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.

Neonatal outcomes in trial of vaginal birth versus repeat caesarean delivery in preterm pregnancies: A prospective cohort study.

OBJECTIVE: To characterise neonatal morbidity following preterm trial of labour (TOL) in comparison with elective repeat caesarean section (eRCS) specifically among patients without a previous vaginal delivery who may have a lower success rate of vaginal birth after caesarean. DESIGN: This is a secondary analysis of a multicentre prospective database. SETTING/POPULATION: Maternal and Fetal Medicine Unit Cesarean Section Registry. POPULATION: Singleton pregnancies in women without a previous vaginal delivery who delivered at 24+0  weeks to 36+6  weeks gestation. METHODS: Neonatal outcomes were compared between those with a TOL and those undergoing eRCS. Logistic regression was used to control for confounders, including gestational age at delivery. MAIN OUTCOME MEASURES: Composite neonatal morbidity. RESULTS: A total of 1906 patients were included, 985 with TOL and 921 with no TOL. The TOL success rate was 63.1%. The rate of uterine rupture was low, at 0.10% in the TOL group and 0.11% in the eRCS group (p = 0.32). After adjustment, neonates born to women undergoing a TOL had no statistically significant difference in outcomes including composite neonatal outcome (adjusted odds ratio 0.86, 95% CI 0.68-1.09), neonatal intensive care unit admission, respiratory distress syndrome, necrotising enterocolitis, hypoxic ischaemic encephalopathy, seizures, transient tachypnoea of the newborn, compared with patients who underwent eRCS, with the exception of decreased risk of proven/suspected sepsis (adjusted odds ratio 0.68, 95% CI 0.52-0.87) CONCLUSION: A TOL in preterm patients without a previous vaginal delivery was not found to have a statistically significant association with increased neonatal morbidity.

Outcomes and risk factors for failed trial of labor after cesarean delivery (TOLAC) in women with one previous cesarean section: a Chinese population-based study.

OBJECTIVE: To evaluate the outcomes and risk factors for trial of labor after cesarean delivery (TOLAC) failure in patients in China. METHODS: Consecutive patients who had a previous cesarean delivery (CD) and attempted TOLAC were included from 2014 to 2020. Patients who successfully delivered were classified into the TOLAC success group. Patients who attempted TOLAC but had a repeat CD due to medical issues were classified into the TOLAC failure group. Multiple logistic regression analyses were performed to examine the risk factors for TOLAC failure. RESULTS: In total, 720 women who had a previous CD and attempted TOLAC were identified and included. The success rate of TOLAC was 84.2%(606/720). Seven patients were diagnosed with uterine rupture, none of whom underwent hysterectomy. Multiple logistic regression analysis showed that the induction of labor (OR = 2.843, 95% CI: 1.571-5.145, P < 0.001) was positively associated with TOLAC failure, but the thickness of the lower uterine segment (LUS) (OR = 0.215, 95% CI: 0.103-0.448, P < 0.001) was negatively associated with TOLAC failure. CONCLUSIONS: This study suggested that TOLAC was effective in decreasing CD rates in the Chinese population. The induction of labor was positively associated with TOLAC failure, but the thickness of the LUS was negatively associated with TOLAC failure. Our findings need to be confirmed in larger samples with patients of different ethnicities.

Risk factors and outcomes associated with type of uterine rupture.

PURPOSE: To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn. METHODS: Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared. RESULTS: 92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017). CONCLUSION: TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

Planned mode of birth after previous caesarean section and special educational needs in childhood: a population-based record linkage cohort study.

