Number Of Cesarean Sections Research Articles

A transvaginal ultrasound-based diagnostic calculator for uterus post-cesarean scar defect

BackgroundA cesarean scar defect (CSD) is incomplete healing of the myometrium at the site of a prior cesarean section (CS), complicating more than half of all cesarean sections. While transvaginal ultrasound (TVU) is the most common modality for diagnosing this defect, hysteroscopy remains the gold standard. We aimed to develop an efficient diagnostic tool for CSD among women with abnormal uterine bleeding (AUB) by integrating TVU findings and participants’ demographic features.MethodsA single-center cross-sectional study was conducted on 100 premenopausal and non-pregnant women with a history of CS complaining of AUB without a known systemic or structural etiology. Each participant underwent a hysteroscopy followed by a TVU the next day. The defect dimensions in TVU, patients’ age, and the number of previous CSs were integrated into a binary logistic regression model to evaluate their predictive ability for a hysteroscopy-confirmed CSD.ResultsHysteroscopy identified 74 (74%) participants with CSD. The variables age, the number of CSs, defect length, and defect width significantly contributed to the logistic regression model to diagnose CSD with odds ratios of 9.7, 0.7, 2.6, and 1.7, respectively. The developed model exhibited accuracy, sensitivity, and specificity of 88.00%, 91.89%, and 76.92%, respectively. The area under the receiver operating curve was 0.955 (P-value < 0.001).ConclusionAmong non-pregnant women suspected of CSD due to AUB, looking at age, the number of previous CSs, and TVU-based defect width and length can efficiently rule CSD out.

Unusual presentation of placenta increta in mid-trimester loss: A case report

Introduction: Abnormal placentation is a major cause of maternal morbidity and mortality worldwide. There are three variants: placenta accreta, when the chorionic villi attach to the myometrium; placenta increta, in which placental villi extend into the myometrium; and placenta percreta, when the villi invade through the myometrium into the uterine serosa and may invade adjacent organs, such as the bladder. Previous caesarean section (CS) is the most important risk factor. The risk increases with the number of CSs. Other risk factors include uterine curettage resulting in Asherman syndrome and uterine anomalies. The diagnosis is established by ultrasonography and supplemented by magnetic resonance imaging (MRI). There are a number of different management approaches; conservative, methotrexate, uterine artery embolisation and balloon tamponade.

Does an increased number of cesarean sections result in greater risk for mother and baby in low-risk, late preterm and term deliveries?

Objective:To compare surgical complications and maternal and neonatal outcomes of low-risk, late preterm and term pregnant women who have had one or two previous cesarean sections (CSs) with those who have had three or more CSs.Methods:We conducted a retrospective study of 850 patients undergoing repeat CS at a tertiary level maternity hospital in Ankara, Turkey. Of those, 380 had previously undergone one or two CSs (Group-I: second or third CS) and 470 had previously undergone three or four CSs (Group-II: fourth or fifth CS). Outcomes and complications were compared between the groups.Results:The two groups were statistically significantly different in terms of maternal age, parity, body mass index, maternal weight gain during pregnancy, and length of hospital stay (all p<0.001). Although the prevalence of intraperitoneal adhesions and placenta previa was higher in Group-II than in Group-I (p<0.001), there was no statistically significant difference in terms of cesarean hysterectomy and adjacent organ injuries (p>0.05). There were also no significant differences between the groups in terms of neonatal outcomes (p>0.05).Conclusion:Although the increase in the number of CSs appears to be associated with intraperitoneal adhesions and placenta previa, adverse maternal and neonatal outcomes were not observed in those women with low-risk pregnancies who underwent CS for the fourth or fifth time. Therefore, fourth and fifth CSs may be considered relatively safe surgical procedures in this cohort.

