Previous Cesarean Research Articles

Cesarean section and the gestational duration of subsequent pregnancies: A nationwide register-based cohort study

Introduction Preterm delivery risk is increased for women with a previous cesarean section, which are becoming more common worldwide. However, this risk is based on studies which have not fully accounted for selection bias, and the studied outcomes have been limited to the study of early deliveries. This study aimed to determine the impact of previous delivery modes on the incidence of deviant duration of subsequent pregnancies. Material and methods This retrospective cohort study used clinical data registered in the Swedish Medical Birth Register. 612 935 women with their first two pregnancies and 157 581 women with their first three pregnancies were included. The outcome was the gestational duration of the last pregnancy of the series, depending on previous delivery modes. The associations were analysed with multivariable logistic regression (with the gestational duration categorised) and survival models including Cox regression analyses. Results When using standard logistic regression, previous cesarean section was associated with an increased risk of both spontaneous preterm birth (adjusted odds ratio [aOR] 1.67, 95% CI 1.57–1.77) and postterm birth (aOR 1.55, 95% CI 1.49–1.62). However, the more appropriate survival models only showed an association between cesarean section and longer gestational duration of the subsequent pregnancy (adjusted hazard ratio 0.72, 95% CI 0.71–0.73). Conclusions The survival model handles bias related to management differences between the exposure and reference groups better than standard logistic regression, making it the statistical method of choice when conducting studies on this research topic. This study shows that the main association between cesarean section and the gestational duration of the subsequent pregnancy is the prolonging of it, which stands in contrast with previous research on the topic.

Effectiveness of Intracervical Foley Catheter for Induction of Labor in Women With Singleton Term Pregnancy and Previous Lower Segment Cesarean Section: A Pilot Study

Effectiveness of Intracervical Foley Catheter for Induction of Labor in Women With Singleton Term Pregnancy and Previous Lower Segment Cesarean Section: A Pilot Study

Health care provider's perceived factors for the increased practice of caesarean delivery in North West Amhara referral hospitals, Ethiopia, 2022: a qualitative study

BackgroundCaesarean delivery is an essential obstetric intervention to reduce maternal and newborn mortality in emergencies. However, in Ethiopia, there is a high prevalence of caesarean deliveries. Therefore, this study aimed to explore the factors perceived by healthcare providers that contribute to the excessive rates of caesarean deliveries in North West Amhara referral hospitals, Ethiopia, in 2022.MethodsA phenomenological study design was employed, utilizing semi-structured interview guide for data collection. Fifteen healthcare providers working in referral hospitals in the north-western region of Amhara were interviewed using a heterogeneous purposive sampling approach until data was saturated. Transcribed interviews were translated coded and finally thematic analyses were employed using Open Code 4.0 software.ResultsHealthcare providers observed a significant increase in the frequency of caesarean deliveries. Multiple factors were identified as contributing to this rise, including the involvement of medical students, the use of cardiotocography, a decline in instrumental deliveries, inadequate trial of labor after previous caesarean deliveries, and the absence of clear indications for performing caesarean deliveries for social or maternal requests. Notably, patients who had received care in private clinics were more likely to undergo caesarean deliveries.ConclusionCaesarean deliveries were observed to be performed based on subjective or approximate indications, rather than clear obstetric indications. Encouraging greater emphasis on trial of labor, instrumental delivery, and performing caesarean deliveries only when there are definitive obstetric indications, rather than for social or maternal requests, can contribute to reducing the prevalence of caesarean delivery rates.

Parto vaginal después dos cesáreas. ¿Es una práctica segura?