OBJECTIVE: To investigate the association between planned mode of birth after previous caesarean section and a child's risk of having a record of special educational needs (SENs). DESIGN: Population-based cohort study. SETTING: Scotland. POPULATION: A cohort of 44 892 singleton children born at term in Scotland between 2002 and 2011 to women with one or more previous caesarean sections. METHODS: Linkage of Scottish national health and education data sets. MAIN OUTCOME MEASURES: Any SENs and specific types of SEN recorded when a child was aged 4-11 years and attending a Scottish primary or special school. RESULTS: Children born following planned vaginal birth after previous caesarean (VBAC) compared with elective repeat caesarean section (ERCS) had a similar risk of having a record of any SENs (19.24 versus 17.63%, adjusted risk ratio aRR 1.04, 95% CI 0.99-1.09) or specific types of SEN. There was also little evidence that planned VBAC with or without labour induction compared with ERCS was associated with a child's risk of having a record of any SENs (21.42 versus 17.63%, aRR 1.09, 95% CI 1.01-1.17 and 18.78 versus 17.63%, aRR 1.03, 95% CI 0.98-1.08, respectively) or most types of SEN. However, an increased risk of sensory impairment was seen for planned VBAC with labour induction compared with ERCS (1.18 versus 0.78%, risk difference 0.4%, adjusted odds ratio aOR 1.60, 95% CI 1.09-2.34). CONCLUSIONS: This study provides little evidence of an association between planned mode of birth after previous caesarean and SENs in childhood beyond a small absolute increased risk of sensory impairment seen for planned VBAC with labour induction. This finding may be the result of performing multiple comparisons or residual confounding. The findings provide valuable information to manage and counsel women with previous caesarean section concerning their future birth choices. TWEETABLE ABSTRACT: There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

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.

Timing of Repeat Cesarean Delivery for Women with a Prior Classical Incision.

OBJECTIVE: This study aimed to compare neonatal outcomes for delivery at 36 weeks compared with 37 weeks in women with prior classical cesarean delivery (CCD). STUDY DESIGN: This was a secondary analysis of the prospective observational cohort of the Eunice Kennedy National Institute for Child and Human Development's Maternal-Fetal Medicine Unit Network Cesarean Registry. Data on cases of repeat cesarean delivery (RCD) in the setting of a prior CCD were abstracted and used for analysis. This study compared outcomes of women who delivered at 360/7 to 366/7 versus 370/7 to 376/7 weeks. The primary outcome was a composite of adverse neonatal outcomes that included neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), hypoglycemia, mechanical ventilation, sepsis, length of stay ≥5 days, and neonatal death. A composite of maternal outcomes that included uterine rupture, blood transfusion, general anesthesia, cesarean hysterectomy, venous thromboembolism, maternal sepsis, intensive care unit admission, and surgical complications was also evaluated. RESULTS: There were 436 patients included in the analysis. Women who delivered at 36 weeks (n = 176) were compared those who delivered at 37 weeks (n = 260). There were no differences in baseline characteristics. Delivery at 37 weeks was associated with a reduction in composite neonatal morbidity (24 vs. 34%, adjusted odds ratio [aOR] = 0.61 [0.31-0.94]), including a decrease in NICU admission rates (20 vs. 29%, aOR = 0.63 [0.40-0.99]), hospitalization ≥5 days (13 vs. 24%, aOR = 0.48 [0.29-0.8]), and RDS or TTN (9 vs. 19%, aOR = 0.43 [0.24-0.77]). There was no difference in adverse maternal outcomes (7 vs. 7%, aOR = 0.98 [0.46-2.09]). CONCLUSION: Delivery at 37 weeks for women with a history of prior CCD is associated with a decrease in adverse neonatal outcomes, compared with delivery at 36 weeks. KEY POINTS: · Classical cesarean section may have increased risk of uterine rupture in future pregnancies.. · This study compares outcomes of delivery at 370/7 to 376/7 versus 360/7 to 366/7 weeks.. · Delivery at 370/7 to 376/7 weeks was associated with decreased neonatal morbidity..

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.

Association between surgical technique, adhesions and morbidity in women with repeat caesarean section: a retrospective study in a rural hospital in Western Tanzania.

