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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

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 5th 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. [ABSTRACT FROM AUTHOR]

Background & Objective: Although the safety of cesarean sections has increased, there are still considerations, especially for women with a history of repeated cesarean sections. This study was conducted with the aim of investigating maternal and neonatal outcomes in candidates for cesarean sections due to repeat cesarean sections according to the number of previous cesarean sections. Materials & Methods: This prospective descriptive study was conducted from April 2020 to June 2022 at Taleghani Hospital. All candidates for cesarean sections due to repeated cesarean sections were included in the study. According to the number of previous cesarean sections, they were divided into three groups. Statistical analysis was performed with Kruskal-Wallis, Chi-squared and Fisher's exact tests. A P value < 0.05 indicated statistical significance. Results: A total of 345 women were included in the study. The results of this study showed that these three groups were significantly different in terms of duration of surgery (P<0.001), abnormal placental adhesion (0.012), and the presence of intraperitoneal adhesions (P<0.001), but there was not a significant difference in terms of other maternal and neonatal outcomes (P<0.05). Conclusion: The results of this study showed that an increase in the number of previous cesarean sections does not increase most maternal and neonatal complications during a current cesarean section. Of course, it should be noted that the number of women with a history of three or more previous cesarean sections was small in this study, and for this reason, more studies are needed. [ABSTRACT FROM AUTHOR]

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. Synopsis: The dramatic fall in trial of labor after cesarean section rates globally may reflect overestimation of risks and underestimation of benefits associated with vaginal birth. [ABSTRACT FROM AUTHOR]

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.

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. Synopsis: Educating gynecologists toward trial of labor after cesarean section is an intervention that leads to increasing vaginal birth after cesarean section, even improving neonatal well‐being. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of short inter-pregnancy interval on the outcome of vaginal birth after cesarean section. Study Design: Comparative cross-sectional study. Place and Duration of Study: Obstetrics and Gynecology Department, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jan to Oct 2021. Methodology: A total of 400 pregnant females were selected for this study. For every consecutive pregnant woman with a previous cesarean section and short inter-pregnancy interval (18 months’ inter-pregnancy interval had a successful VBAC. In patients with a history of vaginal delivery, the success of vaginal birth after the cesarean section was significantly higher than in those without previous vaginal delivery or VBAC (p=0.005). 231 out of 250(92.4%) pregnant females with spontaneous onset of labour had a successful VBAC compared to those who had induction of labour, 19(7.6%) (p=0.005). Patients who needed augmentation during delivery had a higher rate of undergoing a cesarean section than VBAC (p=0.003). However, no significant difference was observed in the spontaneous onset of labour and the need for induction and augmentation of labour for the inter-pregnancy interval. Conclusion: Our study concluded that with increasing inter-pregnancy interval, the chances of a successful VBAC increase (p=0.001) with fewer reported complications.

Raha Maroyi,1,2 Bahaya Naomi,2 Madeline K Moureau,3 Balungwe Sifa Marceline,1 Celeste Ingersoll,4 Roselyn Nerville,5 Denis Mukwege1,2,6 1Department of Obstetrics and Gynecology, Panzi Referral Hospital, Bukavu, South Kivu, Democratic Republic of Congo; 2Université Evangélique en Afrique (UEA), Bukavu, South Kivu, Democratic Republic of Congo; 3Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 4Department of Statistics, Brigham Young University, Provo, UT, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6International Center for Advanced Research and Training (ICART), Bukavu, South Kivu, Democratic Republic of CongoCorrespondence: Raha MaroyiUniversité Evangélique en Afrique (UEA), PO Box: 266, Bukavu, South Kivu, Democratic Republic of CongoTel +243 997 254 812Email ken.raha01@gmail.comPurpose: 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.Keywords: trial of labor, delivery, repeat cesarean section, sub-Saharan Africa, Democratic Republic of Congo

Introduction: The selection of repeat cesarean delivery instead of trial of labor after cesarean (TOLAC) has a great contribution to cesarean rate. Ultrasonographic measurement of lower uterine segment (LUS) thickness for prediction of real uterine thickness was investigated by several researchers. In this study, LUS transvaginal (TV) and transabdominal (TA) ultrasonography (USG) measurements were evaluated for usefulness in patients with the previous cesarean scar. Methods: Pregnant patients between 37 and 40 weeks of gestational age who were admitted to our clinic with the decision of repeat cesarean delivery were evaluated by TV and TA USG by measuring the LUS full-thickness and myometrium before cesarean delivery. The patients were divided into two groups: Translucent LUS and intact myometrium. The real myometrial thickness also assessed by vernier caliper in the operation. Correlations between ultrasonographic and vernier caliper measurements were analyzed and cutoff values for the ultrasonographic measurements of LUS were evaluated. Results: Manual caliper measurements had a correlation (r) of 0.347 with TA USG full thickness, 0.337 with myometrial measurements, 0.443 with TV USG full thickness, and 0.475 with myometrial measurements. The extremely thin LUS ratio was 7.07% (n=14). Receiver operating curve, cutoff values are 3.55 mm for TA USG full-thickness LUS measurements, 2.75 mm for TV USG full-thickness, and 1.35 mm for TV USG myometrial LUS measurements. Discussion and Conclusion: LUS USG measurements are useful for predicting the intact LUS and can be used in clinical decision-making for TOLAC, but the low positive predictive value suggests that it cannot be recommended in the prediction of extremely thin LUS. [ABSTRACT FROM AUTHOR]

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.

