Previous Cesarean Section

Results: Of the 15664 women with a previous cesarean section, 5399 (34.5%) women underwent elective repeat cesarean section, 7752 (49.5%) women who underwent emergency repeat cesarean section and 2513 (16.0%) had successful trial of labor (S-TOL). There was failed trial of labor (F-TOL) in 1522 cases and requiring an emergency cesarean section for delivery of baby. Therefore, total no. of 7752 women had an emergency cesarean section. The overall maternal morbidity was 22.5%, 20.7% in Em-RCS and El-RCS respectively. Blood loss was more than 1000ml in 7.2% of Em-RCS where as in El-RCS it was 8.8%, blood transfusion was 7.5% in Em-RCS where as it was 6.5% in El-RCS, dehiscence of scar in Em-RCS was 4.7% as compared to 2.2% in El-RCS, uterine rupture was 1.2% in Em-RCS as compared to 0.7 % in El-RCS found statistically significant. Post-operative complication was 5.9% cases in Em-RCS where as in El-RCS was 5.8% (p=0.79 non-significant). Maternal mortality was reported in 12 (0.2%) cases of Em-RCS as compared to 5 (0.1%) cases in El-RCS (p=0.37) which was not statistically significant. Conclusions: Maternal morbidity was found more in emergency repeat cesarean section than in elective repeat cesarean section. Complications and referral of women who are likely to undergo cesarean section should be diagnosed at an early stage so that the maternal morbidity and mortality can be prevented.

In Saudi Arabia, the current preference is for higher parity.The mean family size of household respondents from Saudi Arabia was 6.53 members [5]. So, emphasis is highly put on avoiding repeated Cesarean deliveries. Multiple Cesarean sections has been shown to be asso- ciated with higher maternal morbidity and mortality. The overall morbidity rises continually with each suc- cessive Cesarean section specifically for major mor- bidity from the triad of placenta previa, placenta ac- creta and hysterectomy [6]. Decreasing the primary Cesarean section is important as well as increasing the uptake of VBAC. The problem arises when the preg- nant women with prior Cesarean section do not go into spontaneous labor and the need for induction arises. It has been shown that augmentation of labor in women with previous Cesarean section is safe when oxytocin is used judiciously [7]. There is less convincing evidence for the use of prostaglandin for induction of labor (IOL) in these women.

Data collection was achieved using a proforma. Data obtained included bio data, sociodemographic characteristics, details of the previous Cesarean section, mode of delivery, outcome, and possible complications of each delivery. All women included in the study were followed through delivery and for at least 48 hours after delivery. Information was sought directly from the women and recorded in a proforma. The main outcome measure was the delivery outcome in the index pregnancy. Secondary outcome measures included perinatal complications and maternal complications as well. Each labor was monitored closely using a partogram and regular auscultation of the fetal heart at least once every 30 minutes. For the single case of induction of labor, cervical ripening was done by intra cervical catheter and the entire process of induction was physically monitored by a senior obstetrician.

A 35-year-old woman, gravida 2, with a previous cesarean section for eclampsia in 2003, was admitted to our department for cervical pregnancy at 6 weeks and 1 day of gestation. At the admission, the blood count was red cell 4.95×10 6 /µL, hemoglobin (Hb) 13.60 g/dl, and white cell 6.46×10 3 /µL. The patient underwent to transvaginal ultra- sound that showed a retroverse enlarged uterus and a gestational sac with a single 3 mm embryo with heart activity at the level of the cervical canal. Adnexals were normal. An intramural posterior myoma of 1.2 cm was detected (Fig. 1).

The collected data were organized, tabulated and statistically analyzed using SPSS software (Statistical Package for the Social Sciences, version 19, SPSS Inc. Chicago, IL, USA). For quantitative data, the range, mean and standard deviation were calculated and the Shapiro-Wilk test for normality was performed. For normally distributed data, values were expressed as mean ± standard deviation and Independent samples T test was performed for comparison between two groups. For data that were not normally distributed median and interquartile range (expressed as 25th-75th percentiles) were calculated and Mann-Whitney test was used, for qualitative data, which describe a categorical set of data by frequency, percentage or proportion of each category, comparison between two groups and more was done using Chi-square test (2), Fisher's exact or Fisher-Freeman-Halton exact tests. For comparison between more than two means of parametric data, F value of ANOVA (analysis of variances) test was calculated. Correlation between variables was evaluated using Spearman correlation coefficient (r). Logistic regression was used to conclude the variables that can be utilized to devise the score which predict intra-abdominal adhesions and its degree among pregnant women with history of previous cesarean section. The Receiver Operating Characteristic (ROC) curve was done, to detect the area under the curve which reflects the sensitivity of abdominal striae gravidarum degrees in diagnosis of intra- abdominal adhesions and its degree among patients, and was carried out to test the discrimination power of the devised score to predict intra-abdominal adhesions in pregnant patients, significance was adopted at p<0.05 for interpretation of results of tests of significance (Dawson, 2001).

