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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).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.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).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.

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: Many women who need caesarian section in most sub Saharan Africa do not get it or do so too late, thereby resulting in an unnecessary increase in maternal and perinatal adverse outcome. Refusal of caesarian section has been attributed to poverty and sociocultural factors. Objective: The objective of the study was to determine the level of acceptance of repeat cesarean section (CS) among pregnant women attending care in a government-funded health facility with a policy of free maternity care services. Materials and Methods: This cross-sectional study surveyed 157 consecutive consenting antenatal clinic clients with previous CS presenting for booking in Central Hospital, Agbor, Delta State, Nigeria. The women completed a questionnaire with sections on sociodemographic attributes, inquiry about previous CS outcome and associated factors, a desire to accept a repeat CS if clinically indicated in index pregnancy, as well as reasons to decline a repeat CS. Results: The acceptance rate of repeat CS was 54%. Women with two or more previous CS were more likely to accept repeat CS (71.8% vs. 48.3%, prevalence ratio: 1.5; P = 0.02). There was no sociodemographic variable or any event related to the previous CS which was significantly associated with the women's choice regarding repeat CS. The rejection of repeat CS was mainly due to concerns about postoperative pain and being tagged with “failure of womanhood.” Conclusions: The level of acceptance of repeat CS in Central Hospital, Agbor, is low despite the policy of free maternity care. Along with the increasing effort to make health care affordable, attention needs to be paid to the role of patient and community engagement in the form of health education and continuous counseling to address noncost barriers to achieving improved maternal and perinatal health indices.

PURPOSE OF REVIEW The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section. RECENT FINDINGS This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation. SUMMARY According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.

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. Resumen Introducción: Una estrategia de reducción del número de cesáreas es permitir el parto vaginal después de cesárea. Objetivo: Validar dos modelos predictivos, Metz y Grobman, para el parto vaginal exitoso después de una cesárea. Métodos: Estudio de cohorte retrospectivo con mujeres con antecedente de una cesárea segmentaria previa, embarazo único ≥37 semanas y presentación cefálica . Se determinó la proporción de parto vaginal en todas las gestantes y se comparó con aquellas con parto exitoso después de cesárea, se elaboró los modelos y se determinó la capacidad predictiva de ellos mediante curva-receptor-operador. Resultados: La proporción de parto exitoso en gestantes con cesárea previa e indicación de parto vaginal fue 85.64%. La proporción de parto observado para cada decil predicho en el modelo de Grobman fue inferior al 15%, excepto para el decil 91-100%, en el que fue 64.09%, el área bajo la curva fue 0.95. Para el modelo de Metz, la proporción de parto exitoso real fue menor a lo predicho en puntajes entre 4-14 y dentro de lo esperado para puntaje entre 15-23, con un área bajo la curva de 0.94. Conclusiones: La tasa de parto vaginal después de cesárea fue menor a lo esperado de acuerdo a los modelos predictivos de Grobman y Metz. La implementación de estos modelos en forma prospectiva puede llevar una mayor tasa de parto exitoso.

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.

In our report, we present a case of repeat cesarean section in a 29-year-old Ecuadorian mother who contracted COVID-19 and traveled to the United States during her last trimester of pregnancy. We assembled a multidisciplinary team to safely deliver the mother by cesarean section. She received supportive care for her COVID-19 infection. Infection prevention procedures were based on early available data, and the baby was delivered without complications.

Introduction: Cesarean section is the surgical delivery of a baby through an incision made in the mother's abdomen and uterus. Repeat cesarean section has recently increased, partly because of concern about increased risk of uterine rupture in women attempting vaginal birth after cesarean delivery. Among the women who underwent cesarean section in their first delivery, 80-96% had a second surgical delivery. Therefore, the present study aimed to describe the prevalence of repeat cesarean section among Nepali women presented at Kathmandu Medical College and Teaching Hospital who had a previous cesarean section. Methods: This was a descriptive cross-sectional study conducted in Kathmandu Medical College and Teaching Hospital from 1st of February to 31st of May 2020. Ethical approval was taken from the Institutional Review Committee of the Kathmandu Medical College. Convenient sampling was done. All pregnant patients between gestational ages of 37-40 weeks with previous cesarean section admitted for safe confinement were included in the study. Results: Among the 104 women, who had prior cesarean section, 99 (95.19%) had second cesarean section and 5 (4.81%) had vaginal birth after cesarean. The most common indication for the first cesarean section was fetal distress 31 (29.81%) while the indication for the second cesarean section among previously cesarean section women was cephalo pelvic disproportion 39 (39.40%). Conclusions: The proportion of cesarean section in both first and subsequent delivery is quite high. This high rate may compromise the reproductive future of the women who underwent consecutive cesarean section with possible consequent complications.

