Previous Cesarean Delivery Research Articles

Effect of Personality and Pain Catastrophizing on Postoperative Analgesia Following Cesarean Section: A Prospective Cohort Study.

This study aimed to investigate the effects of different psychological personalities and pain catastrophizing levels on postoperative analgesia in patients undergoing cesarean section. Puerperas who underwent cesarean section at our hospital between January and August 2023 were recruited into the study and assessed using the Eysenck Personality Questionnaire-Revised Short Scale (EPQRSC) and Pain Catastrophizing Scale (PCS). Data on the numerical pain intensity at rest and during activity 24 h after surgery, number and dosage of analgesia pumps, and satisfaction with analgesia were recorded. According to the numerical pain score during activity 24 h post-operation, the patients were divided into the analgesia incomplete group (≥4) and control group (<4). Univariate analysis, Spearman correlation analysis, and binary logistic regression analysis were used to evaluate the influence of personality characteristics and PCS on postoperative analgesia. A total of 778 women were included in the study. The incidence of inadequate analgesia was 89.8%. The satisfaction rate of analgesia was 66.8%. Univariate analysis showed that extraversion; neuroticism; PCS; numbers of previous cesarean delivery; ASA; analgesic satisfaction; and 24-h analgesia pump compressions and dosage were associated with postoperative analgesia after cesarean section (P<0.05). Using binary logistic regression analysis, the first cesarean section (odds ratio [OR]=0.056, 95% confidence interval [CI]=1.913-19.174), the number of 24-h analgesic pump compressions (OR=8.464, 95% CI=0.356-0.604), extraversion (OR=0.667, 95% CI=0.513-0.866), neuroticism (OR=1.427, 95% CI=1.104-1.844), and PCS (OR=7.718, 95% CI=0.657-0.783) were factors affecting postoperative analgesia. The incidence of inadequate analgesia after a cesarean section was high (89.8% on the first day after surgery). Formulating accurate analgesia programs for women undergoing cesarean section with extraversion, neuroticism personality characteristics, and pain catastrophizing behaviors is necessary for improving their postoperative analgesia effects and satisfaction and promoting postpartum comfort.

Analysis of Cesarean Section using Robsons classification at Teaching Hospital of Eastern Nepal

Introduction: Cesarean section is an operative procedure for delivery of fetus and placenta by making an incision over abdomen and uterus after period of viability. Aims: The aim of study is to analyze rate of cesarean section and perform an analysis based on Robsons ten group classification. Methods: A cross sectional study was conducted at Department of Obstetrics and Gynecology of a teaching hospital of eastern Nepal, over a period of one year from October 2022 to September 2023. All details regarding demography, obstetric history, medical history, labor status, indication of cesarean section, etc. were collected. Then all pregnant ladies were assigned to one of Robsons ten group classification systems and recorded into labor confinement book. The statistical analysis was performed using Statistical Package for Social Sciences version 21. Descriptive statistical tools were used to express the results. All tests were done with a significance level of 5% (p-value &lt;0.05) and 95% confidence Interval. Results: The overall rate of cesarean section was 1,829(46.93%). Majority 1323(72.30%) were in age group 20-30 years. Maximum 1,629(89.10%) delivered at&gt;37 weeks of gestation. Majority 789(43.10%) of cases had lower segment cesarean section because of previous cesarean delivery. According to Robsons classification system, Group 5 has highest cesarean section rate 725 (39.60%) followed by Group 2(A+B), 334(18.21%). Conclusion: Implementing Robsons Ten Group Classification System at our setting has helped us to identify major contributor of overall cesarean section rate. Group 5 was at top followed by group 2. Thus with adequate trial of labor after cesarean, proper labor monitoring and judicious use of induction protocol can significantly reduce rate of cesarean section.

