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To compare scar quality associated with metal staples or tissue adhesive for closure of the skin incision at repeat cesarean delivery (CD).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.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.In women undergoing CD, stapled wounds and those closed with tissue adhesive result in equivalent cosmetic appearance of the scar.

Background and Objectives The rate of cesarean section (CS) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania, is currently higher than 50%. Mothers and infants are typically separated immediately after CS. The aims of this study were to develop and implement an early skin-to-skin contact (SSC) after CS protocol and to describe the mothers’ perceptions of early SSC after CS. Design An action research design with a questionnaire survey was used. Setting MNH located in Dar es Salaam, Tanzania. Patients Pregnant women who underwent elective repeat CS from August 2018 to the end of September 2018. Intervention A two-step educational program, which consisted of a training program for the medical staff and an information program for the pregnant women, and early SSC after CS were implemented. Interviews were conducted to examine the participants’ perceptions of SSC after CS. Results A total of 26 pregnant women were recruited, of whom 17 (65%) participated. All 17 mothers answered very satisfied or satisfied of the early SSC after CS using a 5-point scale. The information program for the pregnant women was scored on a 10-point scale (0 = completely useless; 10 = very useful). There were 15 mothers (88%) who scored the program 10 points, and the remaining two mothers (12%) eight points. Some mothers wanted extended times and places of early SSC after CS. Conclusions The developed early SSC after CS protocol facilitated understanding of the perceptions of SSC after CS and may be a promising program for implementing early SSC after CS.

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.

Background In the literature, the terms “angular”, “interstitial” and “cornual” have often been inappropriately interchanged. The consequence is under-recognition of their differences as well as inaccurate imaging guidelines which do not reliably distinguish them as distinct entities. Angular pregnancies should be considered viable and may be managed to term. Case A woman at 7w5d was transferred for surgical management of a presumed interstitial ectopic pregnancy. Sonography and MRI confirmed an eccentric fundal pregnancy with a thin myometrial mantle of 2–5 mm; the diagnosis of interstitial pregnancy was favored. Upon laparoscopy, the round ligament was displaced lateral to the pregnancy bulge and the diagnosis of angular pregnancy was thus apparent. The pregnancy was continued to term and delivered via repeat cesarean section without incident. Conclusion Angular and interstitial pregnancies are different entities which cannot always be reliably distinguished via imaging alone. Diagnostic laparoscopy may be a final step in determining pregnancy location. Angular pregnancies should be considered potentially viable and may be managed to term., Highlights • Angular, cornual, and interstitial pregnancies are distinct entities. • Medical literature has often confused the terms, creating management dilemmas. • Angular pregnancies are likely under-recognized and should be considered viable. • Angular pregnancies are difficult to diagnose by antenatal imaging alone. • Diagnostic laparoscopy may be needed to distinguish between interstitial and angular location.

Background Spontaneous triplets in a uterus didelphys are an extremely rare finding. Only four other cases are reported in the literature. Case A 24 year old gravida 3 para 2-0-0-2 conceived spontaneous triplets in a uterine didelphys. She developed cervical insufficiency and underwent cerclage placement at 17 weeks. After spontaneous rupture of membranes at 29 weeks gestation, she underwent repeat cesarean section, with delivery of three viable fetuses. Mother and all three babies are currently alive and well. Conclusion Expectant management with cerclage placement is a possible alternative to selective reduction for desiring patients with triplets in a uterus didelphys.

Elective repeat cesarean section continues to remain the standard of care in the United States. This paper is a study of 242 patients with previous cesarean section who requested and were allowed a trial of labor. One hundred sixty-six (69%) achieved successful vaginal delivery with no maternal or fetal mortality or significant morbidity. Review of the English literature indicates similar results in other independent studies. Continued accumulation of cases showing the efficacy of post-cesarean section trial of labor should encourage a reassessment of the continuing practice of elective repeat cesarean section.

The rationale for routine repeat cesarean section (RCS) is avoidance of uterine rupture during labor. However, the incidence of uterine rupture following modern cesarean section is low, and the charge for cesarean section is greater than that for a trial of labor (TOL). The technique of decision analysis was used to investigate strategies of elective RCS and TOL with precautionary monitoring. Hypothetical cohorts of 10,000 pregnant women with previous low-transverse cesarean incisions were assumed. Probability data were obtained from the literature. In the TOL cohort, 6,623 patients were delivered vaginally. Uterine rupture occurred in 73 patients. In spite of this, TOL resulted in 37 fewer perinatal deaths and 0.7 fewer maternal deaths than elective RCS. The excessive perinatal mortality in the RCS cohort was related to iatrogenic prematurity that is now avoidable with the lecithin/sphingomyelin test. Direct costs were $5 million geater in the RCS cohort. We concluded that in contemporary practice mortality rates are essentially equal for both delivery practices. However, substantial cost savings are available with TOL.

