDs. The women were divided into those with five or more CDs (Group 5) versus those with fewer than five (Groups 1 to 4). The maternal outcomes included intra-operative surgical complications, blood loss, and intensive care unit (ICU) admission. The neonatal outcomes included preterm birth, neonatal ICU (NICU) admission, respiratory distress syndrome (RDS), and perinatal death., Results: Of the 6,316 women in the study, 2,608 (41.3%) had a primary CD. 30.3%, 17.5%, and 7.3% of the cohort had their second, third, and fourth CDs, respectively. Women undergoing the 5 th CD and above formed the remaining 3.5% (227). Women in Group 5 had the highest risk of suffering a surgical complication (3.1%, p = 0.015) and postpartum hemorrhage (7.5%, p = 0.010). 24% of babies in Group 5 were born preterm (p < 0.001). They also had a 3.5 times higher risk of having a surgical complication (RR = 3.5, 95% CI 1.6-7.6, p = 0.002), a 1.8 times higher risk of developing postpartum hemorrhage (RR = 1.8, 95% CI 1.1-2.9, p = 0.014), a 1.7 times higher risk of delivering between 32-37 weeks of gestation (RR = 1.7, 95% CI 1.3-2.2, p < 0.001), a higher risk of the baby getting admitted to NICU (RR = 1.3, 95% CI 1.0-1.6, p = 0.038), and developing RDS (RR = 1.5, 95% CI 1.2-2.0, p = 0.002) compared to Groups 1-4. The risks of neonatal outcomes such as NICU admission (RR 2.9, 95% CI 2.1-4.0) and RDS (RR 3.5, 95% CI 2.3-5.5) were much higher in elective CDs performed at term compared to preterm births (p < 0.001 for both)., Conclusion: Maternal morbidity significantly increases with the increasing number of CD. The increased risk of RDS and NICU admissions in the neonate with multiple CDs reflects lower gestational age and birthweight in these groups-consideration of preoperative steroids for lung maturation in these women to reduce neonatal morbidity warrants further discussion., Competing Interests: The authors have no conflicts of interest to declare., (© 2024 Ajmal, Farrell, Minisha, Al Obaidly, AlQubaisi, Khenyab, Ali, Salama, Pallivalappil, Al Dewik, Al Rifai, licensee HBKU Press.)

At the start of the 20th century, cesarean section (CS) was uncommon in obstetrics. By the end of the century, CS rates had increased dramatically worldwide. Although the explanation for the increase is multifactorial, a major driver in the ongoing escalation is the increase in women who are delivered by repeat CS. This is due, in part, to the fact that there has been a sharp fall in vaginal birth after CS (VBAC) rates as fewer women are offered a trial of labor after CS (TOLAC), due principally to fears of a catastrophic intrapartum uterine rupture. This paper reviewed international VBAC policies and trends. A number of themes emerged. The risk of intrapartum rupture and its associated complications is low and may sometimes be overestimated. Individual maternity hospitals in both developed and developing countries are inadequately resourced to safely supervise a TOLAC. Efforts to mitigate the risks of TOLAC by careful patient selection and good clinical practices may be underutilized. Given the serious short-term and long-term consequences of rising CS rates for women and for maternity services generally, a review of TOLAC policies worldwide should be prioritized and consideration given to convening a Global Consensus Development Conference on Delivery after CS., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: Repeat urgent cesarean sections (CS) carry an increased risk of severe maternal outcomes. As CS increase in sub-Saharan Africa, creative strategies are necessary to reduce the rate of urgent repeat CS. The Zigama-Mama Project in rural Burundi uses complimentary ultrasounds to create a clinical touchpoint to counsel women with a prior CS for a hospital-based delivery., Methods: From July 2019 to June 2020, complimentary ultrasounds were offered to all antenatal patients with prior CS, along with counseling for monitored trial of labor after cesarean (TOLAC) or scheduled repeat CS. Community engagement and feedback from district health centers were evaluated., Results: In total, 500 women with a prior CS presented for a complimentary ultrasound. During the intervention year, a relative and absolute reduction in urgent repeat CS (baseline: n  = 114 {70.8%}, intervention: n  = 97{49.7%}, p  < 0.001) was observed, with no significant change in maternal mortality or ruptured uteri. All health center personnel agreed the project improved their confidence in referring women with prior CS., Conclusion: Offering complimentary ultrasounds as a clinical touchpoint for scheduling a monitored delivery or CS for women at high risk for delivery complication may be an affordable and creative strategy to care for women with previous CS during subsequent deliveries., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Mclaughlin, Nagy, Magorwa, Kibinakanwa and Mclaughlin.)