The Association between Placenta Previa in Pregnant Women with Previous Caesarian Section at Combined Military Hospital

Background: Placenta praevia is defined as a placenta implanted partially or completely over the lower uterine segment. Placenta praevia is a major cause of massive obstetric bleeding that leads to significant maternal morbidity and mortality. In the present day, the hypothesis is that previous cesarean section is the risk of development of placenta praevia.&#x0D; Objective: To assess the relationship between placenta praevia and previous cesarean section.&#x0D; Material and Methods: It was a descriptive cross-sectional study carried out in the Department of Obstetrics and Gynaecology, Combined Military Hospital, Dhaka, from July 2021 to July 2022. Total 35 patients with placenta praevia were included in this study. Informed verbal and written consent were taken from the study participants. A detailed history was taken, general physical and per abdominal examination and previous records were reviewed properly. Placenta praevia was diagnosed by patient clinical presentation, ultrasonogram, and incidentally during cesarean section.&#x0D; Results: The study shows the incidence of placenta praevia was 1.75% and incidence of placenta praevia in woman with previous caesarean section was 1% compared with 0.75% without previous caesarean section. The commonest age group was 26-30 years, which included 44%, and 32% belonged to 31-35 years age group. The mean age was 29.28± 10 years. Most of the patients were multigravida (62%). In maximum number of cases, (52%) were admitted at the gestational period between 35-38 weeks. Common clinical presentations were per vaginal bleeding 84% and 16% of patients were symptomatic. Regarding preoperative findings, 30(62.5%) patients had average preoperative bleeding. Postpartum hemorrhages corrected conservatively were 14(29.1%), and postpartum hemorrhage needed hysterectomy were 4(8.3%). In patients with no history of previous cesarean section 90% were delivered by cesarean section and 10% were delivered vaginally. Among patients with a history of the previous cesarean section all patients underwent cesarean section.&#x0D; Conclusion: There is a strong association between having a previous caesarean delivery and the subsequent development of placenta praevia. The risk increases with the number of cesarean sections. So, pregnant women with a history of caesarean section must be regarded as high risk for placenta praevia and must be monitored carefully.

Placenta accreta spectrum disorder: An updated literature review

Placenta accreta spectrum disorder (PASD) refers to a range of pathological placental adhesions to the uterine wall, previously classified into three subtypes: placenta accreta, placenta increta, and placenta percreta, based on the invasiveness of the villous tissue. This article provides an updated review of the literature on PASD with new insights into the etiopathology of PASD. Recent evidence suggests that extravillous trophoblasts are not overly invasive and that accreta placentation is more likely due to decidualisation failure resulting from blastocyst implantation within a caesarean scar defect (CSD). Previous caesarean delivery has been the most well-known risk factor of PASD, with the increased occurrence of PASD along with the increased number of previous caesarean deliveries. Antenatal identification of PASD is strongly recommended to improve outcomes before the onset of labour or bleeding, so that placental abruption can be avoided. Ultrasonography can identify PASD in the first trimester with good sensitivity and specificity. A standardised approach with a comprehensive multidisciplinary care team is required to manage PASD effectively. The Royal College of Obstetricians and Gynaecologists (RCOG), along with The American College of Obstetricians and Gynaecologists (ACOG), have published guidelines for the best clinical management of PASD. Future research should concentrate on gathering prospective data on the diagnosis and management of PASD in order to assess the association between prenatal imaging, clinical grading, and histology findings. This will lead to more accurate PASD screening, reliable diagnostic criteria, and alternatives to prenatal treatment.

Predictive Factors for Successful Cervical Ripening among Women with Gestational Diabetes Mellitus at Term: A Prospective Study.

The purpose of this prospective cohort study is to identify the predictive factors for vaginal delivery among women (n = 146) who underwent cervical ripening using a dinoprostone insert (PG) alone (13.7%), cervical ripening balloon (CRB) alone (52.7%), oral misoprostol (M) alone (4.1%), or repeated methods (R, 29.5%) for gestational diabetes mellitus (GDM) at term, and to analyze maternal and neonatal morbidity outcomes according to the method for cervical ripening. After cervical ripening, vaginal delivery occurred in 84.2% (n = 123) and was similar among groups (90.0% after PG, 83.1% after CRB, 83.3% after M, and 83.7% after R; p = 0.89). After a multivariable logistic regression analysis adjusted for potential confounders, the internal cervical os being open before cervical ripening was a predictor of vaginal delivery (adjusted odds ratio (OR) of 4.38, 95% confidence index (CI) of 1.62-13.3, p = 0.03), and previous cesarean delivery was a predictor of cesarean delivery (aOR of 7.67, 95% CI of 2.49-24.00, p < 0.01). Birthweight was also significantly associated with cesarean delivery (aOR of 1.15, 95% CI of 1.03-1.31, p = 0.02). The rates of maternal and neonatal morbidity outcomes were 10.9% (n = 16) and 19.9% (n = 29), respectively, and did not differ according to the mode of delivery and to the method used for cervical ripening. Identifying these specific high-risk women (previous cesarean delivery and internal cervical os being closed before cervical ripening) for cesarean delivery among women who underwent cervical ripening for GDM at term is important and practical for all physicians to make a decision in partnership with women.