Cesarean section is now the most frequently performed major operation in the United States. Nearly one out of every four American babies is delivered by this operation. “Elective repeat” has become the most common indication for cesarean section. Although the safety of vaginal birth after cesarean section has been documented in several recent publications, automatic repeat cesarean section remains the rule in this country. We present one of the largest series of trial of labor ever reported. Of 57,553 live births, 4929 (8.6%) were of women with prior cesarean sections. Among 1776 patients who underwent a trial of labor, 1314 (74%) delivered vaginally. These was no maternal or perinatal mortality related to uterine scar rupture. Thus during the study period 1314 major operations were avoided. We conclude that, for the vast majority of women, allowing a trial of labor is a safe alternative to automatic elective repeat cesarean section

There has been a fourfold increase in cesarean births in Canada in the last 20 years. The two main indications are dystocia and repeat cesarean section. Of all primary cesarean sections, about half are due to dystocia. This is largely confined to nulliparous women. Work from Ireland suggests that a policy of active management of labor may reduce dystocia. This involves a uniform policy of amniotomy once a diagnosis of labor is established, followed by oxytocin augmentation if labor is nonprogressive (less than 1 cm/hr). From October 1, 1985, to December 31, 1986, this policy was carried out on 552 consecutive normal nulliparous women in spontaneous labor at greater than or equal to 37 weeks' gestation with a single fetus in vertex presentation with no fetal distress. These results were compared with a control group of 533 similar nulliparous women delivered between January 1, 1984 and March 31, 1985. The cesarean section rate dropped to 4.3% from 13% (p less than 0.005) and the forceps delivery rate dropped to 19.4% from 29% (p less than 0.005). The duration of labor greater than 12 hours dropped to 7% from 20% (p less than 0.005). There was no increase in fetal morbidity or mortality.

Trial of labor is a safe and effective management alternative but remains underused in current clinical practice. To explore whether this underuse is justified, decision analysis is developed to compare a trial of labor with elective repeat cesarean section. With the use of available probability estimates and outcome scoring based on a survey of perinatologists, decision analysis identifies trial of labor as superior to elective repeat cesarean section for both the mother and the neonate. Going beyond the simple comparisons of management options and outcomes, the ethical implications of such results are discussed in terms of "utility ethics," "informed consent," and "universal equality." Such considerations suggest that there is a professional (ethical) responsibility to increase the application of trial of labor.

There are benefits to patients and a busy obstetric service if repeat cesarean section operations are performed on a scheduled basis. Optimum management avoids prematurity and reduces the need for amniocentesis. Over a period of 20 months repeat cesarean sections were performed at Tripler Army Medical Center while a protocol with the following elements was used: (1) known last menstrual period; (2) landmarks: positive urine human chorionic gonadotropin test by 6 weeks, Doppler fetal heart tone by 12 weeks, date determination by examination before 10 weeks, fetoscope fetal heart tone by 20 weeks, and date determination by size before 30 weeks; (3) date determination by midtrimester sonogram(s); (4) normal third-trimester glucose screening; (5) biparietal diameter of 9.2 or 9.5 cm before scheduling. With two or more clinical landmarks and one date by sonogram or one landmark and date by two sonograms, elective repeat cesarean section was scheduled at 39 weeks if the biparietal diameter was greater than or equal to 9.2 cm (127). If dates by sonogram were less than dates by last menstrual period but greater than 1 week or if last menstrual period was unknown, dates by sonogram and landmarks corresponding to dates by sonogram were used to electively schedule, with biparietal diameters of 9.2 or 9.5 cm respectively required (28). If protocol criteria were not met or earlier delivery was indicated (e.g., vertical scar or diabetes), amniocentesis was performed (42), except when not possible, advisable, or refused when patients either elected labor (20) or were scheduled if three or more criteria for 40+ weeks were met (18). Of 225 patients (70.5%) scheduled by protocol (173), amniocentesis (34), or medical indication (18), 188 (58.9%) were delivered without labor. In the 147 patients (46.1%) delivered electively by protocol without labor or amniocentesis, there were no cases of respiratory distress syndrome and the mean birth weight was 3517 gm. With early care and better patient compliance nearly all repeat cesarean sections can be safely delivered electively with the use of this protocol.

This article addresses these frequently raised questions regarding allowing a trial of labor in selected patients who have undergone a prior cesarean section: What is the risk of a trial of labor to the fetus and to the mother? What is the probability of successful vaginal delivery after a prior cesarean section? How does one manage the labor of such patients? What are the legal risks to the obstetrician who deviates from the previously widely accepted policy of repeat cesarean section? What are the other potential consequences of this change in policy?

