Increase In Caesarean Section Rate Research Articles

Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: a quasi-experimental, pre- vs. post-intervention study

BackgroundTanzania has a relatively high maternal mortality ratio of 410 per 100,000 live births. Severe postpartum hemorrhage (PPH) is a major cause of maternal deaths, but in most cases, it is preventable. However, most pregnant women that develop PPH, have no known risk factors. Therefore, preventive measures must be offered to all pregnant women.This study investigated the effects of multi-professional, scenario-based training on the prevention and management of PPH at a Tanzanian zonal consultant hospital. We hypothesized that scenario-based training could contribute to improved competence on PPH-management, which would result in improved team efficiency and patient outcome.MethodsThis quasi-experimental, pre-vs. post-interventional study involved on-site multi-professional, scenario-based PPH training, conducted in a two-week period in October 2013 and another 2 weeks in November 2014. Training teams included nurses, midwives, doctors, and medical attendants in the Department of Obstetrics and Gynecology. After technical skill training on the birthing simulator MamaNatalie®, the teams practiced in realistic scenarios on PPH. Each scenario was followed by debriefing and repeated scenario. Afterwards, the group swapped roles and the observers became the participants.To evaluate the effects of training, we measured patient outcomes by determining blood transfusion rates. Patient data were collected by randomly sampling Medical birth registry files from the pre-training and post-training study periods (n = 1667 and 1641 files, respectively). Data were analyzed with the Chi-square test, Mann-Whitney U-test, and binary logistic regression.ResultsThe random patient samples (n = 3308) showed that, compared to pre-training, post-training patients had a 47% drop in whole blood transfusion rates and significant increases in cesarean section rates, birth weights, and vacuum deliveries. The logistic regression analysis showed that transfusion rates were significantly associated with the time period (pre- vs. post-training), cesarean section, patients tranferred from other hospitals, maternal age, and female genital mutilation and cutting.ConclusionsWe found that multi-professional, scenario-based training was associated with a significant, 47% reduction in whole blood transfusion rates. These results suggested that training that included all levels of maternity staff, repeated sessions with realistic scenarios, and debriefing may have contributed to reduced blood transfusion rates in this high-risk maternity setting.

Perinatal Outcome in Multiple versus Singleton Pregnancies in Neonates Born in Fatemieh Hospital of Hamadan, Iran

Background: Multiple pregnancies are responsible for the increased risk of maternal and neonatal morbidity and mortality. This study aimed to compare the perinatal outcome between multiple and singleton pregnancies. Materials and Methods: This is a retrospective cohort study. A sample of 50 multiple birth neonates- born in Fatemieh Hospital of Hamadan, Iran in 2015- was selected using simple random sampling. Meanwhile, they were compared with 50 single birth neonates in the same center on gender, gestational age, mean birth weight, Apgar score, the use of Assisted Reproductive Techniques (ART), delivery method, cause of neonatal admission, duration and short outcome of neonatal hospitalization. The data were collected from the medical files of neonates and their mothers. The data were analyses using SPSS version 16.0 software. Results: In this study, 100 neonates (50 single births and 50 multiple births) were compared. The mean gestational age and mean birth weight of multiple births were lower than that of single births (P 0.05). A significant difference was found on the frequency of in vitro fertilization (IVF) method, rate of cesarean section and preterm delivery (P<0.05). Conclusion: In this study, multiple pregnancies were associated with maternal complications including preterm delivery and the increased cesarean section rate, and neonatal complications such as low birth weight, prematurity and increased rate of neonatal hospitalization that increases risk of perinatal morbidity and mortality.

Prevalence of and risk factors associated with cesarean section in Lebanon - A retrospective study based on a sample of 29,270 women.

During the last decades, there has been an alarming and dramatic increase in the number of cesarean births in both developed and undeveloped countries. This increase has not been clinically justified but, nevertheless, has raised an important number of issues. The aim of this study was to determine the risk factors associated with the high cesarean section rates in Lebanon. This study is based on a sample of 29,270 Lebanese women who were pregnant between 2000 and 2015. Among these, 14,327 gave birth by cesarean section and 14,943 gave birth vaginally. To identify the risk factors of cesarean section, logistic regression was applied as a statistical method using the SPSS statistical package. Of the 29,270 pregnant women included in the study, 49% had cesarean sections while 51% gave birth vaginally. Repeat cesarean section accounted for 23% while vaginal birth after cesarean accounted for only 0.2% of deliveries. In addition, weekdays were associated with a preference of providers to carry out more cesarean sections. According to an analysis of our data using logistic regression, the risk factors associated with the increase in cesarean section rates were advanced maternal age, elective cesarean section, malpresentation of fetus, multiple birth, prolonged pregnancy, prolonged labor, and fetal distress. Based on these results, it is recommended that a new health policy be implemented to reduce the number of unnecessary cesarean deliveries in Lebanon.