BACKGROUND: The worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions. METHODS: A cross-sectional, retrospective medical records study of all women undergoing CS in Ndala Hospital in 2011 and 2012. RESULTS: Of the 3966 births, 450 were by CS (11.3%), of which 321 were 1st CS, 80 2nd CS, 36 3rd CS, 12 4th and one 5th CS (71, 18, 8, 3 and 0.2% respectively). Adhesions were considered to be severe in 56% of second CSs and 64% of third CSs. In 2nd CSs, adhesions were not associated with closure of the peritoneum at 1st CS, but were associated with the prior use of a midline skin incision. There was no increase in maternal morbidity when severe adhesions were present. Adverse neonatal outcome was more prevalent when severe adhesions were present, but this was statistically non-significant (16% vs 6%). CONCLUSIONS: Our results give insight into the practice of repeat CS in our rural hospital. Adhesions after CSs are common and occur more frequently after midline skin incision at 1st CS compared to a transverse incision. Reviewing local data is important to evaluate quality of care and to compare local outcomes to the literature.

Establishment of an antepartum predictive scoring model to identify candidates for vaginal birth after cesarean.

BACKGROUND: Evidence-based medicine has shown that successful vaginal birth after cesarean (VBAC) is associated with fewer complications than an elective repeat cesarean. Although spontaneous vaginal births and reductions in cesarean delivery (CD) rates have been advocated, the risk factors for VBAC complications remain unclear and failed trials of labor (TOL) can lead to adverse pregnancy outcomes. METHODS: To construct an antepartum predictive scoring model for VBAC. Retrospective analysis of charts from 1062 women who underwent TOL at no less than 28 gestational weeks with vertex singletons and no more than one prior CD. RESULTS: We constructed our scoring model based on the following variables: maternal age, previous vaginal delivery, interdelivery interval (time between prior cesarean and the following delivery), presence of prior cesarean TOL, dystocia as prior CD indication, intertuberous diameter, maternal predelivery body mass index, gestational age at delivery, estimated fetal weight, and hypertensive disorders. Previous vaginal delivery was the most influential variable. The nomogram showed an area under the curve of 77.7% (95% confidence interval, 73.8-81.5%; sensitivity, 78%; specificity, 70%; cut-off, 13 points). The Kappa value to judge the consistency of the results between the predictive model and the actual results was 0.71(95% confidence interval 0.65-0.77) indicating strong consistency. We used the cut-off to divide the VBAC women into two groups according to the success of the TOL. The maternal and neonatal outcomes such as labor time, number of deliveries by midwives, postpartum hemorrhage, uterine rupture, neonatal asphyxia, puerperal infection were significantly different between the two groups. CONCLUSIONS: Our predictive scoring model incorporates easily ascertainable variables and can be used to personalize antepartum counselling for successful TOLs after cesareans.

Intrauterine Pressure Catheter Use Is Associated with an Increased Risk of Postcesarean Surgical Site Infections.

OBJECTIVE: This study aimed to determine if intrapartum placement of an intrauterine pressure catheter (IUPC) is associated with an increased rate of surgical site infections in women undergoing a cesarean delivery. STUDY DESIGN: This was a secondary analysis of the prospective observational Maternal-Fetal Medicine Units Network Vaginal Birth after Cesarean Registry. We compared patients with and without IUPC use. A multivariable logistic regression was performed to evaluate for an association between IUPC use and postcesarean surgical site infections. RESULTS: The study included 16,887 women: 7,441 with IUPC use and 9,446 without IUPC use. After adjustment for potential cofounders, IUPC use was associated with an increased risk of postcesarean infections compared with those without IUPC use (adjusted odds ratio: 1.28; 95% confidence interval: 1.10-1.50; p = 0.002). CONCLUSION: IUPC use is associated with an increased risk of postcesarean surgical site infections. This supports the judicious use of IUPC for limited clinical indications and provides a potential area of focus for reduction in postcesarean infections.

Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland.