Abnormally adherent placenta

Advances in image-scanning technology have led to vast improvements in medicine, especially in the diagnosis of fetal anomalies and placenta evaluation. In general, two main technologies are used to obtain images within the uterus during pregnancy – ultrasound (US) and magnetic resonance imaging (MRI). US examination is the primary method of gravid uterus assessment because it is patient-friendly, effective, cost-efficient and considered to be safe. MRI is generally used when US cannot provide sufficiently high-quality images. It offers high-resolution fetal and placenta imaging with excellent contrast that allows visualization of internal tissues. Placenta percreta is the most feared form of abnormally adherent placenta. Its incidence has increased because of high cesarean section rates. The main imaging findings in abnormally adherent placenta are: • Loss of the “clear zone” or irregularity of the hypoechoic plane in the myometrium underneath the placental bed. •Abnormal placental lacunae. Presence of numerous lacunae including some that are large and irregular often containing turbulent flow. • Bladder wall interruption. • Placental bulge. Deviation of the uterine serosa away from the expected plane. The uterine serosa appears intact, but the outline shape is distorted. • Focal exophytic mass. Placental tissue seen breaking through the uterine serosa and extending beyond it. • Color Doppler imaging shows uterovesical hypervascularity. • Bridging vessels appearing to extend from the placenta across the myometrium and beyond the serosa into the bladder or other organs. Often running perpendicular to the myometrium. The key concern of this talk will be: • The risk of placenta accreta increases according the number of Cesarean-section. • Placenta accreta is mostly associated with placenta previa. • The most sensitive US finding for placenta accreta is the presence of placenta lacunae, that can also be observed in MRI. • MRI may aid in diagnosis by demonstrating increased intraplacental vascularity, fibrin band of dark T2 signal and direct placental invasion of adjacent structures.

Frequency and causes of emergency hysterectomy along with vaginal delivery and caesarean section in Hamadan, Iran.

BackgroundEmergency hysterectomy (peripartum) is a high-risk surgery that almost always is done in the treatment or prevention of severe and life-threatening bleeding that occurs after vaginal delivery or caesarean.ObjectiveTo compare the frequency and causes of emergency hysterectomy along with the vaginal delivery and caesarean section (CS).MethodsThe cross-sectional research was conducted on patients who underwent a peripartum hysterectomy from 2005 to 2015 at Fatemieh Hospital in Hamadan City, Iran. Data collection tools included a questionnaire about demographic features and factors associated with hysterectomy surgery. Data were analyzed using SPSS version 21 and by descriptive statistics, chi-square, paired t-test, and one-way analysis of variance (ANOVA).ResultsThe mean age of women was 33.4±5.09 years. In recent years, 37 cases of hysterectomy were reported, with the peak occurring in 2015. The highest prevalence of hysterectomy was associated with 28 (77.8%) women with a third pregnancy and second parity, while 32 cases (86.5) were related to those with no history of vaginal delivery, 15 (45.5%) were related to repeated CS and second repeated CS; 28 cases (75.7%) to those with no history of placenta previa; 21 cases (56.8) to the majority with the anterior placenta;, 33 cases (97.1%) to those with no over-distance of uterine; and 36 cases (97.3%) to those without a history of uterine myoma. Among 37 cases who had hysterectomy, placenta accreta was observed in 27 cases (77.1%), with placenta increta in three (8.1%) and placental attachment, including percreta, were seen in seven cases (18.9 %).ConclusionThe rate of hysterectomy in multiparous women (in their third or fourth pregnancy) was higher. The greatest cause of hysterectomy was related to attached placenta including accreta, uterus atony, a history of CS, multipara, and repeated CS. Therefore, due to the increase in the number of CSs in recent years, planning should be taken into account in order to encourage pregnant women for vaginal delivery.

Cesarean section scar diverticulum evaluation by saline contrast-enhanced magnetic resonance imaging: The relationship between variable parameters and longer menstrual bleeding.