Background: The rates of repeat cesarean section (CS) among women with previous CS are increasing worldwide. The predictors of a repeat CS can vary across different populations., Objective: To determine the predictors of repeat CS among women from Malaysia with one previous lower segment CS (LSCS) who underwent trial of labor (TOLAC)., Materials and Methods: This retrospective cohort study included women with one previous LSCS who followed up and delivered their current pregnancy at Hospital Universiti Sains Malaysia (USM), Kelantan, Malaysia, between January 01, 2016, and December 31, 2017. Women with singleton pregnancies were included while those who had a history of classical CS, current pregnancy with preterm birth, non-cephalic pregnancy, lethal fetal anomalies, uterine rupture, and severe preeclampsia or planned for elective CS were excluded. Logistic regressions were performed., Results: The study included 388 women who underwent TOLAC and successfully gave childbirth through vaginal birth after cesarean (VBAC) ( n = 194) or emergency LSCS ( n = 194). Factors significantly associated with repeat CS were no history of vaginal delivery (adjusted odds ratio (aOR): 2.71; 95% confidence interval (CI): 1.60, 4.60; P < 0.001), estimated fetal weight ≥3500 grams (aOR: 4.78; 95% CI: 2.45-9.34; P < 0.001), and presence of meconium-stained liquor (aOR: 2.40; 95% CI: 1.33-4.35; P = 0.004)., Conclusion: The above-mentioned predictors of a repeat CS among women from Malaysia with one previous LSCS who underwent TOLAC can be useful for clinicians in making an informed decision., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Saudi Journal of Medicine & Medical Sciences.)

Objective: To investigate the effect of a quality improvement project with an educational/motivational intervention in northern Italy on the implementation of the trial of labor after cesarean section (CS)., Method: A pre-post study design was used. Every birth center (n = 23) of the Emilia-Romagna region was included. Gynecologist opinion leaders were first trained about Italian CS recommendations. Barriers to implementation were discussed and shared. Educational/motivational interventions were implemented. Data of multipara with previous CS, with a single, cephalic pregnancy at term, were collected during two periods, before (2012-2014) and after (2017-2019) the intervention (2015-2016). The primary outcome was the rate of vaginal birth after CS (VBAC) and perinatal outcomes., Results: A total of 20 496 women were included. The VBAC rate increased from 18.1% to 23.1% after intervention (P < 0.001). The likelihood of VBAC-adjusted for age 40 years or older, Caucasian, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) at least 30, previous vaginal delivery, and labor induction-was increased by the intervention by 42% (odds ratio 1.42, 95% confidence interval 1.31-1.54). Neonatal well-being was improved by intervention; neonates requiring resuscitation decreased from 2.1% to 1.6% (P = 0.001)., Conclusion: Educating and motivating gynecologists toward the trial of labor after CS is worth pursuing. Health quality improvement is demonstrated by increased VBAC even improving neonatal well-being., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Cesarean section rates are constantly rising, and the number of women with a prior cesarean considering a delivery mode for their next labor is increasing. We aimed to compare maternal and neonatal outcomes and feeding method in women undergoing vaginal birth after cesarean (VBAC) versus elective repeat cesarean delivery (ERCD). This was a retrospective cohort study of women with one prior cesarean delivery (CD) and no previous vaginal births, delivering vaginally or by a CD in a single institution between 2016 and 2018. 355 live singleton spontaneous vaginal and cesarean deliveries were included. 121 women delivered vaginally and 234 had a CD. Neonates born by a CD were more likely to have higher birth weight (p < 0.001), higher weight at discharge (p < 0.001), macrosomia (p = 0.030), lose >10% of their body mass (p = 0.001), be mixed-fed (p < 0.001), and be hospitalized longer (p < 0.001). Children born vaginally were more likely to be exclusively breastfed (p < 0.001). Women undergoing VBAC were more likely to deliver preterm (p = 0.006) and post-term (p < 0.001), present with PROM (p < 0.001), have greater PROM latency period (p < 0.001), and experience intrahepatic cholestasis of pregnancy (p = 0.029), postpartum anemia (p < 0.001), and peripartum blood loss >1 L (p = 0.049). The incidence of anemia during pregnancy was higher in the ERCD cohort (p = 0.047). Women undergoing VBAC are more likely to breastfeed their children, perhaps for the same reason they choose the vaginal method of delivery, as vaginal delivery and breastfeeding along with antibiotic use, are the most important factors decreasing the risk for future diseases in their offspring.

