We conducted this study between October 2013 and August 2015 in the Department of Obstetrics and Gynecol- ogy, University of the Ryukyus Hospital. Pregnant women between 37 and 41 gestational weeks with or without a previous CD who attempted a planned CD were recruited into the study. Exclusion criteria were: placental abnormalities (abruption, accreta, previa), uterine leiomyomas, fetal anomalies, abnormal fluid volume (oligo- hydramnios or polyhydramnios), and uterine contractions. All patients provided written informed consent before enrollment. This study was conducted according to the principles stated in the 1964 Declaration of Helsinki and all subsequent revisions, and was approved by the Institutional Review Board of our university on September 18, 2013 (#571). Eighty-nine pregnant women who underwent a planned CD between 37 and 41 weeks of gestation were enrolled and divided into two groups. Group A (n = 69) consisted of women with a previous CD who did not want to attempt a vaginal delivery and Group B (n = 20) consisted of women with previous vaginal delive- ries and no uterine scar.
the reason of maternal mortality in 5.51% of the cases (6). The main risk factors of uterine rupture during pregnancy are previous classical cesarean section, previous hysterot- omy (very rare), previous myomectomy, placenta accreta, motor vehicle accidents, Mullerian anomalies of uterus, hysteroscopic metroplasty, difficult curettage for miscar- riage. Ehler-Danlos syndrome, chronic steroid use and the use of cocaine are the other rare causes of uterine rupture. The main risk factors of uterine rupture during labour are previous cesarean section, previous myomectomy, grand multiparity, malpresentation, unrecognised cephalopelvic disproportion, obstructed labour, prostaglandin and oxy- tocin augmentation in women with high parity and pre- vious cesarean section, use of high doses of misoprostol in parous women during labour induction and assisted breech deliveries. Tumours obstructing the birth canal and pelvic deformity are the other rare causes of uterine rupture. After delivery, precipitate labour, manual remov- al of placenta, uterine manipulation (intrauterine balloon) and placenta akreta are the risk factors (7). In patients with no antenatal care, the trial of delivery of a hydrocephalic or macrosomic fetus may result in rupture of an unscarred uterus. Assisted fundal pressure may also lead to an atyp- ical rupture of an unscarred uterus during delivery of the baby in the second stage of labour (8). In very complicated cases, the rupture of ureter may also accompany (9). The symptoms and signs of uterine rupture are fetal dis- tress (abnormalities in fetal heart rate) (78%-87%), dimin- ished baseline uterine pressure, loss of uterine contractil- ity, abdominal pain (13%-60%), recession of the present- ing fetal part, hemorrhage (11%-67%), shock (29%-46%), sudden onset gross haematuria (1). In the diagnosis, pathological retraction ring and the “staircase” sign on fetal monitorization are also important (10,11). When, a hematoma accompanies to the uterine rupture, especially in cases in atypical ruptures with tears beneath the uter- ine serosa together with a hematoma within broad liga- ment, uterus may deviate to the opposite side. This should
Background: Placenta previa (P.P) is a rare pregnancy complication where a placenta particularly or completely covers the internal cervical os thereby preventing normal vaginal delivery. This study was conducted to evaluate the relationship between repeated cesarean deliveries and sub- sequent development of placenta previa. Methods & Materials: This cross-sectional study was held in Imam Reza Hospital Kermanshah-Iran during 2008-2011. This study included all pregnant women with repeated cesarean sections while nullipara and patients with placenta previa without previous surgery were excluded. Diagnosis was made on ultrasound and at surgery. Results: among 2696 Women, 98 cases had P.P (3.63%). The mean age was 30 years, 76.5% (75 cases) had gravidity 2 and 3 and 87.8% (86 cases) had parity 1 - 3. Anterior location of placenta was 44.9% while posterior was 55.1%. 48% were complete P.P, 32.7% low lying P.P, 13.3% marginal P.P, and 6% Partial P.P. 26.5% of patients had history of abortion. 55.1% of patients had male fetus. There was an increase in frequency of placenta previa with just one previous C-section (74.5%). Fre- quency of accreta P.P 32% (n = 7), increta (14.3%, n = 3) and percreta 28% (n = 6). Among those who underwent emergency hysterectomy (21 cases) 23.8% cases had no abnormal placentation. 30.6% of newborns had birth weight < 2500 g. Conclusion: we concluded that patients with history of one pervious cesarean delivery had more Placenta previa and need to hysterectomy were more than those with history of 2 and 3 previous cesarean delivery. The most common type of abnormal placentation was accreta, percreta and increta respectively.
