Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-20 A curved clamp is placed across the lateral vaginal fornix below the level of the cervix, and the tissue incised medially to the point of the clamp. of the cuf Each lateral vaginal fornix is secured to the uterosac raliligaments to mitigate later vaginal prolapse. For cuf closure, some surgeons instead prefer to close the vagina by apposing the anterior and posterior vaginal walls with interrupted figure-of ll sites are examined carefully for bleeding. One technique is to perform a systematic bilateral survey from the fallopian tube and ovarian ligament pedicles to the vaginal vault and bladder lap. Bleeding sites are ligated with care to avoid the ureters. The abdominal wall normally is closed in layers, as previously described for cesarean delivery (p. 578).


Obstentrics_Williams

Obstentrics_Williams. To perform a subtotal nysterectomy, the uterine body is amputated immediately above the level of uterine artery ligation. The cervical stump may be closed with continuous or interrupted chromic catgut suture. Subtotal hysterectomy is often all that is necessary to stop hemorrhage. It may be preferred for women who would benefit from a shorter surgery or for those with extensive adhesions that threaten significant urinary tract injury. Because of the large adnexal vessels and their close proximity to the uterus, it may be necessalY to remove one or both adnexa to obtain hemostasis. Briery and colleagues (2007) reported unilateral or bilateral oophorectomy in a fourth of cases. Preoperative counseling for anticipated hysterectomy should include this possibility. hese injuries are rare during cesarean delivery. The bladder laceration rate approximates 2 per 1000 cesarean deliveries, FIGURE 30-21 A running-lock suture approximates the vaginal wall edges.


Obstentrics_Williams

Obstentrics_Williams. hese injuries are rare during cesarean delivery. The bladder laceration rate approximates 2 per 1000 cesarean deliveries, FIGURE 30-21 A running-lock suture approximates the vaginal wall edges. whereas that for ureteral trauma nears 0.3 per 1000 cases (Giingordiik, 2010; Oliphant, 2014; Rajasekar, 1997). Bowel is damaged in about 1 in 1000 cesarean deliveries (Silver, 2006). Bladder laceration most commonly occurs during blunt or sharp dissection in the vesicouterine space to create the bladder lap, during peritoneal cavity entry, and during hysterotomy (Phipps, 2005; Rahman, 2009). Risks are prior cesarean delivery; emergency cesarean delivery; comorbid adhesive disease; cesarean hysterectomy, especially cases with morbidly adherent placenta; and surgery in second-stage labor compared with irst-stage (Alexander, 2007; Silver, 2006; Yossepowitch, 2004).


Obstentrics_Williams

Obstentrics_Williams. Bladder injury is typically identified intraoperatively, and initially, a clear-luid gush or the Foley bulb may be seen. If cystotomy is suspected, it can be conirmed with retrograde instillation of infant formula or methylene-blue-stained saline through a Foley catheter into the bladder. Leakage of opaque milk or methylene blue aids in identiication of the laceration as well as delineation of its borders. The dome is lacerated in 95 percent of cases, and injuries at the trigone form the remainder (Phipps, 2005). Prior to cystotomy repair, ureters are examined, and surveillance for urine jets from each oriice follows. This can be done directly through the cystotomy, if at the dome, or through a separate diagnostic extraperitoneal or retropubic cystotomy, if injury nears the trigone. Jet visualization can be assisted by 50 mg of methylene blue administered intravenously.


Obstentrics_Williams

Obstentrics_Williams. Once ureteral patency is conirmed, the bladder may be closed with a two-or three-layer running closure using a 3-0 absorbable or delayed-absorbable suture (Fig. 30-22). he first layer inverts the mucosa into the bladder. The bladder is then illed with a marker luid to demonstrate integrity of the repair. Leaking defects can be closed with interrupted reinforcing stitches. Subsequent layers reapproximate the bladder muscularis. Postoperative care requires continuous bladder drainage for 7 to 14 days to permit healing and minimize the risk of fistula formation. U ropathogen prophylaxis during this drainage is not required. Also, cystourethrography need not be routinely performed prior to catheter removal for a simple, �ingle laceration (Davis, 1999).


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-22 Cystotomy repair, A. The primary layer inverts the bladder mucosa with running or interrupted sutures of 3-0 delayedabsorbable or absorbable suture, B. Second and possibly a third layer approximate the bladder muscularis to reinforce the incision closure. Larger lacerations in or near the trigone require careful attention. Specialists may be consulted, and in preparation, ureteral stents can be assembled. In these cases, ureteral oriices are directly inspected to document jets from both. If not seen, then stents may be passed through the cystotomy and into each oriice to conirm patency. Once this is confirmed, repair should not disrupt the ureteral orifices, and stents may remain to ensure ureteral patency.


Obstentrics_Williams

Obstentrics_Williams. U nrepaired cystotomy can manifest as hematuria, oliguria, abdominal pain, ileus, ascites, peritonitis, fever, urinoma, or istula. For diagnosis, retrograde cystography or abdominal computed tomography (CT) with cystography can be used (Tarney, 2013). Cystoscopy is also an option but may require an operating room. Once identified, prompt repair is indicated (Balgobin, 2017).


Obstentrics_Williams

Obstentrics_Williams. hese injuries occur most oten during repair of hysterotomy extensions into the broad ligament or vagina (Eisenkop, 1982). If ureteral injury is suspected, methylene blue is administered. The pelvis is directly inspected for dye extravasation, which suggests ureteral transection. Next, brisk dye-stained urine jets are sought from each oriice to exclude ureteral kinking or ligation. Oriice viewing may be via cystoscopy, if available; through a comorbid traumatic cystotomy; or through a diagnostic cystotomy. With sluggish or absent jets, consultation with a specialist is typically requested. A ureteral catheter is irst threaded to identiY a potential obstruction site and guide ureterolysis. Kinked or ligated ureters can be relieved by release of ensnaring sutures. Crush injuries are inspected to ensure vital tissue. In these cases, stents are let to avert ureteral stricture. A Foley cath�ter remains for 7 to 10 days, and the ureteral catheters are removed via cystoscopy ater 14 days.


Obstentrics_Williams

Obstentrics_Williams. to ensure vital tissue. In these cases, stents are let to avert ureteral stricture. A Foley cath�ter remains for 7 to 10 days, and the ureteral catheters are removed via cystoscopy ater 14 days. Intravenous pyelography (IVP) is usually not necessary before removal of the stent if it was placed as a precautionary measure ater relatively minor injury (Davis, 1999).


Obstentrics_Williams

Obstentrics_Williams. Crush injuries with devascularization, thermal injury, or transection require more extensive repair. If a healthy-appearing ureter can be reimplanted into the bladder without undue tension, then ureteroneocystostomy is preferable. For more proximal injuries, ureteroureterostomy, psoas hitch, or Boari lap creation may be needed. An explanation of these more extensive procedures is found in Cunningham and Gistrap s Operative Obstetrics, 3rd edition (Balgobin, 2017). Unrecognized ureteral injury can mimic those of cystotomy with the addition of possible costovertebral angle tenderness. CT urography is a preferred initial diagnostic tool (Sharp, 2016). he duration of time from injury to identification directs repair. hose identified early are often suitable for immediate repair.


Obstentrics_Williams

Obstentrics_Williams. Serosal tears represent weak points in the small bowel. If obstruction develops postoperatively, these weak spots may perforate, leading to peritonitis. If serosal tears are few in number, they can be oversewn with either a ine absorbable or nonabsorbable suture (Davis, 1999). More signiicant lacerations are often repaired in consultation with a general surgeon or gynecologic oncologist.


Obstentrics_Williams

Obstentrics_Williams. During and after cesarean delivery, requirements for intravenous luids can vary considerably. Administered fluids consist of either lactated Ringer solution or a similar crystalloid solution with 5-percent dextrose. Typically, at least 2 L is infused during surgery. Blood loss with uncomplicated cesarean delivery approximates 1000 mL. he average-sized woman with a hematocrit of 30 percent or more and with a normally expanded blood and extracellular luid volume most often will tolerate blood loss up to 2000 mL without diiculty. Unappreciated bleeding through the vagina during the procedure, bleeding concealed in the uterus after its closure, or both commonly lead to underestimation.