Objective: To compare scar quality associated with metal staples or tissue adhesive for closure of the skin incision at repeat cesarean delivery (CD)., Study Design: Single-center Randomized Controlled Trial (ClinicalTrial.gov ID: NCT04302597), including women undergoing repeat CD using metal staples or 2- octylcyanoacrylate for closure of the skin incision. Patients were randomized to have skin closure following CD with either staples or tissue adhesive. Scar quality was evaluated 2 and 6 months postoperatively using the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale., Results: Of the 66 patients who were recruited, 55 successfully completed the study. The duration of surgery was comparable in both groups. A partial wound dehiscence occurred in one patient who had tissue adhesive closure. No difference in subjective and objective scar cosmesis rating was found between tissue adhesive and staples groups at either 2 months or 6 months., Conclusions: In women undergoing CD, stapled wounds and those closed with tissue adhesive result in equivalent cosmetic appearance of the scar., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: We sought to determine the success rate of VBAC and factors associated with achieving VBAC at a referral hospital in the Democratic Republic of Congo in women with a subsequent pregnancy greater than or equal to 18 months from their primary cesarean section (CS)., Patients and Methods: Patients were included for participation if they had an inter-delivery interval (IDI) of at least 18 months from their primary CS, accepted TOLAC, and had no contraindications. Information was collected about patients' demographics, obstetric history, and factors impacting their labor process. Descriptive analyses compared patients that had a successful VBAC and those who did not. Univariate and multivariate binary logistic regression models identified factors associated with a successful VBAC., Results: Among 231 eligible patients who attempted a VBAC, 57.6% (133) achieved VBAC. Participants had a mean age of 29 (SD 6), with the majority having a prior vaginal delivery (68.8%). VBAC was positively associated with a higher Bishop score (AOR 1.12, 95% CI 1.02, 1.23) and a spontaneous labor onset (AOR 3.06, 95% CI 1.52, 6.17). VBAC was negatively associated with a macrosomic fetus (AOR 0.21, 95% CI 0.08, 0.58)., Conclusion: TOLAC results in VBAC more than half the time and is associated with a spontaneous labor onset and a higher Bishop score. Women with a macrosomic fetus were more likely to have an unsuccessful VBAC, resulting in an RCS. An optimal IDI was not enough to ensure a successful VBAC. Upon patients' arrival to the hospital, practitioners should re-evaluate their eligibility to attempt a VBAC based on their Bishop score and if they had a spontaneous labor onset to decrease the health risks of an RCS., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Maroyi et al.)

Introduction: Rising rates of caesarean section (CS) is an issue of particular concern. Recently, there has been research supporting Vaginal Births After Caesarean (VBAC), which is controversial. In Greece, over half of births in the country are by CS, placing Greece among countries with the highest CS rates. The aim of this study was to investigate the prevalence and the factors associated with VBACs and to compare the maternal/neonatal outcomes with a 'non-caesarean' control group., Methods: The data were evaluated and retrospectively gathered on archived singleton births, from medical records of a midwifery-led team, between May 2006 and May 2013. The target group of the study included mothers with a previous CS, who had a second birth. The sample consisted of 71 VBAC women and 583 who had normal spontaneous vaginal delivery (NSVD) as the 'non-caesarean' control group., Results: The duration of labour was longer for the VBACs compared with first-time mothers who gave birth naturally (for duration 481-720 min, 27% vs 10.3%, respectively), episiotomy was more common for VBAC (20.7% vs 7.9%), and epidural analgesia was more often for VBAC (68.4% vs 10%). The percentage of 1-min Apgar score in the range 0-7 in the VBAC group was 5%, and there was no significant difference in women who had NSVD (3.6%). The Apgar score in the 5th minute was always above 8 for both groups., Conclusions: Severe maternal and neonatal complications are infrequent, and therefore the necessity arises for further continuous studies to ascertain the safety of VBAC., Competing Interests: V.G. Vivilaki reports that she is the Editor-in-Chief of EJM journal and that there are no conflicts of interest with this current work. The rest of the authors also have completed and submitted an ICMJE form for disclosure of potential conflicts of interest and none was reported., (© 2019 Charitou A.)