Introduction: A widely held belief is that a mother who has had a cesarean section will no longer be able to deliver vaginally; however, there is evidence that it is possible even with two or more previous cesarean sections. Objective: To describe the results of vaginal delivery after one and two previous cesarean sections in a secondary care hospital in Djibouti. Methods: A descriptive, longitudinal study was conducted, which included patients with one or two previous cesarean sections more than two years ago, in labor, with no condition contraindicating transpelvic delivery. Results: All patients with two previous cesarean sections, and 96.9% of those with one previous cesarean section, were delivered with more than 4cm of cervical dilation. When the Flamm score was applied, 18 of the 33 patients with a previous cesarean section had a high probability of success if vaginal delivery was continued. The overall success rate with one previous cesarean section was 78.8%, and 87.5% with a history of two cesarean sections. There were 8 complications, 7 of which occurred in patients with only one previous cesarean section. The most frequent complication was immediate postpartum hemorrhage. Conclusions: The frequency of successful vaginal delivery after one or two cesarean sections was high. The prediction was more accurate for the group with two previous cesarean sections, although in both groups, when the Flamm score was high, vaginal delivery was almost always possible.

Development and internal validation of a model predicting successful trial of labour among pregnant individuals with previous one caesarean section: A cohort study (DEVI-CS model).

To develop and internally validate a model predicting successful trial of labour among pregnant women with previous caesarean scar. Cohort study. Tertiary care and teaching hospital. All pregnant women with one previous caesarean delivery, presenting with singleton pregnancies in cephalic presentation at a gestation age of 37weeks or more between 2018 and 2022. A stepwise multivariable logistic regression, followed by bootstrapping, was used to develop and validate the model. Success was defined as vaginal birth after caesarean section (VBAC) without complications for the mother and baby. Out of 4515 cases of TOLAC, 39.8% had a successful trial of labour. Maternal age (OR=0.950, 95%CI: 0.927-0.974), previous baby weight (OR=1.000, 95%CI: 1.000-1.001), indication of previous caesarean section such as breech presentation (OR=0.453, 95%CI: 0.315-0.652), failed induction (OR=0.346, 95%CI: 0.267-0.447), BISHOP score (OR=1.725, 95%Cl: 1.673-1.774) and induction of labour (OR=0.587, 95%CI: 0.466-0.741) were the strongest predictors of successful TOLAC. DEVI-CS model showed good discrimination with an area under the curve (AUC) of 0.928(95%CI: 0.921-0.936) and good agreement between predicted and observed probabilities. Decision curve analysis showed a net benefit between 5% and 90% between the predicted thresholds. The new DEVI-CS prediction model, based on easily captured clinical variables, can quantify the chances of a successful trial of labour after a previous caesarean section. It could aid in shared decision-making regarding the mode of delivery among women with planning the trial of labour after caesarean section.

Inter-pregnancy interval and uterine rupture during a trial of labour after one previous caesarean delivery and no previous vaginal births: a retrospective population-based cohort study.

Short interpregnancy interval (IPI) following caesarean delivery is associated with uterine rupture in subsequent pregnancies. However, the interval required to minimise this risk is unknown. We investigated how the interval between pregnancies and induction or augmentation of labour affect the likelihood of uterine rupture among parturients with one previous livebirth by caesarean delivery who had a subsequent trial of labour. In this population-based cohort study, we used data from U.S National Vital Statistics System from 2011 to 2021. Multiple pregnancies and births of infants with congenital abnormalities were excluded. A linear spline logistic regression with one knot was used to assess the relationship between uterine rupture and interpregnancy interval for spontaneous and for induced/augmented labours. Multivariable logistic regression was performed with multiple imputation and stepwise backward elimination to adjust for maternal demographic and clinical factors including maternal age, height, and BMI and gestational age. The predicted risk of uterine rupture was tabulated for interpregnancy intervals between zero and 21 months. Adverse outcomes were compared between labours with and without uterine rupture. We examined 491,998 trials of labour among parturients with one previous livebirth by caesarean delivery and no previous vaginal births. The odds ratio (OR) of uterine rupture per three months interpregnancy interval was 0.91 (95% CI 0.88-0.94) between zero and 21 months after adjusting for confounders, with no further change in risk detected beyond 21 months. The OR was 2.51 (95% CI 2.27-2.78) for induced or augmented labours compared with spontaneous labours. Other factors associated with uterine rupture included older maternal age, shorter maternal height, more advanced gestational age (from 35 to 43 weeks), and heavier birthweight. Predicted rates of uterine rupture ranged from 0.36% at zero to 0.19% at 21 months' interpregnancy interval for spontaneous labours and from 0.91% to 0.47% for induced/augmented labours for parturients with a typical clinical and demographic background. When uterine rupture occurred, the rates of unplanned hysterectomy, intrapartum or neonatal death, and neonatal seizures were 4.0% (95% CI 3.2-5.1%), 3.7% (95% CI 2.7-5.1%), and 2.6% (95% CI 1.8-3.3%) respectively. The risk of uterine rupture progressively decreases as IPI increases until about 21 months and then stabilises. Counselling should advise that for women choosing between a planned TOLAC or a planned caesarean delivery after one previous caesarean delivery and no previous vaginal births waiting until 21 months or longer after a prior low transverse caesarean delivery might minimise the risk of uterine rupture. The absolute risk of certain serious maternal and fetal/neonatal complications such as unplanned hysterectomy and perinatal death is low. No funding.