To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. A descriptive epidemiological study using data from secondary birth records from the Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. The overall rate of CS was of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. Over half of the births in Brazil were cesarean sections. The Midwest had the highest CS rates, while the North had the lowest. The largest obstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5. Identificar as taxas de cesárea de acordo com a Classificação de Robson nas cinco regiões do Brasil. MéTODOS: Estudo epidemiológico descritivo utilizando dados secundários obtidos do Departamento de Informática do Sistema Único de Saúde (Datasus) entre 1° de janeiro de 2014 e 31 de dezembro de 2016, incluindo todos os nascidos vivos no Brasil. Cesáreas representaram 56% de todos os nascimentos. A amostra foi dividida em 11 grupos, e partos vaginais foram mais frequentes nos grupos 1 (53,6%), 3 (80,0%) e 4 (55,1%). As maiores taxas de cesárea foram encontradas nos grupos 5 (85,7%), 6 (89,5%), 7 (85,2%) e 9 (97,0%). A taxa geral de cesárea variou de 46,2% no Norte a 62,1% no Centro-Oeste. O grupo 5 representou a maior população obstétrica no Sul, Sudeste e Centro-Oeste, e o grupo 3, no Norte e Nordeste. O grupo 5 contribuiu mais para a taxa geral de cesárea, totalizando 30,8%. CONCLUSãO: Mais da metade dos nascimentos no Brasil ocorreu por cesárea. O Centro-Oeste apresentou a maior taxa, e o Norte, a mais baixa. A maior população obstétrica no Norte e no Nordeste foi o grupo 3, enquanto no Sul, Sudeste e Centro-Oeste foi o grupo 5. Entre todas as regiões, a maior contribuição para a taxa geral de cesárea foi do grupo 5.

To investigate factors influencing women's decisions to undergo trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery (ERCD) based on the Multidimensional Health Locus of Control (MHLC), religious observance and family planning.Cross-sectional study of candidates for TOLAC or ERCD at two hospitals in Israel. Eligible women completed a demographic questionnaire and Form C of the MHLC scale.The study included 197 women. Those who chose TOLAC (N = 101) were more religiously observant, wanted more children and had higher Internal and Chance health locus of control. Women who chose ERCD (N = 96) were more likely to be secular and had a higher health locus of control influenced by Powerful Others, notably physicians. Women not influenced by others were more likely to choose TOLAC.A woman's choice of TOLAC or ERCD is influenced by her sense of control over her health, degree of religious observance and number of children desired. Healthcare providers can use this information to better understand, counsel and educate women regarding appropriate delivery decisions. Women who feel in control of their health, educated about delivery options and are less influenced by provider preference, might choose TOLAC; thus, reducing the rate of unnecessary ERCD.

Cesarean deliveries have risen significantly over the past few decades due to advanced maternal age, defensive obstetric practice, medico-legal concerns, and maternal request. A cesarean section is a life-saving surgical procedure when certain complications arise during pregnancy and labor. However, it is a major surgery and is associated with immediate maternal and perinatal risks and may have implications for future pregnancies as well as long-term effects that are still being investigated. A major obstetric hazard of repeat cesarean section is the increased risk of uterine scar rupture during pregnancy resulting in high fetal and maternal morbidity and mortality. Also, there are increased risks associated with placenta previa and placenta accreta spectrum. We present a unique case of a woman who underwent her 10th cesarean section which was uncomplicated.

Objective To identify socio-cultural and clinician determinants in the decision-making process in the choice for trial of labor after cesarean (TOLAC) or elective repeat cesarean section (ERCS) in delivering women. Methods A tailored questionnaire focused on epidemiological, socio-cultural and obstetric data was administered to 133 patients; of these, 95 were admitted for assistance at birth at Fondazione Policlinico Universitario “A. Gemelli” (FPG) IRCCS, Rome, and 38 at S. Chiara Hospital (SCH), Trento, Italy. Descriptive analysis and logistic regression modeling were performed. Results Vaginal birth after cesarean (VBAC) rates were higher at SCH than at FPG (68.4% vs. 23.2%; P Conclusion In the attempt to promote person-centered care, increases in TOLAC/VBAC rates could be achieved by focusing on individual maternal needs. An ad hoc strategy for making birth safer should begin from accurate information at the time of the previous CS.

We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity.We analyzed intra-abdominal adhesions of 672 patients.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.Emergency operations and adhesions increased complications.