omen with previous cesarean section (CS) constitute a high risk group in obstetrics. Vaginal birth after cesarean (VBAC) is the practice of delivering a baby vaginally after a previous baby has been delivered through cesarean section. VBAC was a common practice in 1980 and 1990s in several countries but it suffered a major setback after publication of the study by Mc Mohan which concluded that repeat CS was associated with less maternal complications than VBAC. 1 Since last two decades the number of VBACs has declined, contributing to the overall increase in cesarean delivery. 2,3 In India, the cesarean section rate has increased to 10.6%; an increase of 7.7% during last 10 years. 4 Similarly, in Tamil Nadu state of India, the current cesarean section rate is 23% (an increase of 15.9% in last 10 years). 4 This rising trend in cesarean section is mainly because of repeat CS that are being performed. 5

Background: With an aim to reduce the rates of repeat cesarean section in women with a previous scar, prediction of scar rupture or dehiscence is important. If we could predict the risk of rupture by measuring the scar thickness closer to term, we could pursue a trial of scar safely. Aims: To evaluate the use of ultrasound measured thickness of lower uterine segment as one of the predic- tors of scar rupture or dehiscence in labour and establish a cut off beyond which trial of labour can be attempted safely. Methodology: 187 randomly selected pregnant women with history of one previous cesarean section in the past who satisfied the inclusion criteria, attending the outpatient clinic over a period of six months, at a tertiary level teaching institution in southern India were selected and counseled to undergo a transvaginal measurement of the scar region. These women were then followed up until delivery and the outcome of trial of scar, successful vaginal delivery, rupture or dehiscence of uterus was analysed in relation to the scar thickness and various other contributing factors. Results: 187 women with history of previous cesarean section, attending the outpatient clinic were randomly chosen to undergo trans vaginal scan at term. 52 underwent elec- tive cesarean section and 135 went through trial of scar. The median cut-off of the lower uterine segment in this study population of 135 was 2.4 mm. The sensitivity was 90.9%, specificity was 43.5%, positive predictive value was 12.5%, and negative predictive value was 98.3% at this cut- off for scar rupture or dehiscence. Conclusions: The lower uterine scar thickness could be a useful tool to predict scar rupture. This could aid in making decisions regarding induction of labour with oxytocin in women with previous cesarean section.

Results: Out of 215 studied cases majority of the patients belonged to age group of 21-30 years (75.35%) and were 2nd gravida (61.86%). 164 (76.28%) patients attended ANC OPD at least for 3 times during pregnancy. 73 (33.95%) patients had Hb of less than 10 gms while blood transfusion was required to be given in 11 (5.12%) patients. cesarean section was required in 172 (80%) patients out of which 166 (77.21%) patients had undergone emergency LSCS while in 6 (2.79%) patients elective LSCS was done. Scar tenderness was the most common indication for repeat cesarean section. There was no maternal mortality in any patients while there was 1 still birth and 1 neonatal death. Conclusions: Previous cesarean section is one of the important causes of CS in subsequent pregnancies hence decision of doing CS, especially primigravida, must be taken in accordance with strict guidelines and the practice of “cesarean section on demand” should be discouraged.

Abstract Total laparoscopic hysterectomy (TLH) in the presence of patients with previous cesarean section (CS) is becoming increasingly common. When performing TLH in these patients, bladder adhesions to the uterus may make dissection much more difficult with higher complication rates. The aim of this study was to assess the safety of TLH in patients with previous CS in an OBGYN residence program. Retrospective study of all TLH performed at our center for either benign or malignant conditions. Of our study cohort, 40 % had undergone one or more previous CS. Average sur- gical time was 128 min for patients without previous CS and 136 min for patients with previous CS (p = NS). Conversion to laparotomy was required in 1 % of cases showing no variation between the CS and non-CS groups. The overall complication rate among patients undergoing TLH was 3.5 %. Major com- plication rate was of 3 % (n=14), 5 cases with previous CS and 9 cases with no previous CS (p = NS). Urologic lesion was the most common major complication, accounting for 1.5 % (n=7) of all cases, 3 cases with previous CS and 4 with no previous CS (p = NS). Of urologic complications, three were cystotomies, 1 with no previous CS and 2 with previous CS (p = NS). TLH in patients with 1 or more previous CS is technically feasible. In the hands of thoroughly trained lapa- roscopic surgeons using a standardized technique, it is a safe procedure with minimal complication rates and may be even performed by OBGYN residents ensuring the same success rates.