Introduction: A strategy for reducing the number of cesarean sections is to allow vaginal delivery after cesarean section., Objective: To validate two predictive models, Metz and Grobman, for successful vaginal delivery after a cesarean section., Methods: Retrospective cohort study involving women with previous history of a previous segmental cesarean section, single pregnancy ≥37 weeks and cephalic presentation. The proportion of vaginal delivery in all pregnant women was determined, and it was compared with those (women) with successful delivery after cesarean section. Then, there were elaborated the models, and their predictive capacity was determined by curve-receiver-operator., Results: The proportion of successful delivery in pregnant women with a previous cesarean section and indication of vaginal delivery was 85.64%. The observed proportion of birth for each decile predicted in the Grobman model was less than 15%, except for the 91-100% decile, where it was 64.09%; the area under the curve was 0.95. For the Metz model, the actual successful delivery rate was lower than predicted in scores between 4 and 14, and within expected for a score between 15 and 23; the area under the curve was 0.94., Conclusions: The vaginal delivery rate after cesarean was lower than expected according to the predictive models of Grobman and Metz. The implementation of these models in a prospective way can lead to a higher rate of successful birth., Competing Interests: Conflict of interest: Author not have any conflict of interest and the financing institutions did not influence in any way in the report of the results or their implications.

Objective: To compare surgical complications and maternal and neonatal outcomes of low-risk, late preterm and term pregnant women who have had one or two previous cesarean sections (CSs) with those who have had three or more CSs., Methods: We conducted a retrospective study of 850 patients undergoing repeat CS at a tertiary level maternity hospital in Ankara, Turkey. Of those, 380 had previously undergone one or two CSs (Group-I: second or third CS) and 470 had previously undergone three or four CSs (Group-II: fourth or fifth CS). Outcomes and complications were compared between the groups., Results: The two groups were statistically significantly different in terms of maternal age, parity, body mass index, maternal weight gain during pregnancy, and length of hospital stay (all p<0.001). Although the prevalence of intraperitoneal adhesions and placenta previa was higher in Group-II than in Group-I (p<0.001), there was no statistically significant difference in terms of cesarean hysterectomy and adjacent organ injuries (p>0.05). There were also no significant differences between the groups in terms of neonatal outcomes (p>0.05)., Conclusion: Although the increase in the number of CSs appears to be associated with intraperitoneal adhesions and placenta previa, adverse maternal and neonatal outcomes were not observed in those women with low-risk pregnancies who underwent CS for the fourth or fifth time. Therefore, fourth and fifth CSs may be considered relatively safe surgical procedures in this cohort., Competing Interests: Conflict of Interest and Funding: None declared.