Cesarean Scar Ectopic Pregnancy: Experience From Benghazi Medical Center, 2022

Background: Cesarean scar pregnancy (CSP) is a rare consequence of a previous cesarean delivery and a new type of ectopic pregnancy, but it is life-threatening if unrecognized and inadequately managed. Despite the rising incidence of CSP, there are no consensus or evidence-based guidelines for management. Aims: To review risk factors, clinical features, diagnostic methods, and management of women with CSP at Benghazi Medical Center. Materials and methods: A descriptive-case series study of CSP cases between the Ist of March 2018 and Ist of April 2022.. Data collected retrospectively. The data included demographics, presenting symptoms and signs, ultrasound findings, treatment used, and any complications. Results: The total number of ectopic pregnancies in period between 1st March 2018 and 1st April 2022 was 262, ten women (3.82%) were diagnosed as scar ectopic, The women's ages ranged from 28 to 47 years, about 60% had three or four previous cesarean scars, abdominal pain with vaginal bleeding was in 30% of the cases, while 60% of patients were asymptomatic and all patients were stable during the diagnosis, except for one case that had signs of shock. ultrasound finding was 80% presence of gestational sac implanted low near the previous scar; initial diagnosis was delayed by 50%. The management was laparotomy and gestational sac excision in four cases that did not require further treatment, dilatation and uterine evacuation were done in two cases that required use of uterine balloon to control bleeding and further use of methotrexate In one case (10%), systemic methotrexate alone was effective. Severe bleeding was seen among 60% of women, and 20% underwent hysterectomy. The complications were significantly (P&lt; 0.05) more common among women with high parity and also in cases where there was no intervention during the diagnosis. Conclusion: A previous uterine scar is the main risk factor for CSP; there is no specific clinical feature for CSP; ultrasound is used for the diagnosis; surgical management appears to be a better option, serious complications were seen mainly when no intervention was done during the diagnosis.

The association between obesity and the success of trial of labor after cesarean delivery (TOLAC) in women with past vaginal delivery.

To evaluate the effect of overweight (body mass index; BMI 25.0-29.9 kg/m2), and obesity (BMI>30 kg/m2), on the success of trial of labor after cesarean delivery (TOLAC), with consideration of successful past vaginal birth. This retrospective cohort study was performed using electronic database of obstetrics department at a university-affiliated tertiary medical center. All women admitted for TOLAC at 37-42 weeks of gestational age, carrying a singleton live fetus at cephalic presentation, with a single previous low segment transverse cesarean delivery between 1/2015 and 5/2021 were included. Primary outcome was the rate of cesarean delivery during labor, and subgroup analysis was performed for the presence of past vaginal birth. Of the 1200 TOLAC deliveries meeting the inclusion criteria, 61.9 % had BMI in the normal range, 24.6 % were overweight (BMI 25.0-29.9 kg/m2), and 13.4 % were obese (BMI of 30 kg/m2 and over). Using a multivariate analysis, BMI≥30 kg/m2 was associated with increased risk of cesarean delivery compared to normal weight. However, in the subgroup of 292 women with a history of successful vaginal birth BMI did not affect TOLAC success. BMI does not affect the success of TOLAC in women with previous vaginal birth. This information should be considered during patients counselling, in order to achieve a better selection of mode of delivery and higher patients' satisfaction.

Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial

Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. Canadian Institutes of Health Research (CIHR, MOP-142448).

