**Complications**

[28] Sparic R, Kadija S, Stefanovic A, et al. Cesarean myomectomy in modern obstetrics: More light and fewer shadows The Journal of Obstetrics and Gynecology Research. May

[29] Song D, Zhang W, Chames MC, Guo J. Myomectomy during cesarean delivery.

[30] Hatırnaz Ş, Güler O, Başaranoğlu S, Tokgöz C, Kılıç GS. Endometrial myomectomy: A novel surgical method during cesarean section. The Journal of Maternal-Fetal & Neonatal Medicine. 2018 Feb;**31**(4):433-438. DOI: 10.1080/14767058.2017.1286320. Epub 2017 Feb 9

[31] Alessandro C, Antonio M, Carlo A, 354 Ioannis T, Ida S, Adam M, Giuseppe DP. Techniques to reduce the blood loss during open myomectomy: A qualitative review of literature. European Journal of Obstetrics & Gynecology and Reproductive Biology.

[32] Desai BR, Patted SS, Pujar YV, Sherigar BY, Das SR, Ruge JC. DGOA novel technique of selective uterine devascularization before myomectomy at the time of cesarean section:

[33] Pei-Chun M, Yin-Chen J, I-De W, Chien-Han C, Wei-Min L, Cherng-Jye J. A huge leio

[34] Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classifica

[35] Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, et al. Adverse obstetric outcomes associated with sonographically identified large uterine fibroids. Fertility and

[36] Topcu Hasan O, İskender Can T, Hakan T, Oktay K, Tuba M, Nuri D. Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uter

[37] Li H, Du J, Jin L, Shi Z, Liu M. Myomectomy during cesarean section. Acta Obstetricia et

[38] Sparic R,Malvasi A,Tinelli A. Analysis of clinical, biological and obstetric factors influ

[39] Seshadri S, Khalil M, Osman A, Clough A, Jayaprakasan K, Khalaf Y. The evolving role of saline infusion sonography (SIS) in infertility. Eu Published. European Journal of Obstetrics & Gynecology and Reproductive Medicine. February 1, 2015;**185**:66-73. © 2014

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2017;**43**(5):798-804

78 Caesarean Section

**Chapter 6**

**Provisional chapter**

**Complications of Cesarean Operation**

**Complications of Cesarean Operation**

DOI: 10.5772/intechopen.75901

In the last decades, there has been a huge increase in the incidence of the cesarean section that worldwide became a routine procedure in most hospitals despite the potential complications which in some cases can cause permanent damage or can even be fatal, affecting both the mother and the fetus. In this chapter, we will discuss the most frequent complications that occur in the cesarean section both in the surgical act and after the

**Keywords:** cesarean section, intraoperative complications, postoperative complications

The progressive increase in the incidence of cesarean section during the last decades has been constant worldwide, increasing; at the same time, the indications, many of them unnecessary, resulting in indiscriminate practice, becoming the most frequent surgical intervention performed in health institutions, both private and public. Currently, the obstetrician is able to more accurately assess the hostility of the intrauterine environment and thus, as the development of fetal medicine is so significant, and it is also safe to perform a cesarean section since there are also factors that facilitate decision-making in favor of interrupting pregnancy through the abdominal route such as new generations of antibiotics with greater coverage, suture materials with less adverse reaction, better surgical techniques and skills, better hospi-

This increase is also favored by non-professional communication in social networks that minimize the surgical risks of cesarean section, promoting false advantages aimed mainly at family comfort; as well as by health professionals not related to obstetrics and although it bother

tal infrastructure and greater ease of extra-hospital monitoring at the exit.

us to recognize it, also by some "obstetricians" who seek personal benefits [1–11].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75901

Enrique Rosales Aujang

Enrique Rosales Aujang

**Abstract**

event.

**1. Introduction**

#### **Complications of Cesarean Operation Complications of Cesarean Operation**

#### Enrique Rosales Aujang Enrique Rosales Aujang

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75901

**Abstract**

In the last decades, there has been a huge increase in the incidence of the cesarean section that worldwide became a routine procedure in most hospitals despite the potential complications which in some cases can cause permanent damage or can even be fatal, affecting both the mother and the fetus. In this chapter, we will discuss the most frequent complications that occur in the cesarean section both in the surgical act and after the event.