Investigating the implementation of a Trial of Labour After Caesarean (TOLAC) delivery bundle with respect to decreasing caesarean delivery rates: a multisite quality improvement initiative

ObjectivesTo study the effect of implementing a Trial of Labour After Caesarean (TOLAC) delivery bundle with respect to decreasing caesarean delivery rates across five hospitals.DesignProspective quality improvement study.SettingFive Canadian hospital...

Sonographic Lower Uterine Segment Thickness after Prior Cesarean Section to Predict Uterine Rupture

Introduction: Uterine rupture occurs in many pregnancies. The risk is higher for women who plan to have a normal birth after a previous cesarean section than for those who have another cesarean section. Objectives: This study aimed to predict the thickness of the lower uterine segment (LUS) by comparing a 2D transvaginal ultrasound with the findings during a cesarean section (C/S) in pregnant women with a history of previous cesarean sections. Methodology: This cross-sectional study was done at the Department of Obstetrics and Gynaecology, at the Institute of Child and Mother Health, Bangladesh from June 2023 to May 2024. A well-structured questionnaire was used for data collection. 100 women underwent transvaginal ultrasound followed by cesarean section (C/S) within a maximum of one week later. Also, an expert gynaecologist classified LUS thickness into four grades in the operation room. Result: The mean age of the women in the study was 30.7 years (±9.62), while the mean thickness of the lower uterine segment (LUS) was 2.25 cm (± 0.55). Among the participants, 43 were classified as grade I for the LUS based on intraoperative findings. The results indicated a significant difference in the mean thickness of the LUS measured by ultrasound across the three grades identified by the gynaecologist (P = 0.04). However, there were no significant differences in maternal age, gestational age, parity, or the time since the last cesarean section among women with different LUS grades (P > 0.05). Transvaginal ultrasound may be useful in assessing the risk of scar dehiscence and uterine rupture in women with LUS grades I and II who have a history of previous cesarean sections. Conclusion: Sonographic lower uterine segment thickness prediction is very important in the study of lower uterine segment thickness after a prior cesarean section to predict uterine rupture. 2D vaginal ultrasonography can be used to assess the risk of uterine scar dehiscence of grades I and II.

Development and validation of a prognostic nomogram forsevere postpartum hemorrhage after cesarean delivery: Atwo-center retrospective study.

To develop and validate a nomogram to predict severe postpartum hemorrhage following cesarean delivery. This is a two-center retrospective cohort study. Cesarean delivery patients from the First Affiliate Hospital of Jinan University were divided into a development cohort (n = 11 137) and an internal validation cohort (n = 4739). Cesarean delivery patients from the Dongguan Maternal and Child Health Care Hospital (n = 13 775) were enrolled in the external validation cohort. The nomogram was based on independent risk factors for severe postpartum hemorrhage obtained by multivariate logistic regression. We evaluated the discrimination and calibration of the nomogram in the development and validation cohorts. The nomogram used data including previous cesarean delivery, pre-pregnancy weight, preterm birth, placenta previa, placenta accreta spectrum disorders, placental abruption, and mode of anesthesia. The area under the curves of the nomogram in the internal and external validation cohorts were 0.922 (95% confidence interval [CI] 0.897-0.947) and 0.813 (95% CI 0.785-0.841), respectively. Consistency between the predicted and actual probabilities was observed in both validation cohorts. The nomogram displayed good calibration and discrimination and can be used for screening in clinical practice to enable clinicians to intervene appropriately.