Obstentrics_Williams

Obstentrics_Williams. Blood loss averages 1500 mL with elective cesarean hysterectomy, although this is variable (Pritchard, 1965). Most peripartum hysterectomies are unscheduled, and blood loss in these cases is correspondingly greater. Thus, in addition to close monitoring of vital signs and urine output, the hematocrit should be determined intra-or postoperatively as indicated.


Obstentrics_Williams

Obstentrics_Williams. he amount of vaginal bleeding is closely monitored for at least an hour in the immediate postoperative period. he uterine fundus is also identiied frequently by palpation to ensure that the uterus remains irmly contracted. Unfortunately, as conduction analgesia fades or the woman awakens from general anesthesia, abdominal palpation is likely to produce pain. A patient-controlled analgesia (PCA) pump can be efective. Once regional analgesia begins to fade or the woman becomes fully awake following general anesthesia, criteria for transfer to the postpartum ward include minimal bleeding, stable vital signs, and adequate urine output. Analgesia, Vital Signs, Intravenous Fluids


Obstentrics_Williams

Obstentrics_Williams. Analgesia, Vital Signs, Intravenous Fluids Several schemes are suitable for postoperative pain control. One PCA regimen uses intravenous morphine given as needed as a I-mg dose with a 6-minute lockout interval and maximum dose of 30 mg in 4 hours. An additional 2-mg booster dose is permitted for a maximum of 2 doses. Alternatively, intramuscular (1M) meperidine, 50 to 75 mg every 3 to 4 hours, or 1M morphine, 10 to 15 mg every 3 to 4 hours, is suitable. In a trial using these options, Yost and associates (2004) found that morphine provided superior pain relief to meperidine and was associated with significantly higher rates of breastfeeding and continuation of newborn rooming in. Breastfeeding can be ini tiated the day of surgery. If the mother elects not to breastfeed, a binder that supports the breasts without marked compression usually will minimize discomfort.


Obstentrics_Williams

Obstentrics_Williams. After transfer to her room, the woman is assessed at least hourly for 4 hours, and thereafter at intervals of 4 hours. Deep breathing and coughing are encouraged to prevent atelectasis. Vital signs, uterine tone, urine output, and bleeding are evalu ated. The hematocrit is routinely measured the morning after surgery. It is checked sooner if there was unusual blood loss or if there is hypotension, tachycardia, oliguria, or other evidence to suggest hypovolemia. If the hematocrit is decreased signii cantly from the preoperative level, the measurement is repeated and a search is instituted to identiy the cause. If the hematocrit stabilizes, the mother can be allowed to ambulate, and if there is little likelihood of further blood loss, iron therapy is preferred to transfusion.


Obstentrics_Williams

Obstentrics_Williams. Postpartum, the patient begins to mobilize and excrete her physiologically expanded extravascular volume. Thus, mainte sistent oral intake is reestablished. If urine output falls below 30 mLlhr, however, the woman should be reevaluated promptly. The cause of the oliguria can range from unrecognized blood loss to an antidiuretic efect from infused oxytocin. Women undergoing unscheduled cesarean delivery may have pathological retention or constriction of the extracellular fluid compartment caused by severe preeclampsia, sepsis syndrome, vomiting, prolonged labor without adequate fluid intake, or increased blood loss. Women with these complications are generally observed in the recovery room until stabilization is assured.


Obstentrics_Williams

Obstentrics_Williams. The Foley catheter most often can be removed by 12 hours postoperatively, or more conveniently, the morning after surgery. he prevalence of urinary retention following cesarean delivery approximates 3 to 7 percent (Chap. 36, p. 660). Failure to progress in labor and postoperative narcotic analgesia are identified risks (Chai, 2008; Kandadai, 2014; Liang, 2007).


Obstentrics_Williams

Obstentrics_Williams. In uncomplicated cases, liquids or solid food may be ofered within hours of surgery and advanced as tolerated (Guo, 2015). Some degree of adynamic ileus follows virtually every abdominal operation, but in most cases of cesarean delivery, it is negligible. Postoperative ileus symptoms include abdominal distention, gas pains, and an inability to pass flatus or stool. With persistent nausea and vomiting or with prolonged bowel function delay, radiological imaging may aid exclusion of bowel obstruction. A plain abdominal radiograph is a frequent first choice. However, in the general population, this study is diagnostic in only 50 to 60 percent of small bowel obstruction cases (Maglinte, 1997). Thus, a radiograph may best serve as a triage tool in cases in which ileus is the suspected diagnosis. Notably, an enlarged postpartum uterus can compress the rectosigmoid and prevent it from illing with gas. Thus, indings suggesting a distal colonic obstruction may confuse true cases of transient


Obstentrics_Williams

Obstentrics_Williams. Notably, an enlarged postpartum uterus can compress the rectosigmoid and prevent it from illing with gas. Thus, indings suggesting a distal colonic obstruction may confuse true cases of transient ileus (Kammen, 2000). In comparison, CT with intravenous contrast provides greater accuracy for small bowel obstruction. Oral contrast is concurrently given when SBO is a consideration (Katz, 2013). Last, although uncommon, an unrecognized bowel injury may be responsible for otherwise unexplained fever and poor bowel function. Here, CT may be most diagnostic of potential etiologies.


Obstentrics_Williams

Obstentrics_Williams. As treatment of ileus, intravenous luids compensate for poor oral intake and losses from emesis. Electrolyte imbalances are corrected to improve smooth muscle activity and avoid bowel edema. Nasogastric decompression is necessary only with persistent vomiting or severe distention. For prevention, intraoperative goals strive to minimize bowel manipulation, avoid excess intravenous luids or profound hypovolemia, and limit surgery length (Bragg, 2015). Postoperatively, gum chewing enhances early bowel function recovery by nearly 7 hours after cesarean delivery (Zhu, 2014). Among studies, chewing was initiated immediately or up to 12 hours later, lasted 15 to 60 minutes, and was repeated in at least three sessions daily (Pereira Gomes Morais, 2016).


Obstentrics_Williams

Obstentrics_Williams. As discussed earlier, women undergoing cesarean delivery have an increased risk of venous thromboembolism compared with those delivering vaginally. Early ambulation lowers the thromboembolism risk. Walking to the bathroom begins, initially with assistance. Brief walks are encouraged, and ambulation can be timed so that a recently administered analgesic will minimize discomfort. lthough not evidence based, we remove the surgical dressing after 24 hours and inspect the incision daily. One small randomized trial showed no wound healing diferences if removed at 6 hours (Peleg, 2016). By the third postpartum day, showering is not harmful to the incision. Prior to this, a plastic cover can maintain dryness during showers. If used, staples often are removed on the fourth day. Once removed, dressing strips (Steri-Strips) can be placed as needed for 1 week to reinforce skin edge integrity. If there is concern for supericial wound separation, staples remain in place for 7 to 10 days.


Obstentrics_Williams

Obstentrics_Williams. For uncomplicated cesarean delivery, the average hospitalization length is three to four days (Buie, 2010). Data from studies suggest that earlier discharge is feasible for properly selected women and newborns (Bayoumi, 2016; Tan, 2012). Protocols ideally include earlier reevaluation for neonatal jaundice.