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. [ABSTRACT FROM AUTHOR]

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Abstract Objective To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. Methods A descriptive epidemiological study using data from secondary birth records fromthe 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. Results The overall rate of CSwas 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. Conclusion Over half of the births in Brazil were cesarean sections. The Midwest had the highestCS rates,while theNorth had the lowest. The largestobstetric 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.

Objective: To analyze the correlation between intraoperative hemorrhage and anesthesia factors during the repeat cesarean section to provide research basis for optimizing anesthesia management program. Methods: A total of 1192 parturient women, who underwent caesarean section again, were selected and divided into study group (the amount of intraoperative hemorrhage≥ 500 mL) and control group (the amount of intraoperative hemorrhage <500 mL) according to the amount of intraoperative hemorrhage. The general factors and anesthesia factors related to intraoperative hemorrhage between the two groups of parturient women were compared and analyzed. Results: The amount of intraoperative hemorrhage of 106 cases ≥500 mL, the incidence was 8.89%. The proportion of abortion history, the proportion of prenatal anemia, the proportion of placenta previa, the proportion of placenta adhesion, the proportion of placenta implantation, the proportion of uterine atony of the parturient women in the study group were higher than those in the control group, and the pregnancy process was shorter than that in the control group, the differences were statistically significant (P<0.05). The time of operation, the proportion of hysterectomy or partial hysterectomy, the proportion of ASA Ⅱ ~ Ⅲ grade and the proportion of ropivacaine dosage > 15 mg of the parturient women in the study group were significantly higher than those in the control group, the differences were statistically significant (P<0.05). The results of logistic multiple regression analysis showed that the occurrence of intraoperative hemorrhage during the repeat cesarean section was correlated with placenta previa, placenta implantation, uterine atony, hysterectomy or partial resection and ASA grade (P<0.05). Conclusion: The risk of intraoperative hemorrhage during the repeat cesarean section is not only related to placental and uterine factors, but also affected by operation and anesthesia factors. The clinician should make a comprehensive and accurate preoperative evaluation on the parturient women, optimize anesthesia management plan and operation strategy, so as to reduce the occurrence of intraoperative hemorrhage and ensure the safety of operation. [ABSTRACT FROM AUTHOR]

Background: Cesarean section (CS) is the most common performed obstetric surgery world widely. Repeat CS is associated with a variety of complications, including intra-peritoneal adhesion, placenta previa, uterine rupture and cesarean hysterectomy. The present study aimed to determine the characteristics, maternal and fetal outcomes and post-operative complications of pregnant women with repeat CS using Clavien-Dindo classification in the Central Vietnam. Methods: We conducted a prospective study on 1342 women who underwent repeat CS between June 2020 and October 2021 at the Department of Obstetrics and Gynecology, Hue University Hospital, Hue, Vietnam. Numerous risk factors and adverse pregnancy outcomes of repeat CSs were identified and analyzed. Results: Intra-operative complications occurred at a rate of 18.2%, whereas post-operative complications rate was 2.8%. There were statistically significant differences in intra-operative complication rates between the pregnant women who had previously undergone only one CS and those who had previously two or more CSs (p = 0.011, 95% CI 1.9: 1.1–2.9). Among 1342 women who were indicated for repeat CS, thirty-seven women suffered from complications after surgery, accounting for 2.8%, as categorized by Clavien-Dindo. In which grade I accounted for 2.0%, grade II accounted for 0.4%, grade IIIa accounted for only 0.3%. No maternal mortality was reported in this study. Conclusions: Post-operative complications rate of cesarean section is extremely low. Application of the Clavien-Dindo classification in clinical scenario to classify those complications has shown to be highly practical.

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.