subsequent pregnancies indicated that pregnancy following previous CS was associated with higher risks of placenta previa (OR=1.74, 95% CI=1.62 – 1.87), morbidly adherent pla- centa (OR=2.95, 95% CI=1.32 – 6.60), placental abruption (OR=1.38, 95% CI=1.27 – 1.49), miscarriage (OR=1.17, 95% CI=1.03 – 1.32) and stillbirth (OR=1.27, 95% CI=1.15 – 1.40). 38 Postoperative adhesions play a central role for an increased risk of adjacent organ injury during subsequent operations. Adhesions can distort normal anatomy of organs that are in close surgical proximity to operation fi elds. Intraperitoneal adhesions form in ~ 25 – 45% after a fi rst CS and they increase with the increasing number of CS. 39 As would be anticipated, a previous CS is associated with a signi fi cantly higher risk of injury to urinary and gastrointestinal tracts during a repeat CS. 39,40 Intraperitoneal adhesion can prolong operative time in a subsequent surgery, which can result in higher periopera- tive morbidities. A recent cohort study assessing 6,507 repeated CS noted that women undergoing a repeated CS who experienced prolonged operative time carried higher risks of post-operative blood transfusion (4.4% vs 1.5%), prolonged hospitalization (8.4% vs 4.0%), postoperative infection (2% vs 1%), and readmission (1.8% vs 0.8%) when compared to those who did not repeat a CS. 41

Background: The rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia. Methods: This retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS.

As a complementary and safe noninvasive imaging modal- ity during pregnancy, MRI is a highly interesting approach but not yet sufficiently investigated [11–14]. With our recent scientific results we demonstrated MRI to be an adequate additional noninvasive image modality for prenatal LUS diagnostics in patients with previous CS. Because of the dif- ferent technique and the associated advantages and disad- vantages MRI might be a useful additive diagnostic tool when ultrasound conditions are limited [15, 16]. We further- more believe that MRI as a different imaging approach with- out the requirement of an adequate acoustic window also holds the potential of providing new insights and offers the possibility of finding a more reliable diagnostic algorithm. A comparison of LUS findings and thickness between pregnant women with and without previous CS in MRI has never been done before. To improve the distinction of pathologic and normal findings, we sought to study whether there are specific morphologic signs in patients with a scarred uterus compared to those without a scar which might be useful for future risk stratification. Because an LUS thinning is normal merely by the growing pregnancy we compared the LUS thickness of patients with and without CS. Thereby we

A recent randomised controlled trial in 12 hospitals in the Netherlands enrolling women with a term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix, an indication for induction of lab- our, and no prior caesarean section. 824 were randomly allocated to induction of labor with a 30 mL Foley catheter or vaginal prostaglandin E2 gel. A meta-analysis including the trial data confirmed that a Foley catheter did not reduce caesarean section rates. However two se- rious maternal adverse events recorded, both in the pros- taglandin group: one uterine perforation and one uterine rupture. Caesarean section rates were much the same between the two groups (23% vs 20%, risk ratio [RR] 1.13, 95% CI 0.87 - 1.47) [24].