Cook Cervical Ripening Balloon successfully prevents excessive hemorrhage combined with ultrasound-guided suction curettage in the treatment of cesarean scar pregnancy.

Cesarean scar pregnancy (CSP) is a rare occurrence of ectopic pregnancy. CSP incidence has increased significantly as a result of the increase in cesarean section rates. At present, there are no standard treatment guidelines for CSP; therefore, we report a minimally invasive treatment method for patients diagnosed with CSP. This study included 15 women who were diagnosed with CSP. Ultrasound-guided suction curettage was performed on all patients. The Cook Cervical Ripening Balloon was used to tamponade and prevent hemorrhage during the procedure. In 12 patients, the balloon was placed immediately following ultrasound-guided suction curettage; in two patients, the balloon was placed when excessive bleeding occurred post-curettage; and in one patient, the balloon was placed after the gestational sac evacuated by itself, and then suction aspiration was performed on day 5, following the evacuation. Human chorionic gonadotropin levels were evaluated three days after the procedure. Placement and inflation of the Cook Cervical Ripening Balloon was well tolerated by all patients. The balloon tamponade effectively reduced or prevented vaginal bleeding in all patients, and none of the patients had an estimated blood loss higher than 1000 ml. Ultrasound-guided suction curettage is effective in the treatment of CSP. The Cook Cervical Ripening Balloon is easy to place and inflate and successfully prevented bleeding or assisted in the management of bleeding complications. We recommend the Cook Cervical Ripening Balloon as an adjuvant method for ultrasound-guided suction curettage for the treatment of CSP.

An analysis of variations of indications and maternal-fetal prognosis for caesarean section in a tertiary hospital of Beijing: A population-based retrospective cohort study.

In recent decades, we have observed a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries, especially in China. According to the World Health Organization (WHO) systematic review, if the increase in CS rate was between 10% and 15%, the maternal and neonatal mortality was decreased. However, above this level, increasing the rate of CS is no longer associated with reduced mortality. To date, no consensus has been reached on the main factors driving the cesarean epidemic. To reduce the progressively increasing rate of CS, we should find indications for the increasing CS rate. The aim of our study was to estimate the change of CS rate of Beijing Obstetrics and Gynecology Hospital and to find the variation of the indications.From January 1995 to December 2014, the CS rate of Beijing Obstetrics and Gynecology Hospital was analyzed. For our analysis, we selected 14,642 and 16,335 deliveries respectively that occurred during the year 2011 and 2014, to analyze the difference of indications, excluding incomplete data and miscarriages or termination of pregnancy before 28 weeks of gestation because of fatal malformations, intrauterine death, or other reasons.The average CS rate during the past 20 years was 51.15%. The highest caesarean delivery rate was 60.69% in 2002; however, the caesarean delivery rate declined to 34.53% in 2014. The obviously different indications were caesarean delivery on maternal request and previous CS delivery. The rate of CS due to maternal request in 2014 was decreased by 8.16% compared with the year 2011. However, the percentage of pregnancy women with a previous CS delivery increased from 9.61% to 20.42% in 3 years. Along with the decline of CS rate, the perinatal mortality and the rate of neonatal asphyxia decreased in 2014 compared with that in 2011.After a series of measures, the CS rate declined indeed. Compared with 2011, the perinatal mortality and the rate of neonatal asphyxia decreased in 2014. Caesarean delivery on maternal request (CDMR) cannot improve the maternal-fetal prognosis compared with the spontaneous vaginal delivery. With the releasing of China's 2 children policy, more CS will be implemented due to previous CS. There is a need for further research that evaluates interventions for increasing VBAC rates that target clinicians.

Postcesarean wound infection: prevalence, impact, prevention, and management challenges.

Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.

Twin birth - planned vaginal delivery still standard of care.