Introduction: Candidates of cesarean section with a previous history of such surgery are at a higher risk of intra-abdominal adhesions in comparison to those having undergone vaginal delivery. Intra-abdominal adhesions lead to prolonged operative time, intraoperative hemorrhage, fetomaternal morbidity, and requirement of the help of other surgeons. Therefore, this study was conducted to study the characteristics of abdominal scars in order to predict and manage intra-abdominal adhesions before operation. Methods: This descriptive prospective study was conducted on 109 candidates of cesarean section with a previous history of such surgery in Taleghani Hospital, Tehran, Iran, in 2017. The data recorded for each patient included demographic characteristics, body mass index, abdominal scar characteristics, and severity of abdominal adhesion. The collected data were analyzed in SPSS software (version 22) using the Chi-square test and Mann-Whitney U test. P-value less than 0.05 was considered statistically significant. Results: Out of 109 participants, 36 (32.02%) women had adhesion, 17 (15.6 %) cases of whom had dense vascular adhesions or frozen pelvis. The analysis showed a significant difference between the filmy adhesion or non-adhesion group and adhesive adhesion or frozen pelvis group in terms of flat and non-flat scars (P=0.042), scar height (P=0.005), and depressed and non-depressed scars (P=0.004). Conclusion: As the findings indicated, a depressed abdominal scar resulting from a previous cesarean delivery was correlated with the incidence and severity of intra-abdominal adhesions (P

Abstract Objective To describe a case of vesicouterine fistula and to review the literature related to this condition. Methods For the review, we accessed the MEDLINE, BIREME and LILACS databases; the references of the searched articles were also reviewed. Results A 38-year-old woman, in the 1st day after her 3rd cesarean, presented heavy hematuria, which was considered secondary to a difficult dissection of the bladder. A total of 6 months after delivery, she failed to resume her regular menstrual cycles and presented cyclic menouria and amenorrhea. At this time, she had two episodes of urethral obstruction by blood clots. She remained without a correct diagnosis until about two years postdelivery, when a vesicouterine fistula was confirmed through cystoscopy. A surgical correction through open abdominal route, coupled with hysterectomy, was performed. After the surgery, the symptoms disappeared. The review showed a tendency of change in the relative frequency of the different types of genitourinary fistulae. Vesicovaginal fistulae, usually caused by inadequate care during labor, are becoming less frequent than those secondary tomedical procedures, such as vesicouterine fistulae. The most common cause of this latter kind of fistula is cesarean section, especially repeated cesarean sections. The diagnosis is confirmed through one or more imaging exams, or through cystoscopy. The most common treatment is surgical, and the routes are: open abdominal, laparoscopic, vaginal or robotic. There are some reports of success with the conservative treatment. Conclusion Vesicouterine fistulae are becoming more common because of the increase in the performance of cesarean sections, and the condition must be considered a possible complication thereof.

Objectives: Adhesions developed after cesarean sections (CS) vary according to the number of repeat section. Delivery times were reported to increase with increased number of CS. Materials and Methods: This is a prospective cohort study done in Assiut Women Health Hospital from August 2012 to August 2015 to evaluate the implications of doing adhesiolysis at CS either before delivery of the fetus or after that on maternal morbidity during current CS and recurrence rate in next sections. Adhesiolysis during CS avoids the use of anti-adhesion substances which is costly and not available in our low-income society. Results: Fifty patients were included in the study. The dominant type of adhesion was omental, bladder and uterine adhesions forming bands with the anterior abdominal wall. The uterovesical adhesion was present in all cases. No maternal morbidity occurred during adhesiolysis. Follow up of those patients were continued for 3 years. The percentage of adhesions in the next CS after this adhesiolysis was only 2 cases (4%) and both cases were omental adhesions.Conclusion: The use of adhesiolysis in repeat CS adhesions with an ascending curve of experience is essential in our low socioeconomic countries and associated with no maternal or neonatal complications.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

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. [ABSTRACT FROM AUTHOR]

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.)