of Medicine, Shanghai Jiao Tong University; Shanghai, China, comprised the patient pool of this study. The re- search protocol was approved by the ethics committee of the three hospitals above. The inclusion criteria were (i) history of previous cesarean delivery before hospitalization, (ii) first-visit ultrasonography revealing an empty uterine and cervical canal and a myometrial defect at the caesar- ean scar site that was surrounded by a rich blood supply and in which a gestational sac was embedded and (iii) be- ing immediately treated with intra-arterial MTX + UAE and followed by combined laparoscopy and hysteroscopy or curettage. The exclusion criteria were (i) receiving MTX treatment or curettage before hospitalization and/or presenting a massive uterine hemorrhage and (ii) being treated with conservative or other surgical measures, eg. intramuscular MTX, curettage, hysteroscopy, etc., as the first-line therapeutic methods. A total of 58 patients were therefore included and then divided into two cohorts (groups), i.e., 25 patients in the study group, who received intra-arterial MTX + UAE + combined laparoscopy and hysteroscopy, and 33 patients in the control group, who received intra-arterial MTX + UAE + ultrasound-guided curettage. The medical records and follow-up information of these patients were carefully and thoroughly reviewed.
However, a prospective study of 196 patients by Desalu and Afolabi in South Western Nigeria, showed con- trasting findings . In their series, elective surgery was performed for 17.3%, while 47.4% and 28.6% had urgent and emergency cesarean delivery respectively. Urgency of surgery was not documented in 6.7% of cases. Previous cesarean delivery was the commonest indication for elective procedures (47%), foetal distress for emergency (62.5%) and previous cesarean delivery in labour for urgent procedures (30.1%). The study by Desalu et al.  showed that general anaesthesia was employed in 33.2% of patients while regional anaesthesia was used in 66.8%. This is very similar to trends seen by Okafor et al. . Fifty per cent of emergency cases had general anaesthesia. Regional anaesthesia was used in 72% of urgent and 85.3% of elective procedures. The commonest regional technique was spinal anaesthesia (60.7%). Desalu et al.  concluded that the choice of anaesthesia depends on the urgency of surgery and the medical condition of the mother and that general anaesthesia was more likely to be administered for bleeding emergencies and foetal distress, while spinal anaesthesia was preferred for elective and urgent cases or when maternal disease existed.
estimate regarding the rate of elective cesarean deliveries. The Taiwan NHIS defines medical indications for cesar- ean deliveries as fetal distress, dysfunctional labor, antepartum hemorrhage, malpresentation, cord prolapse, induction failure, genital herpes, previous cesarean, prior uterine surgery, condyloma acuminata infections, treat- able fetal congenital abnormalities, pre-eclampsia, infant weight <1500 g, abnormal pelvis, infant weight >4000 g, cephalo-pelvic disproportion, obstructive delivery, com- plications resulting from major internal diseases, and other special indications . Medically indicated cesar- ean deliveries are fully covered by the NHIS, while cesar- ean deliveries without medical indication are paid for by women themselves. For cesarean delivery reimburse- ment, the NHIS reviews medical record case by case afterwards. If physician has recorded well-recognized indications for the cesarean delivery, it is highly likely that the health insurance payment will be passed. For our study, we defined cesarean delivery without medical indi- cation by indications regulated by the NHIS. Though pre- vious cesarean delivery is not a necessary medical indication for cesarean delivery, more than 95% of women opted for a cesarean section after a previous cesarean delivery in Taiwan . Therefore, we treated previous cesarean section as a medical indication. We sought to identify cesarean deliveries with or without medical indications in order to shed light on unnecessary cesarean deliveries.
In addition to medical and obstetric risk factors identi- fied from the analysis of medical records, interviews with obstetricians shed light on several provider-related drivers of CS. The analysis revealed three important fac- tors that could be contributing to the expansion in CS rates:  a convenience incentive;  lack of supervision and training;  and absence of or lack of familiarity with clinical guidelines. A little less than half of obstetri- cians confirmed a personal preference for CS. Inter- viewed physicians cited the shorter duration of a CS compared to a vaginal delivery as a reason for why CS might be favored. This combined with the ability of doc- tors to decide on the timing of the delivery make CS a more convenient option for physicians. That most CS deliveries in this study took place on a Saturday, which is the first working day of the week where most staff are available, and rarely on Friday – which is considered a holy day and a day of rest, is evidence that physicians may prefer CS owing to scheduling preferences. In com- parison, vaginal deliveries were equally likely to occur at any given day of the week.
11 Read more
This study has a few limitations. First, the sample was non-randomly drawn from only two hospitals in Zhejiang Province, and is clearly not generalizable to the rest of China, particularly less-developed areas. However, evidence shows that CD rates are decreasing in many cities where they had previously reached 50 – 70%, so the situation described in this study is probably mirrored elsewhere . Another limitation was that our inter- views focused on the woman and healthcare provider; in China, the husband and the family are also important participants in the decision-making process. Selection bias and response bias could have also been a factor; because interviews were conducted in a hospital set- ting, interviewees may have been more likely to re- spond according to doctors ’ wishes. However, given the researcher was not affiliated with the hospital, they seemed to talk candidly about their experiences. Finally, we only interviewed postpartum women, whose responses might have been affected by ex-post rationalization; further research should follow and interview women throughout their pregnancy and after delivery to better describe the process of child- birth decision-making.