Commentary on: Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph KS, Mason D, Ohlsson A, Ross S, Sanchez JJ, Asztalos EV. Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369: 1295–305. In this unique international effort to find evidence for the optimal mode of delivery for twins, planned Caesarean section did not reduce the risk for perinatal death or serious neonatal morbidity as compared to vaginal delivery 1. As pointed out by the authors, this finding may in part be explained by the high rate of Caesarean section (>40) in the planned-vaginal-delivery group, with most of these deliveries occurring during labour. Nevertheless, the design, the size of the study and high follow-up rate suggest that the findings are robust. Why is this knowledge important to neonatologists? Mainly, because the neonatologist is an important participant in counselling of women (and their partners) having twins, as well as in discussions with the obstetricians responsible for the delivery. With expectations of being the expert advisor acting in ‘the best interest of the baby’, the professional role of the neonatologist is to provide and discuss the safest mode of delivery. In this context, the study by Barrett et al. is central. The Twin Birth Study is also reassuring for those who try to challenge the ongoing increase in Caesarean section rates, not only for twin births 2 but also in general 3. Today, Caesarean section is the most common surgical procedure in women of reproductive ages and in many large countries and hospitals, Caesarean section rates exceed 50% by far. Besides the Twin Birth Study and the Term Breech Trial 4, there is a very weak evidence base for Caesarean section outside the emergency situation. For example, there is no randomized controlled trial testing Caesarean section for preterm birth; still, Caesarean section is often recommended for deliveries occurring before term. Given that half of the infants in the Twin Birth Study were born at 32–36 weeks of gestation, there seems to be little evidence for improved outcome after planned Caesarean section in moderately preterm infants. On the contrary, the opposite may be the case as suggested by observational data 5, 6. In this study, only short-term maternal and infant outcomes were compared. Epidemiological studies have reported associations between birth by Caesarean section and later health problems, such as increased risk for chronic immune disorders 7. While the underlying pathways for these associations are still obscure 8, it seems important that further long-term follow-up of participants in the Twin Birth Study will take place. https://ebneo.org/2015/04/twin-birth-planned-vaginal-delivery-still-standard-of-care/ None. None.

Cesarean section in Ahmadu Bello University Teaching Hospital Zaria, Nigeria: A five-year appraisal

Objective : In 1985, the WHO recommended an optimum Cesarean section (CS) rate of 10–15% and stated that there was no justification for any region to have higher rates. The global increase in CS rate is causing concern and it is a major public health issue. Our objective is to appraise the CS intervention, observe trend, and proffer solutions. Materials and Methods : All relevant clinical data from the patients delivery records in Ahmadu Bello University Teaching Hospital (ABUTH) Zaria over the period 2010–2014 were pooled and used to analyze the clinical information. Results : There were a total of 9,388 deliveries during the period out of which 2,254 were CS, giving a rate of 24.5%. The mean age and parity of the study groups were 30.6 ± 4.8 years and 1.9 ± 1.6, respectively. A total of 288 (12%) of them were done as elective. Most of the CS was done due to previous scar, pre‑eclamsia/eclampsia. The maternal mortality rate (MMR) during this period was 870/100000 live births, the CS‑related mortality was 339/100,000, and the perinatal mortality (PM) was 43.9/1000 live births. Conclusion : The CS rate, the MMR, and PM are all high and the indications show that alternative interventions can be used to reverse the ugly trend but there is a need for training. Key words : Cesarean section; rate; maternal mortality; perinatal mortality; indications; trend and training.

As invited Speaker I send my Abstract Non-tubal ectopic pregnancies

Nontubal ectopic pregnancies comprise pregnancies implanted at sites other than the fallopian tube. These ectopic pregnancies may implant in the cervix, caesarean section scar, cornua of the uterus, ovary, or abdominal cavity. Nontubal ectopic pregnancies were considered rare occurrences in the past, but they are becoming more common in recent years. The chief reasons for the rising incidence of these ectopic pregnancies worldwide include increase in pregnancies with assisted reproductive technologies and increase in caesarean section rates. The diagnosis of nontubal ectopic pregnancy is difficult and requires high suspicion and ultrasound expertise. Advances in ultrasound technology and the availability of quantitative beta-hCG have made diagnosis of such pregnancies possible at early gestation. In nontubal ectopic pregnancies, early diagnosis is of utmost importance, because conservative treatment is highly successful and morbidity is minimal in early ectopic pregnancy. The delay in diagnosis is associated with a higher morbidity and requires additional procedures for management. In the past the traditional treatment of nontubal ectopic pregnancies has been hysterectomy or extensive cornual resection, which is associated with high morbidity and loss of reproductive function. Conservative management of nontubal ectopic pregnancies is possible now, although there is no universally accepted protocol to effectively treat these ectopic pregnancies. Nevertheless, conservative medical treatment and less-invasive interventions ultrasound-guided, should be the preferred treatment in these pregnancies. Modern conservative treatment of ectopic pregnancies has overall brought highly successful outcomes with minimal morbidity and preservation of reproductive function.

