Prediction of Intraperitoneal Adhesions in Repeated Cesarean Deliveries with Stria Gravidarum Scoring System: A Cross-sectional Study.

BACKGROUND: The preoperative prediction of intraperitoneal adhesion (IPA) before repeated cesarean deliveries (CD), which are becoming more prevalent, is crucial for maternal health. AIM: The aim of the study was to preoperatively predict IPA in repeated CD with the stria gravidarum (SG) scoring system. METHODS: A total of 167 patients with at least one previous CD at or beyond 37 weeks of gestation were analyzed. Preoperative SG was calculated according to the Davey scoring system: 0-2 score were defined as mild SG (Group 1; n: 94, 56.2%), and 3-8 score were defined as severe SG (Group 2; n = 73, 43.8%). Preoperative previous cesarean incision features were evaluated according to the Vancouver scar scale. IPA was evaluated according to the Nair's and modified Nair's scoring systems. RESULTS: Parity, younger age at first pregnancy, higher body mass index, number of previous CDs, rate of scar symptoms, Nair's and the modified Nair's scores were statistically significant in Group 2 (P = 0.01; P = 0.04; P = 0.007; P = 0.004; P < 0.001; P = 0.007; P = 0.02, respectively). Davey score ≥3 and Vancouver score ≥4.5 were determined as the cut-off value to predict IPA (P = 0.1 and 0.07, respectively). According to multivariate analysis, both Davey and Vancouver scores are independent factors in predicting IPA (P = 0.02 and 0.04, respectively). CONCLUSION: Evaluating the SG score through the Davey score in women with a history of previous CD may assist in predicting IPA status before the planning of a subsequent surgery.

Trial of labor after 2 previous cesareans: a multicenter study.

BACKGROUND: Trial of labor after cesarean after 2 cesarean deliveries is linked to a lower success rate of vaginal delivery and higher rates of adverse obstetrical outcomes than trial of labor after cesarean after 1 previous cesarean delivery. OBJECTIVE: This study aimed to investigate the factors associated with failed trial of labor after cesarean among women with 2 previous cesarean deliveries. STUDY DESIGN: This was a multicenter retrospective cohort study, which included all women with singleton pregnancies attempting trial of labor after cesarean after 2 previous cesarean deliveries between 2003 and 2021. This study compared labor, maternal, and neonatal characteristics between women with failed trial of labor after cesarean and those with successful trial of labor after cesarean. Univariate analysis was initially performed, followed by multivariable analysis (adjusted odds ratios with 95% confidence intervals). RESULTS: The study included a total of 1181 women attempting trial of labor after cesarean after 2 previous cesarean deliveries. Among these cases, vaginal birth after cesarean was achieved in 973 women (82.4%). Women with failed trial of labor after cesarean had higher rates of maternal and neonatal morbidities. Several factors were found to be associated with failed trial of labor after cesarean, including longer interpregnancy and interdelivery intervals, lower gravidity and parity, lower rates of previous successful vaginal delivery, smoking, earlier gestational age at delivery (38.3±2.1 vs 39.5±1.3 weeks), late preterm delivery (34-37 weeks of gestation), lower cervical dilation on admission, no use of epidural, and smaller neonatal birthweight. Our multivariable model revealed that late preterm delivery (adjusted odds ratio, 3.79; 95% confidence interval, 1.37-10.47) and cervical dilation on admission for labor <3 cm (adjusted odds ratio, 2.58; 95% confidence interval, 1.47-4.54) were associated with higher odds of failed trial of labor after cesarean. CONCLUSION: In the investigated population of women with 2 previous cesarean deliveries undergoing trial of labor after cesarean, admission at the late preterm period with a cervical dilation of <3 cm, which reflects the latent phase, may elevate the risk of failed trial of labor after cesarean and a repeated intrapartum cesarean delivery.

A jump into the deep end - Women's strategies on the way to VBAC in Poland.