12 Read more
• Class III - Thickness of lower uterine segment <3mm, had asymmetrical lower uterine segment, comparative high degree of ballooning and wedge defect. This was considered as pathologic finding. Detailed history including age, parity, gestational age, socio economic status, antenatal care during pregnancy, chief complaints and duration with special emphasis on pain at previous scar site and associated medical disorder were taken. In obstetric history number of previous delivery, abortion, type of delivery, indication of previous cesarean section was taken as per proforma attached. After ultrasonography, patients were followed up to the time of delivery whether delivered by LSCS or by vaginal route. Those delivered by LSCS were considered for final analysis.
Women with previous cesarean section (CS) constitute a high risk group in obstetrics. The present study was done to determine the mode of delivery, various indications for repeat CS, maternal and perinatal outcomes among women with previous CS. A hospital based observational study was done in Pondicherry Institute of Medical Sciences, Puducherry. All pregnant women at ≥34 weeks of gestation with history of previous one lower segment caesarean section (LSCS) and singleton pregnancy in cephalic presentation were enrolled. Study protocol was approved by Institute Ethics Committee. Taking the incidence of repeat CS as 50% among women with previous one CS, a sample size of 96 was calculated. However 103 women were enrolled. Proportions were calculated for categorical variables and chi-square test was applied for significance. Among 44 women who were given trial of labour, 18 (40.9%) delivered vaginally. Most common indication for emergency cesarean section in trial of labour group was scar tenderness (46.2%) followed by non-progress of labour (34.6%). Among women who underwent elective CS, emergency CS and VBAC, the proportion of complications was 10.3%, 8.7% and 11.1% respectively. Almost one-fourth of the newborns had complications (24.3%). 88% of them required NICU admission and 36% had some form of respiratory morbidity. Trial of labour is a reasonable option for properly selected group of pregnant women with prior one LSCS.
This review shows that in SSA, the role of CS is compli- cated. Global health leadership (WHO) has asserted that the way forward in terms of safe labor and delivery practices that reduce adverse outcomes for mothers, fetuses, and babies, is that all women should deliver in a facility with a skilled birth attendant and access to com- prehensive emergency obstetrical care . This requires education of women, families, and communities and political will from providers, healthcare systems, and governments. It requires infrastructure, training, and most of all, money. But along with recommending facil- ity delivery and the medicalization of childbirth comes a recognition of the fact that, providing quality care is the only way that obstetrics can tip the balance of the risks versus benefits of CS away from causing harm. It is up to obstetricians, their professional organizations, and global health leadership to establish evidence-based guidelines for the provision of safe CS in SSA and other LMIC. CS, the most commonly performed surgical procedure in the world, should be a high-quality life- saving technology that allows pregnant women, their offspring, and their support networks to continue to lead healthy, productive lives.
10 Read more
An important subgroup where induction of labor had a lower risk of CD in our study was women who were randomized to receive LMWH during their pregnancies. These results suggest that women receiving LMWH dur- ing pregnancy may benefit from induction of labor to re- duce the risk of CD. The strength of this subgroup analysis is that LMWH use was randomized. It is pos- sible that the group of women who received LMWH may have had closer monitoring during pregnancy com- pared to women without LMWH, which could have re- sulted in improved delivery outcomes. Details such as the timing of LMWH use during pregnancy and epidural anesthesia rates by group are unknown. LMWH during pregnancy was used in the context of a clinical trial to prevent recurrent placenta-mediated pregnancy compli- cations, so LMWH use may have been stopped days to weeks prior to labor and delivery according to the indi- vidual trial protocol. There was no difference in Table 2 Proportion of women who underwent induction of
that women who had a previous cesarean delivery could safely have a subsequent TOL and VBAC, which would lower the overall cesarean delivery rate. VBAC became a popular choice and as predicted, was effective in lowering the cesarean delivery rate. Between 1990 and 1996, the VBAC rate rose from 19.9% to 28.3% and the cesarean delivery rate dropped from 22.7% to 20.7% 3 thus ‘once a caesarean always caesarean’, espoused by Craigin in 1916, was revised in many countries and vaginal birth after cesarean section grew in popularity. 2
The chances of cesarean delivery are more in women who had already undergone cesarean section for whatever indication. Multiple cesarean sections not only increase the maternal and perinatal morbidity and mortality but also increase the work load of already overloaded health system in developing countries. The culture of “cesarean section on demand” particularly in primigravida must be curbed by obstetrician to reduce the morbidity associated with multiple cesarean sections.