BACKGROUND: Policy consensus in high-income countries supports offering pregnant women with previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or attempting a vaginal birth, known as a planned vaginal birth after previous cesarean (VBAC), provided they do not have contraindications to planned VBAC. However, robust comprehensive information on the associated outcomes to counsel eligible women about this choice is lacking. This study investigated the short-term maternal and perinatal outcomes associated with planned mode of delivery after previous cesarean section among women delivering a term singleton and considered eligible to have a planned VBAC. METHODS AND FINDINGS: A population-based cohort of 74,043 term singleton births in Scotland between 2002 and 2015 to women with one or more previous cesarean sections was conducted using linked Scottish national datasets. Logistic or modified Poisson regression, as appropriate, was used to estimate the effect of planned mode of delivery on maternal and perinatal outcomes adjusted for sociodemographic, maternal medical, and obstetric-related characteristics. A total of 45,579 women gave birth by ERCS, and 28,464 had a planned VBAC, 28.4% of whom went on to have an in-labor nonelective repeat cesarean section. Compared to women delivering by ERCS, those who had a planned VBAC were significantly more likely to have uterine rupture (0.24%, n = 69 versus 0.04%, n = 17, adjusted odds ratio [aOR] 7.3, 95% confidence interval [CI] 3.9-13.9, p < 0.001), a blood transfusion (1.14%, n = 324 versus 0.50%, n = 226, aOR 2.3, 95% CI 1.9-2.8, p < 0.001), puerperal sepsis (0.27%, n = 76 versus 0.17%, n = 78, aOR 1.8, 95% CI 1.3-2.7, p = 0.002), and surgical injury (0.17% versus 0.09%, n = 40, aOR 3.0, 95% CI 1.8-4.8, p < 0.001) and experience adverse perinatal outcomes including perinatal death, admission to a neonatal unit, resuscitation requiring drugs and/or intubation, and an Apgar score < 7 at 5 minutes (7.99%, n = 2,049 versus 6.37%, n = 2,570, aOR 1.6, 95% CI 1.5-1.7, p < 0.001). However, women who had a planned VBAC were more likely than those delivering by ERCS to breastfeed at birth or hospital discharge (63.6%, n = 14,906 versus 54.5%, n = 21,403, adjusted risk ratio [aRR] 1.2, 95% CI 1.1-1.2, p < 0.001) and were more likely to breastfeed at 6-8 weeks postpartum (43.6%, n = 10,496 versus 34.5%, n = 13,556, aRR 1.2, 95% CI 1.2-1.3, p < 0.001). The effect of planned mode of delivery on the mother's risk of having a postnatal stay greater than 5 days, an overnight readmission to hospital within 42 days of birth, and other puerperal infection varied according to whether she had any prior vaginal deliveries and, in the case of length of postnatal stay, also varied according to the number of prior cesarean sections. The study is mainly limited by the potential for residual confounding and misclassification bias. CONCLUSIONS: Among women considered eligible to have a planned VBAC, planned VBAC compared to ERCS is associated with an increased risk of the mother having serious birth-related maternal and perinatal complications. Conversely, planned VBAC is associated with an increased likelihood of breastfeeding, whereas the effect on other maternal outcomes differs according to whether a woman has any prior vaginal deliveries and the number of prior cesarean sections she has had. However, the absolute risk of adverse outcomes is small for either delivery approach. This information can be used to counsel and manage the increasing number of women with previous cesarean section, but more research is needed on longer-term outcomes.

Impact of timing of delivery on maternal and neonatal outcomes for women after three previous caesarean deliveries; a secondary analysis of the caesarean section registry.