PROBLEM: In Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. BACKGROUND: Research shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. AIM: This study aims to explore the elements of Polish maternity services that contribute to or hinder women's chances of having a VBAC. METHODS: The study used qualitative methods of research based on semi-structured interviews. We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. FINDING: Women who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. CONCLUSIONS: Polish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women's social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

Misoprostol and mid trimester termination of pregnancy in patients with two previous scars and more at Elwiya Maternity Teaching Hospital / Misoprostol e interrupção da gravidez no meio do trimestre em pacientes com duas cicatrizes anteriores e mais no Elwiya Maternity Teaching Hospital

Abstract Objectives: to determine efficiency and safety of three misoprostol regimens for 2nd trimester pregnancy termination in individuals with two or more cesarean section scars. Methods: a cross-sectional study included 100 pregnant ladies at 13th-26th weeks gestation with previous two cesarean sections (CSs) who were scheduled for pregnancy termination using misoprostol. Patients were conveniently assigned to 100µg/3h, 200µg/3h or 400 µg/3h regimens. Primary outcome was time to abortion, secondary outcomes were side effect and complications. Results: a significant association was found between number previous CSs and longer time to abortion (p=0.01). A highly significant association was identified between earlier gestational age and longer time to abortion (p<0.001). Lower side effects and complications were associated with 200 µg misoprostol every 3 hours of (p<0.001). Incomplete abortion was the most frequent recorded complication for the successive doses of misoprostol. Conclusions: misoprostol is an effective drug at low doses for pregnancy termination in women with prior two or more caesarean sections. However, its safety needs monitoring of the patient in the hospital to decrease morbidity and mortality behind its use.

Resumo Objetivos: determinar a eficiência e segurança de três regimes de misoprostol para interrupção da gravidez no segundo trimestre em indivíduos com duas ou mais cicatrizes de cesariana. Métodos: um estudo transversal incluiu 100 gestantes entre 13ª e 26ª semanas de gestação com duas cesarianas (CEs) anteriores que foram agendadas para interrupção da gravidez com uso de misoprostol. Os pacientes foram convenientemente designados para regimes de 100 µg/3 horas, 200 µg/3 horas ou 400 µg/3 horas. O desfecho primário foi o tempo para o aborto, os desfechos secundários foram efeitos colaterais e complicações. Resultados: foi encontrada associação significativa entre o número de cesáreas anteriores e o maior tempo até o aborto (p=0,01). Foi identificada associação altamente significativa entre idade gestacional mais precoce e maior tempo para abortar (p<0,001). Menores efeitos colaterais e complicações foram associados com 200 µg de misoprostol a cada 3 horas (p<0,001). O aborto incompleto foi a complicação mais frequente registrada para as doses sucessivas de misoprostol. Conclusões: o misoprostol é um medicamento eficaz em doses baixas para interrupção da gravidez em mulheres com duas ou mais cesarianas anteriores. Porém, sua segurança necessita de monitoramento do paciente no hospital para diminuir a morbimortalidade por trás de seu uso.

Increased Cesarean Section Rates during the COVID-19 Pandemic: Looking for Reasons through the Robson Ten Group Classification System / Aumento das taxas de cesárea durante a pandemia de COVID-19: procurando explicações por meio da Classificação de Robson

Abstract Objective To compare cesarean section (CS) rates according to the Robson Ten Group Classification System (RTGCS) and its indications in pregnant women admitted for childbirth during the first wave of the coronavirus disease 2019 (COVID-19) pandemic with those of the previous year. Materials and Methods We conducted a cross-sectional study to compare women admitted for childbirth from April to October 2019 (before the pandemic) and from March to September 2020 (during the pandemic). The CSs and their indications were classified on admission according to the RTGCS, and we also collected data on the route of delivery (vaginal or CS). Both periods were compared using the Chi-squared (χ2) test or the Fisher exact test. Results In total, 2,493 women were included, 1,291 in the prepandemic and 1,202 in the pandemic period. There was a a significant increase in the CS rate (from 39.66% to 44.01%; p = 0.028), mostly due to maternal request (from 9.58% to 25.38%; p < 0.01). Overall, groups 5 and 2 contributed the most to the CS rates. The rates decreased among group 1 and increased among group 2 during the pandemic, with no changes in group 10. Conclusion There was an apparent change in the RTGSC comparing both periods, with a significant increase in CS rates, mainly by maternal request, most likely because of changes during the pandemic and uncertainties and fear concerning COVID-19.