#276 : Impact of Previous Cesarean Delivery on Pregnancy and Neonatal Outcomes of Subsequent In Vitro Fertilization/Intracytoplasmic Sperm Microinjection and Single Frozen-Thawed Embryo Transfer

Background and Aims: Cesarean delivery (CD) rates continue to rise worldwide. Prior studies have indicated that CD is associated with not only various gynaecological symptoms and obstetric complications but also lower probability of subsequent fertility. However, the recognition about impact of CD on clinical outcomes in subsequent IVF/ICSI-FET is very limited. The purpose was to investigate the effects of previous CD on pregnancy and neonatal outcomes in single frozen-thawed embryo transfer (FET) cycles so that women with a previous cesarean delivery can be given detailed fertility counseling during the ART process. Methods: This is a large retrospective cohort study including a total of 5,750 patients who desired to transfer single vitrified-thawed blastocyst from the same oocyte retrieval cycle as their last live birth between January 2011 and January 2021 in a center for reproductive medicine in Shandong, China, comprising FET cycles of 3,853 previous single CD and 1,897 previous single vaginal delivery (VD). Results: Women with a previous CD had significantly lower rates of biochemical pregnancy (64.52% vs. 71.48% before propensity score matching (PSM), P&lt;0.001; and 65.58% vs. 71.49% after PSM, P&lt;0.001), clinical pregnancy (58.16% vs. 65.79% before PSM, P&lt;0.001; and 59.22% vs. 66.17% after PSM, P&lt;0.001) and live birth (48.17% vs. 55.82% before PSM, P&lt;0.001; and 49.29% vs. 56.10% after PSM, P&lt;0.001) than those with a previous VD. Meanwhile, the CD rate was significantly higher in the CD group (97.85% vs. 18.53% before PSM, P&lt;0.001; and 98.02% vs. 20.51% after PSM, P&lt;0.001). The rates of multiple pregnancy, miscarriage, ectopic pregnancy, multiple live birth, labor complications and preterm and neonatal outcomes were comparable between the two groups. Conclusion: Compared to VD, a previous CD is associated with a significant reduction in the rates of biochemical pregnancy, clinical pregnancy and live birth in patients undergoing subsequent single frozen-thawed blastocyst transfer.

The Impact of Preoperative Ultrasound and Intraoperative Findings on Surgical Outcomes in Patients at High Risk of Placenta Accreta Spectrum

(BJOG. 2023;130:42–50) When placental villous tissue abnormally attaches to the uterine wall it is known as placenta accreta spectrum (PAS). A large number of PAS cases are seen in the setting of placenta previa and previous cesarean delivery (CD). Removing placental villous tissue at delivery typically results in hemorrhaging. This hemorrhaging has been proven to be reduced when PAS is caught before delivery. Studies show that PAS is missed before delivery in over 50% of cases. This study aimed to determine how preoperative ultrasound can help to detect PAS in patients prior to delivery.

Outcome of subsequent pregnancies in women with prior uterine rupture

ObjectiveTo report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture. MethodsThe records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study. ResultsThe cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy. ConclusionWomen with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

A prediction tool for mode of delivery in twin pregnancies—a secondary analysis of the Twin Birth Study

One of the controversies regarding the management of twin gestations relates to the mode of delivery. Currently, counseling regarding the mode of delivery and the chance of successful vaginal twin delivery is based on the average risk for intrapartum cesarean delivery in the general population of twin pregnancies. Decision support tools that provide an individualized risk for intrapartum cesarean delivery based on the unique characteristics of each patient can improve counseling and decision-making regarding the choice of mode of delivery in twin pregnancies. This study aimed to develop and validate a prediction model to determine the risk for intrapartum cesarean delivery in twin pregnancies. In this secondary analysis of the Twin Birth Study, a multicenter randomized controlled trial, we considered the subgroup of individuals who underwent a trial of vaginal delivery. Candidate predictors included maternal age, parity, previous cesarean delivery, conception method, chorionicity, diabetes and hypertension in pregnancy, gestational age at birth, the onset of labor, presentation of the second twin, sonographic fetal weight estimation, and fetal sex. The co-primary outcomes were overall intrapartum cesarean delivery and cesarean delivery of the second twin. Multivariable logistic regression models were used to estimate the probability of the study outcomes. Model performance was evaluated using measures of discrimination (the area under the receiver operating characteristic curve), calibration, and predictive accuracy. Internal validation was performed using the bootstrap resampling technique. A total of 1221 individuals met the study criteria. The rate of overall intrapartum cesarean delivery and cesarean delivery for the second twin was 25.4% and 5.7%, respectively. The most contributory predictor variables were nulliparity, term birth (≥37 weeks), a noncephalic presentation of the second twin, previous cesarean delivery, and labor induction. The models for overall intrapartum cesarean delivery and cesarean delivery of the second twin had good overall discriminatory accuracy (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.688-0.752 and 0.736; 95% confidence interval, 0.669-0.803, respectively) and calibration (as illustrated by the calibration plot and Brier scores of 0.168; 95% confidence interval, 0.156-0.180 and 0.051; 95% confidence interval, 0.040-0.061, respectively). The models achieved good specificity (66.7% and 81.6%, respectively), high negative predictive value (86.0% and 96.9%, respectively), and moderate sensitivity (68.1% and 57.1%, respectively). The prediction models developed in this study may assist care providers in counseling individuals regarding the optimal timing and mode of delivery in twin pregnancies by providing individualized estimates of the risk for intrapartum cesarean delivery.