DOI: 10.5772/intechopen.75901

**Keywords:** cesarean section, intraoperative complications, postoperative complications

#### **1. Introduction**

The progressive increase in the incidence of cesarean section during the last decades has been constant worldwide, increasing; at the same time, the indications, many of them unnecessary, resulting in indiscriminate practice, becoming the most frequent surgical intervention performed in health institutions, both private and public. Currently, the obstetrician is able to more accurately assess the hostility of the intrauterine environment and thus, as the development of fetal medicine is so significant, and it is also safe to perform a cesarean section since there are also factors that facilitate decision-making in favor of interrupting pregnancy through the abdominal route such as new generations of antibiotics with greater coverage, suture materials with less adverse reaction, better surgical techniques and skills, better hospital infrastructure and greater ease of extra-hospital monitoring at the exit.

This increase is also favored by non-professional communication in social networks that minimize the surgical risks of cesarean section, promoting false advantages aimed mainly at family comfort; as well as by health professionals not related to obstetrics and although it bother us to recognize it, also by some "obstetricians" who seek personal benefits [1–11].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In addition, we will never finish insisting that medical legal criteria encourage the belief that maternal morbidity and mainly the perinatal observed in the vaginal route, could be avoided with a cesarean section, favoring the growing doctor's fear to be subject of a legal claim thus evading the responsibility that comes with the adequate and justified indication of a cesarean section [11, 13].

It is generally accepted to limit the amount of bleeding to a maximum of 500 ml for a vaginal delivery and 1000 ml for the cesarean section, and in case of larger amounts, it is termed as obstetric hemorrhage. It is also accepted as a 10% decrease in hematocrit, although this starts

Complications of Cesarean Operation http://dx.doi.org/10.5772/intechopen.75901 83

It must be borne in mind that the indication of cesarean section "per se" implies a pathological background disorder such as the anomalous insertion of the placenta, maternal hypertension, the infection, prolonged labor, uterine overdistention, and so on, which are factors that significantly alter the vascular network and uterine contractility, increasing the bleeding caused by the same vascular damage during the surgical act which increases when there is difficulty in extracting the fetus since it can easily tear the hysterotomy causing greater vascular dam-

In **Table 1**, we see the most frequent risk factors that are associated with bleeding as a compli-

The treatment of the hemorrhage depends on the cause, and hemorrhage can precede the indication of cesarean section as in the low insertion of placenta or the premature detachment of placenta or appear in the course or even after surgery. **Figure 1** shows the placental bed

The treatment should start with a quick and precise diagnosis of the origin of the hemorrhage accompanied by measures that maintain an adequate hemodynamics with intravenous solutions of preferably isotonic crystalloids in which blood is obtained for immediate transfusions, taking care not to pass more than 2000 ml of liquids that can cause an acute pulmonary edema or lead to a coagulopathy by dilution, and fresh blood or alternate erythrocyte concentrates should be administered with fresh frozen plasma for the immediate replacement of coagulation factors; immediate cleaning of the uterine cavity at the same time of a uterine massage applied in a uniform and compressive manner. Most of the time, it achieves the

after 4 h with a maximum limit of up to 48 h [19, 21].

Multiple pregnancy, fetal macrosomia, polyhydramnios, Uterine scar

age [3, 4, 14–21].

cation of the cesarean section.

invaded by the trophoblast.

Low insertion of placenta Placental acretism Placenta abruption Hypotonia/uterine atony

Arterial hypertension

Chorioamnionitis Prolonged labor

Poor technique and prolonged surgical time

**Table 1.** Risk factor for hemorrhage.

Multiparity Obesity

A person who has never experienced the effect of surgery can hardly understand the physical effort required by a mother to take care of the newborn during the first months of life and be deprived of a tranquil convalescence and favored by the benefit provided by rest and the attentions that are given to any patient after surgery.