Obstentrics_Williams

Obstentrics_Williams. Activities during the irst week should be restricted to selfcare and newborn care with assistance. Driving can be resumed when pain does not limit the ability to brake quickly and when narcotic medications are not in use. In women with cesarean delivery, intercourse was resumed in 44 percent by 6 weeks postpartum, in 81 percent by 3 months, and 97 percent at 1 year (McDonald, 2013). After the puerperium, the quality of sexual functioning does not difer between those undergoing spontaneous vaginal delivery or cesarean (Chang, 2015; Fehniger, 2013; Rogers, 2014). Rerurn to work is variable. Six weeks is commonly cited, although many women use the Family and Medical Leave Act to allow up to 12 weeks for recovery and newborn bonding. Abdel-Aleem H, Aboelnasr MF, Jayousi TM, et al: Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section. Cochrane Database Syst Rev 4:CDO 1 0322, 2014


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Obstentrics_Williams. Ahmadzia HK, Patel EM, Joshi 0, et al: Obstetric surgical site infections: 2 grams compared with 3 grams of cefazolin in morbidly obese women. Obstet Gynecol 126(4): 08,2015 Alanis Me, Villers MS, Law TL, et al: Complications of cesarean delivery in the massively obese parturient. Am J Obstet Gynecol 203(3):271.e1, 2010 Alexander JM, Leveno KJ, Hauth J, et al: Fetal injury associated with cesarean delivery. Obstet Gynecol 108(4):885, 2006 Alexander JM, Leveno KJ, Rouse OJ, et al: Comparison of matenal and infant outcomes from primary cesarean delivery during the second compared with first stage oflabor. Obstet Gynecol 109(4):917,r2007 American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village, MP, 20r17 American College of Obstetricians and Gynecologists: Scheduling planned cesarean delivery. Patient Safety Checklist No.r3, December 2011


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Scheduling planned cesarean delivery. Patient Safety Checklist No.r3, December 2011 American College of Obstetricians and Gynecologists: Patient safety in the surgical environment. Committee Opinion No. 464, September 2010, Reaffirmed 2014a American College of Obstetricians and Gynecologists: Preoperative planned cesarean delivery. Patient Safety Checklist No.r4, December 2014b American College of Obstetricians and Gynecologists: Informed consent. Committee Opinion No. 439, August 2009, Reairmed 2015 American College of Obstetricians and Gynecologists: Prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011, Reairmed 2016 American College of Obstetricians and Gynecologists: Cesarean delivery on maternal request. Committee Opinion No. 559, April 20l3, Reairmed


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658, February 2016, Reairmed 2017b American College of Obstetricians and Gynecologists: Placenta accreta. Committee Opinion No. 529, July 2012, Reairmed 2017c American College of Obstetricians and Gynecologists: Thromboembolism in pregnancy. Practice Bulletin No. 123, September 201r1, Reairmed 201 d American College of Obstetricians and Gynecologists: Vaginal seeding. Committee Opinion No. 725, November 201/e American Society of Anesthesiologists: Task Force on Obstetrical Anesthesia: practice guidelines for obstetrical anesthesia. Anesthesiology 124:270, 2016 Andrews WW, Hauth JC, Cliver SP, et al: Randomized clinical trial of extended spectrum antibiotic prophylaxis with coverage for Ureaplasma urealyticum to reduce post-cesarean delivery endometritis. Obstet Gynecol 101(6):1183,r2003


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Obstentrics_Williams. Anorlu RI, Maholwana B, Hofmeyr GJ: Methods of delivering the placenta at caesarean section. Cochrane Database Syst Rev 3:CD004 3 , 2008 ASlclOglu 0, Giingordiik K, ASlClOglu BB, et al: Unintended extension of the lower segment uterine incision at cesarean delivery: a randomized comparison of sharp versus blunt techniques. Am J PerinatoI31(10):837, 2014 Atherton N, Parsons SJ, Mansfield P: Attendance of paediatricians at elective Caesarean sections performed under regional anaesthesia: is it warranted? J Paediatr Child Health 42(6):332, 2006


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Obstentrics_Williams. subcuticular suture vs staples for skin closure at cesarean delivery. Am J Obstet GynecoIr203(3):285.e1, 2010 Bateman BT, Mhyre JM, Callaghan WM, et l: Peripartum hysterectomy in the United States: nationwide 14 year experience. Am J Obstet Gynecol 206(l):63.e1,r2012 Bates SM, Greer A, Middeldorp S, et al: VTE, thrombophilia, anti thrombotic therapy, and pregnancy: Antithrombotic herapy and Prevention of hrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141 (2 Suppl):e691S, 2012


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Obstentrics_Williams. Bayoumi YA, Bassiouny YA, Hassan A, et al: Is there a diference in the maternal and neonatal outcomes between patients discharged after 24 h versus 72 h following cesarean section? A prospective randomized observational study on 2998 patients. J \1aten Fetal Neonatal Med 29(8):1339, 2016 Belfort M, Koford S, Vaner M: Massive obstetric hemorrhage in a Jehovah's Witness: intraoperative strategies and high-dose erythropoietin use. Am J Perinatol , 201r1 Berhan Y, Berhan A: A meta-analysis of reverse breech extraction to deliver a deeply impacted head during cesarean delivery. Int J Gynaecol Obstet 124(2):99,r2014 Bloom SL, for the National Institute of Child Health and Human Development \1aternal-Fetal Medicine Units Cesarean Registry: Decision to incision times and infanc outcome. Am J Obstet Gynecol 185:S121, 2001 Bloom SL, Leveno KJ, Spong CY, et al: Decision-to-incision times and maternal and fetal outcomes. Obstet Gynecol 108(1):6,r2006


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Obstentrics_Williams. Bloom SL, Leveno KJ, Spong CY, et al: Decision-to-incision times and maternal and fetal outcomes. Obstet Gynecol 108(1):6,r2006 Bodelon C, Bernabe-Ortiz A, Schif MA, et al: Factors associated with peri partum hysterectomy. Obstet Gynecol 114(1): 115, 2009 Bohman VR, Gilstrap L, Leveno K, et al: Subcutaneous tissue: to close or not to close at cesarean section. Amr] Obstet Gynecol , 1992 Bolze PA, Massoud M, Gaucherand P, et al: What about the Misgav-Ladach surgical technique in patients with previous cesarean sections? Am J Perinatol 30(3):197, 2013 Boyle A, Reddy UM, Landy HJ, et al: PrimalY cesarean delivery in the United States. Obstet Gynecol 122(1):33,r2013 Boyle JG, Gabbe SG: T and J vertical extensions in low transverse cesarean births. Obstet Gynecol 87(2):238, 1996


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Obstentrics_Williams. Boyle JG, Gabbe SG: T and J vertical extensions in low transverse cesarean births. Obstet Gynecol 87(2):238, 1996 Bragg 0, EI-Sharkawy AM, Psaltis E, et al: Postoperative ileus: recent developments in pathophysiology and management. Clin Nutr 34(3):367,r2015 Briery CM, Rose CH, Hudson T, et al: Planned vs emergent cesarean hys terectomy. Am] Obstet Gynecol 197(2):154.el, 2007 Buie VC, Owings MF, DeFrances CJ, et al: National Hospital Discharge Survey: 2006 summary. National Center for Health Statistics. Vital Health Stat 13(168):1,r2010 CAESAR Study Collaborative Group: Caesarean section surgical techniques: a randomised factorial trial (CAESAR). BJOG (11):1366,2010 Cahill AG, Stamilio OM, Odibo AO, et al: Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am ] Obstet Gynecol 195(4): 1143, 2006


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Obstentrics_Williams. Cahill AG, Stamilio OM, Odibo AO, et al: Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am ] Obstet Gynecol 195(4): 1143, 2006 Caissutti C, Saccone G, Zullo F, et al: Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis Obstet Gynecol 130(3):527, 2017 Carpenter L, Baysinger CL: Maintaining perioperative normothermia in the patient undergoing cesarean delivery. Obstet Gynecol Surv 67(7):436, 2012 Chai AH, Wong T, Mak HL, et al: Prevalence and associated risk factors of retention of urine after caesarean section. 1m Urogynecol J Pelvic Floor Dysfunct 194(4):537,r2008 Chang SR, Chen KH, Ho HN, et al: Depressive symptoms, pain, and sexual dysfunction over the irst year following vaginal or cesarean delivery: a prospective longitudinal study. Int J Nurs Stud 52(9): 1433, 2015


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Obstentrics_Williams. Chapman SJ, Owen J, Hauth JC: One versus two-layer closure of a low transverse cesarean: the next pregnancy. Obstet Gynecol 89: 16, 1997 Chaudhuri P, Mandi S, Mazumdar A: Rectally administrated misoprostol as an alternative to intravenous oxytocin infusion for preventing post-partum hemorrhage after cesarean delivery. J Obstet Gynaecol Res 40(9):2023, 2014 Cheesman K, Brady]E, Flood P, et al: Epidemiology of anesthesia-related complications in labor and delivery, New York State, 2002-2005. Anesth Analg 109:1174,r2009 Chelmow 0, Rodriguez E], Sabatini MM: Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 103:974,r2004 Clark SL, Belfort MA, Dildy GA, et al: Matenal death in the 21st centlllY: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 199(1):36.e1, 2008