Resumo Objetivo Comparar as taxas de cesárea segundo a Classificação de Robson, assim como suas indicações, em mulheres admitidas para parto durante a primeira onda de doença do coronavírus 2019 (coronavirus disease 2019, COVID-19, em inglês), com as do ano anterior. Materiais e Métodos Conduzimos um estudo transversal que comparou as mulheres admitidas para parto entre abril e outubro de 2019 (pré-pandemia) e entre março e setembro de 2020 (durante a pandemia). As cesarianas e as suas indicações foram classificadas conforme o sistema proposto por Robson, e obteve-se a via de parto (vaginal ou cesárea). Ambos os períodos foram comparados usando-se os testes do Qui quadrado ou o exato de Fisher. Resultados Ao todo, 2.943 mulheres foram incluídas, das quais 1.291 antes da pandemia e 1.202 durante a pandemia. A taxa de cesárea aumentou significativamente (de 39.66% para 44,01%; p = 0,028), principalmente devido a desejo materno (de 9,58% para 25,38%; p < 0,01). Os grupos 5 e 2 foram os que mais contribuíram para as taxas de cesárea. Durante a pandemia, o grupo 1 reduziu sua frequência, enquanto o grupo 2 a aumentou. Conclusão Houve uma aparente mudança nas características da população conforme a classificação de Robson. Observou-se significativo aumento nas taxas de cesárea, principalmente por desejo materno, o que reflete possíveis incertezas e medos relacionados à COVID-19.

Prediction of intraperitoneal adhesions in repeated cesarean sections: A Systematic review and Meta-analysis.

OBJECTIVE: With the rate of repeated cesarean sections on the rise, intraperitoneal adhesions caused by repeated cesareans could give rise to maternal morbidity during delivery. As a result, it's critical to have the ability to predict adhesions. The current meta-analysis aims to determine if intraperitoneal adhesions are likely to be present based on the characteristics of the cesarean scar, striae gravidarum, and sliding sign. MATERIALS AND METHODS: We systematically searched electronicdatabases beforeretrieving articles up until October 13th, 2022 for analysis. After data extraction and literature screening, we first performed a quality assessment using the QUADAS-2 score system. Following that, a bivariate random-effect meta-analysis model was used to obtain the combined diagnostic and predictive values. To pinpoint the origins of heterogeneity, we conducted a subgroup analysis. Fagan's Nomogram was used to validate the clinical utility. Sensitivity analysis was used to gauge the reliability of each included study, and Egger's test and funnel plot asymmetry was used to investigate publication bias. RESULTS: 25 studies totaling 1840 patients with intra-abdominal adhesions and 2501 controls without adhesions were included in the systematic review. Diagnostic values from 8 studies regarding skin characteristics were combined, and the results for depressed scar showed: sensitivity[95 %CI] = 0.38[0.34-0.42]; Specificity[95 %CI] = 0.88[0.85-0.90]; DOR[95 %CI] = 4.78[2.50-9.13]; AUC = 0.65. Negative sliding sign from 7 studies, although not showing a diagnostic difference between cases and controls, had excellent predictive values: sensitivity[95 %CI] = 0.71[0.65-0.77]; Specificity[95 %CI] = 0.87[0.85-0.89]; DOR[95 %CI] = 6.88[0.6-78.9]; AUC = 0.77. Subgroup analysis illustrated non-Turkish studies to reveal more significant associations than Turkish studies. CONCLUSION: Our meta-analysis found that the occurrence of adhesions can be predicted by the characteristics of abdominal wounds, particularly depressed scar, and scar width,as well as a negative sliding sign following a previous cesarean section.

The effectiveness of preoperative diagnostic methods in predicting intra-abdominal adhesions before repeat cesarean section delivery.

OBJECTIVE: This study aimed to evaluate the effectiveness of skin appearance, striae gravidarum severity, and ultrasonographic "sliding sign" in predicting preoperative adhesions before repeat cesarean section delivery on the same patient and find the most useful one. METHODS: This was a prospective cohort study conducted on pregnant women with a history of cesarean section delivery. Davey's scoring system was used for stria evaluation. The scar was assessed using their visual appearance, and transabdominal ultrasonography was applied to detect sliding sign existence. Surgeons blinded to preoperative assessment graded the severity of intra-abdominal adhesions intraoperatively using Nair's scoring system. RESULTS: Of the 164 pregnant women with at least one previous cesarean section delivery, 73 (44.5%) had filmy or dense intra-abdominal adhesions. Statistically significant association was found between three groups regarding parity, previous cesarean number, scar appearance, total stria score, and sliding sign existence. Negative sliding sign had a likelihood ratio of 4.198 (95%CI 1.178-14.964) for the detection of intra-abdominal adhesions. Stria score and scar appearance were also valuable for detection adhesions with likelihood ratios of 1.518 (95%CI 1.045-2.205) and 2.405 (95%CI 0.851-6.796), respectively. After receiver operator characteristics curve analysis, striae score cutoff value in adhesion prediction was determined as 3.5. CONCLUSION: Stria score, scar appearance, and sliding sign are all significant predictors for intraperitoneal adhesions, and sliding sign, as an easy-to-apply, inexpensive, useful sonographic marker, is the most effective adhesion predictor before repeat cesarean section delivery compared to other known adhesion markers.