In 2016, it had been 100 years since Edward Craigin suggested that "once a cesarean, always cesarean," a concept that not only continues in many obstetricians but also becoming increasingly popular, so that the same patients increasingly request a cesarean section of repetition without considering the reproductive impact that it entails and without a full knowledge of the possible complications that even in our days have a considerable risk of high morbidity and mortality, both maternal and fetal [1–10].

We can divide the complications into trans-surgical and postsurgical, and the latter one into early and late.

#### **2. Trans-surgical complications**

#### **2.1. Hemorrhage**

Hemorrhage is the most frequent complication of the cesarean section during or after the surgical event. However, there is no consensus on the actual incidence, worldwide; it is estimated that around 75% of obstetric hemorrhages occur in cesarean section.

In developing countries, obstetric hemorrhage alternates the first and second position with preeclampsia as a cause of maternal death, and the World Health Organization accepts a rate of 10% worldwide in all births with live fetus [3, 4, 14–21].

The physiological changes that occur in the circulatory system during pregnancy act as an important factor, remember that the hypervolemia that occurs progressively from the first trimester reaches a maximum in the third quarter of up to 45% higher than the volume in the non-pregnant woman, which among other functions, and it has to meet the metabolic demands of the uterus which develops a very hypertrophic vascular network and protect the pregnant woman against blood loss related to childbirth. These two functions paradoxically become a risk factor for the pregnant woman undergoing cesarean section since this modification in the vascular network increases the risk of injuring important vessels when surgically affecting or extracting the fetus through the hysterotomy, and on the other hand, hypervolemia favors the tendency of the obstetrician to underestimate the bleeding that occurs during surgery, causing an excess of confidence that ends up in most of the cases causing adverse effects [19].

It is generally accepted to limit the amount of bleeding to a maximum of 500 ml for a vaginal delivery and 1000 ml for the cesarean section, and in case of larger amounts, it is termed as obstetric hemorrhage. It is also accepted as a 10% decrease in hematocrit, although this starts after 4 h with a maximum limit of up to 48 h [19, 21].

It must be borne in mind that the indication of cesarean section "per se" implies a pathological background disorder such as the anomalous insertion of the placenta, maternal hypertension, the infection, prolonged labor, uterine overdistention, and so on, which are factors that significantly alter the vascular network and uterine contractility, increasing the bleeding caused by the same vascular damage during the surgical act which increases when there is difficulty in extracting the fetus since it can easily tear the hysterotomy causing greater vascular damage [3, 4, 14–21].

In **Table 1**, we see the most frequent risk factors that are associated with bleeding as a complication of the cesarean section.

The treatment of the hemorrhage depends on the cause, and hemorrhage can precede the indication of cesarean section as in the low insertion of placenta or the premature detachment of placenta or appear in the course or even after surgery. **Figure 1** shows the placental bed invaded by the trophoblast.

The treatment should start with a quick and precise diagnosis of the origin of the hemorrhage accompanied by measures that maintain an adequate hemodynamics with intravenous solutions of preferably isotonic crystalloids in which blood is obtained for immediate transfusions, taking care not to pass more than 2000 ml of liquids that can cause an acute pulmonary edema or lead to a coagulopathy by dilution, and fresh blood or alternate erythrocyte concentrates should be administered with fresh frozen plasma for the immediate replacement of coagulation factors; immediate cleaning of the uterine cavity at the same time of a uterine massage applied in a uniform and compressive manner. Most of the time, it achieves the


**Table 1.** Risk factor for hemorrhage.

In addition, we will never finish insisting that medical legal criteria encourage the belief that maternal morbidity and mainly the perinatal observed in the vaginal route, could be avoided with a cesarean section, favoring the growing doctor's fear to be subject of a legal claim thus evading the responsibility that comes with the adequate and justified indication of a cesarean

A person who has never experienced the effect of surgery can hardly understand the physical effort required by a mother to take care of the newborn during the first months of life and be deprived of a tranquil convalescence and favored by the benefit provided by rest and the