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Obstentrics_Williams. Clark SL, Belfort MA, Dildy GA, et al: Matenal death in the 21st centlllY: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 199(1):36.e1, 2008 Clark SL, Miller DO, Belfort A, et al: Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol 200(2): 156. el,r2009 Conde-Agudelo A, Nieto A, Rosas-Bermudez A, et al: Misoprostol to reduce intraoperative and postoperative hemorrhage during cesarean delivery: a systematic review and metaanalysis. Am J Obstet Gynecol 209(1 ):40.e1, 2013 CORON1S Collaborative Group, Abalos E, Addo V, et al: Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial. Lancet 388(10039):62,r2016 CORON1S Collaborative Group, Abalos E, Addo V, et al: Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, ran domised controlled trial. Lancet 382(9888):234,r2013


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Obstentrics_Williams. CORON1S Collaborative Group, Abalos E, Addo V, et al: Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, ran domised controlled trial. Lancet 382(9888):234,r2013 Cromi A, Ghezzi F, Di Naro E, et al: Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol 199(3):292.el, 2008 Dahlke JD, Mendez-Figueroa H, Rouse OJ, et al: Evidence-based surgery for cesarean delivery: an updated systematic review. Am ] Obstet Gynecol 209(4):294,r2013 Davis JD: Management of injuries to the urinary and gastrointestinal tract during cesarean section. Obstet Gynecol Clin North Am 26(3):469, 1999 Daykan Y, Sharon-Weiner M, Pastenak Y, et al: Skin closure at cesarean delivery, glue versus subcuticular sutures: a randomized controlled trial. Am J Obstet GynecoIr216(4):406.el, 201


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Obstentrics_Williams. Daykan Y, Sharon-Weiner M, Pastenak Y, et al: Skin closure at cesarean delivery, glue versus subcuticular sutures: a randomized controlled trial. Am J Obstet GynecoIr216(4):406.el, 201 Declercq E, Menacker F, MacDorman M: Rise in "no indicated risk" primary caesareans in the United States, 1991-2001: cross sectional analysis. BM] 1,r2005 Dodd ]M, Anderson ER, Gates S, et al: Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev 7:CD004732, 2014 Dolan LM, Hilton P: Obstetric risk factors and pelvic floor dysfunction 20 years after first delivery. Int Urogynecol] 21(5):535,r2010 Duggal N, Poddatoori V, Noroozkhani S, et al: Perioperative oxygen supplementation and surgical site infection after cesarean delivery: a randomized trial. Obstet GynecoIr122(1):79, 2013


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Obstentrics_Williams. Duggal N, Poddatoori V, Noroozkhani S, et al: Perioperative oxygen supplementation and surgical site infection after cesarean delivery: a randomized trial. Obstet GynecoIr122(1):79, 2013 Durnwald C, Mercer B: Uterine rupture, perioperative and perinatal morbidity after single-layer and double-layer closure at cesarean delivery. Am ] Obstet Gynecol 189:925,r2003 Edwards RK, Ingersoll M, Gerkin RD, et al: Carboxymethylcellulose adhesion barrier placement at primary cesarean delivery and outcomes at repeat cesarean delivery. Obstet Gynecol 123(5):923,r2014 Eisenkop SM, Richman R, Platt LD, et al: Urinary tract injury during cesarean section. Obstet GynecoIr60(5):591, 1982 Eke AC, Shukr GH, Chaalan TT, et al: Intra-abdominal saline irrigation at cesarean section: a systematic review and meta-analysis. J Maten Fetal Neonatal Med 29(10):1588,r2016 Fehniger ]E, Brown ]S, Creasman ]M, et al: Childbirth and female sexual function later in life. Obstet Gynecol 122(5):988,r2013


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Obstentrics_Williams. Tita AT, Hauth ]C, Grimes A, et al: Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis. Obstet Gynecol 111(1):51,2008 Tita AT, Landon MB, Spong CY, et al: Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Englr] Med 360(2): Ill, 2009 Tita AT, Szychowski ]M, Boggess K, et al: Adjunctive azithromycin prophy laxis for cesarean delivery. N Engl] Med 375(13):1231, 2016 Tolcher MC, Johnson RL, El-Nashar SA, et al: Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol 123(3):536,r2014 Tulandi T, Agdi M, Zarei A, Miner L, et al: Adhesion development and morbidiry after repeat cesarean delivery. m] Obstet Gynecol 201(1):56.e1, 2009 Tuuli MG, Liu], Stout M], et a1: A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl] vIed 374(7):647, 2016a


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Obstentrics_Williams. Tuuli MG, Liu], Stout M], et a1: A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl] vIed 374(7):647, 2016a Tuuli MG, Odibo AO, Fogertey P, et al: Utility of the bladder lap at cesarean delivery: a randomized controlled trial. Obstet GynecoI119(4):815, 2012 Tuuli MG, Stout M], Martin S, et al: Comparison of suture materials for subcuticular skin closure at cesarean delivery. Am] Obstet Gynecol 215 (4) :490. el, 2016b Villar ], Carroli G, Zavaleta N, et al: Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. B]M 335:1025, 2007 Viney R, Isaacs C, Chelmow D: Intra-abdominal irrigation at cesarean delivery: a randomized controlled trial. Obstet Gynecol 119(6): 11 06, 2012 Walsh CA, Walsh SR: Extraabdominal vs intraabdominal uterine repair at cesarean delivery: a metaanalysis. Amr] Obstet Gynecol 200(6):625. e1,r2009


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Obstentrics_Williams. Walsh CA, Walsh SR: Extraabdominal vs intraabdominal uterine repair at cesarean delivery: a metaanalysis. Amr] Obstet Gynecol 200(6):625. e1,r2009 Wang HY, Hong SK, Duan Y, et al: Tranexamic acid and blood loss during and after cesarean section: a meta-analysis.r] PerinatoIr35(10):818, 2015 Witt A, Doner M, Petricevic L, et al: Antibiotic prophylaxis before surgery vs after cord clamping in elective cesarean delivery: a double-blind, prospective, randomized, placebo-controlled trial. Arch Surg 146(12): 1404, 2011 Worley KC, Mcintire DD, Leveno K]: he prognosis for spontaneous labor in women with uncomplicated term pregnancies: implications for cesarean delivery on maternal request. Obstet Gynecol 113(4):812,r2009 Wrench I], Allison A, Galimberti A, et al: Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience. Int] Obstet Anesth 24(2):124,2015


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Obstentrics_Williams. Wyckof MH, Aziz K, Escobedo MB, et 1: Part 13: Neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 132(18 SuppI2):S543, 2015 Wylie B], Gilbert S, Landon MB, et al: Comparison of transverse and vertical skin incision for emergency cesarean delivery. Obstet GynecoIr115(6):1134, 2010 Xodo S, Saccone G, Cromi A, et a1: Cephalad-caudad versus transverse blunt expansion of the low transverse uterine incision during cesarean delivery. Eur] Obstet Gynecol Reprod BioI 202:75, 2016 Yildirim G, Gungorduk K, AsIClOgiu 0, et 1: Does vaginal preparation with povidone-iodine prior to caesarean delivery reduce the risk of endometritis? A randomized controlled trial.] Matern Fetal Neonatal Med 25(11):2316,r2012 Yossepowitch 0, Baniel ], Livne PM: Urological injuries during cesarean section: intraoperative diagnosis and management.r] UroIr172(1):196, 2004


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Obstentrics_Williams. Yost NP, Bloom SL, Sibley MK, et al: A hospital-sponsored quality improvement study of pain management after cesarean delivery. Amr] Obstet Gynecol 190:1341, 2004 Young OM, Shaik IH, Twedt R, et al: Pharmacokinetics of cefazolin prophylaxis in obese gravidae at time of cesarean delivery. Am ] Obstet Gynecol 213(4):541.e1,r2015 Zaphiratos V, George RB, Boyd ]c, et al: Uterine exteriorization compared with in situ repair for cesarean delivery: a systematic review and meta-analysis. Can] Anaesth 62(11):1209,r2015 Zhu P, Wang WJ, Zhang SL, et al: Efects of gum chewing on postoperative bowel motility after caesarean section: a meta-analysis of randomised controlled trials. B]OG 121(7):787,r2014 100 YEARS OF CONTROVERSY .e....e...e....e....e...e. 591 INFLUENCING FACTORS ....e. .e.. .e....e......e. 592 DELIVERY ROUTE RISKS . . ........e..... ..e... 593 CANDIDATES FOR TRIAL OF LABOR. . . . . . . . . . . . . . . 594 LABOR AND DELIVERY CONSIDERATIONS ..e..e...e.. 597