Preoperative sonographic sliding sign for prediction of intra-abdominal adhesions before repeat cesarean delivery.

OBJECTIVE: To evaluate the usefulness of the uterine sliding sign for predicting intra-abdominal adhesions in women undergoing repeat cesarean section (CS) and the association of the sliding sign with other operative and neonatal outcomes. METHODS: A prospective cohort study was conducted among pregnant women with at least one previous CS. Transabdominal ultrasonography was performed and classified as a positive or negative sliding sign. Surgeons blinded to the sonographic results assessed intra-abdominal adhesions. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Operative and neonatal outcomes of the positive and negative sliding sign groups were compared. Factors associated with intraoperative adhesions were also analyzed. RESULTS: A total of 380 women were recruited. The sensitivity and specificity of the uterine sliding sign to detect moderate-to-thick adhesions were 60.6% and 91.9%, respectively. A negative sliding sign was significantly associated with a higher incidence of adhesions, longer skin-to-delivery time, longer total operative time, and lower 5-min APGAR score in newborns. A negative sliding sign and history of two or more previous CS were significant predictors of moderate-to-thick adhesions. CONCLUSION: The uterine sliding sign is an independent predictor of intraoperative adhesions, with acceptable sensitivity and high specificity and negative predictive value.

Average maternal hemoglobin decline after first elective cesarean section compared to higher order cesarean sections.

INTRODUCTION: Lower uterine segment scarring after cesarean section can decrease intraoperative bleeding during subsequent surgery. We examined whether first elective cesarean section is associated with greater average blood loss compared to repeated surgery. METHODS: Decrease in maternal hemoglobin and hematocrit after surgery was retrospectively compared between three study groups, women in their first, second and third or more cesarean section. Surgery length and need for blood transfusion were also compared. RESULTS: Out of 9401 cases reviewed between January 2010 November 2020, 3917 had a first cesarean section, 3159 s cesarean section and 2325 had a third or more cesarean section. Hemoglobin and hematocrit drops were highest after first cesarean section (1.1 vs 1.0 vs 1.0 mg/dL, P < 0.001 and 3.3 vs 3.0, vs 2.9%, P < 0.001, respectively). Surgery length was significantly longer and more patients after third cesarean section required blood transfusions (2.5% vs 1.4% vs. 0.8%, P < 0.001). First cesarean section, younger age and BMI >35 were associated with increased hemoglobin drop in univariate and multivariate analysis. CONCLUSIONS: Although repeated cesarean section is associated with longer surgery and higher need for blood transfusion, average hemoglobin drop after first cesarean section is higher. Scarring of the lower uterine segment can explain this paradoxical finding.

The use of ultrasound sliding sign for prediction of adhesions in women undergoing repeated caesarean section.