BACKGROUND: As more women are presenting with three previous caesarean deliveries (CD), providers may suggest early term delivery as a means to avoid the risk of spontaneous labour and associated maternal morbidity. OBJECTIVE: To determine whether early term delivery is associated with lower maternal and neonatal morbidity for women with three previous CD. STUDY DESIGN: Secondary analysis of a prospective registry of CD at 19 US academic centres from 1999 to 2002. POPULATION: Women with three previous CD undergoing scheduled or emergent delivery with live, singleton gestations 37-41+ weeks of gestation were included. Women with non-low transverse incisions, antepartum stillbirth, previous myomectomy, fetal anomalies, more or fewer than three previous CD or attempting trial of labour after caesarean section were excluded. METHODS: Gestational age was categorised by week. We fitted logistic regression models to adjust for clinically relevant or statistically significant confounders. MAIN OUTCOME MEASURES: The primary and secondary outcomes were composites, respectively, of maternal and neonatal morbidity. RESULTS: In all, 821 women met the inclusion criteria; maternal morbidity composite occurred in 9.86% and neonatal morbidity occurred in 10.5%. After adjusting for confounding variables, maternal and neonatal morbidity occurred least frequently at 39 weeks. CONCLUSIONS: In women with three previous CDs, adverse maternal outcomes do not increase with increasing gestational age beyond 37 weeks but early term elective repeat CDs are associated with higher neonatal morbidity. Elective delivery of women with three previous CD at 39 weeks of gestation is safe in the absence of maternal or fetal indications for early term delivery. TWEETABLE ABSTRACT: Delivery of women with three previous caesarean deliveries at 39 weeks, in the absence of maternal or fetal indications for early term delivery, is associated with decreased maternal morbidity.

Blood transfusion following intended vaginal birth after cesarean vs elective repeat cesarean section in women with a prior primary cesarean: A population-based record linkage study.

INTRODUCTION: There is a lack of evidence around the risk of transfusion following vaginal birth after cesarean (VBAC) compared with elective repeat cesarean section (ERCS); this is important for decision-making about birth options. The aim of this study was to determine transfusion rates and risk of transfusion following intended VBAC and ERCS. MATERIAL AND METHODS: Women with a primary cesarean who had a subsequent birth at term (≥37 weeks) in New South Wales between 2000 and 2012, were identified from the New South Wales Perinatal Data Collection. Blood transfusions were identified from linked hospital records. Women deemed ineligible for VBAC were excluded. Modified Poisson regression was used to determine transfusion risk associated with intended VBAC compared with ERCS. Intended mode of birth was classified as: (1) intended VBAC and vaginal birth, (2) intended VBAC and cesarean, (3) intended ERCS and (4) "intention uncertain". RESULTS: A total of 90 439 women were eligible for VBAC. Rates of transfusion were: 1.4% for intended VBAC and vaginal birth (n = 17 849); 1.2% for intended VBAC and cesarean (n = 7648); 0.3% for intended ERCS (n = 60 471); and 1.1% for "intention uncertain" (n = 4471). After adjusting for maternal and pregnancy characteristics, risk of transfusion was almost four times higher for women classified as intended VBAC than intended ERCS (adjusted risk ratio = 3.73, 95% confidence interval 2.90-4.78). CONCLUSIONS: Following a prior primary cesarean, there was a higher risk of transfusion associated with attempting VBAC compared with ERCS. Though the absolute risk is small, it is important for women considering VBAC to choose birthing facilities with ready access to blood products.

Management of bleeding from morbidly adherent placenta during elective repeat caesarean section: retrospective -record -based study.

BACKGROUND: Controlling massive haemorrhage from morbidly adherent placenta (MAP) at caesarean section is a major surgical challenge to obstetricians. This study compares different intra-operative interventions to control haemorrhage from morbidly adherent placenta and its impact on maternal morbidity. METHODS: Retrospective analysis was done for baseline characteristics, intra-operative and postoperative complications of 125 patients with morbidly adherent placenta who had elective CS at 35-38 weeks gestation in the period from 01/2012 to 01/2017. The included patients were categorized into three groups according to intra-operative interventions they had for controlling bleeding; Group A (n = 42) had only balloon tamponade, Group B (n = 40) had balloon tamponade and bilateral uterine artery ligation, in Group C (n = 43) all cases were managed by bilateral uterine artery ligation and inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment using the cervix as a natural tamponade. RESULTS: There were no differences of baseline characteristics of patients in all groups. Group C had significantly better outcomes as compared with groups A and B; less total blood loss (Group C 2869.5 ml vs Group B 4580 ml, Group A 4812 ml, P <  0.001), less requirement of blood transfusion more than 4 units (Group C 4/43, Group B 10/40,Group A 12/42, P <  0.02), significant reduction in prolonged hospital stay over 10 days (Group C 2/43, Group B 9/40,Group A 14/42, P < 0.001) and lower risk of coagulopathy (Group C 4/43, B 8/40, A 9/42), visceral injuries (Group C 4/43 vs B 8/40, A 10/42,P < 0.01) and need for hysterectomy (Group C 4/43 vs B 11/40, A 13/42,P < 0.001). CONCLUSION: A combination bilateral uterine artery ligation and using the cervix as a natural tamponade are very effective and simple methods in controlling bleeding resulting from separated placenta accreta. TRIAL REGISTRATION: The findings are part of the research project registered in ClinicalTrials.gov NCT02590484 . Registered 28 October 2015.

