Intra-abdominal adhesions: vaginal or abdominal delivery?

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We read Herzberger et al.’s article regarding intra-abdominal adhesions [1], and the subsequent comment [2] and reply [3] with great interest. Adhesions can result from a cesarean section (CS) and seem to be greatly influenced by individual factors [1]. Patients who form adhesions are likely to have more adhesions at a subsequent operation. This fits my clinical impression based on a four decadelong obstetric practice. If adhesions are anticipated before CS, obstetricians can prepare for it, exercising greater caution and deployment of more experienced obstetricians. Does the anticipation of severe adhesions influence not only the preparation for CS but also the mode of delivery itself (vaginal or abdominal)? For the sake of discussion, let us assume a particular patient who underwent adhesiolysis for endometriosis and also was abdominally delivered due to a breech presentation, when severe intra-abdominal adhesions were noted. In a second pregnancy, with a head presentation, ultrasound indicates a placental-edge cord-insertion, with a risk of intrapartum non-reassuring fetal status (NRFS). Which is better for this patient and her baby, a trial of labor or a planned CS? The question is whether adhesions favor ‘‘vaginal’’ over ‘‘abdominal’’ delivery, or vice versa. Of course, the answer may depend on the patient’s desire and also on the situation at the particular hospital. The experience of the staff and their availability may influence the type of delivery that is best for this patient. For simplicity, we here do not take the effect of CS on the next pregnancy into consideration. In our view, many, or at least not a small percentage of obstetricians, may answer, ‘‘A trial of labor may be better because severe adhesions may be present at this second CS’’. If a vaginal delivery was performed, one would never encounter severe adhesions because abdomen had not been opened. Thus, a trial of labor may be a good choice in this situation. However, if NRFS occurred during the night, an emergent CS is obviously needed. In some institutions, a relatively less experienced practitioner (compared with those available during daytime) may have to perform an emergent CS in the presence of severe adhesions. All the bad outcomes, i.e., long-time to infant delivery, bladder injury, large amount of blood loss, are more likely to occur. We fundamentally believe that adhesions favor a planned CS over a trial of labor. As the likelihood of severe adhesions increases, we are more likely to employ a planned CS. We necessarily encounter severe adhesions because we open the abdomen. However, experienced clinicians who are available during the daytime can manage this situation. There is an analogous situation, which occurs in anesthesia practice, with a patient for whom intubation is expected to be difficult. The decision is whether to perform general anesthesia with endotracheal intubation or regional anesthesia. In the case of massive bleeding or hemodynamic instability during the operation, intubation may be This comment refers to the article available at doi:10.1007/s00404015-3718-x.