We carried out this study to validate the use of ultrasound sliding sign to predict intraperitoneal adhesions in women undergoing repeated caesarean section (CS). A cross-section study was performed in women with at least one CS scheduled for an elective CS. We used the sliding sign of the uterus against the anterior abdominal wall to assess intraperitoneal adhesions, positive sliding sign if uterus moved freely and a negative sliding sign if limited mobility. The obstetrician was blind to the ultrasound results, asked to report if adhesions were absent or present during CS to validate accuracy of the sliding sign. We examined 120 women, negative sliding was reported in 54 patients, positive sliding in 66 women. The presence of intra-abdominal adhesions was confirmed in 44/54 cases assigned to the high-risk group, while the prediction of low risk for adhesions confirmed in 66/66 patients with a sensitivity of 100%, specificity of 86.84%. Sliding sign is an effective method to detect intra-abdominal adhesions in women with a history of repeated caesarean delivery.Impact statementWhat is already known on this subject? There has been a dramatic increase in the caesarean section (CS) rate worldwide; repeated CSs may be associated with intraperitoneal adhesions that result in difficulty during the procedure and may be related to bowel or bladder injuries and neonatal morbidities.What do the results of this study add? The sliding sign by ultrasound has a sensitivity of 100%, specificity of 86.84%, a positive predictive value of 81.5, a negative predictive value of 100, and accuracy of 91.67, considering it rapid, easy and reliable method for prediction of intraperitoneal adhesions.What are the implications of these findings for clinical practice and/or future research? The use of sliding sign by ultrasound in cases with repeated CSs offers a good predictor tool for presence of intraperitoneal adhesions and subsequently avoid severe sequels during surgery and good preparation.

Intra-abdominal Adhesions among Patients Undergoing Repeat Caesarean Section in Department of Obstetrics and Gynaecology of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Adhesions are one of the common complications encountered after caesarean section whose risk increases with the number of caesarean deliveries. This study aimed to find out the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted on 74 pregnant women undergoing repeat caesarean section in the Department of Obstetrics and Gynaecology of a tertiary care centre from July, 2021 to December, 2021 after receiving the ethical approval from the Institutional Review Committee (Reference number: 2107202103). Pregnant women who met the eligibility criteria were included in the study. Convenience sampling was done. The severity of the adhesions was classified using the Tulandi and Lyell classification. Data were analysed using the Statistical Package for the Social Sciences version 26.0 software. Point estimate at 90% Confidence Interval was calculated along with frequency and percentage for binary data along with mean and standard deviation for continuous data. Results: Out of 74 women undergoing repeat caesarean section, 55 (74.32%) (65.99-82.65 at 90% Confidence Interval) had developed intra-abdominal adhesions. Conclusions: Our study showed that the prevalence of intra-abdominal adhesions among patients undergoing repeat caesarean section was higher when compared to similar studies conducted in similar settings. Keywords: postoperative complications; repeat caesarean section; surgical adhesions.

Omental patch for lower uterine segment repair during caesarean section.

Increasing rates of caesarean section have contributed to a higher number of complications such as vesicouterine fistula. A G6P5 woman in her early forties presented for her third elective repeat caesarean section. At the time of delivery, there was uterine dehiscence and the fetus was visible through a large 7×5 cm transparent window in the lower segment. After delivery of the baby, the uterus was unable to be repaired with sutures so an omental patch was fixed on the lower segment to facilitate healing. It is hypothesised that the angiogenic properties of the omentum may have promoted healing of the uterine defect and reduced the risk of vesicouterine fistula by providing a protective barrier. The patient recovered well and by 4 months post partum, her menstrual cycle had returned. Thereby, the use of an omental patch during uterine repair may reduce long-term complications associated with repeat caesarean section.

Repeat Cesarean Section among Pregnant Women in a Tertiary Center of Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Cesarean Section is the most common obstetrics surgery done for both maternal and fetal indications. There is a rising trend of cesarean section rates which is associated with increased maternal morbidities. This study aims to find out the prevalence of repeat Cesarean Section among women with previous cesarean sections done in a tertiary centre. METHODS: This was a descriptive cross-sectional study conducted in a tertiary care hospital of Nepal from August 2020 to January 2021. Pregnant women with previous Cesarean Section status without other pelvic surgery and medical comorbidities were included and data were collected regarding intraoperative findings. Ethical approval was taken from the Institutional Review Committee (Reference Number: 14). A convenience sampling technique was used. Data were analysed using Statistical Package for the Social Sciences version 22. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage. RESULTS: Out of 1315 patients undergoing Cesarean Section, the prevalence of Repeat Cesarean Section was found to be 184 (13.99%) (12.11-15.86 at 95% Confidence Interval). CONCLUSIONS: The prevalence of Repeat Cesarean Cection from our study was similar to other studies done in similar settings. Repeat Cesarean Cection confers peri-operative morbidities which adversely affect postoperative recovery. Repeat Cesarean Cection continues to contribute to morbidity over subsequent pregnancies and serious maternal morbidity.

Castor oil for labor initiation in women with a previous cesarean section: a double-blind randomized study.