Sliding sign in third-trimester sonographic evaluation of intra-abdominal adhesions in women undergoing repeat Cesarean section: a novel technique.

OBJECTIVE: Intra-abdominal adhesions are associated with an increased risk of complications during repeat Cesarean section (CS), such as bladder and bowel injury, hemorrhage, infection and hysterectomy. We present a simple sonographic marker, the 'sliding sign' of the uterus, for the prediction of intra-abdominal adhesions in the third trimester of pregnancy in women undergoing repeat CS. METHODS: This was a prospective observational study of pregnant women with a history of at least one Cesarean delivery evaluated by transabdominal ultrasound during the third trimester of an ongoing pregnancy. In order to diagnose intra-abdominal adhesions, we assessed a sonographic sign, the sliding of the uterus under the inner part of the fascia of the abdominal muscles during deep breathing. Women were considered to be at high risk for severe adhesions if uterine sliding was absent and at low risk in the presence of obvious or moderate uterine sliding. A comparison between sonographic findings and intra-abdominal adhesions observed during surgery was performed. RESULTS: Of the 63 patients with one or more previous CS examined, 59 completed the study and underwent CS at our institution. In 16 of the 19 cases assigned to the high-risk group for severe adhesions due to absence of sliding of the uterus, the suspicion was confirmed at surgery. The prediction of low risk for adhesions was confirmed in 35 out of 40 patients. The sensitivity and specificity of the sliding sign in predicting presence of intra-abdominal adhesions in women undergoing repeat CS were 76.2% and 92.1%, respectively. Inter- and intraobserver correlation using Cohen's kappa coefficient were 0.52 and 0.77, respectively. CONCLUSION: Our data show that a simple sonographic sign might be able to discriminate between high and low risk for intra-abdominal adhesions in patients with a history of Cesarean delivery. This technique may aid clinical decisions in patients undergoing repeat CS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The Effect of Adding Subarachnoid Epinephrine to Hyperbaric Bupivacaine and Morphine for Repeat Cesarean Delivery: A Double-Blind Prospective Randomized Control Trial.

BACKGROUND: Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery. METHODS: Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale. RESULTS: Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15-60]; P = .007), followed by the HD group to the LD group (30 [15-45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [-15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0-60]; P = .034, 60 [0-93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15-60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0-0], LD: 0 [0-0], NE: 0 [0-3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups. CONCLUSIONS: In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced.

Risk factors for Korean women to develop an isthmocele after a cesarean section.

BACKGROUND: The increase in number of cesarean section (CS) operations has resulted in an increase in cases of isthmocele development. The objective of this study is to determine the risk factors for isthmocele development after CS. METHODS: Isthmocele measurements were taken for 404 women with a history of at least one low transverse CS. The following potential risk factors were investigated: patient's age at CS, cause of CS, weeks of gestation at CS, premature rupture of membrane (PROM), phase of labor, type suture (single/double layer), operation time, uterine flexion (anteversion/retroversion), and blood transfusion during operation. A transvaginal ultrasound was carried out to examine the isthmocele in the uterus after CS, including the shape of the isthmocele, residual myometrial thickness, depth and width of isthmocele, cervical thickness, location of the isthmocele, and clinical characteristics. RESULTS: In our study population, the isthmocele had a prevalence of 73.8%. Most isthmocele had a triangular (65.4%) or semicircular shape (10.4%). The presence of an isthmocele was significantly associated with repeat CS, premature rupture of membrane (PROM), short operation time, and extent of cervix dilatation at CS. The risk of isthmocele was low in women who had placenta previa totalis (PPT), twin, a long operation time, or a transfusion during the operation. CONCLUSIONS: In our study, isthmocele development was significantly associated with repeat CS, PROM, a short operation time, and the extent of cervix dilatation at CS. Therefore, PROM prevention and a more careful uterine closure are needed to reduce the risk of developing an isthmocele after CS.