Are we putting mothers and their babies at risk by postponing elective cesarean sections after 39WG in case of multiscarred uterus?

Background: With the worldwide increase in cesarean section rates, an increasing number of pregnant patients have a multiple scarred uterus. The recommendation to perform elective cesarean section after 39WG, as compared to the 37 + 0 to 38 + 6 WG period, exposes to an increase in emergency procedures, which carry more risks for the mother, and maybe for the neonate. The aim of this study was to analyse the maternal and neonatal morbidity associated with postponing all elective cesarean section after 39WG in patients with a history of at least 2 cesarean sections. Patients and method: We performed a retrospective single-center study, with a before–after methodology. Since the protocol to postpone elective cesarean section after 39WG was initiated in 2009, with studied the period before, from 2006 to 2008, and after, from 2011 to 2013. We included all patients with a history of at least two cesarean sections or a cesarean section and another uterine surgery (myomectomy). We defined composite maternal and neonatal morbidity criteria. We excluded twin pregnancies, stillbirths, and deliveries before 37WG. Results: We included 158 and 199 patients in the period before and after, respectively. Maternal age, BMI, ethnicity, parity, underlying maternal disease, the number of uterine scars, and the delay since the last cesarean section were similar in both groups. These patients represented 2.5% and 2.6% of the entire population over the respective periods. The proportion of elective cesarean section performed >39WG was 40.5% and 64.3% in the before and after periods, respectively (p < .0001), but more emergency procedures were performed in the latter period (26.1% versus 10.8%, p = .004). Maternal morbidity was not statistically different (13.3% vs 9.5%, p = .41). Neonatal complications were significantly more frequent in the first period, especially respiratory distress, admission to NICU and a length of stay of 5 or more days. In the two studied periods, there were significantly less neonatal complications after 39 WG. Conclusion: Even when emergency cesarean section is estimated at higher surgical risk, postponing an elective procedure after 39WG does not increase maternal morbidity while improving neonatal morbidity.

Placenta Accreta: A Review of the Etiology, Diagnosis, and Management

ABSTRACT The incidence of placenta accreta is rising, primarily due to the increase in cesarean section rates. The prenatal diagnosis of placenta accretas has been shown to decrease the amount of blood loss and complications. Real-time ultrasound is helpful for diagnosing placenta accreta, and magnetic resonance imaging (MRI) can increase the sensitivity of prenatal diagnosis. Postpartum hysterectomy for placenta accreta has been the standard of therapy for placenta accreta, but conservative management including uterine artery embolization, and leaving the placenta in situ may be considered in patients who want to preserve their fertility. The etiology of placenta accreta is due to a deficiency of maternal decidua, resulting in placenta invasion into the uterine myometrium. The molecular basis is yet to be elucidated, but it probably involves abnormal paracrine or autocrine signaling between the deficient maternal decidua and the invading placenta trophoblastic tissue. How to cite this article Goh W, Zalud I. Placenta Accreta: A Review of the Etiology, Diagnosis, and Management. Donald School J Ultrasound Obstet Gynecol 2016;10(3):352-363.

The importance of post-partum family planning.