The use of medical and surgical procedures like internal iliac artery ligation, use of internal iliac Artery Balloon Catheter inserted pre operatively as well as Bakry Balloon intra operatively, this in addition to the use of misoprostol, carboprost(hemabate) and Recombinant Factor V11, all of which helped to reduce morbidity and mortality from bleeding and the need for admission to surgical intensive care unit. Further the use of prophylactic antibiotics helped to reduce both wound and urinary tract infection. A unique observation noted in our study group is that 23.5% of babies delivered were with low birth weight (<2499) in comparison to (13.7%) of babies in lower order repeat caesarean section group, this observation was not noted in other series, this may probably be due to increase in ibrosis of uterine wall and/or interference with blood supply to uterus and placenta with repeat caesarean section. [7] advocated delivery of babies by 39 weeks to avoid neonatal illnesses like Respiratory Distress Syndrome, newborn sepsis, seizures, necrotizing enterocolitis, hypoxic ischemic encephalopathy, reduced umbilical cord arterial PH of <7.0, low Apgar score, as well the need for ventilator support within 24 hours of birth. This last fact may explain the high incidence of admission to Neonatal Intensive Care Unit of (27.2%) of cases in our studied group, because caesarean sections were done between 37 and 38 weeks of pregnancy for fear of starting spontaneous uterine contractions and ending in ruptured uterus hence rendering adherence to Kainu et al recommendation non applicable, but at the higher cost of admission to Neonatal Intensive Care Unit. Although [5] is aware of the modi ied dictums of Craigin mentioned previously about repeat caesarean sections, yet the author believes that good supervision the patient can have no limits to delivery by caesarean sections and as much as they wish. This in addition to [2,3] where the conclusion was that higher order caesarean sections do not pose more on the mother and baby than that normally encountered with lower order caesarean sections. This conclusion should be guarded and considered with care, in future, after the data presented in our study where the patients should not be left to go with the redundant and false feeling of reduced injury and easy delivery in future pregnancies without short and long term complications and should be counseled about that.

This observational study was undertaken in the department of obstetrics and gynaecology for a period of one year and six months in collaboration with department of paediatrics, anaesthesia and critical care unit. Authors have blood bank facility, HDU and neonatal intensive care unit in present hospital. Authors have considered women for VBAC trial who went into spontaneous labor at term with cervical dilatation of 4 cm or above and outcome of both mother and baby were noted. Women were counselled nearing at term for intended VBAC trial. Inclusion criteria were single live fetus at term with previous one cesarean section and on admission who has no evidence of scar tenderness, cephalic presentation and in active stage of labor likely to deliver vaginally. Exclusion criteria were gestational age <37 weeks and ≥42 weeks, ≥2 previous cesarean section, intra uterine fetal death, history of rupture uterus, multiple uterine surgery, classical cesarean section, primary indication of cesarean section was placenta previa and contracted pelvis and other contraindication for vaginal delivery and who are not willing to participate in the study and not giving consent. On admission detailed information regarding antenatal check-up, age, parity, literacy, socio economic status was noted. Clinical, abdominal and pelvic examination were done. Antenatal investigations like ABO grouping and RH typing, complete hemogram, blood sugar, VDRL, hepatitis B surface antigen, human immunodeficiency virus rapid test, routine and microscopic examination of urine and ultrasonography for feto-placenta profile were noted. A total of 277 pregnant women at term who fulfil the study criteria and

The objective is the reduction of cesarean sections in primigravidae and the incentive to those pregnant women fit for VBAC, modifying the thought that "once cesarean section always cesarean" (Zaitoun et al., 2013; Chhabra et al., 2006; Madi et al., 2013). At the study site, it is common to indicate a new cesarean section in pregnant women who have two or more previous cesarean sections and in those with a previous cesarean section performed less than two years ago. Current evidence suggests that VBAC should be encouraged for all pregnant women with previous cesarean section longer than 15 months, with at most two previous cesarean sections, absence of traditional contraindications to labor or normal delivery, and adequate maternal pelvis on physical examination (Secretaria de Atenção à Saúde, 2016; American College of Obstetricians and Gynecologists 2010). The frequency of VBAC varies globally. In European countries it is between 29.0% and 55.0%, in the United States and Australia approximately 36.0% and in the United Kingdom 26.0%, rates higher than that found in this study (17.7%), (England NMS-. Hospital Episode Statistics, 2015; Schemann et al., 2015; Alexander et al., 2008). Part of this statistical divergence is due to the variability of the election criteria to consider pregnant women fit to VBAC, who depend on the study site, the protocols of each service, the local physical and socioeconomic structure, factors that limit the comparison of the data. Data from the United States indicate that more than 90.0% of pregnant women with a previous cesarean section were admitted to elective cesarean section.