Introduction: Cesarean section is one of the common obstetric procedures done when the childbirth is not anticipated to occur by the normal vaginal delivery. There has been increased rate of cesarean section globally as well as in our country in recent decades. Methods: This descriptive cross-sectional study has been carried out by reviewing a year of data from maternity ward of Paschimanchal Community Hospital, Prithvi Chowk, Pokhara. The total number of delivery, their modes either vaginal or cesarean, indications for the cesarean section and their outcomes were analyzed. The obtained data was entered and analyzed in Microsoft Excel. Results: Total of 257 cases underwent delivery during the study period and 174 (63.27%) were by cesarean section. Oligohydramnios is the most common indication for cesarean section. Around 25 (14.36%) of the women underwent repeat cesarean section. Conclusions: The rate of cesarean section was quite high in our study and further studies are recommended for understanding of causes and other associated factors with it.

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.

Contains fulltext : 174756.pdf (Publisher’s version ) (Closed access) INTRODUCTION: Large practice variation exists in mode of delivery after cesarean section, suggesting variation in implementation of contemporary guidelines. We aim to evaluate this practice variation and to what extent this can be explained by risk factors at patient level. MATERIAL AND METHODS: This retrospective cohort study was performed among 17 Dutch hospitals in 2010. Women with one prior cesarean section without a contraindication for a trial of labor were included. We used multivariate logistic regression analysis to develop models for risk factor adjustments. One model was derived to adjust the elective repeat cesarean section rates; a second model to adjust vaginal birth after cesarean rates. Standardized rates of elective repeat cesarean section and vaginal birth after cesarean per hospital were compared. Pseudo-R2 measures were calculated to estimate the percentage of practice variation explained by the models. Secondary outcomes were differences in practice variation between hospital types and the correlation between standardized elective repeat cesarean section and vaginal birth after cesarean rates. RESULTS: In all, 1068 women had a history of cesarean section, of whom 71% were eligible for inclusion. A total of 515 women (67%) had a trial of labor, of whom 72% delivered vaginally. The elective repeat cesarean section rate at hospital level ranged from 6 to 54% (mean 29.8, standard deviation 11.8%). Vaginal birth after cesarean rates ranged from 50 to 90% (mean 71.8%, standard deviation 11.1%). More than 85% of this practice variation could not be explained by risk factors at patient level. CONCLUSION: A large practice variation exists in elective repeat cesarean section and vaginal birth after cesarean rates that can only partially be explained by risk factors at patient level. 8 p.

Introduction: In modern Obstetrics, with rising trends of primary Cesarean section (CS) for fetal and maternal interests, pregnancy over the scarred uterus is a challenge to all treating obstetricians. How better the cesarean scar is sutured, its exact fate in next pregnancy is still not measurable. Objective of this study was to evaluate the status of previous cesarean scar during repeat cesarean section (RCS) and calculate the maternal morbidity in those cases in a tertiary hospital. Methods: It was a descriptive, retrospective study conducted at department of Obstetrics of Lumbini Medical College Teaching Hospital. The study was conducted from 15th July 2014 to 14th July 2015. The data were retrieved from the department of Medical Records. Women undergoing RCS were enrolled. The status of scar was evaluated in terms of intact scar, scar rupture, scar dehiscence, thin lower uterine segment, scar placenta previa, and adhesions as indicator of scar integrity. Results: There were 534 (25.4%) CS among 2,098 deliveries during the study period. Ninety one (17.04%) of them were RCS. Elective RCS were 73.6% (n=67), and emergency RCS were 26.4% (n=24). Eighty two (90.1%) women had RCS once and 9 (9.9%) had RCS for second time. Scar was intact in 22 (91.6%), scar dehiscence in 1 (8.3%), scar with adhesions in 1 (8.3%) among emergency RCS and intact in 53 (91.3%) and scar with adhesions in 5 (8.7%) among elective RCS. Among nine women of two RCS, three (37.5%) had thin scar, five (62.5%) had well formed scar, seven (87.5%) had intact scar, and one (12.5%) had scar with adhesion. There was no scar dehiscence and no scar rupture in two RCS women. Adhesions were documented twice higher in women whose primary CS was undertaken outside our hospital. Placenta previa and placenta accreta each were found in two cases. Conclusion: Most of the scars of repeat Cesarean section were healthy with no scar rupture. We can consider trial of labor for scarred uterus with strict vigilance and in need, CS is always at option.