Obstentrics_Williams

Obstentrics_Williams. DELIVERY ROUTE RISKS . . ........e..... ..e... 593 CANDIDATES FOR TRIAL OF LABOR. . . . . . . . . . . . . . . 594 LABOR AND DELIVERY CONSIDERATIONS ..e..e...e.. 597 UTERINE SCAR ......e..e...e........ ... 598 MULTIPLE REPEAT CESAREAN DELIVERIESe. . . . . .. . . . 599 VAGINAL BIRTH AFTER CESAREAN-2017 . ...... 600 The occurrence of pregnancy ater a Caesarean section, however, is not always devoid of danger, cases have been reported in which the uterine cicatrix ruptured in the latter part of a subsequent gestation. It is also stated that the adhesions that sometimes orm between the uterus and the abdominal wall occasionaly exert a deleterious inluence in subsequent pregnancies. -J. Whitridge Williams (1903)


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Obstentrics_Williams. -J. Whitridge Williams (1903) From the above, there was an early appreciation for some of the major problems encountered in women with a prior cesarean delivery. Few issues in modern obstetrics have been as controversial as the management of these women. Indeed, the dangers associated with uterine rupture led to the oft-quoted remark by Cragin in 1916: "Once a cesarean, always a cesarean." As we reach the 100-year mark of Cragin's pronouncement, the issue remains largely unsettled.


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Obstentrics_Williams. By the beginning of the 20th century, cesarean delivery had become relatively safe. But, as women survived the first operation and conceived again, they were now at risk for rupture of the uterine scar. Still, the specter of rupture did not did not result in strict adherence to repeat cesarean delivery. Indeed, Eastman (1950) described a 30-percent postcesarean vaginal delivery rate at Johns Hopkins Hospital. he uterine rupture incidence was 2 percent and associated with a 1 O-percent maternal mortality rate. During the 1960s, observational studies suggested that vaginal delivery was a reasonable option (Pauerstein, 1966, 1969). Germane to this is that through the 1960s, the overall cesarean delivery rate approximated only 5 percent. Since then, as the primary cesarean rate escalated, the rate for repeat cesarean delivery followed (Rosenstein, 2013).


Obstentrics_Williams

Obstentrics_Williams. During the 1980s, a National Institutes of Health (NIH) Consensus Development Conference (1981) was convened, and it questioned the necessity of routine repeat cesarean delivery. With support and encouragement from the American College of Obstetricians and Gynecologists (1988, 1994), enthusiastic attempts were begun to increase the use of vaginal birth after cesa rea n-VBA. These attempts were highly successful, and VBAC rates increased from 3.4 percent in 1980 to a peak of 28.3 percent in 1996. These rates, along with a concomitant decline in total cesarean delivery rates for the United States, are shown in Figure 31-1.


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Obstentrics_Williams. As the vaginal delivery rate increased, so did reports of uterine rupture-related maternal and perinatal morbidity and mortality 1996; Sachs, 1999). These complications dampened prevailing enthusiasm for a trial of labor after cesarean section (TOLAC) and stimulated the American College of Obstetricians and Gynecologists (1998) to caution that such trials should be attempted only j:.:c)�00 .j!a:


Obstentrics_Williams

Obstentrics_Williams. FIGURE 31-1 Total, primary, and low-risk cesarean delivery (CS) rates and vaginal birth after previous cesarean (VBAC) rates in the United States, 1989-2015. Epochs denoted within rectangles represent contemporaneous ongoing events related to these rates. ACOG = American College of Obstetricians and Gynecologists; NIH = National Institutes of Health; PB = practice bulletin. (Data from Hamilton, 2015,2016; National Institutes of Health: NIH Consensus Development Conference, 2010.) in appropriately equipped institutions with physicians readiy available to provide emergency care. Less than a year later, the College (1999) recommended that physicians should be immediatey available. Many believe that this change ofone wordfrom readiy to immediatey available-was in large part responsible for the decade-long decline in national VBAC rates illustrated in Figure 31-1 (Cheng, 2014; Leeman, 2013).


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Obstentrics_Williams. Uddin and colleagues (2013) reported the proportion of women with a prior cesarean delivery who underwent TOLAC. This number peaked in 1995, when slightly more than half of all of these women chose this option. Since that time,


Obstentrics_Williams

Obstentrics_Williams. FIGURE 31-2 Percentage of births with trial of labor among all deliveries with a prior cesarean delivery and percentage ofsuccessful trials oflabor among all trials oflabor ater caesarean delivery in the United States, 1990-2009. TOLAC = trial of labor ater cesarean delivery; VBAC = vaginal birth after cesarean delivery. (Data from Uddin SFG, Simon AE: Rates and success rates oftrial of labor ater cesarean delivery in the United States, 1990-2009. Matern Child Health J 17:1309,2013.) the Oice of Medical Applications of Research (0MAR) convened an NIH Consensus Development Conference Panel (2010) to study the issues of VBAC. The panel report included a contemporaneous summary concerning the risks and benefits of repeat cesarean versus vaginal delivery. These indings are subsequently described along with summaries of current recommendations by various professional organizations. Importantly, data from California indicate that VBAC rates have not perceptibly increased since the 2010 NIH


Obstentrics_Williams

Obstentrics_Williams. along with summaries of current recommendations by various professional organizations. Importantly, data from California indicate that VBAC rates have not perceptibly increased since the 2010 NIH Consensus Conference (Barger, 2013).


Obstentrics_Williams

Obstentrics_Williams. For the woman who has had a previous cesarean delivery, planning for future pregnancies and the delivery route should begin with preconceptional counseling and be addressed once again early in prenatal care. Importantly, any decision is subject to continuing revisions as dictated by exigencies that arise during pregnancy. Assuming no mitigating circumstances, there are two basic choices. First, a TOAC ofers the goal of achieving VBA. If cesarean delivery becomes necessary during the trial, then it is termed a "failed trial oflabor." A second choice is elective repeat cesarean delivey (ERCD). his includes scheduled cesareandelivery as well as unscheduled but planned cesarean delivery for spontaneous labor or another indication. he ultimate decision should weigh clinical factors known to influence TOLAC success as well as benefits and risks. As expected, these rates vary between institutions and providers. Factors that inluence a successful TOLAC are listed in Table


Obstentrics_Williams

Obstentrics_Williams. Finally, economic, staing, and medicolegal factors may shape the decision to ofer TOLAC. the proportion of women attempting TOLAC declined to a nadir in 2006 of about 16 percent and has subsequently increased to 20 to 25 percent through 2009. These investigators further reported that the percentage of VBACs reached its peak in 2000 with approximately 70 percent ofwomen being successful, but this has subsequently declined to a nadir of 38 percent in 2008 (Fig. 31-2). In reality, several other interrelated factors-both medical and nonmedicalhave undoubtedly contributed to declining VBAC rates. Because of their complexity and importance, the Eunice Kennedy Shriver National Institute of Child Health and Human Devel TABLE 31-1. Some Factors That Influence a Successful Trial of Labor in a Woman with Prior Cesarean Delivery aMost consider these absolute contraindications. EGA = estimated gestational age.


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Obstentrics_Williams. TABLE 31-1. Some Factors That Influence a Successful Trial of Labor in a Woman with Prior Cesarean Delivery aMost consider these absolute contraindications. EGA = estimated gestational age. As evidence mounted that the risk of uterine rupture might be greater than expected, the American College of Obstetricians and Gynecologists (1988, 1998, 1999, 2017a) issued updated Practice Bulletins supporting labor trials but also urging a more cautious approach. It is problematic that both options have risks and beneits to mother and fetus but that these are not always congruent.


Obstentrics_Williams

Obstentrics_Williams. Rates of uterine rupture and associated complications clearly are increased with TO LAC. Uterine rupture typically is classified as either (1) complete, when all layers of the uterine wall are separated, or (2) incomplete, when the uterine muscle is separated but the visceral peritoneum is intact. Incomplete rupture is also commonly referred to as uterine dehiscence. It is these risks that underpin most of the angst in attempting TOLAC. Despite this, some have argued that these factors should weigh only minimally in the decision because their absolute risk is low. One systematic review by Guise and colleagues (2010) concluded that the risk of uterine rupture was significantly elevated in women undergoing TOLAC-absolute risk of 0.47 percent and relative risk of 20.7-compared with those choosing ERCD.