This study was conducted to determine a more accurate imaging method for the diagnosis of cesarean scar diverticulum (CSD) and to identify the parameters of CSD strongly associated with prolonged menstrual bleeding. We enrolled 282 women with a history of cesarean section (CS) who presented with prolonged menstrual bleeding between January 2012 and May 2015. Transvaginal ultrasound, general magnetic resonance imaging (MRI) and contrast-enhanced MRI were used to diagnose CSD. Five parameters were compared among the imaging modalities: length, width, depth and thickness of the remaining muscular layer (TRM) of CSD and the depth/TRM ratio. Correlation between the five parameters and days of menstrual bleeding was performed. Finally, multivariate analysis was used to determine the parameters associated with menstrual bleeding longer than 14 days. Contrast-enhanced MRI yielded greater length or width or thinner TRM of CSD compared with MRI and transvaginal ultrasound. CSD size did not significantly differ between women who had undergone one and two CSs. Correlation analysis revealed that CSD (P = 0.038) and TRM (P = 0.003) lengths were significantly associated with days of menstrual bleeding. Longer than 14 days of bleeding was defined by cut-off values of 2.15 mm for TRM and 13.85 mm for length. TRM and number of CSs were strongly associated with menstrual bleeding longer than 14 days. CE-MRI is a relatively accurate and efficient imaging method for the diagnosis of CSD. A cut-off value of TRM of 2.15 mm is the most important parameter associated with menstrual bleeding longer than 14 days.

Standardized ultrasonographic approach for the assessment of risk factors of incomplete healing of the cesarean section scar in the uterus

ObjectiveTo identify factors related to the healing of a Cesarean uterine incision using the standardized ultrasonographic approach of scar assessment in the non-pregnant uterus. Study designMeasurements of the uterine scar were taken from 409 women with a history of at least one low transverse cesarean section (CS) with a single layer uterine closure. Residual myometrial thickness (RMT), width (W) and depth (D) of the triangular hypoechoic scar niche, D/RMT ratio and clinical characteristics were analyzed. For statistical analysis, the Mann–Whitney U test, chi-square test, Spearman's rank correlation coefficient, ANOVA test, and logistic regression were used. Results268 women presented with a scar defect. RMT values were significantly correlated with the number of CSs (R=−0.17) and uterus retroflection (R=−0.15). The presence of a scar defect was significantly associated with lower RMT values (R=−0.33), greater gestational age (R=0.10), and younger maternal age (R=−0.11). The mean RMT value was significantly smaller in women with CSs performed in the second stage of labor (0.62) when compared to women with CSs in the first stage of labor (0.97) or without cervical dilatation (0.91). ConclusionA standardized approach of CS scar assessment in the non-pregnant uterus helps to identify women at risk of long-term complications of CS.

Are multiple repeated cesarean sections really as safe?

Aim: Surgical complications were compared between patients with three or less prior cesarean deliveries and four or more prior cesarean deliveries.Materials and methods: Records of 120 patients who had undergone cesarean sections (CSs) in our Department of Obstetrics and Gynecology, between August and November 2015, were retrospectively studied. Cases were reviewed on the basis of age, type of operation, type of anesthesia, number of CSs, time of hospitalization, and intra-operative and post-operative complications.Results: Cesarean sections had been performed on 62 (51.7%) patients whose cesarean number was three or less, while 58 (48.3%) patients had multiple CSs four or more. Patients with four or more prior cesareans had an increased rate of intra-abdominal adhesions, compared with the other group. There was no significant difference in the gestational weeks, neonatal admission rate, incidence of cesarean hysterectomy, uterine scar rupture, placenta previa with placental invasion anomalies, bladder and bowel injuries, incidence of peripartum hemorrhage and blood transfusion rate between the two groups.Conclusion: There is no greater risk of maternal complications in patients with four or more prior cesareans, excepting intra-abdominal adhesions.

Analysis of Cesarean Section Rate using Robson's Ten Group Classification System and comparing the Trend at a Tertiary Hospital for 2 Years