We present a case in which there was optimal management of recurrent cervicovesical fistula. The patient sustained a fistula shortly after a cesarean for cephalopelvic disproportion in the second stage. She underwent an unsuccessful attempt at vaginal repair 3 months postpartum and continued experiencing intermittent urinary leakage through the vagina. She expressed a wish for further childbearing and was counseled to undergo fistula repair at the time of repeat cesarean section. Twenty-seven months after her first delivery, she had a second healthy pregnancy and the repair of her cervicovesical fistula was performed with collagen graft interposition at the time of her elective cesarean section. This case report highlights the importance of surgical timing and comments on various factors that possibly enhance the success of the fistula repair.

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.

To evaluate the effect of elective repeat cesarean section on the maternal and neonatal outcomes.A retrospective clinic- and hospital-based survey was designed for comparing the maternal and neonatal outcomes of elective repeat cesarean section [RCS group (one previous cesarean section) and MRCS group (two or more previous cesarean sections)] and primary cesarean section (FCS group) at Peking Union Medical College Hospital from January 1998 to December 2007.The incidence of repeat cesarean section increased from 1.26% to 7.32%. The mean gestational age at delivery in RCS group (38.1+/-1.8 weeks) and MRCS group (37.3+/-2.5 weeks) were significantly shorter than that in FCS group (38.9+/-2.1 weeks, all P0.01). The incidence of complication was 33.8% and 33.3% in RCS group and MRCS group respectively, and was significantly higher than that in FCS group (7.9%, P0.05). Dense adhesion (13.5% vs. 0.4%, OR=7.156, 95% CI: 1.7-30.7, P0.01) and uterine rupture (1.0% vs. 0, P0.05) were commoner in RCS group compared with FCS group. Neonatal morbidity was similar among three groups (P0.05).Repeat cesarean section is associated with more complicated surgery technique and increased frequency of maternal morbidity. However, the incidence of neonatal morbidity is similar to primary cesarean section.

Objective To determine the delivery mode preferred by pregnant women with 1 previous cesarean delivery and to investigate the relationship between preferred and actual mode of delivery. Method We reviewed the records of 215 women who were delivered in a London hospital with a history of 1 cesarean delivery. Women who planned an elective repeat cesarean section (ERCS) were compared with those who planned a vaginal birth after cesarean (VBAC). Results Although 55.3% chose VBAC overall, only 37.8% of those who chose it were delivered by it, whereas 94.8% of those who chose ERCS were delivered by ERCS. Nonwhite women were more likely to choose VBAC than white women (odds ratio, 3.5; 95% confidence interval, 1.9–6.1) but less likely to be deliver by it (odds ratio, 0.31; 95% confidence interval, 0.14–0.68). Conclusion In this study, VBAC was the method of delivery preferred by most women. Nonwhite women were more likely to choose VBAC over ERCS but less likely to be delivered by VBAC.

Objective. The connection between adhesions and post-operative symptoms is well established. Adhesions are found in nearly half of the women at the time of their repeat cesarean section. For the first time a prospective pilot study has been done in order to evaluate the clinical significance of post-cesarean adhesions. Study design. Fifty women who underwent cesarean section in their first pregnancy were interviewed prior to their repeat operation regarding their symptoms after the first surgery. The clinical history was correlated with the findings during the second intervention. Results. No correlation was found between the clinical symptoms and the operative findings regarding abdominal pains, urinary symptoms, dyspareunia, or dysmenorrhea. Surprisingly, although non-significant, women with adhesions reported fewer postoperative gastrointestinal symptoms than the women with no adhesions. Conclusion. More studies will have to been done, but the analysis of this pilot study supports the hypothesis that adhesions following cesarean section are a unique entity.

Over the last three decades, there is a steady rise in cesarean sections globally [1]. This has mainly happened due to expanding indications for primary cesarean section. We now perform elective CS in almost all breech pregnancies; preterm labor; various pregnancy situations such as associated medical problems, e.g., diabetes, hypertension, and immune problems; IVF pregnancies; advanced age pregnancies; and morbidly obese mothers. These higher rates of primary cesarean sections have led to very high repeat cesarean section rates! In almost all recent surveys for indications for CS, “previous cesarean section” has become the number one indication, contributing to almost 40–50 % of CS. The US data also shows a rise from 21 % to 32 % in 15 years [2]. These factors like previous cesarean section, morbidly obese woman, and preterm elective cesarean section have brought in their wake peculiar situations for the delivery of the baby during CS. We have tried to discuss various difficulties encountered in delivering the baby during CS and various means to minimize trauma to the baby as well as to the mother. We have also outlined current concepts and have enlisted suggestions to ease the delivery of the baby with the evidence base. Difficult fetal extraction occurs in approximately one in ten cesarean deliveries, more commonly seen with preterm, elective, and late intrapartum cesarean sections.