Although the study was performed rigorously, there are some important limitations when interpreting our study. The analyses were performed after propensity score matching to reduce intergroup differences; never- theless, our results may still be affected by confounders that we failed to collect. We were unable to collect im- portant outcomes, such as anesthetic level during LEA and a subjective pain score. Secondly, although obstetri- cians conformed to the guidelines that strictly define the indications for assisted vaginal delivery and cesarean section, there are some differences among individual caregivers in clinical practice. A study by Goyert et al. has shown that, even in the same institution, the rate of cesarean section greatly varied (from 19% to 41%) be- tween individual obstetricians, indicating that the inter- pretation of the guidelines may vary . We chose 5% difference as clinically significant difference among groups to calculate sample size which was based on pre- vious reports. Although our result failed to show statis- tical difference of cesarean section among two groups, the tendency of increased rate was rather high in the EL
Table 2 shows that CD delivery (both emergency and elective), male gender, gestational age of 35 to 37 weeks, birth weight of # 2500 g, SGA status, and decreasing age at ﬁ rst OAE were sig- ni ﬁ cantly associated with failure on ﬁ rst OAE (univariate analyses). Con- versely, Apgar scores at 1 and 5 minutes, TTN, phototherapy and gentamicin treat- ment were not signi ﬁ cantly associated with failure on ﬁ rst OAE. Table 3 shows the adjusted ORs and 95% con ﬁ dence intervals for failure on ﬁ rst OAE by perinatal variables. Variables that were independently signi ﬁ cantly asso- ciated with failure on ﬁ rst OAE included male gender (OR 1.42 [1.02 – 1.98]), birth by CD (emergency CD: OR 3.18 [2.21 – 4.57], elective CD: OR 3.32 [2.04 – 5.42]), early age (12 – 23 hours) of ﬁ rst OAE (OR 3.1 [2.1 – 4.58]), and SGA status (OR 2.2 [1.15 – 4.28]).
Our study has some limitations. Instead of relying on timed second-look laparoscopy, we evaluated adhesions at repeat cesarean delivery. A second-look procedure especially in postpartum women is inconvenient for new mothers and their baby, but would likely yield more accurate results. Our study was only from one center. While we have large volume in our practice, these results may not be fully applicable to other institutions with different practice patterns or techniques.
Despite the fact that, in 1384, granted farahani, in their study, the use of modern techniques and supportive care, midwifery and emotional needs of each woman’s individual medical centers had recommended to the delivery of the interventions caesarean section and the tool is reduced but still in treatment centers, we see conventional obstetric care more than we are already.
Finally, the administrative data used to assess provider- level cesarean rate was restricted to the provider listed on the birth certificate and subject to errors of attribution. For example, the provider listed as “Delivering Clinician” on the Birth Certificate is usually but not always the person that managed the majority of a patient’s labor or made the decision to go to cesarean. Unfortunately, this method discounts information about providers who do not carry cesarean privileges but may play a major role in intrapar- tum care, and may be key decision-makers along the route that ends in either cesarean or vaginal delivery. For example, a provider may decide to admit a patient prior to the onset of active labor or use continuous electronic fetal monitoring despite a patient’ s low-risk status, both of which increase the likelihood of that patient requiring a cesarean, yet the cesarean birth would be attributed to the clinician who performed the surgery itself and not the provider man- aging the labor. Further studies are needed to assess the interplay of personnel on labor and delivery wards, how key decisions are made and birth outcomes attributed.
Previous studies have reported Cesarean delivery as a risk factor for PND, 10,11 however limited evidence is available on the pre-operative factors during Cesarean delivery that is associated with PND. 9 To our best knowl- edge, this is the ﬁ rst study looking into analgesic and psychological factors to generate an association model in PND after Cesarean delivery. There are several limitations in this study. The study was conducted in a study popula- tion with Chinese being the major ethnicity, and hence may not provide wider spectrum of information in other ethnicities. Other confounding factors such as the history of depression and mental illness, intraoperative and post- operative factors (endocrine hormone levels, infection, fever, etc.) as well as socioeconomic factors (education, income, occupation) were not collected that could be used for adjustments. We did not determine whether pre- existing pain, not due to any disease, was present in patients before the delivery, and it is conceivable that patients classi ﬁ ed in this study as PND could have prior pain problems and a heightened fear-avoidance status of childbirth and surgery. The ﬁ ndings reported herein are limited only to women undergoing elective Cesarean delivery in our institution. Patients who went for emer- gency Cesarean delivery may have a higher prevalence of PND as compared with elective Cesarean delivery, 34 as the psychological and pain pro ﬁ le before delivery would be different from the present study. Finally, we utilized EPDS
13 Read more