ABSTRACT Aims and objectives To classify the cesarean section (CS) in different groups of Robson's ten-group classification system (TGCS) and comparing the rate and relative size of groups with that of previous year at the tertiary hospital. Materials and methods This retrospective study was conducted in Cheluvamba Hospital, which is a tertiary hospital attached to Mysore Medical College &amp; Research Institute, Mysuru, between January 1, 2014 and December 31, 2014. The data collected was compared with the previous year data between January 1, 2013 and December 31, 2013. The data collected included parity, mode of previous delivery, gestational age, onset of labor-spontaneous or induced, delivery notes of labor ward, and operative notes of CS. This data was then applied to the Robson's TGCS for the year 2014 and compared with that of 2013. Results The total deliveries during 2014 were 12,930 and in 2013 were 15,182. The number of CSs during 2014 was 3,793 and in 2013 it was 3,917. Cesarean section rate in 2014 was 29.33% while in 2013 it was 25.8%. The CS rate has come down to half in group I (nulliparous, single, cephalic. 37 weeks, in spontaneous labor) and to onefourth in group III [multiparous (excluding previous CS) single, cephalic. 37 weeks, in spontaneous labor] in 2014. Conclusion Robson's TGCS is easy to classify. Clinical significance The study showed reduction in CS rate by half in group I and by one-third in group III in 2014 in our institution. This was probably due to the increased awareness among the staff of the institute by the previous year study about higher CS rate. How to cite this article Prameela RC, Shilpa G, Farha A, Prajwal S. Analysis of Cesarean Section Rate using Robson's Ten Group Classification System and comparing the Trend at a Tertiary Hospital for 2 Years. J South Asian Feder Obst Gynae 2016;8(3):175-180.

Validation of a Prediction Model for Predicting the Probability of Morbidity Related to a Trial of Labour in Quebec

Between 2000 and 2006, births by cesarean section (CS) increased from 21.2% to 26.3% in Canada and reached greater than 30% in the United States. A prior CS is the primary indication for greater than 30% of all CS procedures in Canada. The number of CSs could be decreased if more women who could undergo a trial of labor after CS (TOLAC) chose this option. The decision to attempt a TOLAC or to have an elective repeat CS (ERCS) is often made by considering the fear of a repeat failed labor or the odds of developing maternal and neonatal complications with either delivery mode. Grobman’s model, which allows an estimation of the probability of vaginal delivery for women with 1 prior CS undergoing a TOLAC, was developed from 9616 American women experiencing a TOLAC and validated using an independent cohort. Maternal and neonatal morbidity decreased as the predicted chance of vaginal birth after cesarean (VBAC) increased. Morbidity was similar between TOLAC and ERCS when the probability of successful VBAC was 70% or greater. Because the Grobman model has not been validated in a Canadian population and because American and Canadian populations and clinical practices may differ, validation is needed before the prediction model can be used in Canada. The present study was performed to determine whether Grobman’s model for predicting TOLAC success in an American population can predict the probability of morbidity associated with TOLAC in a Canadian population. A perinatal database with 185,437 deliveries from 32 obstetric centers in Quebec was used, and women with 1 prior CS who were eligible for a TOLAC were selected. The probability of VBAC was calculated from the Grobman model, using maternal age, body mass index, history of vaginal delivery, timing of vaginal delivery in relation to the CS, and indication for the prior CS. Major and minor maternal morbidities and newborn morbidities were determined. Women were then categorized by deciles of their predicted probability of VBAC, and the frequencies of maternal and neonatal morbidities between those who underwent TOLAC and those who had ERCS were compared using either the Fisher exact or χ2 analysis. Statistical significance was defined as P < 0.05. Of 8508 women with 1 prior CS, 3113 had a TOLAC (36.6%) and 5395 underwent an ERCS (63.4%). Minor and major maternal morbidity occurred in 1.9% and 1.1%, respectively; the frequency of neonatal morbidity was 5.1%. Maternal and neonatal morbidities became less frequent as the predicted chance of VBAC increased among women who underwent TOLAC (P < 0.05). No comparable trend was apparent among women who had ERCS. When the predicted chance of VBAC was less than 60%, women undergoing a TOLAC were more likely to have morbidity than women who underwent an ERCS (P < 0.05). When the probability of VBAC success reached 60%, this difference was not present. Neonatal morbidities showed a similar pattern, but they became equivalent between TOLAC and ERCS only when the probability of VBAC was 70% or greater. All women were grouped according to predicted probabilities of VBAC success of either 60% or 70%. When the predicted chance of VBAC was less than 60%, women undergoing a TOLAC were more likely to have maternal morbidity (RR 2.3; 95% confidence interval [CI], 1.4–4.0) than those who underwent an ERCS. However, when the predicted chance of VBAC was 60% or greater, maternal morbidity did not differ between the groups (RR, 0.8; 95% CI, 0.6–1.1). Neonatal morbidity was similar between groups when the probability of VBAC reached 70% (RR, 1.2; 95% CI, 0.9–1.5). This prediction model for VBAC success as validated in the United States is also predictive for Canadian women in Quebec. Maternal and neonatal morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOLAC. The findings of this study confirm that individual assessment of the probability of VBAC success allows health care providers to refine and improve counseling to inform women with a prior CS about their chance of successful VBAC and their level of risk, to enable them to make an informed choice regarding their mode of delivery.