Exploring barriers and facilitators of vaginal birth after caesarean section (VBAC), awareness, and preferences among females in Western Saudi Arabia

ABSTRACT Background: Women with a history of previous Cesarean Sections (CS) are faced with two choices during their pregnancy: Vaginal Birth After Cesarean (VBAC) or Elective Repeat Cesarean Delivery (ERCD). VBAC refers to vaginal delivery in women who have previously undergone a CS. Objectives: Despite limited studies on VBAC in Saudi Arabia, this research aims to assess the knowledge and awareness of Saudi women regarding VBAC. Methodology: This cross-sectional study was conducted among adult females in Western Saudi Arabia utilizing a convenient snowball sampling technique. The total number of participants was 901 females. The participants completed a self-administered questionnaire, which covered general information, knowledge about VBAC, and factors influencing their decision. Statistical analysis employed Chi-squared, Independent T-Test, and ANOVA. Results: Our findings revealed that 67.5% of participants had inadequate knowledge about VBAC. Only 45.6% of participants were familiar with the term VBAC. The primary reason for choosing CS over VBAC was medical necessity, as reported by 36.3% of participants. The most common reasons for rejecting VBAC were fear for their child’s safety and the fact that a CS was recommended, both reported by 35.1%. The lowest reported reason was external interference from family or spouses, at 10.5%. Conclusion: Although the majority of our sample consisted of highly educated women, most exhibited poor knowledge regarding VBAC. Therefore, raising awareness about VBAC, especially through healthcare professionals and their clinics, is essential.

Risk of Stillbirth After a Previous Caesarean Delivery: A Swedish Nationwide Cohort Study

(Abstracted from BJOG 2024;131:1054–1061) The rate of cesarean delivery (CD) rose from 12% in 2000 to 21% in 2015. There may be as many as 6.2 million CDs performed each year without a specific medical indication.

Impact of previous cesarean delivery on pregnancy and neonatal outcomes in subsequent in vitro fertilization/intracytoplasmic sperm injection and single frozen-thawed embryo transfer: a historical cohort study with a large sample size.

This study aims to explore the impact of a woman's previous cesarean delivery (CD) on pregnancy and neonatal outcomes for subsequent in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) and single frozen-thawed embryo transfer (FET), compared with vaginal delivery (VD). This was a retrospective cohort study that included a total of 5817 patients who desired to transfer a single vitrified-thawed blastocyst from the same oocyte retrieval cycle as their last live birth between January 2011 and January 2021 at a single reproductive medicine center. Patients with a single previous CD were classified in the CD group, while those with a single VD were assigned to the VD group. All patients underwent single blastocyst transfer. To minimize the effect of confounding factors, modified Poisson regression analyses with different adjustment models and propensity score matching (PSM) analyses were performed. Women with a previous CD had significantly lower rates of biochemical pregnancy, clinical pregnancy, and live births than those with a previous VD. Meanwhile, the CD rate was significantly higher in the CD group. There were no significant differences in the rates of multiple pregnancies, miscarriage, ectopic pregnancy, multiple live births, maternal complications, or preterm and neonatal outcomes. 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. Additionally, it increases the rates of repeat CD.