Introduction: Increased prevalence of uterus with prior cesarean sections is due to rising rate of cesarean births worldwide. Birth management after a prior cesarean section is a challenging issue, since medical practices are divergent. Objectives: Analyze pregnancy outcome and management of childbirth from a uterus with one cesarean scar. Setting and method: It was an observational, descriptive and cross-sectional study carried out from December 15, 2014 to September 14, 2015 in the University Clinic of Gynecology and Obstetrics (CUGO) of the National University Teaching Hospital (CNHU-HKM) of Cotonou. It involved 132 female patients. The data were analyzed with Epi Info 7 software. Results: The prevalence of childbirth on uterus with one prior C-section is 7.57%. Patients' mean age was 30 years. Most of them were admitted for second childbirth. Most pregnancies were singleton ones (94.70%). The interval between cesarean section and current childbirth is higher than 24 months in most cases (83.76%). The rate of uterine contraction is low (29.55%); the same applies to the one of vaginal birth (25%). The main indications for repeat cesarean section were narrowing of the pelvis (19.19%), acute fetal distress (14.14%) and renal vascular diseases (11.11%). The maternal and perinatal prognosis for vaginal birth had been better than the one of repeat cesarean section. Conclusion: The challenging issue of childbirth management in women with one prior C-section is still a matter of concern in Cotonou. Some efforts still have to be made to improve technical medical equipment so as to extend the indications for uterine contraction during labor, thereby contributing to reduce the rate of repeat cesarean section.

Objective Most women eligible for a trial of labor after a cesarean (TOLAC) undergo an elective repeat cesarean section (ERCS). We hypothesized that this is largely because of poor patient education. Study Design This was a prospective study of women who presented to our hospital from November 2010 through July 2011 who were candidates for TOLAC. Women filled out a questionnaire prior to their scheduled ERCS or upon admission for TOLAC. A χ 2 and a Student t test were used, as appropriate. Results The study included 155 women, 87 for TOLAC and 68 for ERCS. Women in both groups demonstrated a lack of knowledge on the risks and benefits of TOLAC and ERCS. When patients perceived their providers as having a preference for ERCS, very few chose TOLAC, whereas the majority chose TOLAC if this was their provider's preference. Conclusion Candidates for TOLAC appear to know little about the risks and benefits associated with their mode of delivery, and provider preference affects this choice.

PURPOSE OF REVIEW To review the current literature on vaginal birth after cesarean delivery efficacy and safety. RECENT FINDINGS There are two major themes in current vaginal birth after cesarean delivery research. The first is continued work on the short-term safety, including maternal events such as uterine rupture and perinatal death. The second theme focuses on identifying predictors for success and failure. SUMMARY Current information suggests that the rate of major maternal and neonatal complications with vaginal birth after cesarean delivery is low, and this option should be offered to women with a single prior low transverse cesarean. Future research should focus on an evaluation of both short-term and long-term consequences of vaginal birth after cesarean delivery compared with elective repeat cesarean section.

Background: Although cesarean section is known to be associated with higher hospital charges than vaginal delivery, cost comparisons require further investigation. This study compared maternal hospital charges of women with one previous cesarean section undergoing a trial of labor with the charges of women who underwent an elective repeat cesarean section. Hospital charges for the trial of labor group were also compared with charges of women with a previous vaginal delivery but no previous cesarean section. Methods: A retrospective analysis of three primiparous privately insured patient groups who gave birth from July 1992 to October 1993 was conducted. Hospital charges for 50 primiparas with previous cesarean births who underwent a trial of labor were compared with those of 50 contemporaneous primiparas who underwent elective repeat cesarean section, and with those of 50 primiparas without a past history of cesarean birth. Results: Trial of labor was associated with a mean maternal hospital charge of $5820 ±$1609 compared with $6785 ±$771 for elective repeat cesarean section (p < 0.001). Trial of labor was also associated with a decreased length of stay when compared with elective cesarean section (2.48 ± 0.88 days vs 3.62 ± 0.57 days, p < 0.001). The difference in charges between these two groups was primarily due to charges associated with length of stay and the operating room, but was partly offset by charges associated with labor. The group of women without a past history of cesarean birth had a mean maternal hospital charge of $4685 ±$966 and a mean length of stay of 1.96 ± 0.63 days. Conclusions: Trial of labor is associated with an overall 14 percent reduction in maternal hospital charges and a 31 percent reduction in length of stay compared with elective repeat cesarean section. (BIRTH 25:2 June 1998)