In 2016, it had been 100 years since Edward Craigin suggested that "once a cesarean, always cesarean," a concept that not only continues in many obstetricians but also becoming increasingly popular, so that the same patients increasingly request a cesarean section of repetition without considering the reproductive impact that it entails and without a full knowledge of the possible complications that even in our days have a considerable risk of high morbidity

We can divide the complications into trans-surgical and postsurgical, and the latter one into

Hemorrhage is the most frequent complication of the cesarean section during or after the surgical event. However, there is no consensus on the actual incidence, worldwide; it is estimated

In developing countries, obstetric hemorrhage alternates the first and second position with preeclampsia as a cause of maternal death, and the World Health Organization accepts a rate

The physiological changes that occur in the circulatory system during pregnancy act as an important factor, remember that the hypervolemia that occurs progressively from the first trimester reaches a maximum in the third quarter of up to 45% higher than the volume in the non-pregnant woman, which among other functions, and it has to meet the metabolic demands of the uterus which develops a very hypertrophic vascular network and protect the pregnant woman against blood loss related to childbirth. These two functions paradoxically become a risk factor for the pregnant woman undergoing cesarean section since this modification in the vascular network increases the risk of injuring important vessels when surgically affecting or extracting the fetus through the hysterotomy, and on the other hand, hypervolemia favors the tendency of the obstetrician to underestimate the bleeding that occurs during surgery, causing an excess of confidence that ends up in most of the cases causing adverse

that around 75% of obstetric hemorrhages occur in cesarean section.

of 10% worldwide in all births with live fetus [3, 4, 14–21].

section [11, 13].

82 Caesarean Section

early and late.

**2.1. Hemorrhage**

effects [19].

attentions that are given to any patient after surgery.

and mortality, both maternal and fetal [1–10].

**2. Trans-surgical complications**

of the hemorrhage will be achieved. B-Lynch described in 1997 a simple technique without ligating the uterine artery to control the obstetric hemorrhage that consists of passing a suture of chromic catgut of number 2 beginning under the uterine incision toward the interior of the cavity, later it is incised toward the outside above the incision to surround the uterine fundus and re-enter the cavity through the posterior part at the level of the segment, the same maneuver is carried out in reverse form on the opposite side leaving the cavity from the back to finish in the anterior face below the hysterotomy, nesting firmly and with adequate traction

Complications of Cesarean Operation http://dx.doi.org/10.5772/intechopen.75901 85

Since its creation, several authors have described modifications to the original technique;

Arterial ligation is a frequently used resource, especially when it is desired to preserve the reproductive function. Hemorrhage control is carried out by lowering the blood pressure without suppressing the uterine irrigation that continues through the collateral network where there is less pressure, allowing coagulation to be carried out adequately with the subsequent formation of a clot that will not be removed by the arterial pulse. The uterine artery is ligated in a primary form on the side near where the bleeding originates predominantly, if the entire surface is the ligature is performed bilaterally accompanied by the ovarian arteries. This resolves a high percentage of cases of uterine atony; otherwise, it is opted for the ligation

Some hospitals have material resources and personnel specialized in interventional radiology with sufficient experience to perform an embolization of the pelvic arteries through an angiogram, being an adequate resource in a very high percentage to stop the hemorrhage and

If all the above is not enough to stop the hemorrhage, then the indication to carry out a hysterectomy appears, which can be performed subtotally given the haste and critical conditions in which most of the patients are, as well as being a surgery which implies greater difficulty due mainly to the vascular changes that arise with pregnancy. With this procedure, if there are

however, all handle the same concept, that is, uterine compression [27, 28].

(**Figure 2**).

of the hypogastric arteries.

**Figure 2.** B-lynch technique.

preserve the reproductive function [18].