Objective: Intra-abdominal adhesions are associated with an increased risk of complications during repeat Cesarean section (CS), such as bladder and bowel injury, hemorrhage, infection and hysterectomy. We present a simple sonographic marker, the 'sliding sign' of the uterus, for the prediction of intra-abdominal adhesions in the third trimester of pregnancy in women undergoing repeat CS., Methods: This was a prospective observational study of pregnant women with a history of at least one Cesarean delivery evaluated by transabdominal ultrasound during the third trimester of an ongoing pregnancy. In order to diagnose intra-abdominal adhesions, we assessed a sonographic sign, the sliding of the uterus under the inner part of the fascia of the abdominal muscles during deep breathing. Women were considered to be at high risk for severe adhesions if uterine sliding was absent and at low risk in the presence of obvious or moderate uterine sliding. A comparison between sonographic findings and intra-abdominal adhesions observed during surgery was performed., Results: Of the 63 patients with one or more previous CS examined, 59 completed the study and underwent CS at our institution. In 16 of the 19 cases assigned to the high-risk group for severe adhesions due to absence of sliding of the uterus, the suspicion was confirmed at surgery. The prediction of low risk for adhesions was confirmed in 35 out of 40 patients. The sensitivity and specificity of the sliding sign in predicting presence of intra-abdominal adhesions in women undergoing repeat CS were 76.2% and 92.1%, respectively. Inter- and intraobserver correlation using Cohen's kappa coefficient were 0.52 and 0.77, respectively., Conclusion: Our data show that a simple sonographic sign might be able to discriminate between high and low risk for intra-abdominal adhesions in patients with a history of Cesarean delivery. This technique may aid clinical decisions in patients undergoing repeat CS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To determine the true incidence of complete uterine rupture and uterine dehiscence among women delivered by cesarean section after a previous cesarean section., Methods: Medical records of all women who delivered at University Hospital in Malmö, Sweden, during 2005-2009 (n = 21 420) were retrieved from the electronic patient record system (EPRS). After adjustment for inaccuracies, 716 women who had undergone repeat cesarean section were identified and their operation reports were reviewed. Descriptions of complete uterine rupture or uterine dehiscence in operation reports were compared with diagnoses registered in EPRS with International Classification of Diseases codes version 10 (ICD-10). Sensitivity and specificity of complete uterine rupture registration were calculated., Results: There were 13 women with a registered diagnosis of uterine rupture. After reviewing medical records of women with repeat cesarean section, seven additional cases of complete uterine rupture, 33 cases of uterine dehiscence and 39 cases of extremely thin myometrium were identified. The incidence of complete uterine rupture and uterine dehiscence for women who delivered by repeat cesarean section was 2.8% and 10.1%, respectively., Conclusions: Diagnosis of complete uterine rupture was underreported in the EPRS by 35% and diagnosis of uterine dehiscence was missing in 100% of cases.

Purpose of Investigation: We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity., Materials and Methods: We analyzed intra-abdominal adhesions of 672 patients., Results: Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively., Conclusions: Emergency operations and adhesions increased complications.

Aim: To study the evolution in cesarean section (CS) categories in a single center from 2002 to 2012., Methods: We performed a retrospective study on all live births from 2002, 2007, and 2012 using a modified Robson classification accounting for cervical ripening in the induction groups, post-term pregnancies, and the number of uterine scars., Results: We recorded 2162, 2105 and 2380 deliveries with caesarean delivery rates of 23.2%, 24.9%, and 30.4% in 2002, 2007, and 2012 respectively. Nulliparous women in spontaneous labor (group 1) decreased from 36.3% to 27.4% of the total population, but CS rates in this group increased from 14.1% to 19.5% (P < 0.05). Labor induction and CS before labor in nulliparous women category (group 2) increased from 6.7% to 14.2% but with stable CS rates. Induction of labor and cervical ripening in this group increased from 91 and nine in 2002 to 119 and 240 in 2012, respectively. In the same period, maternal pathology increased from 11% to 33%. Scarred uterus remained the major source of CS (almost 30% of all CS in 2012)., Conclusion: CS rates increased throughout the studied period, associated with an increase in rates of maternal pathology, induction by cervical ripening, and scarred uterus., (© 2016 Japan Society of Obstetrics and Gynecology.)

Aim: The evaluation of the effect of repeat cesarean sections in adolescent pregnancies on the morbidity, obstetric and perinatal results., Materials and Methods: We reviewed the patient file and hospital records of patients who underwent at least one cesarean section among adolescent age group pregnant women who gave birth at our clinic between January 2010 and May 2013. The patients were divided into two groups as the patients who underwent the second cesarean section (116 patients) and those who underwent the third cesarean section (36 patients). The demographic data, maternal data and obstetric and perinatal results of the patients were evaluated., Results: A significant difference was present between the patients in the evaluation of the total number of examinations during pregnancy (P = 0.001), total maternal weight gain during pregnancy (P = 0.006), and the first examination gestational age (P = 0.006) and all values were less favorable in the third cesarean group. The gestational week at birth (P < 0.001), birth weight (P < 0.001), and APGAR score (P < 0.001) in the group with the third cesarean section were statistically significantly lower than the second cesarean section. The third cesarean cesarean was found to cause a significant risk increase for placenta accreta risk in adolescent pregnancies (P = 0.042)., Conclusion: The increasing number of cesarean sections in the adolescent group is seen to be a significant risk factor for low gestational week of birth, low birth weight and related morbidities. The most important reason for the increased morbidity with increasing cesarean sections in the adolescent age has been defined as placenta accreta.

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery., (Copyright © 2014 Elsevier Inc. All rights reserved.)