The Impact of Previous Cesarean Delivery on Preterm Birth: A Comprehensive Review

Obstetric complication in preterm birth has significantly affected both mothers and their new-borns; therefore, increasing the incidence for women with previous history of cesarean delivery. It leads to complications, like uterine rupture, cervical insufficiency, and abnormality of the placenta, with a likelihood that increases chances for preterm births. Such pregnancies may also be further sub-classified under spontaneous or medically indicated categories. Spontaneous preterm birth is largely attributed to complications like uterine rupture, that is, with more severe outcomes; however, medically indicated premature birth, mostly due to the mother's health issues or fetal distress, has risks for neonatal respiratory complications. The more cesarean deliveries, the higher is the risk of preterm birth. With multiple repeat cesarean deliveries, the risk of complications like placenta previa and placenta accreta due to cumulative uterine scarring and adhesions increases as well. Short interpregnancy intervals may pose particular risks for preterm birth, especially for intervals under 18 months; complications such as uterine rupture and abnormal placentas contribute to these risks. Obesity and advanced maternal age are maternal variables that enhance the risk of preterm birth following cesarean delivery. Preeclampsia, diabetes, and gestational hypertension are added risks associated with obesity. In order to enhance outcomes for moms and newborns, the report emphasizes early intervention, meticulous risk factor control, and proper birth spacing. To enhance the health of the mother and the baby and reduce the likelihood of preterm delivery in women who have had prior cesarean sections, a better understanding of the complex relationships between these factors is necessary.

Pregnancy Outcomes and Maternal Characteristics in Women with Pregestational and Gestational Diabetes: A Population-Based Study in Spain, 2016-2022.

Background/Objectives: The objective of this study was to compare trends in the incidence of deliveries and in obstetric interventions and outcomes in women with and without type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM). Methods: This was an observational study using the Spanish National Hospital Discharge Database (2016-2022). Results: A total of 1,995,953 deliveries were recorded between 2016 and 2022 (6495 mothers with T1DM, 5449 with T2DM, and 124,172 with GDM). The incidence of T1DM and GDM increased over time, although it remained stable in women with T2DM. Women with T2DM were more likely to have obstetric comorbid conditions (72.93%) than women with GDM (63.04%), women with T1DM (59.62%), and women who did not have diabetes (45.3%). Pre-eclampsia, previous cesarean delivery, and arterial hypertension were the most prevalent conditions in all types of diabetes. The highest frequency of cesarean delivery was recorded for women with T1DM (55.04%), followed by women with T2DM (44.94%), and those with GDM (28.13%). The probability of cesarean delivery was 2.38, 1.79, and 1.19 times greater for T1DM, T2DM, and GDM, respectively, than for women who did not have diabetes. The adjusted rate for severe maternal morbidity was significantly higher for women with T1DM (RR 2.31; 95%CI 2.02-2.63) and T2DM (RR 1.58; 95%CI 1.34-1.87) than for women without diabetes. Conclusions: The incidence of deliveries in women with T2DM remained unchanged between 2016 and 2022; the incidence of deliveries increased in women with T1DM and GDM. The prevalence of comorbidity and obstetric factors increased over time in women with T1DM and GDM.

Exploring pathophysiological insights to improve diagnostic utility of ultrasound markers for distinguishing placenta accreta spectrum from uterine-scar dehiscence.