Impact of Caesarean section on pregnancy outcomes in ART after transfer of one or more frozen blastocysts

IntroductionThe prevalence of Caesarean delivery is rising steadily worldwide, and it is important to identify its future impact on fertility. A number of articles have been published on this subject, but the impact of Caesarean section on reproductive outcomes is still under debate, and none of these articles focus exclusively on frozen blastocysts. ObjectiveThe aim of this study was to evaluate the impact of a previous Caesarean delivery compared with a previous vaginal delivery on the chances of a live birth following the transfer of one or more frozen embryos at the blastocyst stage. MethodsThis was a retrospective, bicentric study at the University Hospitals of Nîmes and Montpellier, conducted between January 1st, 2016 and February 1st, 2021. Three hundred and ninety women with a history of childbirth and a transfer of one or more frozen embryos at blastocyst stage were included in the analysis. The primary outcome was the number of live births. Secondary outcomes were: the rate of positive HCG, miscarriage, ectopic pregnancy and clinical pregnancy, as well as the live birth rate according to the presence or absence of an isthmocele. ResultsOf the 390 patients included, 118 had a previous Caesarean delivery and 272 a vaginal delivery. No statistically significant differences were found for the primary (p = 0.9) or secondary outcomes. A trend towards lower live birth rates was observed in patients with isthmoceles, but this did not reach significance (p>0.9). On the other hand, transfers were more often described as difficult in the Caesarean delivery group (p = 0.011). ConclusionOur study found no effect of previous Caesarean delivery on the chances of live birth after transferring one or more frozen blastocysts. However, further prospective studies are needed to confirm these results.

Accuracy of Ultrasound in the Prediction of the FIGO Classification of Placenta Accreta Spectrum

ObjectivesTo evaluate the accuracy of greyscale ultrasound (US) and colour Doppler detecting placenta accreta spectrum (PAS) based on the newly recommended International Federation of Obstetrics and Gynaecology (FIGO) grading system. MethodsThis prospective study was conducted on women diagnosed with placenta previa or low-lying placenta involving the anterior uterine wall and associated with PAS as identified by the US. Transabdominal and transvaginal greyscale US was performed on admission between 34 and 36 weeks of gestation and compared to clinical grading and histopathological examination after cesarean hysterectomy. ResultsIn total, 36 pregnant females who underwent a cesarean hysterectomy due to placenta previa complicated by PAS were included in this study. All patients had a history of previous cesarean deliveries, ranging from 1 to 5 deliveries. The US has an overall sensitivity of 33%, 55%, and 84.62%, and specificity of 100%, 75%, and 60% in detecting the 3 degrees of PAS, respectively. US cannot differentiate between the different subtypes of PAS grade 3 (a, b, and c). ConclusionThe overall US evaluation was highly significant in predicting the FIGO diagnosis of PAS; however, all ultrasonographic signs were equally relevant in diagnosing grade 1 and/or 2 PAS and were inaccurate in differing the subtypes of PAS grade 3.

Uterine scars after caesarean delivery: From histology to the molecular and ultrastructural level.