2002-2003, showed that 44% of all parturitions were performed through cesarean section that 74% of them was emergency and 26% was selective. The most common reasons for emergency cesarean section were fetal distress (30.2 %), previous cesarean section (22.1 %) and lack of progression of parturition (20.6 %) and in elective cesarean section: previous cesarean section (43.3%), narrow pelvis (20%), hazardous pregnancy (7.7%) non-appearance of the fetal head (6%). The relative frequency of cesarean section in hospitals of Shahrekord ,Social Security, Broujen, Farsan, and Lordegan was respectively 46%, 60%, 39%, 39%, 39%,and 28%. [14] It has been reported that the incidence of cesarean section among 6 hospitals in the city of Tabriz in 2004-2005 was 45.6% [15] and in Birjand was 40.3%. The cause of 45.8% of performed cesarean sections was due to previous cesarean section, tubal ligation and patients’ request, 40% due to the lack of progress of parturition, cephalo-pelvic disproportion, narrow pelvis, placenta previa, twin birth and eclampsia and 14.2% due to fetal distress and mekonial. [1] In a study performed in 2007, the number of cesarean sections performed in Ahwaz Imam Khomeini Hospital and Alhadi Hospital were up to 23% and 33%, respectively. [16] The primary purpose of the cesarean section was saving the lives of mothers who were in danger of death due to the cessation of parturition process. But during next years, indications of its performing were expanded and encompassed man other parturitions during which mother’s and fetus’s lives were at risk due to various reasons. Increased safety of this method, mainly is due to advances in surgical techniques, improvement of anesthesia conditions, effective antibiotics, and the possibility of blood transfusion. Obstetricians after

due date or earlier (if they went into spontaneous labor before expected date). Those who did not go into spontaneous labour after completion of 41 weeks were induced with Foleys Catheter, Progress of labor was recorded on a ‘WHO’ partogram. Attempt at vaginal delivery was abandoned if there was any suspicion of scar dehiscence or sign of fetal distress or unsatisfactory progress of labour and repeat cesarean section was undertaken. The outcome of vaginal birth after a previous cesarean section, maternal and neonate’s details were recorded after delivery till the time of discharge from the hospital.

This prospective observational study was conducted in the department of obstetrics and gynaecology for a period of one year and six months in collaboration with department of neonatology and anaesthesia. Inclusion criteria were all women at term with one previous cesarean section admitted through OPD or emergency for planned or emergency cesarean section with written informed consent. Exclusion criteria were gestational age <37 weeks and ≥42 weeks, ≥2 previous cesarean section, VBAC trial women, ruptured uterus cases and those women who are not willing to participate in the study. After admission, detailed information regarding indication of previous cesarean section, type of cesarean section, size of the fetus, duration of labor were noted. Careful history of antenatal check-ups till admission of the present pregnancy was noted with age, parity, socio- economic status etc. Clinical examination including general, abdominal and pelvic examination were done with routine investigations like complete haemogram, ABO grouping and RH typing, blood sugar, VDRL, hepatitis B surface antigen, HIV rapid test, urine examination and ultrasonography for feto-placenta profile were noted. A total of 1003 pregnant women at term who fulfil the study criteria and gave consent were included in the study. Blood was arranged after proper grouping and cross matching. During post-partum period the condition of the mother and baby were observed. An ethical clearance has been taken from the institutional ethical committee. After completion of the study all the data were entered in MS Excel 2007 software and analysis was done for statistical purpose, where p<0.05 was taken as statistically significant. In some cells, values are <5; thus, yate’s correction is done. Chi-squared test was used where it is appropriate.

The effect of IV oxytocin is rapid following administration. The individual response to oxytocin can vary considerably, and administration is usually increased slowly and incrementally. Hyperstimulation of the uterus, which can result from oxytocin augmentation, can place the fetus at risk for asphyxia. Hyperstimulation is defined as more than five contractions in 10 minutes, contractions lasting longer than 60 seconds, and increased uterine tonus either with or without significant decrease in FHR. Uterine rupture has also been linked to oxytocin administration, particularly for periods longer than four hours. Oxytocin has a small antidiuretic effect that is usually dose related and that can lead to water intoxication (hyponatremia). Onset occurs gradually and may go unnoticed. Signs may include reduced urine output, confusion, nausea, convulsions, and coma. Mothers receiving oxytocin need to have their blood pressure monitored closely, as both hypotension and hypertension can occur, and—although the subject remains controversial—evidence suggests oxytocin increases the incidence of neonatal jaundice.Although oxytocin may put women with a classical cesarian section scar from a prior delivery at increased risk of uterine rupture, contraindications to the use of the drug are virtually the same as contraindications for labor. Other side effects of oxytocin include nausea, vomiting, cardiac arrhythmias, and fetal bradycardia. When used judiciously, oxytocin is a very effective medication for the progression of labor.