Accurate differentiation between placenta accreta spectrum (PAS) and uterine-scar dehiscence with underlying non-adherent placenta is often challenging, even for PAS experts, both prenatally and intraoperatively. We investigated the use of standardized two-dimensional grayscale ultrasound and Doppler imaging markers in differentiating between these closely related, yet distinct, conditions. This was a retrospective cohort study conducted in two centers with specialized PAS services. All consecutive women with at least one previous Cesarean delivery and a current pregnancy with a low-lying placenta or placenta previa, for whom detailed prenatal ultrasound, management and outcome information was available for review by the research team, were included. PAS was diagnosed clinically by the abnormal adherence of the placenta to the uterus. The PAS cases were classified using the International Federation of Gynecology and Obstetrics clinical classification. Grade 1 was considered low-grade PAS while Grades 2 and 3 were classified as high-grade PAS. The ultrasound markers were categorized according to their underlying pathophysiology, including lower uterine segment (LUS) remodeling, uteroplacental vascular remodeling and serosal hypervascularity. The combined ultrasound features were analyzed among the PAS and non-PAS subgroups using the chi-square test or Fisher's exact test, and univariable and multivariable logistic regression analysis. Additionally, receiver-operating-characteristics (ROC) curves were used to evaluate the diagnostic accuracy of the combined ultrasound features in differentiating between high-grade PAS and uterine-scar dehiscence. Out of the 150 cases retrieved, six cases were excluded for not meeting the eligibility criteria. The included 144 cases comprised 89 cases of PAS, 23 cases of uterine-scar dehiscence and 32 cases of uncomplicated low-lying placenta or placenta previa. Among the PAS cases, there were 16 cases of low-grade PAS and 73 of high-grade PAS. Combined signs of LUS remodeling were present in most cases of uterine-scar dehiscence (20/23 (87.0%)) and high-grade PAS (67/73 (91.8%)) (P = 0.444), while these signs were absent in cases of low-grade PAS (0/16) and uncomplicated low-lying placenta or placenta previa (0/32). A subgroup analysis of cases with all LUS remodeling features present revealed that the combined signs of serosal hypervascularity (adjusted odds ratio (aOR), 41.2 (95% CI, 7.5-225.3)) and uteroplacental vascular remodeling (aOR, 116.0 (95% CI, 15.3-878.3)) were significantly associated with high-grade PAS. Diagnostic accuracy testing within this subgroup revealed an area under the ROC curve (AUC) of 0.90 (95% CI, 0.81-0.99), sensitivity of 89.6% (95% CI, 79.7-95.7%) and specificity of 90.0% (95% CI, 68.3-98.8%) for the diagnosis of high-grade PAS when all signs of uteroplacental vascular remodeling were present. If both signs of serosal hypervascularity were present, the AUC was 0.84 (95% CI, 0.74-0.95) with a sensitivity of 83.6% (95% CI, 72.5-91.5%) and specificity of 85.0% (95% CI, 62.1-96.8%) for the diagnosis of high-grade PAS. The combined ultrasound markers of LUS remodeling are common in both high-grade PAS and uterine-scar dehiscence, while the combined features of abnormal vascularity (uteroplacental vascular remodeling and serosal hypervascularity) are specific to high-grade PAS. Understanding these pathophysiological differences would enhance the diagnostic accuracy of ultrasound in distinguishing between these two conditions. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Tugging the Foley catheter balloon every three hours in induction of labor after one previous cesarean: a randomized controlled trial.

Induction of labor after 1 previous cesarean delivery with an unripe cervix have an especially high risk for unplanned cesarean delivery and uterine rupture. Mechanical balloon ripening is often preferred over prostaglandin-based ripening during induction of labor after 1 previous cesarean delivery, because uterine rupture has been associated with prostaglandin use. The transcervical Foley balloon can be dislodged past the ripened cervix and be retained comfortably in the vagina during passive placement. Tugging of the Foley catheter can be a noninvasive and tolerated method for timelier retrieval of the retained balloon; expediting discovery of a ripened cervix would permit an earlier follow-on amniotomy and oxytocin infusion, thereby hastening birth. This study aimed to evaluate the effect of tugging of the Foley balloon for 30 seconds every 3 hours during 12 hours of scheduled placement in comparison with standard care (no tugging) on the induction to birth interval and patient satisfaction. This randomized controlled trial, conducted at a university hospital in Malaysia, recruited participants from April 2023 to March 2024. Eligible participants admitted for Foley balloon induction of labor who had 1 previous cesarean were recruited. After balloon insertion, participants were randomized to tugging or standard care. Following balloon displacement, a vaginal examination was performed to check the cervix. The examination findings then dictated the follow-on management of induction of labor after 1 previous cesarean according to standard practice. The primary outcomes were the induction (Foley insertion) to delivery interval and participants' satisfaction with the birthing process. Secondary outcomes were largely derived from the core outcome set for trials on induction of labor. Based on a superiority hypothesis, it was calculated that a sample size of 126 would be required to detect a 4-hour reduction in the induction-to-delivery interval and a 1.5 point increase in the satisfaction score based on a 0 to 10 numerical rating scale with the level of significance set at 0.05, power at 80%, and a 10% drop out rate. Comparative analyses using an intention-to-treat approach were conducted using t tests, Mann-Whitney U tests, chi square tests, and Fisher exact tests as appropriate. A total of 126 participants were randomized with 63 in each trial arm. The induction to birth interval was (mean ± standard deviation) 29.7±9.6 hours for those in the 3-hourly tugging group and 29.8±9.1 hours for those under standard care (P=.950), and maternal satisfaction with the induction of labor after 1 previous cesarean delivery birth process, assessed using a 0 to 10 numerical rating scale, was (median [interquartile range]) 8 [7-9] and 8 [7-9] (P=.936), respectively. The cesarean delivery rate was 37 of 63 (59%) vs 41 of 63 (65%) (P=.238) for those in the tugging group vs standard care, and the main indication for unplanned cesarean delivery was failure to progress with an incidence of 24 of 37 (65%) and 24 of 41 (59%) (P=.914) for tugging vs standard care arms, respectively. Three-hourly tugging also did not shorten the interval from induction to balloon displacement, amniotomy, the start of oxytocin infusion, or the second stage of labor. Tugging the catheter every 3 hours during scheduled 12-hour Foley balloon placement for induction of labor after 1 previous cesarean delivery did not hasten birth or improve patient satisfaction when compared with standard care.