The increase in caesarean section rates led the World Health Organization (WHO) to review the guidance from 1985 which stated that there is no justification for any region to have a rate higher than 10–15%. The WHO statement on caesarean section rates from 2015 highlights that caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons; that at population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates; and that the effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being, are still unclear and more research is needed to understand the health effects of caesarean section on immediate and future outcomes.1 In addition, caesarean sections that are medically unjustified increase health care costs unnecessarily. In this issue of Public Health Action, van den Boogaard et al. do not report on the overall caesarean rate in the district, instead focusing on the 2-year post-caesarean section outcomes for both the mothers and children, and in particular on family planning adherence and the inter-pregnancy interval.2 Reasons mentioned for non-initiation of, low acceptance of and low adherence to family planning after a caesarean section are religion and partner's consensus. Other factors that could play a role are education level, as women with higher education levels are more likely to better conceptualise the benefits of child spacing and are more likely to negotiate contraceptive use with their partners, rumours and misinformation about contraception side effects, taboos in the community, and financial or opportunity costs. Globally, 225 million women have an unmet need for family planning, resulting in 54 million unintended pregnancies, 16 million unsafe abortions and 79 000 maternal deaths annually.3 The promotion of family planning in countries with high birth rates has the potential to avert 32% of all maternal deaths and nearly 10% of childhood deaths.4 Effective use of post-partum and post-abortion family planning is an obvious way in which progress towards this goal could be achieved. Possible ways to strengthen family planning programmes is to have multiple programme elements linking demand with supply interventions, such as mass media and interpersonal communication approaches, male involvement, contracting with the private sector to expand service and product availability, and incentives such as conditional cash transfers that encourage patients to make decisions that lead to better health and motivate providers to exert the efforts necessary to deliver quality care. Political commitment is crucial as well. To help improve the quality of family planning programmes, the WHO updated the medical eligibility criteria for contraceptive use in 2015.5 One limitation mentioned in the study is the loss to follow-up of 20% of mothers, assumed to be due to giving an incorrect address. This could indicate that their children's birth was not registered and that they would thus miss out on the benefits of registration, and it highlights the need to strengthen civil registration and vital statistics systems worldwide. Finally, causes and solutions to health problems are often multisectoral in nature, and this is underscored by the global strategy for women's, children's and adolescents' health (2016–2030),6 which provides a road-map for collective action to advance the health and well-being of women, children and adolescents, and which will be central to achieving the United Nations' Sustainable Development Goals.7

Access to Cesarean Section Will Reduce Maternal Mortality in Low-Income Countries: A Mathematical Model.

Despite global efforts to reduce the maternal mortality ratio (MMR) through the World Health Organization's (WHO) Millennium Development Goal 5 (MDG5), MMR remains unacceptably high in low-income countries (LICs). Maternal death and disability from hemorrhage, infection, and obstructed labor may be averted by timely cesarean section (CS). Most LICs have CS rates less than that recommended by the WHO. Without access to timely CS, it is unlikely that MMR in LICs will be further reduced. Our purpose was to measure the MMR gap between the current MMR in LICs and the MMR if LICs were to raise their CS rates to the WHO recommended levels (10-15%). This model makes the assumption that increasing the CS rates to the recommended rates of 10-15% will similarly decrease the MMR in these LICs. WHO health statistics were used to generate estimated MMRs for countries with CS rates between 10 and 15% (N=14). A weighted MMR average was determined for these countries. This MMR was subtracted from the MMR of each LIC to determine the MMR gap. The percent decrease in MMR due to increasing CS rate was calculated and averaged across the LICs. We found an average 62.75%, 95%CI [56.38, 69.11%] reduction in MMR when LICs increase their CS rates to WHO recommended levels (10-15%). Maternal mortality is unacceptably high in LICs. Increasing CS rates to WHO recommended rates will decrease the maternal mortality in these countries, significantly decreasing the mortality ratio toward the projected MDG5.

Medical management of cesarean scar pregnancy at advanced age: case report and literature review

Aim: Cesarean scar pregnancy is a rare condition that is increasing in frequency parallel to the increase in cesarean section rates. The authors hereby discuss a case with cesarean scar pregnancy at advanced age that was treated with methotrexate (MTX) in Nyala Sudan Turkey Training and Research Hospital. Conclusion: Cesarean scar pregnancy is a rare type of ectopic pregnancy that is increasing in number due to the increase in cesarean deliveries. Clinical vigilance is imperative for diagnosis and treatment of this highly mortal and morbid entity.