Identifying risk factors for cesarean scar pregnancy: a retrospective study of 79 cases.

OBJECTIVES: To explore the possible risk factors for cesarean scar pregnancy (CSP), the incidence of which is increasing rapidly in China. MATERIAL AND METHODS: 79 patients with CSP and 69 non-CSP expectant mothers with at least 1 previous cesarean section were employed in the study. The obstetric histories of the participants were collected and analyzed using Chi square test. RESULTS: We found that 77.2% CSP patients had ≥ 3 pregnancies and only 36.2% women had ≥ 3 pregnacies in non-CSP group. During the previous cesarean delivery, 21.5% of CSP patients had entered the first stage of labor, which was 43.5% in non-CSP group (P < 0.05). Cephalopelvic disproportion occurred in 51.9% of CSP patients, which was significantly higher than that (23.2%) in non-CSP group (P < 0.01). 11.4% of CSP patients had undergone cesarean section due to breech and shoulder presentation in the past, which was only 1.4% in non-CSP group. However, no significance was noted (P > 0.05). We did not find significant differences between the CSP and non-CSP patients in maternal age, multiple cesarean sections, gestational age, emergency or elective caesarean section. CONCLUSIONS: Multiple pregnancies, absence of the first stage of labor, and cephalopelvic disproportion might be the risk factors for the occurrence of CSP.

Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy.

BACKGROUND: Uterine rupture is a potential life-threatening complication during a trial of labor after cesarean delivery. Single-layer closure of the uterus at cesarean delivery has been associated with an increased risk of uterine rupture compared with double-layer closure. Lower uterine segment thickness measurement by ultrasound has been used to evaluate the quality of the uterine scar after cesarean delivery and is associated with the risk of uterine rupture. OBJECTIVE: To estimate the impact of previous uterine closure on lower uterine segment thickness. STUDY DESIGN: Women with a previous single low-transverse cesarean delivery were recruited at 34-38 weeks' gestation. Transabdominal and transvaginal ultrasound evaluation of the lower uterine segment thickness was performed by a sonographer blinded to clinical data. Previous operative reports were reviewed to obtain the type of previous uterine closure. Third-trimester lower uterine segment thickness at the next pregnancy was compared according to the number of layers sutured and according to the type of thread for uterine closure, using weighted mean differences and multivariate logistic regression analyses. RESULTS: Of 1613 women recruited, with operative reports available, 495 (31%) had a single-layer and 1118 (69%) had a double-layer closure. The mean third-trimester lower uterine segment thickness was 3.3 ± 1.3 mm and the proportion with lower uterine segment thickness <2.0 mm was 10.5%. Double-layer closure of the uterus was associated with a thicker lower uterine segment than single-layer closure (weighted mean difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In multivariate logistic regression analyses, a double-layer closure also was associated with a reduced risk of lower uterine segment thickness <2.0 mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic thread, the use of catgut for uterine closure had no significant impact on third-trimester lower uterine segment thickness (WMD: -0.10 mm; 95% CI, -0.22 to 0.02 mm) or on the risk of lower uterine segment thickness <2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure was associated with a reduced risk of uterine scar defect (RR, 0.32; 95% CI, 0.17 to 0.61) at birth. CONCLUSION: Compared with single-layer closure, a double-layer closure of the uterus at previous cesarean delivery is associated with a thicker third-trimester lower uterine segment and a reduced risk of lower uterine segment thickness <2.0 mm in the next pregnancy. The type of thread for uterine closure has no significant impact on lower uterine segment thickness.