**Figure 1.** Placenta accreta invading the uterine muscle layer.

adequate contraction of the uterus, and if it is not achieved, it must be started with the administration of the following substances to contract the uterus [3, 4, 14–18, 22–24]:


If there is no response to the previous measures, it will be attempted to stop the bleeding by applying an intrauterine tamponade that can be immediately with textile compresses and if you have the resource, try latex or silicone balloons of the Sengstaken-Blackmore, Rush or Bakri type that act by increasing intrauterine pressure compressing the vascular network until hemostasis is achieved by hemostatic physiological mechanisms [25, 26].

If there is no recourse to the balloons, a compressive suture will be attempted.

If at the moment of compressing the uterus bimanually, a decrease in the hemorrhage is observed, it can be expected that by maintaining this compression with a suture, the cessation of the hemorrhage will be achieved. B-Lynch described in 1997 a simple technique without ligating the uterine artery to control the obstetric hemorrhage that consists of passing a suture of chromic catgut of number 2 beginning under the uterine incision toward the interior of the cavity, later it is incised toward the outside above the incision to surround the uterine fundus and re-enter the cavity through the posterior part at the level of the segment, the same maneuver is carried out in reverse form on the opposite side leaving the cavity from the back to finish in the anterior face below the hysterotomy, nesting firmly and with adequate traction (**Figure 2**).

Since its creation, several authors have described modifications to the original technique; however, all handle the same concept, that is, uterine compression [27, 28].

Arterial ligation is a frequently used resource, especially when it is desired to preserve the reproductive function. Hemorrhage control is carried out by lowering the blood pressure without suppressing the uterine irrigation that continues through the collateral network where there is less pressure, allowing coagulation to be carried out adequately with the subsequent formation of a clot that will not be removed by the arterial pulse. The uterine artery is ligated in a primary form on the side near where the bleeding originates predominantly, if the entire surface is the ligature is performed bilaterally accompanied by the ovarian arteries. This resolves a high percentage of cases of uterine atony; otherwise, it is opted for the ligation of the hypogastric arteries.

Some hospitals have material resources and personnel specialized in interventional radiology with sufficient experience to perform an embolization of the pelvic arteries through an angiogram, being an adequate resource in a very high percentage to stop the hemorrhage and preserve the reproductive function [18].

If all the above is not enough to stop the hemorrhage, then the indication to carry out a hysterectomy appears, which can be performed subtotally given the haste and critical conditions in which most of the patients are, as well as being a surgery which implies greater difficulty due mainly to the vascular changes that arise with pregnancy. With this procedure, if there are

**Figure 2.** B-lynch technique.

adequate contraction of the uterus, and if it is not achieved, it must be started with the admin-

• Oxytocin. Apply 10 units in a slow intravenous form followed by a continuous infusion

• Ergometrine. It is applied in doses of 0.2 mg intramuscularly and with minimum intervals of every 6 h, the main side effect is hypertension, especially with previous history of the

• Carbetocin. It is a synthetic analog of oxytocin with a long-acting synthetic analog of oxytocin that has a rapid and prolonged action, initiating its effect at 2 min and lasting up to 2 h intramuscularly and can be administered in slow intravenous form. It is administered

• Misoprostol. Analog of prostaglandin E1 is administered in a dose of 600–800 μg rectally obtaining an uterotonic effect 10 min after its administration, being possible to repeat doses

• Tranexamic acid. It is an antifibrinolytic that is administered at a dose of 1 g in an intravenous bolus and can be continued in perfusion of 1 g for 8 h. Care should be taken in patients

If there is no response to the previous measures, it will be attempted to stop the bleeding by applying an intrauterine tamponade that can be immediately with textile compresses and if you have the resource, try latex or silicone balloons of the Sengstaken-Blackmore, Rush or Bakri type that act by increasing intrauterine pressure compressing the vascular network until

If at the moment of compressing the uterus bimanually, a decrease in the hemorrhage is observed, it can be expected that by maintaining this compression with a suture, the cessation

hemostasis is achieved by hemostatic physiological mechanisms [25, 26].

If there is no recourse to the balloons, a compressive suture will be attempted.

istration of the following substances to contract the uterus [3, 4, 14–18, 22–24]:

same.