Induction of labour versus expectant management at term by subgroups of maternal age: an individual patient data meta-analysis

BackgroundBritish women are delaying childbirth. Women aged 35 years or over have a higher risk of perinatal death. There is a linear relationship between maternal age and delivery by emergency caesarean in nulliparous women. Many obstetricians induce older women at term attempting to improve perinatal outcomes, others are reluctant for fear of increasing caesarean rates. A recent systematic review of induction of labour versus expectant management in women at term, found induction was associated with a reduction in caesareans (OR 0.83, 95% CI 0.76–0.92). ObjectivesTo identify whether induction of labour changes the risk of caesarean section in women aged 35 years or over. Study designSearch strategy: Available data sets from RCTs included in the Wood et al. systematic review (31 trials) and suitable RCTs published since week 23, 2012.Selection criteria: Studies were included if they were randomised controlled trials comparing induction of labour with expectant management at term with intact membranes with a singleton or multiple pregnancy in a cephalic presentation.Data collection and analysis: A quantitative meta-analysis of individual patient data (IPD) using a random-effects model to calculate odds ratios. ResultsIn total 2675 women (five studies) were included in the meta-analysis and 2526 women (four studies) were included in the IPD meta-analysis. There was no statistically significant increase in caesarean section rates seen in either analysis. ConclusionsInduction of labour in women of advanced maternal age has no statistically significant effect on caesarean section rates.

Does an increased cesarean section rate improve neonatal outcome in term pregnancies?

To clarify whether an increased cesarean section rate improves the short-term neonatal outcome in singleton term pregnancies with cephalic presentation. A retrospective study of institutional data on the mode of delivery and neonatal outcome. The study included two cohorts: 1998-1999 (n=7437) and 2004-2005 (n=8505), since the institutional cesarean section rate increased sharply between these cohorts and has remained stable after the latter study period. The caesarean section rate almost doubled from 6.8 to 11.3% (p<0.001), during the study period. The rate of neonates suffering severe birth asphyxia remained low in both cohorts (0.4 vs. 0.6%) and there were no significant differences in neonatal outcome (Apgar score <4 at 1min and Apgar score <7 at 5min, severe birth asphyxia, resuscitation or artificial ventilation) between the study periods. In the subgroup of neonates delivered vaginally, no significant differences were found in the above-mentioned neonatal outcomes between the cohorts. Apart from other outcomes admissions to neonatal intensive care unit increased significantly (p<0.001) during the latter period (0.8 vs 1.6%). Increasing cesarean section rate from a low to a moderate does not improve the short-term neonatal outcome in term singleton pregnancies. On the contrary neonatal intensive care unit admissions increased with increasing caesarean section rate. Furthermore it is possible to achieve good neonatal outcome with a low cesarean section rate.

Birth after caesarean section.

Birth after caesarean section (CS) is an issue of growing importance. As a consequence of increasing CS rates, more women having experienced a prior CS will need counselling about preferred second delivery mode. There are two choices: elective repeat caesarean section (ERCS) or trial of labour (TOL). It is well known, that a TOL ending in an emergency CS carries the largest risks for mother and child. We wanted to investigate for which women and infants it would be safest to recommend an ERCS or a TOL. We assumed, that underlying conditions/indications for the first CS performed would often recur in the second pregnancy and be important for the second delivery outcome. Therefore, a hierarchical system was developed, in which efforts were made to classify according to underlying conditions instead of focusing on conditions appearing during labour, in an attempt to diminish the subjective impact of diagnoses recorded after delivery. The hierarchical system was used through the four papers. We investigated women in the Swedish medical birth register with their first two deliveries 1987-2007 (Paper I-III), or giving birth at least twice, including one CS and at least one delivery after the CS 1992-2011 (Paper IV). In Papers I-III, we have shown that all first CS indications had a statistically significant risk to recur in the second pregnancy/ delivery. Women with a first CS were older, shorter, and had a higher body mass index than women with a first vaginal delivery. The risk for unplanned CS in TOL increased by the women’s age, body mass index, and smoking, while increasing height lowered the risk. Women with a prior CS had an all-over increased risk for unplanned CS in TOL, compared with primiparous women. Infants born to mothers with one prior CS had an almost doubled risk for low Apgar score and perinatal death compared with infants of women with one prior vaginal birth. The risk was lower but still statistically significant after adjustment for possible maternal and fetal/infant confounders. For infants of women with one previous CS, the risk for low Apgar score was higher after a TOL than after an ERCS. In all studies, the risk for adverse outcomes differed substantially between hierarchical indications for the first CS performed. When the first CS was performed without medical indication, no inreased risk for low Apgar score or perinatal death could be detected. The results suggest that underlying conditions, not the previous CS per se, contributed to the risk increase. In Paper IV, we validated a widely used prediction model for chance of successful TOL after CS, developed by Grobman et al. (2007) for US conditions. As the original model was not directly applicable for Swedish settings, we modified it stepwise. The final, new model included maternal age, body mass index, prior vaginal birth, prior vaginal birth after CS, maternal height, first CS hierarchical indication, and the rates of ERCS and unplanned CS in the respective delivery wards. We reached an excellent predictability for vaginal birth in TOL after CS. Counselling about the safest delivery mode after one CS is a challenge. Our study results, combined with previous findings, add important scientific knowledge. However, non-medical factors are vital in the decision-making after one CS, and a trust between the woman, her partner, the obstetrician and the midwife is fundamental. Considering the new information would possibly make counselling easier and, hopefully, lower the rate of unplanned CS in TOL after CS and decrease the rate of low Apgar score and perinatal death in the birth after a caesarean delivery. (Less)