Pregnancy on Scar: About 3 Cases

Introduction: Pregnancy on a cesarean scar is a rare form of ectopic pregnancy that occurs within the myometrium of a previous cesarean scar. Its incidence is estimated between 1 in 1,800 and 1 in 2,500 pregnancies. This condition poses significant risks, including massive hemorrhage and uterine rupture, due to its often-delayed diagnosis and challenging management. Methods: Authors present three clinical cases of pregnancies on cesarean scars, managed at our maternity ward. Diagnostic and treatment approaches varied, including methotrexate therapy and surgical interventions. Authors analyzed the incidence, diagnostic criteria, and treatment outcomes based on these cases and recent literature. Results: The incidence of pregnancies on cesarean scars in our service was 0.05%. Diagnoses were made through ultrasound, with advanced imaging used when necessary. Treatments included methotrexate and surgical procedures, with success rates comparable to those reported in the literature. Management strategies were adapted to individual patient circumstances. Discussion: The incidence of pregnancies on cesarean scars appears to be increasing. Diagnostic challenges and the potential for severe complications necessitate early detection and tailored treatment strategies. Methotrexate remains a key component of medical management, though surgical options are essential for severe cases. Preventive measures, including early ultrasound screening and scar assessment, are recommended to reduce recurrence risks. Conclusion: Early diagnosis and appropriate management of pregnancies on cesarean scars are crucial to prevent severe outcomes. The increasing frequency of this condition highlights the need for continued research and development of standardized diagnostic and treatment protocols. Ensuring thorough evaluation and individualized care can significantly improve patient outcomes.

Total Laparoscopic Hysterectomy in Women with Previous Cesarean Section: An Observational Study