Uterine rupture during a trial of labor after caesarean delivery (CD) is a serious complication for mother and fetus. The lack of knowledge on histological features and molecular pathways of uterine wound healing has hindered research in this area from evolving over time. We analysed collagen content and turnover in uterine scars on a histological, molecular and ultrastructural level. Therefore, tissue samples from the lower uterine segment were obtained during CD from 16 pregnant women with at least one previous CD, from 16 pregnant women without previous CD, and from 16 non-pregnant premenopausal women after hysterectomy for a benign disease. Histomorphometrical collagen quantification showed, that the collagen content of the scar area in uterine wall specimens after previous CD was significantly higher than in the unscarred myometrium of the same women and the control groups. Quantitative real-time PCR of uterine scar tissue from FFPE samples delineated by laser microdissection yielded a significantly higher COL3A1 expression and a significantly lower COL1A2/COL3A1 ratio in scarred uteri than in samples from unscarred uteri. Histological collagen content and the expression of COL1A2 and COL3A1 were positively correlated, while COL1A2/COL3A1 ratio was negatively correlated with the histological collagen content. Transmission electron microscopy revealed a destroyed myometrial ultrastructure in uterine scars with increased collagen density. We conclude that the high collagen content in uterine scars results from an ongoing overexpression of collagen I and III. This is a proof of concept to enable further analyses of specific factors that mediate uterine wound healing.

Late registration for ante natal care by pregnant women with previous caesarean section

BackgroundDespite good access to antenatal care services for most women in Botswana, and regular training of health care workers in obstetrics and gynaecology, many pregnant women with previous caesarean section still presented late for antennal care at Letsholathebe II Memorial Hospital (LIIMH), in Maun, Botswana. Presenting late for antenatal care may lead to morbidity and mortality among pregnant women with previous caesarean section, and the babies they are carrying. Knowing the reasons why women with previous caesarean section present late for antenatal care may help in the formulation of interventions that decrease late presentation. Decreasing late presentation for ante natal care among pregnant women with previous caesarean section may decrease morbidity and mortality among these women and their babies.Aim The aim of the study was to explore the reasons why pregnant women with previous caesarean section registered late for ante natal care.SettingThis study was done at Letsholathebe II Memorial Hospital (LIIMH); a district a hospital situated in Maun Botswana.MethodsThis was a descriptive qualitative study. Consenting pregnant women who had a previous caesarean section delivery, were interviewed in the local language, until data saturation. These women presented at LIIMH, Maun, after the 20th week of pregnancy. The interviews were audio recorded, transcribed, translated into English and analysed thematically, using ATLAS-ti software.ResultsThe reasons that were raised by participants for late registration for antenatal care were lack of information, misconception on the appropriate booking time, and not knowing the place for their antenatal care. Participants’ dissatisfaction with the quality of clinic antenatal care, use of alternative antenatal care providers, delayed referral from local clinics, and experience from previous pregnancies were also mentioned as reasons for late registration.Discussion and ConclusionInadequate knowledge of antenatal care, and not knowing the planned place of delivery contributed to delays in registering for antenatal care at LIIMH. Dissatisfaction with antenatal care, and use of alternative antenatal care providers was another important factor. There is a need to keep pregnant women with previous caesarean section well informed about plans for their delivery, and for enlisting the help of alternative ante natal care providers, so as to improve management of pregnant women with previous caesarean section.

First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry

BackgroundCesarean scar pregnancy (CSP) is an iatrogenic consequence of a prior cesarean delivery (CD). The gestational sac implants into a niche created by the incision of the previous CD carrying a substantial risk for major maternal complications. The aim of this study is to report, analyze and compare effectiveness and safety of different treatments options of CSP managed in the first trimester through a registry. ObjectivesTo study the ultrasound findings, disease behavior, and management of first trimester CSP. Study designWe created an international registry of CSP to study the ultrasound findings, disease behavior, and management of CSP. The CSP-registry collects anonymized ultrasound and clinical data of individual CSP patients on a secure digital information platform. Cases were uploaded by 31 participating centers in 19 countries. In this study we only included live and failing CSP (with or without positive fetal heart beat) who received active treatment (medical or surgical) before 12+6 weeks’ gestation in order to evaluate effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of pregnancy without the need for any additional medical intervention. ResultsBetween 29 August 2018 and 28 February 2023, we recorded 460 patients with CSP (281 live, 179 failing CSP) who fulfilled the inclusion/exclusion and were registered. 270/460 (58.7%) patients were managed surgically, 123/460 (26.7%) underwent medical management, 46/460 (10%) underwent balloon management and 21/460 (4.6%) underwent other, less frequently used treatment options. Suction evacuation was very effective, with 202/221(91.5%, 95%CI 87.8-95.2) success rate whilst systemic methotrexate was least effective with only 38/64 (59.4%, 95% CI 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of CSP was successful in 236/258 (91.5%, 95% CI 88.4-94.5) and the complication rate was 24/258 (9.3%, 95% CI 6.6-11.9). ConclusionCSP in the first trimester of pregnancy can be managed effectively in more than 90% of cases with either suction evacuation, balloon treatment or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age CSP should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with KCl or methotrexate is less efficient in and has higher rates of complications compared to the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first line treatment.