Objective: To evaluate the efficacy of castor oil in initiation of labor in women who had one previous cesarean section. This study was conducted as a trial to increase the rate of vaginal birth after cesarean (VBAC) and decrease the rate of elective repeated cesarean section (ERCS).Methods: A double-blinded randomized controlled study was conducted in an Egyptian University Hospital from July 2019 to July 2020. The participants were 70 pregnant women who had one previous cesarean section, singleton pregnancy in cephalic presentation, with a Bishop score ≤6 attempting to perform a trial of labor. Sixty mL castor oil was administered to group A and 60 mL sunflower oil was administered to group B (as a placebo) for initiation of labor at the start of week 39. Primary outcomes were the percentage of women entering the active phase of labor within 24 h after receiving castor oil or placebo and the number of successful VBAC deliveries.Results: Labor started in 16 patients (45.7%) within 24 h in the castor oil group and in 3 patients in the placebo group (8.5%), while the rate of successful VBAC was 65.7% (23 patients) in the castor oil group and 48.5% (17 patients) in the placebo group.Conclusion: Castor oil appears to be an effective, low-cost, and non-harmful method for the initiation of labor in patients with a previous cesarean section.

Recurrent uterine rupture in third trimester of pregnancy.

We report a case of recurrent upper segment uterine rupture in a 31-year-old woman at 32+5/40 weeks of gestation. She had fundal uterine rupture 3 years ago in her first pregnancy at 40 weeks of gestation. There was no history of uterine malformation or prior uterine surgery. However, we noted that she had had three laparoscopic procedures for endometriosis treatment. She was scheduled to have an elective repeat caesarean section at 34+6/40 weeks of gestation in the index pregnancy. Unfortunately, she presented at 32+5/40 weeks with features of acute abdomen and signs of fetal distress. She had a category 1 caesarean section and was found to have fundal uterine rupture at the same site. She had a smooth uneventful recovery following a timely intervention and discharged home on day 5 postoperatively in a good condition with her baby girl.

Repeated cesarean section and vaginal delivery after cesarean section in São Paulo State in 2012 / Repetição de cesárea e parto vaginal após cesárea, no Estado de São Paulo, em 2012

Abstract Objectives: describe mothers, pregnancies and newborns' characteristics according to the type of childbirth history and to analyze repeated cesarean section (RCS) and vaginal delivery after cesarean section (VBACS), in São Paulo State in 2012. Methods: data are from the Sistema de Informações sobre Nascidos Vivos (Live Birth Information Systems). To find the RCS's group, the current type of childbirth equal to cesarean section was selected and from these all the previous cesareans. To identify the VBACS's group all live birth with current vaginal delivery were selected and from these all previous cesareans. Mothers with a history of RCS and VBACS were analyzed according to the characteristics of the pregnancy, newborn and the childbirth hospital. Results: 273,329 mothers of live birth with at least one previous child were studied. 43% of these were born of RCS and 7.4% of VBACS. Mothers who underwent RCS are older and higher educated and their newborns presented a lower incidence of low birth weight. Early term was the most frequent rating for gestational age born of RCS. Live births were of VBACS and had greater proportions of late term. The RCS was more common in hospitals not affiliated with the Sistema Único de Saúde (SUS) (Public Health System) (44.1%). Conclusion: the high RCS's rates, especially in the private sector, highlight the necessity of improvements in childbirth care model in São Paulo.

Resumo Objetivos: descrever características das mães, da gestação e do recém-nascido, segundo histórico de tipo de parto, analisando repetição de cesárea (RC) e parto vaginal após cesárea (PVAC), no Estado de São Paulo, em 2012. Métodos: os dados são provenientes do Sistema de Informações sobre Nascidos Vivos. Para encontrar o conjunto RC, selecionou-se o tipo de parto atual igual a cesárea e destes buscou-se todos com cesárea anterior. Para identificar o grupo PVAC, selecionou-se os recém-nascido com parto atual vaginal e destes buscou-se todos com cesárea anterior. Foram analisadas mães com história de RC e PVAC, segundo características da gestação, do recémnascido e hospital do parto. Resultados: estudou-se 273.329 nascidos vivos de mães com pelo menos um filho anterior. Destes, 43% nasceram por RC e 7,4% por PVAC. As mães que realizaram RC são mais velhas e mais escolarizadas, seus recém-nascidos apresentaram menor proporção de baixo peso ao nascer. Termo precoce foi a mais frequente idade gestacional dos que nasceram por RC. Os recém-nascidos por PVAC apresentaram maiores proporções de termo tardio. RC foi mais frequente nos hospitais sem vínculo com o Sistema Único de Saúde (44,1%). Conclusão: as altas taxas de RC, principalmente no setor privado, evidenciam necessidade de melhoras no modelo de atenção ao parto em São Paulo.