A Lateral to Anterior Approach to the Scarred Bladder Flap and Anterior Abdominal Wall Adhesions at the Time of Laparoscopic Hysterectomy

The purpose of this video is to present a lateral to anterior approach to the scarred bladder flap and anterior abdominal wall adhesions. The increase in cesarean section rate has made this surgical scenario more prevalent. We will present videos from two separate case. Both patient has 2 previous cesarean sections, suspected adenomyosis, and had failed medical management. We will demonstrate an anatomic based technique where the paravesicle spaces are developed bilaterally. The bladder is then backfilled and the adhesions over the supravaginal septum are transected. The vesicouterine ligaments are then transected at their origin at the pericervical ring. This allows the vesicovaginal space to be developed.

The optimization of reparative processes after cesarean section (clinical-experimental research)

Development and introduction of materials influenced on reparation process in a myometrium is actual direction of modern obstetrics in connection with the increase of cesarean section rate. One of such preparation is «Collost», it stimulates the processes of neoangio- and myogenesis and excludes the disorderly growth of scars tissue. Aim: To study the influence of bioplastic material «Collost» on the reparation process in myometrium after cesarean section. Objectives: to estimate the morpho-functional state of scar on uterus after cesarean sections depending on implantation of collagen membrane. Material and methods: There were included 13 female rabbits in experimental part of the study. In clinical part of the study there were included 20 pregnant woman with intraoperative application of «Collost» (main group), 30 pregnant woman without «Collost» implantation (comparison group) and 10 pregnant with vaginal delivery (control group). Results: histological, immunohistological and immunological findings of postoperative uterine scars of female rabbits showed significant differences of expressions of miosin, vascular endothelial growth factor and collagen I type. The myometrium was significantly thicker in the area of uterine scar in main group (with collagen membrane implantation) than in comparison group. Conclusions: bioplastic material «Collost» leads to full formation of muscular wall and vascular ture in the area of postoperative uterine scar.

Cesarean section increases the risk of respiratory adaptive disorders in healthy late preterm and two groups of mature newborns.

The rates of delivery by Cesarean section (CS) have been trending upwards in recent decades, perhaps leading to higher rates of dysfunction in respiratory adaptation in newborns. We present epidemiological data for pulmonary adaptation by mode of delivery for healthy late preterm and term infants born at a regional tertiary care center. The overall CS rate was 22% with the largest proportion of these in late preterms (39%). This drops to 30% in infants born after 37 weeks gestation and to 11% for those born after 40 weeks. Infants needing respiratory support decreased significantly as gestational age increased: 88% at 34 weeks, 67% at 35 weeks, 28% at 36 weeks, 17% at 37 weeks and 8% at 40 weeks. The risk of respiratory morbidity following CS as compared to vaginal delivery (VD) was substantially higher. 50% of infants born by CS needed respiratory support compared to only 12% following VD. 82% of all late preterm infants born by CS developed respiratory morbidity compared to 36% following VD. Comparable data for infants born after 37 and 40 weeks gestation were 33% compared to 9% and 26% compared to 6% respectively. Late preterm infants born after 36 weeks gestation showed the most marked difference by mode of birth with 66% needing respiratory support following CS as compared to only 9% following VD. Our data could be useful in counselling parents about risk associated with delivery by Cesarean section. A critical view should be taken of increasing CS rates worldwide because of a clear correlation in increased morbidity in infants, especially late preterm infants.