84 Caesarean Section

as a single dose of 100 μg.

with intervals of every 6 h.

with a history of thromboembolic diseases.

**Figure 1.** Placenta accreta invading the uterine muscle layer.

with 20–40 units taking care of the hypotension caused by the vasodilatation.

still no significant alterations in the coagulation, the problem is solved in its entirety since the origin of the hemorrhage is removed, although the reproductive function is lost [17, 20, 21].

identified, it is convenient to "mark" the damaged site with a wet compress since, if it is not

Complications of Cesarean Operation http://dx.doi.org/10.5772/intechopen.75901 87

They are very rare but when they occur, they are accompanied by high morbidity, becoming

In regional anesthesia, the most frequent are hypotension caused by sympathetic nerve block aggravated by aorto-cava compression that produces the pregnant uterus in the supine position, and it is solved with intravenous fluids prior to the event, with change of position to lateral decubitus and the use of ephedrine that has a vasoconstrictor effect without affecting

Another complication is headache by puncture of the arachnoid hard membranes that cause an escape of cerebrospinal fluid with loss of cushioning effect. It is solved with the application

Finally, there may be a total blockage causing a respiratory arrest that forces to handle the

General anesthesia presents the failed airway intubation as a main problem secondary to the difficulty implied by the pregnant woman due to an increase in body mass and decreased functional lung capacity. In most cases, it is resolved by temporarily deferring the surgery initiating 100% lime oxygenation with a face mask and the appropriate position of the head and neck. However, the deferral of the cesarean section, most of the time, it may not be pos-

Another complication of general anesthesia is the chemical pneumonitis by aspiration of gas-

Fetal lesions with the scalpel when the uterus impinges are reported with a very low frequency, on average of less than 1%, and most of the occasions occur when there is an indication to extract the fetus with urgency. This frequency is higher in school hospitals due to the

Postsurgical hemorrhage occurs mainly due to hypotonia or uterine atony that is managed with sustained uterotonic medications during the following hours after the surgery; however, when there is no favorable response, the same sequence of treatment of trans-surgical hemorrhage must be followed. Less frequently, it is due to a poor technique in the repair of the surgical planes, favoring the formation of bruises that, when they extend, can dissect the adjacent tissues in an important way. Another cause is the defects in the coagulation either by the pathology previous to the event as in the case of preeclampsia or due to the consumption of

airway with the difficulties that this implies in the pregnant patient.

tric contents which has an unfavorable prognosis [33–37].

lack of experience of the obstetric surgeon in training [38].

done, the injured area is easily lost, and after the uterus closes, it is repaired [1, 6, 10].

**3.2. Anesthetic complications**

of a blood patch in the epidural space.

sible due to the urgent indication of it.

**4. Early postsurgical complications**

**4.1. Hemorrhage**

lethal.

the placental flow.

While there is no new technology and adequate measures to control bleeding, the above described will continue to be the best option for the management of this serious complication.

#### **3. Urological injuries**

Often the cesarean section involves careful dissections to reject the bladder, so that it can sometimes be injured. It is the most common lesion in urinary organs, although sometimes the ureter can be damaged by causing obstruction by ligature or angulation and partial or complete section.

Bladder injury can occur when the peritoneum is opened if care is not taken to empty it adequately through a catheter or in cases of previous surgeries that firmly attach the bladder to the anterior side of the uterus where it is also common to find a large engorgement of the venous plexus that easily breaks, complicating the dissection by the hemorrhage provoked. When tears of the hysterotomy occur, they can be prolonged to the bladder damaging it.

It is necessary to identify the bladder lesion well and outline the extension well. The repair is carried out with the inversion of the tissues in two planes with chromic catgut or vicryl 00, and it is important not to leave the suture under tension since it favors the appearance of fistulas. Always immobilize the bladder with a permanent catheter for at least 10 days. The appropriate closure should be confirmed with the instillation of methylene blue or when the resource is available, a cystoscopy is performed at the end of the closure. Sometimes, only the muscular layer is damaged, finding the mucosa intact, in which case, it must be repaired with chromic catgut 000 since they can easily produce fistulas.