The study conducted in retrospective manner in 150 bedded Government Victoria Hospital; a Maternity Hospital affiliated to Andhra Medical College, Visakhapatnam, Andhra Pradesh. The rates and indications of primary and repeat Cesarean sections (CS) were analyzed among 8121 live births during the year 2014 and present Cesarean section rate was compared with 2004 and 2009 Cesarean rates. In our study, the Cesarean section rate was 25.66%. There is an increase in the CS rate over last decade from 16.14% in 2004, 20.33% in 2009 to 25.66% in 2014. The main contribution to this rise in CS is due to increase in numbers of repeat sections. CS becomes increasingly the procedure of choice in high risk pregnancies to prevent perinatal morbidity and mortality. This has become possible due to improved patient care, availability of effective antibiotics, blood transfusion services, safer anesthesia, improved surgical technique and sophisticated neonatal care services. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective: To determine the effect of short interpregnancy interval on the outcome of vaginal birth after cesarean section. Study Design: Comparative cross-sectional study. Place and Duration of Study: Obstetrics and Gynecology Department, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jan to Oct 2021. Methodology: A total of 400 pregnant females were selected for this study. For every consecutive pregnant woman with a previous cesarean section and short interpregnancy interval (<18 months) recruited into the study, a suitable control with interpregnancy interval ≥18 months were recruited. Results: Only 107(53.5 %) females with short interpregnancy interval had a successful vaginal birth after cesarean section, whereas 143(71.5 %) females with >18 months' interpregnancy interval had a successful VBAC. In patients with a history of vaginal delivery, the success of vaginal birth after the cesarean section was significantly higher than in those without previous vaginal delivery or VBAC (p=0.005). 231 out of 250(92.4%) pregnant females with spontaneous onset of labour had a successful VBAC compared to those who had induction of labour, 19(7.6%) (p=0.005). Patients who needed augmentation during delivery had a higher rate of undergoing a cesarean section than VBAC (p=0.003). However, no significant difference was observed in the spontaneous onset of labour and the need for induction and augmentation of labour for the interpregnancy interval. Conclusion: Our study concluded that with increasing interpregnancy interval, the chances of a successful VBAC increase (p=0.001) with fewer reported complications. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the puerperal complications following twin deliveries. Study design: We conducted a population-based analysis of puerperal delivery-related complications of twins born in Slovenia for comparing three groups of births (vaginal, elective and emergent cesarean). Results: A total of 1,001 elective, 1,109 emergent cesarean sections, and 2,204 vaginal twin births were evaluated. No differences were found between the complications after emergent and elective cesareans. Uterine atony was more frequent after vaginal births (OR 1.8-2.0, 95 % CI 1.1-1.2, 2.9-3.3). Vaginal births had a higher frequency of endometritis compared with elective cesarean (OR 4.1, 95 % CI 1.2, 13.6). Conversely, vaginal deliveries were less frequently associated with anemia, hematoma formation, and need for blood transfusion as compared to both modes of cesarean deliveries. Conclusion: No solid data exist to show a clear advantage or disadvantage in terms of puerperal complications of an elective cesarean over vaginal birth for twins. [ABSTRACT FROM AUTHOR]

An estimated 40% of the 1.3 million cesarean deliveries performed each year in the United States are repeat procedures. The appropriate clinical management approach for women with previous cesarean delivery remains challenging because options are limited. The risks and benefits of clinical management choices in the woman’s health need to be quantified. Thus, we discuss the available published scientific data on (1) the short-term maternal outcomes of trial of labor after cesarean and elective repeat cesarean delivery, (2) the differences between outcomes for both, (3) the important factors that influence these outcomes, and (4) successful vs. unsuccessful vaginal birth after cesarean. For women with a previous cesarean delivery, a successful trial of labor offers several distinct, consistently reproducible advantages compared with elective repeat cesarean delivery, including fewer hysterectomies, fewer thromboembolic events, lower blood transfusion rates, and shorter hospital stay. However, when trial of labor after cesarean fails, emergency cesarean is associated with increased uterine rupture, hysterectomy, operative injury, blood transfusion, endometritis, and longer hospital stay. Care of women with a history of previous cesarean delivery involves a confluence of interactions between medical and nonmedical factors; however, the most important determinants of the short-term outcomes among these women are likely individualized counseling, accurate clinical diagnoses, and careful management during a trial of labor. We recommend a randomized controlled trial among women undergoing a TOLAC and a longitudinal cohort study among women with previous cesarean to evaluate adverse outcomes, with focused attention on both mother and the infant. [Copyright &y& Elsevier]

Background. Maternal preferences should be considered in decisions about mode of delivery following a previous cesarean, but risks and benefits are unclear. Decision aids can help decision making, although few studies have assessed costs in conjunction with effectiveness. Objective. Economic evaluation of 2 decision aids for women with 1 previous cesarean. Design. Cost-consequences analysis. Materials and Methods. Data sources were self-reported resource use and outcome and published national unit costs. The target population was women with 1 previous cesarean. The time horizon was 37 weeks' gestation and 6 weeks postnatal. The perspective was health care delivery system. The interventions were usual care, usual care plus an information program, and usual care plus a decision analysis program. The outcome measures were costs to the National Health Service (NHS) in the United Kingdom (UK), score on the Decisional Conflict Scale, and mode of delivery. Results of Main Analysis. Cost of delivery represented 84% of the total cost; mode of delivery was the most important determinant of cost differences across the groups. Mean (SD) total cost per mother and baby: 2033 (677) for usual care, 2069 (738) for information program, and 2019 (741) for decision analysis program. Decision aids reduced decisional conflict. Women using the decision analysis program had fewest cesarean deliveries. Results of Sensitivity Analysis. Applying a cost premium to emergency cesareans over electives had little effect on group comparisons. Conclusions were unaffected. Limitations. Disparity in timing of outcomes and costs, data completeness, and quality. Conclusions. Decision aids can reduce decisional conflict in women with a previous cesarean section when deciding on mode of delivery. The information program could be implemented at no extra cost to the NHS. The decision analysis program might reduce the rate of cesarean sections without any increase in costs. [ABSTRACT FROM AUTHOR]