To analyze the cesarean section rate evolution in a tertiary hospital and the main indications for cesarean section.A retrospective study was conducted at a major academic hospital and included 5 751 women who had a cesarean section from 2005 to 2011. The rates of overall, primary and repeat cesarean sections were analyzed. A linear regression and adjusted R-square were used to access the relative contribution of each indication to the variation in primary cesarean section.During the 7-year period of the study the cesarean section rate decreased from 30.9% to 27.6%. This was due to a decrease in primary cesarean section (21.9% to 18.2%), although an increase in repeat cesarean section was observed (9.0% to 9.4%). Among the indications for primary cesarean section, maternal-fetal indications and malpresentation were the ones that decreased the most with adjusted R-square of 0.70 and 0.55, respectively.The collected data identified that the decrease in the cesarean section rate at the hospital resulted from a decrease in primary cesarean section deliveries, especially the ones performed for maternal-fetal indications and malpresentation.The decrease in primary cesarean section rate may be attributed to several changes in medical policies in the Department, such as the implementation of an external fetal version program, the induction of labor only after the 41st week of gestation in low-risk pregnancies and the trial for vaginal birth in maternal-fetal disease. Nevertheless subjective indications such as labor arrest disorders and nonreassuring fetal heart rate are still major contributors for primary cesarean section rate.Introdução: Analisar a evolução da taxa de cesarianas e as principais indicações para cesariana num centro terciário.Material e Métodos: Estudo retrospectivo conduzido num hospital universitário que incluiu 5751 grávidas submetidas a cesariana entre 2005 e 2011. Analisaram-se as taxas de cesarianas, incluindo a taxa de primeiras cesarianas e de cesarianas repetidas. Para avaliar a contribuição relativa de cada uma das indicações na variação da taxa de primeiras cesarianas recorreu-se à regressão linear e determinou-se o valor do r2 ajustado.Resultados: Durante o período do estudo a taxa de cesarianas diminuiu de 30,9% para 27,6%. Esta descida deveu-se à diminuição da taxa de primeiras cesarianas (21,9% para 18,2%), apesar de se ter constatado um ligeiro aumento da taxa de cesarianas repetidas (9,0 para 9,4%). Entre as indicações para primeiras cesarianas, as causas materno-fetais e de apresentação anómala foram as que diminuiram mais, com valores de r2 ajustado de 0,70 e 0,55, respectivamente.Discussão: Os dados coligidos permitiram identificar a hipótese de que a diminuição da taxa de cesarianas se deveria a uma retração detectada sobretudo a nível das primeiras cesarianas, em particular as decorrentes de causas materno-fetais e apresentação anómala.Conclusão: A diminuição da taxa de primeiras cesarianas pode ser atribuída a várias modificações na prática clínica do Departamento, como a implementação da versão cefálica externa, a indução do trabalho de parto a partir das 41 semanas de gestação, em gravidezes de baixo risco e da realização de provas de trabalho de parto em casos de patologia materno-fetal. No entanto, indicações subjectivas, como a paragem de progressão do trabalho de parto e a suspeita de sofrimento fetal são ainda causas major de primeiras cesarianas.

Objective The purpose of this study was to evaluate the development and implications of intraabdominal adhesions after repeat cesarean section delivery (CS). Study Design We reviewed the charts of 1283 women who underwent repeat CS and 203 other women who underwent primary CS. Primary outcome measures were incidence and extent of adhesions, incision-to-delivery interval, and operating time. Results No adhesions were found in primary CS. Compared with those women with a second CS (24.4%), significantly more women had adhesions after 3 CSs (42.8%; 95% confidence interval [CI], 0.84-0.99). Compared with a first CS (7.7 ± 0.3 minutes), the delivery time was significantly longer at subsequent CSs (second CS, 9.4 ± 0.1 minutes; 95% CI, 1-2; third CS, 10.6 ± 0.3 minutes; 95% CI, 2-4; ≥ 4 CSs, 10.4 ± 0.1 minutes; 95% CI, 1-2). However, complication rates in those women with ≥ 2 CSs were comparable with primary CS. Conclusion Increased adhesion development and a longer time to delivery were found with each subsequent CS.

Objective Gravid uterus with incisional hernia is rarely encountered complication. Aim is to report a case of pregnancy with ruptured incisional hernia. Case report A 35-year-old woman, gravida three, para two presented at 30 weeks of gestation with ruptured abdominal incisional hernia. She had previous two emergency cesarean sections done for contracted pelvis, 3 and 2 years back, respectively. Emergency herniorrhaphy was done. Postoperative period was uneventful and pregnancy advanced well without complication. At 37 weeks of gestation, she had elective cesarean section with bilateral tubal ligation. She delivered a healthy female baby of 2.5 kgs and the postoperative period was uneventful. Conclusion If the woman was aware and had come earlier during antenatal period; she would have been put on conservative management (bed rest, binder, etc) which might had prevented rupture of the hernia and further the emergency herniorrhaphy which is additional risk factor for the mother and the baby. How to cite this article Singhal SR, Sangwan N, Nanda S, Singhal SK. Successful Pregnancy Outcome by Repeat Cesarean Section and Herniorrhaphy in a Case of neglected ruptured Incisional Hernia. J South Asian Feder Menopause Soc 2014;2(1):50-51.