RISING CAESAREAN SECTION RATE

Objective: Compare indications for caesarean section in Military Hospital Rawalpindi in the year 1999 with the year 2005, sixyears apart, with an aim to identify areas where caesarean section rates could be decreased. Study design: Prospective Survey of caesareansection using information provided by doctors/midwives entering data in labour ward /theater registers. Methods: The study was designed asa process evaluation. Indication for caesarean section, parity, previous caesarean section, emergency / elective, labour / pre labour, presenceof previous caesarean section scar, induced or spontaneous labour were noted. Data was plotted into 2 separate classifications and indicationscompared across the 2 years 1999 versus 2005. Statistical significance was calculated and value of &lt;0.05 was considered significant. Results:Overall section rates rose from 16.9% to 34.6% which showed almost doubling of rates in a span of 6 years. The chief contributors to risingrates were as follows. Caesarean section rate rose from 132 (2.2%) to 355 (4.6%) for previous one Caesarean section (p&lt;0.001), from 172(2.9%) to 383 (5% )for previous &gt;1 caesarean (p&lt;0.001), that for nullipara increased from 203 (3.3%) to 632 (8.3%), prelabour or induced labour(p&lt;0.001) and for dystocia from 150(2.5%) to 490 (6.4%) which was again significant (p&lt;0.001) . Increase in section rate for antepartumhaemorrhage, diabetes, previous infertility and intrauterine growth restriction was insignificant. Conclusion : A decrease in the number ofcaesarean sections may be achieved by reducing the number of primary caesarean section and/or encouraging more patients to take a trialof scar. A decrease in induction rates may also lead to lowering of caesarean section rates.

OC133: High prevalence of defects in caesarean section scars at transvaginal ultrasound examination

To determine the ability to correctly identify caesarean section (CS) scars, to estimate the prevalence of defective CS scars and to determine the size and localization of CS scar defects by using transvaginal ultrasound. 287 women underwent transvaginal ultrasound examination 6–9 months after delivery: 108 had undergone one CS, 43 had undergone two CSs, 11 had undergone > 3 CSs, and 125 were primipara who had undergone a vaginal delivery. The ultrasound examiner was blinded to the obstetric history until all scans had been evaluated. None of the 125 vaginally delivered women had a visible scar in the uterus, while all women who had ever undergone CS had at least one visible CS scar. Median myometrial thickness at the level of the isthmus was 11.6 mm in women who had only been delivered vaginally and 8.3 mm, 6.7 mm and 4.7 mm in women who had undergone one, two and > 3 CSs (P = 0.000). Scar defects were seen in 61%, 81%, and 100% of the women who had undergone one, two and > 3 CSs (P = 0.004), at least one defect being classified as large by the ultrasound examiner in 14%, 23% and 46% (P = 0.000), and at least one total defect being seen in 6%, 7% and 18% (P = 0.366). In the women who had undergone one CS, the median distance between an intact scar and the internal cervical os was 4.6 mm (range 0–19) and that between a deficient scar and the internal cervical os was 0 mm (0–26); P = 0.000. CS scars can be reliably detected by ultrasound. Myometrial thickness at the level of the isthmus uteri decreases with the number of CSs and the frequency of large scar defects increases. Scars with defects are located lower in the uterus than intact scars.