The relationship between cesarean delivery and fecundability: a population-based cohort study

BackgroundPrevious studies have found that women with caesarean delivery have fewer pregnancies. Caesarean delivery is also more common among women with lower fecundability. The potential role of caesarean delivery on reduced fecundability is not known. ObjectiveTo assess the bidirectional relationship between caesarean delivery and fecundability. Study DesignThis is a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥ 12 months) according to mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a caesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,025 women. ResultsThe proportion of women with infertility was 6.2% (2711/43936) among women with prior vaginal delivery, and 8.6% (518/6036) among women with a prior caesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval: 1.10 to 1.33). Women with previous caesarean delivery also had lower fecundability ratio (0.90, 95% confidence interval 0.88 to 0.93), compared to women with prior vaginal delivery. When assessing the reverse association between fecundability and caesarean delivery, we found that women who did not conceive within 12 or more cycles had higher risk of caesarean delivery (adjusted relative risk 1.55, 95% confidence interval 1.46 to 1.64) compared to women who conceived within the first two cycles. Associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups. ConclusionAmong women with more than one child, those who had caesarean delivery had subsequent lower fecundability ratio and increased infertility risk compared to those who had vaginal delivery. However, women who needed longer time to conceive were also more prone to be delivered by caesarean delivery. We therefore found evidence of a bidirectional relationship between caesarean delivery and fecundability. This could be due to a common underlying explanatory mechanism, and the surgical procedure itself may not directly influence fecundability.

Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study.

The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period. A population-based cohort study. Regions of Stockholm and Gotland, Sweden, 2008-2020. A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups. The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed. Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures. The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage. Increasing active first stage duration is associated with maternal complications in the early postpartum period.

Vaginal Birth after Caesarean Section: A Study of 60 Patients with Spontaneous Onset of Labor Pain

Background: Most women with a singleton pregnancy of cephalic presentation at 37+ weeks or later who have had a single prior lower segment cesarean delivery, with or without a history of prior vaginal birth, are candidates for planned VBAC and may be offered it for a trial of VBAC. Objective: The objective of this study is to determine the outcome of vaginal birth after caesarean section (VBAC) in a tertiary care hospital in Sylhet. Methods: This prospective study took place between April 2022 and February 2023 and lasted for a total of eleven months. A total of sixty patients were hospitalized in the gynecology and obstetrics department at North East Medical College, all of whom had a history of either one or two previous cesarean sections and were experiencing labor pain. 43 of these patients had their deliveries through the vaginal route. The remainder of the patients had cesarean sections because of fetal distress, scar tenderness, and the patient's wish during 1st stage of labor. Results: The VBAC success rate in this study was 71.67%. Among the 43 patients, the highest number of patients, 51.2%, came from the age range of 28-37 years, followed by 21 patients (48.8%), who were in the age category of 18-27 years. The majority of the patients (24, 55.82%) were in their second pregnancy, with 10 (23.25%) in their third pregnancy and 9 (20.93%) in their more than third pregnancy. Among the 43 patients, 42 (97.7%) had a previous caesarean section, while the remaining 1 patient (2.3%) had two previous caesarean sections. Most patients (58.14%) were admitted to the hospital between 35 and 38 weeks of pregnancy. Among the participants, 97.7% had normal placenta size, 88.4% had average bleeding, 79.1% had clear liquor and 97.7% had no scar rapture. The study shows an extremely low level of complication in VBAC. Conclusion: This study identified that, the success rate of vaginal birth after one caesarean section is very high. An evidence-based systematic review suggested that planned VBAC is a safe and appropriate mode of delivery for the majority of pregnant women with a single previous lower-segment caesarean delivery.