Recently we identified a weak zone in term, pre-labor (repeat Cesarean section) human fetal membranes (FM) overlying the cervix with biochemical characteristics suggestive of apoptosis and collagen remodeling. We suggested that this weak zone is the FM rupture initiation site. Vaginally delivered patients have a weak zone in their FM overlying the cervix; a comparable weak zone lies adjacent to the tear line in FM after spontaneous rupture (SROM).FM from vaginally delivered patients with artificial rupture (AROM) and SROM were collected. FM of AROM patients were marked per vagina to identify the FM zone overlying the cervix. Postpartum FM were cut, strength tested, and piece strengths were remapped to their former location on a three-dimensional model. A 10-cm diameter zone centered on the marked area (AROM), or defined weak zone (SROM) was compared with the remaining FM.AROM FM exhibit a para-cervical weak zone. SROM FM exhibit a comparable zone on the tear line. The mean rupture strength within weak zones was 60% of the remaining membranes (P.001). AROM and SROM FM weak zones both exhibit increased matrix metalloproteinase 9, increased poly (ADP-ribose) polymerase I cleavage, decreased tissue inhibitor of metalloproteinase 3 protein, and histology consistent with remodeling and apoptosis.Vaginally delivered AROM FM contain a weak zone overlying the cervix. Vaginally delivered SROM FM contain a weak zone adjacent to the tear line that exhibits biochemical and mechanical characteristics suggestive of collagen remodeling and apoptosis comparable to those of the AR FM weak zone.

Background: Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a trial of labor after cesarean. Methods: All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a trial of labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the trial of labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). Results: Infants delivered after a trial of labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p

Abnormalities of the lower urinary tract resulting from cesarean section are rare. We present a patient who developed urinary frequency, nocturia and acute pains in the late phase of micturition which we think was due to bladder distortion after repeat cesarean section. She was diagnosed cystographically and treated successfully by bladder flap release.

Many women with previous multiple cesarean sections become pregnant and are exposed to certain risk for a variety of complications for both mother and neonate. Some catastrophic complications during pregnancy and labor after a previous cesarean section were shown to be increased. But there are also studies reporting that uterine rupture or placental implantation disorders with serious consequences for the mother or fetus occur infrequently. It is generally believed that neither vaginal birth after cesarean (VBAC) nor repeat cesarean section is free of risk but successful VBAC usually entails less morbidity than repeat cesarean section. Although there is a strong consensus that a trial of labor is appropriate for most women with prior low transverse cesarean sections increased experience with VBAC indicates that there are potential problems. Reports have implicated numerous maternal and neonatal complications associated with an unsuccessful trial of labor. (excerpt)

OBJECTIVE: The aim of our study was to determine whether the reported increased morbidity associated with failed attempted vaginal birth after cesarean section is attributable to the presence of a uterine scar alone or to labor preceding a cesarean section. STUDY DESIGN: Primiparous women ( N = 237) who underwent repeat cesarean section after a failed trial of vaginal birth after cesarean section were retrospectively compared with 1582 nulliparous women who underwent a primary cesarean section after a failed trial of labor. RESULTS: There were no significant differences in maternal or neonatal morbidity between the two groups except for an increase in the prevalence of thin meconium in patients undergoing primary cesarean section. CONCLUSION: Our results suggest that the presence of a previous cesarean section scar does not increase the overall baseline morbidity associated with cesarean section after labor. (AM J OBSTET GYNECOL 1992;167:1513-7.)

It has recently been reported that the use of halogenated agents during balanced general anesthesia may result in an increase in blood loss associated with cesarean section. This report has been criticized for failure to control for a variety of other factors that may have contributed to the increased blood loss, particularly the indication for and type of cesarean section. The present study was designed in an attempt to resolve this criticism. Blood loss was evaluated in uncomplicated patients undergoing elective repeat cesarean section under either general anesthesia using a halogenated agent (isoflurane) or regional anesthesia (spinal/epidural). All 117 singleton term, nonlaboring women underwent repeat low transverse cesarean section performed through a midline abdominal incision. Exclusion criteria included maternal medical complications, abnormal placentation, polyhydramnios, presence of uterine leiomyomas, and intraoperative complications. Seventy-five patients (64%) received regional and 42 (36%) received general anesthesia. A greater proportion of women undergoing general anesthesia experienced a postoperative decrease in hematocrit of 5 vol% or more compared with patients receiving regional anesthesia (10 of 42 versus 5 of 75, p = 0.018). Thus, we conclude that women undergoing uncomplicated elective repeat cesarean section under general anesthesia supplemented with a halogenated agent are at risk for increased blood loss compared with those women receiving regional anesthesia. However, the increased blood loss was not clinically significant in this study, since none of the patients required transfusion.