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Obstentrics_Williams. he Maternal-Fetal Medicine Units Network conducted a prospective study at 19 academic centers (Landon, 2004). The outcomes of nearly 18,000 women attempting TOLAC were compared with more than 15,000 gravidas undergoing ERCD. The absolute risk of uterine rupture was 0.7 percent compared with no reported uterine ruptures in the ERCD cohort (Table 31-2). .10st studies suggest that the maternal mortaliy rate does not difer significantly between these two groups (Landon, 2004; Mozurkewich, 2000). But, the aforementioned systematic review by Guise (2010) found the Single mother Classical or T incision Increased maternal age Prior rupture Macrosomic fetus Patient refusal Obesity Transfundal surgery Breech Obstetrical contraindication,


Obstentrics_Williams

Obstentrics_Williams. Single mother Classical or T incision Increased maternal age Prior rupture Macrosomic fetus Patient refusal Obesity Transfundal surgery Breech Obstetrical contraindication, Multifetal pregnancy e.g., previa Preeclampsia Inadequate facilities risk of maternal death to be signiicantly reduced for women undergoing TOLAC compared with ERCD. In a retrospective Canadian cohort study, the maternal death rate for women undergoing ERCD was 5.6 per 100,000 cases compared with 1.6 per 100,000 for those attempting TOLAC (Wen, 2005).


Obstentrics_Williams

Obstentrics_Williams. Estimates of maternal morbidiy are also conflicting. he review by Guise (2010) observed no significant diferences in the risk of hysterectomy or transfusion. But, another metaanalysis reported that women undergoing TOLAC were approximately half as likely to require a blood transfusion or hysterectomy compared with those undergoing ERCD (Mozurkewich, 2000). Conversely, in the Network study, investigators observed that the risks of transfusion and infection were significantly greater for women attempting TOLAC (Landon, 2004). This disparity is also found among other studies. Notably, compared with a successful TOLAC, the risk of these major complications was ivefold greater with an attempted vaginal delivery that failed (Babbar, 2013; Rossi, 2008).


Obstentrics_Williams

Obstentrics_Williams. TOLAC is associated with significantly higher perinatal mortaliy rates compared with ERCD. he perinatal rate with TOLAC is 0.13 compared with 0.05 percent for ERCD, and the neonatal mortality rates are 0.i11 versus 0.06 percent, respectively (Guise, 2010). In another study of nearly 25,000 women with a prior cesarean delivery, the vaginal-delivery-related perinatal death risk was 1.3 per 1000 among 15,515 women electing TOLAC. Although this absolute risk is small, it is 11 times greater than the risk found in 9014 women with ERCD (Smith, 2002). TOLAC also appears to be associated with a higher risk of hypoxic ischemic encephalopathy (HIE) than ERCD. The Network study reported the incidence of HIE at term to be 46 per 100,000 TOLACs compared with zero cases in women undergoing ERCD (Landon, 2004). Uterine dehiscence 11s9 (0.7)


Obstentrics_Williams

Obstentrics_Williams. Uterine dehiscence 11s9 (0.7) Hysterectomy 41 (0.2) 76 (0.5) 1.38 (1s.04-1.85) 0.77 (0.51-1s.17) .03 .22 aDenominator is 15,338 for the trial of labor group and 15,014 for the elective repeat cesarean delivery group. confidence interval; HIE hypoxic ischemic encephalopathy; NA not applicablesNICHD = National Institute of Child Health and Human Development; NS = not significant. Adapted from Landon, 2004.


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Obstentrics_Williams. confidence interval; HIE hypoxic ischemic encephalopathy; NA not applicablesNICHD = National Institute of Child Health and Human Development; NS = not significant. Adapted from Landon, 2004. In the systematic review, the absolute risk of transient tachypnea of the newborn was slightly higher with ERCD compared with TOAC-4.2 versus 3.6 percent (Guise, 2010). But, neonatal bag and mask ventilation were used more often in newborns delivered following TOAC than in those delivered by ERCD-5.4 versus 2.5 percent. Finally, there are no signiicant diferences in 5-minute Apgar scores or neonatal intensive care unit admission rates for newborns delivered by TO AC compared with those delivered by ERCD. Birth trauma from lacerations is more commonly seen in neonates born by ERCD.


Obstentrics_Williams

Obstentrics_Williams. Few high-quality data are available to guide selection of TO AC candidates. In a population-based cohort study of 41,450 women he type and number of prior cesarean deliveries are overriding factors in recommending TOAC. Women with one prior low-transverse hysterotomy have the lowest risk of symptomatic scar separation (Table 31-3). The highest risks are with prior vertical incisions extending into the fundus, such as that


Obstentrics_Williams

Obstentrics_Williams. TABLE 31 -3. Types of Prior Uterine Incisions and Estimated Risks for Uterine Rupture delivering in California hospitals, Gregory and colleagues (2008) Classical reported a TOAC success rate of74 percent when no maternal, T-shaped fetal, or placental complications were present. Several algorithms and nomograms have been developed to aid prediction, but none has demonstrated reasonable prognostic value (Grobman, 2007b, 2008,i2009; Macones, 2006; Metz, 2013; Srinivas, 2007). A predictive model for failed trial of labor, however, was found to be somewhat predictive of uterine rupture or dehiscence (Stanhope, 2013). Despite these limitations for precision, several points are pertinent to candidate evaluation and are described in the next sections. Current recommendations of the American College of Obstetricians and Gynecologists (2017 a) are that most women with one previous low-transverse hysterotomy are candidates, and if appropriate, they should be counseled regarding TOAC and ERCD


Obstentrics_Williams

Obstentrics_Williams. of Obstetricians and Gynecologists (2017 a) are that most women with one previous low-transverse hysterotomy are candidates, and if appropriate, they should be counseled regarding TOAC and ERCD options. Although not our practice, those with two prior low-transverse incisions may be considered.


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Obstentrics_Williams. aSee text for definition. Data from the American College of Obstetricians and Gynecologists, 201s7a; Cahill, 20s1 Ob; Chauhan, 2002; Landon, 2006; Macones, 2005a,b; Martin, 1997; Miller, 1994; Sciscione, 2008; Society for Maternal-Fetal Medicine, 2012; Tahseen, 201s0. FIGURE 31-3 Ruptured vertical cesarean delivery scar (arrow) identified at time of repeat cesarean delivery early in labor. The two black asterisks to the left indicate some sites of densely adhered omentum. shown in Figure 3i1-3. Importantly, in some women, a classical scar will rupture before labor onset, and this can happen several weeks before term. In a review of 157 women with prior classical cesarean delivery, one woman had a complete uterine rupture before labor onset, whereas 9 percent had a uterine dehiscence (Chauhan, 2002).


Obstentrics_Williams

Obstentrics_Williams. he risk of uterine rupture in women with a prior vertical incision that did not extend into the fundus is unclear. Martin (1997) and Shipp (1999) and their coworkers reported that these low-vertical uterine incisions did not have an increased risk for rupture compared with low-transverse incisions. The American College of Obstetricians and Gynecologists (2017a) concluded that although evidence is limited, women with a prior vertical incision in the lower uterine segment without fundal extension may be candidates for TOLAC. This is in contrast to prior classical or T -shaped uterine incisions, which are considered by most as contraindications to labor.


Obstentrics_Williams

Obstentrics_Williams. Although there are few indications for a primary classical incision, 53 percent of women undergoing cesarean delivery between 24°/7 weeks and 256r weeks have such an incision (Osmundson, 20l3). By 28 weeks' gestation, the risk drops to 35 percent and declines to < 10 percent by 32 weeks. he likelihood of classical uterine incision is also increased by noncephalic presentations. In those instances-for example, preterm breech fetus with an undeveloped lower segment-the "low vertical" incision almost invariably extends into the active segment. Prior preterm cesarean delivery may result in a twofold increased risk for rupture (Sciscione, 2008). This may be in part explained by the greater likelihood with a preterm fetus of upward uterine incision extension. Lannon and coworkers (2015) compared 456 women with a prior periviable cesarean delivery with more than 10,000 women whose prior cesarean delivery occurred at term. hey observed uterine rupture in 1.8 percent in the prior periviable


Obstentrics_Williams

Obstentrics_Williams. 456 women with a prior periviable cesarean delivery with more than 10,000 women whose prior cesarean delivery occurred at term. hey observed uterine rupture in 1.8 percent in the prior periviable group versus 0.4 percent in the prior term group. Of the uterine ruptures in the periviable group, half were in women whose prior uterine incision was described as low transverse. Harper and associates (2009) did not confirm these findings.