A study of 112 cesarean hysterectomies is presented. They were performed in a 220-bed community hospital by six obstetricians in private practice. Eighty-nine cases were planned during the prenatal course of uncomplicated pregnancies. Twenty-three were unplanned and were performed because of severe medical, surgical, or obstetric problems. Postoperative performance and rate of complications were more favorable in the planned group. True indications for cesarean hysterectomy are discussed. In selected cases, sterilization by cesarean hysterectopmy may be the procedure of choice at the time of repeat cesarean section.This study analyzes a medium-sized community hospital's experience with 112 cesarean hysterectomies performed by 6 private obstetricians. Attention was given as to whether the operation was planned during the prenatal course of uncomplicated pregnancies or whether it was unplanned and performed following hospitalization for medical complications or for complications during labor. 89 (79%) of the cases were planned, and all were performed at greater than 38 week's gestation. 71 of the patients had had at least 1 previous cesarean section and hysterectomy was planned mainly for sterilization following delivery. 23 (21%) of the cases were unplanned during uncomplicated pregnancies but were performed mostly due to severe medical; surgical; or obstetric problems. In the entire series, maternal age ranged from 20 to 47 and the average age was 30 years. Parity was from 0 to 10, with an average of 2.3. The planned group had a parity of 2 while the unplanned had 3.7. The planned group had a more favorable postoperative results than the unplanned group as far as hospital stay, febrile morbidity, and blood transfusions were concerned. The planned group however had more complications (bladder performation, vaginal cuff abscess, superficial wound abscess, and ileus) than the unplanned group (postoperative fever). Sterilization by cesarean hysterectomy may be the method of choice at time of repeat cesarean section in selected cases.

Elective repeat cesarean section is one of the major factors responsible for the increase in the total cesarean section rate observed since 1970. Beginning in January 1980, a voluntary program encouraging a trial of labor for patients with a documented previous low-transverse cesarean section and no apparent recurring indication was instituted. Two hundred seven patients were managed with an adequate trial of labor, and 84.5% were delivered vaginally over a 2-year period. There were no deaths associated with a trial of labor, and maternal and fetal morbidity was negligible. This voluntary program resulted in a 27.9% decrease in the repeat cesarean section rate over the 2 years reported. Patient and physician acceptance of such a program was evaluated by follow-up questionnaires. Current recommendations include a mandatory trial of labor in patients with only one previous low-transverse cesarean section and no current indication for cesarean delivery. A more liberal management policy regarding patients with two or more previous low-transverse cesarean sections also seems warranted.

The American College of Obstetricians and Gynecologists recommends that women with previous low transverse cesarean sections who are candidates for a trial of labor should undergo such a trial only in a special environment. Such recommendations imply that these women are at greater risk than the general population for developing complications necessitating emergent operative intervention. A retrospective review of 5 years' experience reveals that in 1156 term pregnancles in which the patients were given a trial of labor, 18 (1.56%) patients underwent emergent abdominal delivery. This rate and the indications for the emergent operative delivery were not found to be different from those cited for patients without a uterine scar. The incidence of symptomatic uterine rupture was higher in patients scheduled for repeat cesarean section than for patients who underwent a trial of labor. Recommendations for a trial of labor might be reconsidered as they imply an increased risk for matemal and fetal morbidity and mortality that has yet to be demonstrated.

Summary The recent literature with regard to repeat cesarean section has been reviewed. A report of 1,462 cases is submitted and analyzed with respect to maternal complications, fetal mortality, and ruptured uteri. Blood was administered in over one third of the cases and 28 pa tients had ileus requiring suction. There was one maternal death and several severe maternal complications. The corrected perinatal mortality in the premature infants was 9.8 per cent. There were 67 elective premature cesarean sections with a corrected loss of 4 infants. During the same period, there were 11 incompletely ruptured uteri and 2 completely ruptured uteri. The latter both followed previous classical sections. The literature describing the experience of those who have followed the policy of conducting vaginal delivery in pregnancy after cesarean section is reviewed. It is noted that there were no maternal deaths in this group. The literature covering the generic entity “rupture of the uterus” is likewise reviewed. The high matern al mortality ra tes usually associated with the term “ruptured uterus” occur in the spontaneous and traumatic ruptures of the uterus and not in rupture of the postcesarean scar.

1. 1. One hundred four cases of vaginal delivery following cesarean section have been reviewed from private practice. There were no ruptures of the uterine scar. There was no maternal mortality. The uncorrected fetal mortality was 2.9 per cent. 2. 2. One hundred fifty-seven cases of repeat cesarean section have been reviewed from private practice. There were four incomplete “window ruptures” of the uterus among these cases, and these were discovered only at the time of elective repeat cesarean section. Two of these incomplete ruptures were repaired, and two required cesarean hysterectomies. There was no maternal or infant mortality in any of these ruptures.

1. 1. A study of 3,816 cesarean sections, 2,219 primary and 1,597 repeat, has been presented. 2. 2. The gross perinatal mortality in the primary group was 9.0 per cent, and 2.9 per cent in the repeat group. Eliminating deaths prior to labor, these figures are corrected to 6.3 and 2.5 per cent, respectively. The perinatal mortality in mature infants, corrected by eliminating deaths prior to labor, was 2.5 per cent in the primary and 0.9 per cent in the repeat cesarean sections. 3. 3. The type of anesthesia is not an important factor in the cause of perinatal mortality. 4. 4. In the uncomplicated elective repeat cesarean section, the perinatal loss was not affected by performance of the section prior to rather than at the onset of labor.

A case of pregnancy in a patient with a previous bilateral total adrenalectomy is presented. Management by oral substitution therapy was successfully carried out, and dosages are listed. Laboratory findings and the treatment of stress complications are included. Delivery was by repeat cesarean section.