Prediction of intraperitoneal adhesions using striae gravidarum and scar characteristics in women undergoing repeated cesarean sections.

BACKGROUND: The current fact of increasing rates of cesarean deliveries is a catastrophe. Recurrent cesareans result in intraperitoneal adhesions that would lead to maternal morbidity during delivery. Great efforts are directed towards the prediction of intraperitoneal adhesions to provide the best care for laboring women. The aim of the current study was to evaluate the role of abdominal striae and cesarean scar characters in the prediction of intraperitoneal adhesions. METHODS: This was a case- control study conducted in the emergency ward of the obstetrics and gynecology department of a tertiary hospital from June to December 2019. The study was carried on patients admitted to the ward fulfilling particular inclusion and exclusion criteria. The study included two groups, group one was assessed for the presence of striae, and the degree of intraperitoneal adhesions was evaluated during the current cesarean section. Group two included patients without evidence of abdominal striae. They were evaluated for the severity of adhesions also after evaluation of the previous scar. Evaluation of the striae was done using Davey's scoring system. The scar was assessed using the Vancouver Scar Scale. The modified Nair's scoring system was used to evaluate intraperitoneal adhesions. RESULTS: The study group included 203 women, while the control group included 205 women. There were significant differences in the demographic characters of the recruited patients (p-value 0.001 for almost all variables). The mean Davey score in those with mild, moderate, and severe striae was 1.82 ± 0.39, 3.57 ± 0.5, and 6.73 ± 0.94, respectively (p-value < 0.001). Higher scores for the parameters of the Vancouver scale were present in patients with severe striae (1.69 ± 1.01, 1.73 ± 0.57, 2.67 ± 1.23, and 1.35 ± 1.06 for scar vascularity, pigmentation, pliability, and height respectively with a p-value of < 0.001 each). Thick intraperitoneal adhesions were noted significantly in women with severe striae [21 (43.75%), p-value < 0.001)]. The Davey's and Vancouver scores showed highly significant predictive performance in the prediction of intraperitoneal adhesions (p-value < 0.001). CONCLUSION: Abdominal striae and cesarean scar were significant predictors for intraperitoneal adhesions.

Skin Color May Predict Intra-Abdominal Adhesions During Repeated Caesarean Section Deliveries.

OBJECTIVE: Caesarean rates have increased rapidly for various reasons recently. One of the important reasons among these is medicolegal problems. Our aim with this study was to preoperatively predict abdominal adhesion density by combining the scar tissue morphology formed in the post-caesarean Pfannenstiel incision line and the skin color scoring of the patients. MATERIAL AND METHODS: Patients who had undergone one caesarean section previously, completed their terms (37-39 weeks) and were under 35 years old were included in the study. Skin color scoring of the patients was performed using the Fitzpatrick skin color scale. Intra-abdominal adhesion scoring of the participant patients was performed using Nair's adhesion scoring system. RESULTS: The change in abdominal adhesion scores was evaluated based on the Fitzpatrick color scale. Adhesion scores per the Nair intra-abdominal adhesion scoring system were found to be 0.04±0.209 in the FP1 group, 0.35±0.662 in the FP2 group, 1.58±0.923 in the FP3 group, and 2.33±0.577 in the FP4 group (p<0.05). These results showed a significant increase in adhesion density with increasing skin color darkness. Based on these results, it was observed that the abdominal adhesion scores and the frequency of depressed skin scar were significantly increased with increasing Fitzpatrick scores (p<0.05). CONCLUSION: The aim of this study was to increase the prediction rates by adding the skin color scoring to the scar tissue characteristics, which have been used in previous studies. The results of this study indicate that the combination of these two parameters may be more effective in predicting intra-abdominal adhesions. Nevertheless, there is a need for studies with a much higher number of patients and multiple parameters to be able to predict intra-abdominal adhesion density preoperatively with greater accuracy.