Effects of repeated caesarean section on maternal and neonatal outcomes

Objective To investigate the effects of repeated caesarean section (RCS) on maternal and neonatal outcomes. Methods From January 1998 to December 2007, 412 cases underwent RCS at Peking Union Medical College Hospital were reviewed and divided into two groups based on the number of CSs: RCS group (n= 394) and multiple caesarean section (CS) group (MCS group, n= 18). General conditions, maternal complications and neonatal outcomes were compared among RCS group, MCS group and first CS groups (FCS group) which consisted of 480 women underwent the first CS during the same period. Results The incidence of RCS was 4. 0% with an increasing trend during the past ten years. (1) The mean age of RCS and MCS group were (33.7± 4. 3) yrs and (34. 5±5.1)yrs respectively, higher than FCS group (P<0. 05). The average gravidity in RCS and MCS group were (3.5±1.4), (4. 7±1.5) respectively, higher than FCS group (2.1± 1.2, P<0. 05). (2) The rate of severe pelvic adhesion and uterus rupture were significantly higher in RCS group than in FCS group (13.5% vs 0. 4%, 1% vs 0%, P<0. 05). (3) The mean gestations of RCS group and MCS group were (38.1±1.8)weeks and (37.3±2.5)weeks respectively, while it was (38. 9±2. 1) weeks in the FCS group (P<0. 05). Conclusions RCS rate is growing. Although RCS would increase the incidence of dense adhesion and uterine rupture, it is a relatively safe procedure without increasing the neonatal morbidity. Key words: Cesarean section, repeat; Pregnancy outcome; Adhesions; Uterine rupture

Multiple cesarean section morbidity

Objective To quantify maternal risk associated with multiple cesarean sections (CSs) and determine whether the third CS defines a threshold for increased morbidity. Methods From January 1997 to January 2002, the clinical records of 3191 women who were delivered by CS at our referral maternity center were examined for selected indicators of maternal morbidity. The women were assigned to groups based on number of CSs and the frequency of each indicator was determined. A composite score for each indicator among women grouped by number of consecutive CSs was then derived to compare risk between groups and against the third CS. Results By all indicators studied, morbidity increased with successive CSs before and through the third CS. However, compared with the third, the risk of major morbidity was significantly increased with the fifth, and much worse at the sixth CS for placenta previa (odds ratio [OR]=3.8, 95% confidence interval [CI]=1.9–7.4), placenta accreta (OR=6.1, 95% CI=2.0–18.4) and hysterectomy (OR=5.9, 95% CI=1.5–24.4). But the third and fourth CSs had the same risk of major morbidity for placenta previa (OR=1.4, 95% CI=0.8–2.2), placenta accreta (OR=1.0, 95% CI=0.3–2.9) and hysterectomy (OR=0.3, 95% CI=0.0–2.7). Conclusions The third CS does not define a threshold for increased risk to the mother. Instead, overall morbidity rises continually with each successive CS. However, specifically for major morbidity from the triad of placenta previa, placenta accreta and hysterectomy during CS, the fourth CS carries the same risk as the third.

Postpartum contraceptive acceptance in León, Mexico: a multivariate analysis

Objectives: The aim of the present study was to identify the reasons for the acceptance or rejection of contraceptive methods among postpartum women at the Hospital of Obstetrics and Gynecologyin León, Mexico.Methods: A prospective cross-sectional study of 1025 postpartum women was undertaken. Reasons for acceptance or refusal of contraceptives were registered in a written survey.Twelve sociodemographic variables were included as predictors in a logistic regression analysis; the acceptance or refusal was the dependent variable, and statistical significance was set at 0.05.ResultsThere were 513 patients who accepted contraceptives (50.0%) and 512 (50.0%) who refused them. The main reasons for accepting contraceptives were definitive desire for no more children (17.0%) and satisfactionwith previous contraceptive methods (21.5%). The main contraceptive methods chosen were intrauterine device (67.7%) and tubal sterilization (28.5%). Reasons for contraceptive refusal were husband's rejection(33.2%) and delaying contraceptive use until after finishing the postpartum period (31.8%). In the logistic regression model, the variables previous deliveries (p < 0.001), number of Cesareansections (p < 0.001) and women's level of education (p < 0.02) were included as predictors of acceptance.Conclusions: Previous deliveries, previous Cesarean sections and women'slevel of education were significant in contraception acceptance. The rejection of contraceptives was mainly attributed to husbands.