Obstentrics_Williams

Obstentrics_Williams. There are also special considerations for women with uterine malformations who have undergone cesarean delivery. Earlier reports suggested that the uterine rupture risk in a subsequent pregnancy was greater than the risk in those with a prior low transverse hysterotomy and normally formed uterus (Ravasia, 1999). But, in a study of 103 women with miillerian duct anomalies, there were no cases of uterine rupture (Erez, 2007). Given the wide range of risk for uterine rupture associated with the various uterine incision types, it is not surprising that most fellows of the American College of Obstetricians and Gynecologists consider the type of prior incision to be the most important factor when considering a TOLAC (Coleman, 2005).


Obstentrics_Williams

Obstentrics_Williams. Gynecologists consider the type of prior incision to be the most important factor when considering a TOLAC (Coleman, 2005). As discussed in Chapter 30 (p. 577), the low-transverse hysterotomy incision can be sutured in either one or two layers. A metaanalysis by Roberge and colleagues (2014) compared single-versus double-layer closure and locking versus unlocking suture for uterine closure. They reported that rates for uterine dehiscence or uterine rupture for these closures did not difer signiicantly. Single-layer closure and locked irst layer, however, was associated with a reduced myometrial thickness during subsequent sonographic measurement. In contrast, Bennich and coworkers (2016) reported that a double-layer closure did not increase the residual myometrial thickness when saline contrast sonography was done several months postpartum. At Parkland Hospital, we routinely close the lower-segment incision with one running, locking suture line. Number of Prior Cesarean Incisions


Obstentrics_Williams

Obstentrics_Williams. Number of Prior Cesarean Incisions At least three studies report a doubling or tripling of the rupture rate in women with two compared with one prior transverse hysterotomy (.1acones, 2005a; Miller, 1994; Tahseen, 2010). In contrast, analysis of the Network database by Landon and associates (2006) did not conirm this. Instead, they reported an insigniicant diference in the uterine rupture rate in 975 women with multiple prior cesarean deliveries compared with 16,915 women with a single prior operation-0.9 versus 0.7 percent, respectively. As discussed on page 599, other serious maternal morbidity increases along with the number of prior cesarean deliveries (Marshall, 2011). Imaging of Prior Incision


Obstentrics_Williams

Obstentrics_Williams. Sonographic measurement of a prior hysterotomy incision has been used to predict the likelihood of rupture. Large defects in a nonpregnant uterus forecast a greater risk for subsequent rupture (Osser, 201i1). Naji and coworkers (20l3a,b) found that the residual myometrial thickness decreased as pregnancy progressed and that rupture correlated with a thinner scar. In a systematic review, women with a prior low-transverse cesarean incision underwent third-trimester sonographic evaluation (Jastrow, 2010a). Investigators concluded that the thickness of the lower uterine segment was a strong predictor for a uterine scar defect in women with prior cesarean delivery. They deined this segment as the smallest measurement between urine in the maternal bladder and amnionic luid. hat said, they could not ind an ideal threshold value to recommend TOLAC. his same group subsequently recruited 1856 women contemplating vaginal birth after a single low-transverse incision, and they sonographically


Obstentrics_Williams

Obstentrics_Williams. not ind an ideal threshold value to recommend TOLAC. his same group subsequently recruited 1856 women contemplating vaginal birth after a single low-transverse incision, and they sonographically measured lower uterine segment thickness by between 34 weeks and 39 weeks G as trow, 2016). hey grouped women into three risk categories for uterine rupture during TOLAC based on the measured segment value: high risk <2.0 mm; intermediate risk 2.0-2.4 mm; and low risk �2.5 mm. he TOAC rates were 9,42, and 61 percent in the three categories, respectively. Of the 984 TOLACs, there were no symptomatic uterine ruptures. Overall, data are limited, and this evaluation is currently not part of our routine practice.


Obstentrics_Williams

Obstentrics_Williams. Women who have previously sustained a uterine rupture are at greater risk for recurrence. As shown in Table 31-3, those with a previous low-segment rupture have up to a 6-percent recurrence risk, whereas prior upper segment uterine rupture confers a 9-to 32-percent risk (Reyes-Ceja, 1969; Ritchie, 1971). Fox and associates (2014) reported 14 women with prior uterine rupture and 30 women with prior uterine dehiscence. In 60 subsequent pregnancies, they reported no uterine ruptures or severe complications if women were managed in a standardized manner with cesarean delivery prior to labor onset.


Obstentrics_Williams

Obstentrics_Williams. Magnetic resonance imaging studies of myometrial healing suggest that complete uterine involution and restoration of anatomy may require at least 6 months (Dicie, 1997). To explore this further, Shipp and coworkers (2001) examined the relationship between interdelivery interval and uterine rupture in 2409 women with one prior cesarean delivery. There were 29 women with a uterine rupture-l.4 percent. Interdelivery intervalsi:;18 months were associated with a threefold greater risk of symptomatic rupture during a subsequent TOLAC compared with intervalsi> 18 months. Similarly, Stamilio and associates (2007) noted a threefold augmented risk of uterine rupture in women with an interpregnancy interval <6 months compared with one �6 months.


Obstentrics_Williams

Obstentrics_Williams. Prior vaginal delivery, either before or after a cesarean birth, improves the prognosis for a subsequent vaginal delivery with either spontaneous or induced labor (Aviram, 2017; Grinstead, 2004; Hendler, 2004; Mercer, 2008). Prior vaginal delivery also lowers the risk of subsequent uterine rupture and other morbidities (Cahill, 2006; Hochler, 2014; Zelop, 1999). Women with a nonrecurring indication-for example, breech presentation-have the highest VBAC rate of nearly 90 percent (Wing, 1999). Those with a prior cesarean delivery for fetal compromise have an approximately 80-percent VBAC rate, and for those done for labor arrest, VBAC rates approximate 60 percent (Bujold, 2001; Peaceman, 2006). Prior second-stage cesarean delivery can be associated with second-stage uterine rupture in a subsequent pregnancy Gastrow, 2013).


Obstentrics_Williams

Obstentrics_Williams. Most studies show that increasing fetal size is inversely related to VBAC rates. he risk for uterine rupture is less robustly linked. Zelop and associates (2001) studied outcomes of almost 2750 women undergoing TOAC, and the rate of uterine rupture increased-albeit not signiicantly-with rising fetal weight. he rate was 1.0 percent for fetal weight <4000 g, 1.6 percent for >4000 g, and 2.4 percent for >4250 g. Similarly, Jastrow and colleagues (201 Ob) in a retrospective report of 2586 women with a prior low-transverse uterine incision, observed an elevated risk for a failed trial of labor, uterine rupture, shoulder dystocia, and perineal laceration associated with rising birthweights. Conversely, Baron and coworkers (2013) did not ind higher uterine rupture rates with birthweights >4000 g. With a preterm fetus, women who attempt a TOLAC have higher VBAC rates and lower rupture rates (Durnwald, 2006; Quinones, 2005).


Obstentrics_Williams

Obstentrics_Williams. Data supporting external cephalic version (ECV) for breech presentation are limited and are derived from small studies (Burgos, 2014; Weill, 2017). From thes;, ECV success and adverse event rates appear comparable to women without prior cesarean. The American College of Obstetricians and Gynecologists (2016) acknowledges this lack of robust data. At Parkland Hospital, we do not attempt ECV in those with a prior cesarean delivery. Twin pregnancy does not appear to increase the risk of uterine rupture. Ford and associates (2006) analyzed 1850 women with twins and reported a 45-percent successful VBAC rate and a rupture rate of 0.9 percent. Similar studies by Cahill (2005) and Varner (2007) and their colleagues reported rupture rates of 0.7 to 1.1 percent and VBAC rates of 75 to 85 percent. According to the American College of Obstetricians and Gynecologists (2017a), women with twins and a prior low-transverse hysterotomy can safely undergo TO LAC.