Background: Cesarean sections (CS) and hysterectomies are common gynecological surgeries, with CS rates increasing recently. Patients undergoing hysterectomy with a history of CS face higher risks, such as blood loss and urologic injuries, due to pelvic adhesions, which occur in 30%-90% of those with prior laparotomies. The choice of hysterectomy method is crucial, with options including abdominal, vaginal, laparoscopic, and robotic approaches. Laparoscopic hysterectomy, particularly total laparoscopic hysterectomy (TLH), offers benefits like reduced blood loss and faster recovery, though it remains challenging in patients with prior CS. Aim of the study: The study aims to evaluate how previous cesarean deliveries affect the outcomes of total laparoscopic hysterectomy (TLH). Methods: This cross-sectional observational study involved 110 patients undergoing total laparoscopic hysterectomy (TLH) at in the Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University (BSMMU) and in two private Hospitals Dhaka, Bangladesh, from February 2019 to January 2023. Following ethical approval. Patients were divided into two groups: Group A (55 patients) had a previous cesarean section, and Group B (55 patients) did not. Inclusion criteria included women over 30 with a history of cesarean section, while exclusions were for those with laparotomy or genital malignancy. Data on surgery duration, complications, and recovery were analyzed using SPSS, with significance set at p<0.05. Result: The study compared two groups of patients undergoing total laparoscopic hysterectomy, focusing on demographic, clinical, and intraoperative variables. The majority were aged 40-49 years, with similar BMI and parity. Common indications included abnormal uterine bleeding (27.27% in Group A vs. 30.91% in Group B; p=0.325). Chronic pelvic pain was more frequent in Group A (25.45% vs 9.09%; p=0.266). Mean operative time was longer in Group A (73.72±16.47 vs. 59.26±10.57 ...

The relationship between ethnicity and place of birth in England: a mixed-methods study

BackgroundUK maternity policy advocates a choice of birthplace in an obstetric-led unit (OU), a midwife-led unit (MLU) or at home. Although robust evidence supports the safety of birth in midwife-led settings, particularly for women with uncomplicated pregnancies, most births are in the OU. Women and babies from ethnic minority communities experience major health disparities and inequitable care, but there is limited research examining birthplace choices through an ethnicity lens. This study investigated the association between ethnicity and place of birth at an urban NHS Trust in England.MethodsA mixed-methods sequential explanatory study. Analysis of births from 2014–2023 at a London NHS Trust included multivariable logistic regression analysis of birthplace by ethnicity. Planned or pre-labour Caesareans, pre-term, and multiple births were excluded. Significant disparities between White and South Asian women were identified which informed the focus of the qualitative study. Semi-structured interviews with 10 women of South Asian heritage who had given birth in the OU, the alongside MLU or at home were conducted and analysed thematically.ResultsMore White women gave birth in midwife-led settings (27.5%) than all other ethnicities, particularly South Asian women (20.6%). South Asian women had fewer homebirths (0.8%) than White women (2.7%) and were much less likely to birth in a midwife-led setting after adjusting for parity, maternal age, BMI, previous Caesarean, presence of diabetes or hypertensive disorders and onset of labour (aOR 0.61, 95% CI 0.51–0.73, p < 0.001). Places of birth were similar for Black and White women, although the number of Black women in the population was too low to detect significant differences.Themes generated from interviews included the assumption that birth is hospital-based and doctor-led; choosing a midwife-led birth setting went against the cultural norm, but felt safe – physically, psychologically and culturally.ConclusionsThere are ethnic disparities in place of birth. Cultural factors seem influential, but barriers to choice, such as limited evidence-sharing by midwives, may disproportionately affect women from ethnic minority communities, who may particularly benefit from midwife-led birth settings. Women need personalised information about options. Improving choice of birthplace is a step towards reducing health inequalities and promoting optimal health.

Management of Cesarean Scar Ectopic Pregnancies: A Retrospective Study and Literature Review.

Cesarean scar ectopic pregnancy (CSEP) is localized over the scar of a previous cesarean section. CSEP is a challenging entity, both in terms of diagnosis and management. The clinical presentation of CSEP may vary from asymptomatic patients with positive urine pregnancy tests to acute presentations such as pelvic pain, bleeding per vaginum, uterine rupture, and hemodynamic instability. Cesarean scar ectopic pregnancy is primarily diagnosed by transvaginal ultrasound. We present a series of six cases of CSEPs, their diagnostic approaches, and outcomes. Out of our six cases, four patients underwent intracardiac injection of potassium chloride (KCl) followed by methotrexate instillation into the gestational sac. This led to the successful resolution of cardiac activity and the collapse of thegestational sac. Two patients underwent curettage under ultrasound guidance. All of the patients recovered successfully without any major surgery. The key to diagnosis is the high degree of suspicion of CSEP in cases of previous cesarean deliveries, even in the absence of any symptoms.