There has been recent interest in autologous blood donation in obstetric patients, but little attention has been paid to whether such programs are needed or whether the patients that will require transfusion can be accurately predicted. At the University of California San Diego Medical Center from July 1 to Dec. 31, 1988, there were 2265 deliveries; 13 women (0.57%) received blood transfusions. Traditionally accepted risk factors were identified in 251 patients, with only four (1.6%) requiring transfusion. Among the 150 patients delivered by repeat cesarean section, only one (0.7%) required blood. one of 27 (3.7%) multiple gestations, two of eight (25%) patients with placenta previa, and none of the 66 grandmultiparous women had transfusions. These data suggest that autologous blood donation may not be beneficial or cost effective when the low frequency of blood transfusions in this high-risk obstetric population and the difficulty in accurately predicting those likely to require transfusions are considered.

Allowing a trial of labor in patients who have had a single low transverse cesarean section has become increasingly accepted and widespread in the United States. Evidence with regard to the safety of this practice in patients with two or more prior cesarean births has, however, been sparse. We performed a retrospective review of the charts of 170 patients who had undergone two or more low transverse cesarean deliveries and subsequently delivered at Wishard Memorial Hospital between January 1, 1983, and December 31, 1987. Of 35 of these women who underwent a trial of labor, 27 (77%) had a successful vaginal delivery. No increase in maternal or fetal morbidity or mortality was associated with labor. The women who underwent trial of labor had fewer postpartum complications and shorter hospital stays. Although the number of patients in this study was small, growing evidence appears to support a trial of labor in patients with two or more prior cesarean sections as a safe and successful alternative to elective repeat cesarean section.

Despite the known medical safety and success of vaginal birth after cesarean section, rates of planned repeat cesarean sections remain high. The process involved in women's decisions to choose vaginal birth after cesarean section or repeat cesarean section was investigated by a questionnaire study at a private and a public hospital. Women were questioned regarding timing, influence of others, reasons for their choice, satisfaction with the decision, etc. Results from 160 respondents showed that over half the women identified themselves as the primary decision maker. Physicians exerted more influence on the decisions of patients at the public hospital than on the patients at the private hospital. Overall, social exigencies appeared to play a more important role than an assessment of the medical risks in making these decisions.

Most studies on vaginal birth after cesarean section come from medical centers or university hospitals. However, the minority of births in the United States occur in these hospitals. When compared with larger institutions, many small hospitals have longer operating start-up times, less adequate blood banking facilities, and decreased obstetrical anesthesia support. Over a 30-month period in a small hospital, a trial of labor was successful in 76% of patients with prior cesarean section. Despite the limitations of support in a small hospital, vaginal birth can be offered to selected patients with prior cesarean section delivery. In our experience, vaginal birth after cesarean delivery requires significantly more physician hours in the hospital than does repeat cesarean section. The problem of a pregnancy with a prior cesarean section is an ever-increasing one and, in our practice, approximately 25% of multiparous patients have had a prior cesarean delivery.

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

A retrospective study of a trial of labor (TOL) after prior cesarean section was conducted over 18 months in a patient population that is homogeneous with regard to race, socioeconomic class, gestational age, and medical complications. Of 171 women who had undergone previous cesarean sections, 75 were offered a TOL. Thirty-five of these patients had an elective repeat cesarean section, while 40 agreed to a TOL. Thirty-two of the latter patients delivered vaginally (80%). The criteria for offering a TOL and a protocol for TOL are presented. A comparison of the maternal and neonatal morbidity associated with repeat cesarean section versus TOL do not strongly favor either method of delivery in our population. The patients who had undergone cesarean section for cephalopelvic disproportion (CPD) had the lowest acceptance and the lowest success rate of a TOL. The hospital charges and hospital stay of the two groups are presented. The financial aspects of the two methods of delivery and the impact of Diagnosis Related Groups (DRGs) on the management of these patients are discussed. Careful selection of patients for a TOL is essential to maintain the quality of medical care while responding to pressures to reduce the cesarean section rate and to reduce the costs of medical care.

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.