Obstentrics_Williams

Obstentrics_Williams. Multiple studies have reported an inverse relationship between prep regnancy body mass index (BMI) and VBAC rates. Hibbard and coworkers (2006) reported the following rates: 85 percent with a normal BMI, 78 percent with a BMI between 25 and 30, 70 percent with a BMI between 30 and 40, and 61 percent with a BMI �40. Similar findings were reported by Juhasz and associates (2005).


Obstentrics_Williams

Obstentrics_Williams. Most women with a prior cesarean delivery and fetal death in the current pregnancy would prefer a vaginal delivery. Although fetal concerns are obviated, available data suggest that maternal risks are increased. Nearly 46,000 women with a prior cesarean delivery in the Network database had a total of209 fetal deaths at an average gestational age of32.8 weeks (Ramirez, 2010). There were 158 women who elected TOLAC, with a VBAC rate of 87 percent. In the entire TOLAC group, the uterine rupture rate was 2.4 percent. Of the 116 women who underwent an induction oflabor, there were five uterine ruptures (3.4 percent).


Obstentrics_Williams

Obstentrics_Williams. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (2017b) recommend delaying nonmedically indicated deliveries until 39 completed weeks of gestation or beyond. As shown in Figure 31-4, signiicant and appreciable adverse neonatal morbidity has been reported with elective delivery before 39 completed weeks (Chiossi, 2013; Clark, 2009). Thus, if ERCD is planned, it is essential that the fetus be mature. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) have established the following guidelines for timing an elective cesarean delivery, and accurate gestational dating is suitable using any of these criteria. 1. Sonographic measurements taken before 20 weeks' gestation support a gestational age :39 weeks. 2. Fetal heart sounds have been documented for 30 weeks by Doppler ultrasound. 3.


Obstentrics_Williams

Obstentrics_Williams. 1. Sonographic measurements taken before 20 weeks' gestation support a gestational age :39 weeks. 2. Fetal heart sounds have been documented for 30 weeks by Doppler ultrasound. 3. A positive serum or urine �-human chorionic gonadotropin (hCG) test result has been documented for :36 weeks.


Obstentrics_Williams

Obstentrics_Williams. Because of uterine rupture risks for women undergoing TOLAC, the American Academy of Pediatricians and the American College of Obstetricians and Gynecologists (2017) recommend that such trials be undertaken only in facilities with staf immediately available to provide emergency care. Moreover, these centers should have a plan and resources for managing uterine rupture. Some argue that these provisions deny women full access to choices. For example, in an earlier survey of Ohio hospitals, 15 percent of Level I, 63 percent of Level II, and 100 percent of Level III institutions met these requirements (Lavin, 2002). Moreover, an obstetrical anesthesia workforce survey reported that due to stafing limitations, TOLAC was allowed in only 88 percent of hospitals with : 1500 annual deliveries, in 59 percent of those with 500 to 1499 deliveries, and in 43 percent of those with < 500 deliveries (Traynor, 2016). In some cases, women choose to attempt TOLAC at a birthing center or at home


Obstentrics_Williams

Obstentrics_Williams. in 59 percent of those with 500 to 1499 deliveries, and in 43 percent of those with < 500 deliveries (Traynor, 2016). In some cases, women choose to attempt TOLAC at a birthing center or at home (Shields, 2017).


Obstentrics_Williams

Obstentrics_Williams. Labor induction is associated with a higher failure rate during TOLAC. The risks for uterine rupture, however, are less clear with induction or augmentation, with the exception of prostaglandin E1-misoprostol-which is contraindicated (American College of Obstetricians and Gynecologists, 2017a). Although most institutions are not so conservative, we do not induce or augment labor pharmacologically in women electing TOLAC at Parkland Hospital. Instead, we attempt induction only by amniotomy. Other considerations are to avoid induction or augmentation in women with an unknown prior incision type, an unfavorable cervix, or pregnancy >40 weeks.


Obstentrics_Williams

Obstentrics_Williams. Induction or augmentation of labor with oxytocin has been implicated in increased rates of uterine rupture in women undergoing TOLAC (Zelop, 1999). In the Network study reported by Landon and colleagues (2004), uterine rupture was more frequent in women induced with oxytocin alone-I.l percentthan in those in spontaneous labor-O.4 percent. Augmentation of labor was associated with uterine rupture in 0.9 percent. Among women in this trial without a prior vaginal delivery, the uterine rupture risk associated with oxytocin induction was 1.8 percent-a fourfold greater risk compared with spontaneous labor (Grobman, 2007a). In contrast, in one case-control study, induction was not associated with a higher risk for rupture (Harper, 2012a). Cahill (2008) and Goetzl (2001) and their coworkers reported a dose-related risk of rupture with oxytocin.


Obstentrics_Williams

Obstentrics_Williams. Various prostaglandin preparations commonly employed for cervical ripening or labor induction are discussed in Chapter 26 (p. 506). s a group, their safe use in women with a prior cesarean delivery is unclear because of conlicting data. With misoprostol (PGE1), Wing and colleagues (1998)


Obstentrics_Williams

Obstentrics_Williams. With misoprostol (PGE1), Wing and colleagues (1998) FIGURE 31-4 Neonatal morbidity rates seen with 13,258 elective repeat cesarean deliveries. Any adverse outcome includes death. Sepsis includes suspected and proven. RDS = respiratory distress syndrome; IN = transient tachypnea of the newborn. (Data from Tita AT, Landon MB, Spong CY, et al: Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 360(2):1o11,o2009.) compared it versus oxytocin for labor induction in women with a prior cesarean delivery. They terminated their trial after two of the irst 17 women assigned to misoprostol developed a uterine rupture. Other studies confirmed this, and most consider misoprostol to be contraindicated (American College of Obstetricians and Gynecologists, 2017 a).


Obstentrics_Williams

Obstentrics_Williams. Of other prostaglandins, studies to evaluate their use for induction are contradictory. Ravasia and coworkers (2000) compared uterine rupture in 172 women given PGE2 gel with 1544 women in spontaneous labor. The rupture rate was significantly greater in women treated with PGE2 gel-2.9 percent compared with 0.9 percent in those with spontaneous labor. Lydon-Rochelle and associates (2001) found similar results. However, in the Network study cited previously, the uterine rupture rate was 1.4 percent when any prostaglandin was used in combination with oxytocin (Landon, 2004). But, in the subgroup of 227 women in whom labor was induced with a prostaglandin alone, there were no ruptures. Similar findings were reported with intravaginal prostaglandins, which were not associated with a greater uterine rupture risk (Macones, 2005b). These latter investigators, along with Kayani and colleagues (2005), found that sequential use of a prostaglandin followed by oxytocin was associated with a


Obstentrics_Williams

Obstentrics_Williams. uterine rupture risk (Macones, 2005b). These latter investigators, along with Kayani and colleagues (2005), found that sequential use of a prostaglandin followed by oxytocin was associated with a threefold greater risk of rupture compared with spontaneous labor.


Obstentrics_Williams

Obstentrics_Williams. Studies concerning the use of a transcervical Foley catheter for cervical ripening and induction of labor in women with a prior cesarean delivery are limited (Ben-Aroya, 2002; Jozwiak, 2014). In a retrospective study of 2479 women with prior cesarean delivery, the uterine rupture risk using a transcervical Foley catheter for labor induction (1.6 percent) was not significantly greater than that with spontaneous labor (1.1 percent) or with using amniotomy with or without oxytocin (1.2 percent) (Bujold, 2004). In contrast, Hofman (2004) described 138 women who underwent preinduction cervical ripening with a Foley catheter compared with 536 women who entered labor spontaneously. They observed a significant and inordinately high uterine rupture risk during labor following Foley catheter cervical ripening compared with spontaneous onset of labor-6.5 versus 1.9 percent.


Obstentrics_Williams

Obstentrics_Williams. Concerns that epidural analgesia for labor might mask the pain of uterine rupture have not been veriied. Fewer than 10 percent of women with scar separation experience pain and bleeding, and fetal heart rate decel erations are the most likely sign (ieser, 2002). That said, Cahill and coworkers (2010a) documented that more frequent episodes of epidural dosing were associated with increasing uterine rupture rates. VBAC rates are similar, and in some cases higher, among women with labor epidural analgesia compared with those using other forms of analgesia (Aviram,