The most frequent site of ureteral injury is in the bladder or in the junction with the uterine vessels, especially when the bladder is not rejected properly, being more frequent when a hysterectomy is performed. The injury is mostly possible when the cesarean section is performed urgently.

Bladder injury is easily recognized in the course of surgery, but not the ureteral injury that should be suspected at the time to be diagnosed in a timely manner. When we suspect we have to dissect the path in question to achieve an adequate identification of the problem, in case of section, it is convenient to request the intervention of an experienced surgeon or an urologist to perform the immediate anastomosis, if there is only an angulation by a suture, and it is corrected by removing the latter.

When the repair of damage is done immediate, morbidity is greatly reduced [29–32].

#### **3.1. Intestinal lesions**

Intestinal lesions are extremely rare in the cesarean section, and when they occur, they are usually secondary to an urgent abdominal approach with intestinal adhesions to the anterior wall in cases of previous surgeries almost always non-obstetric. When an intestinal lesion is identified, it is convenient to "mark" the damaged site with a wet compress since, if it is not done, the injured area is easily lost, and after the uterus closes, it is repaired [1, 6, 10].

#### **3.2. Anesthetic complications**

still no significant alterations in the coagulation, the problem is solved in its entirety since the origin of the hemorrhage is removed, although the reproductive function is lost [17, 20, 21].

While there is no new technology and adequate measures to control bleeding, the above described will continue to be the best option for the management of this serious complication.

Often the cesarean section involves careful dissections to reject the bladder, so that it can sometimes be injured. It is the most common lesion in urinary organs, although sometimes the ureter can be damaged by causing obstruction by ligature or angulation and partial or

Bladder injury can occur when the peritoneum is opened if care is not taken to empty it adequately through a catheter or in cases of previous surgeries that firmly attach the bladder to the anterior side of the uterus where it is also common to find a large engorgement of the venous plexus that easily breaks, complicating the dissection by the hemorrhage provoked. When tears of the hysterotomy occur, they can be prolonged to the bladder damaging it.

It is necessary to identify the bladder lesion well and outline the extension well. The repair is carried out with the inversion of the tissues in two planes with chromic catgut or vicryl 00, and it is important not to leave the suture under tension since it favors the appearance of fistulas. Always immobilize the bladder with a permanent catheter for at least 10 days. The appropriate closure should be confirmed with the instillation of methylene blue or when the resource is available, a cystoscopy is performed at the end of the closure. Sometimes, only the muscular layer is damaged, finding the mucosa intact, in which case, it must be repaired

The most frequent site of ureteral injury is in the bladder or in the junction with the uterine vessels, especially when the bladder is not rejected properly, being more frequent when a hysterectomy is performed. The injury is mostly possible when the cesarean section is performed

Bladder injury is easily recognized in the course of surgery, but not the ureteral injury that should be suspected at the time to be diagnosed in a timely manner. When we suspect we have to dissect the path in question to achieve an adequate identification of the problem, in case of section, it is convenient to request the intervention of an experienced surgeon or an urologist to perform the immediate anastomosis, if there is only an angulation by a suture,

Intestinal lesions are extremely rare in the cesarean section, and when they occur, they are usually secondary to an urgent abdominal approach with intestinal adhesions to the anterior wall in cases of previous surgeries almost always non-obstetric. When an intestinal lesion is

When the repair of damage is done immediate, morbidity is greatly reduced [29–32].

with chromic catgut 000 since they can easily produce fistulas.

and it is corrected by removing the latter.

**3.1. Intestinal lesions**

**3. Urological injuries**

complete section.

86 Caesarean Section

urgently.

They are very rare but when they occur, they are accompanied by high morbidity, becoming lethal.

In regional anesthesia, the most frequent are hypotension caused by sympathetic nerve block aggravated by aorto-cava compression that produces the pregnant uterus in the supine position, and it is solved with intravenous fluids prior to the event, with change of position to lateral decubitus and the use of ephedrine that has a vasoconstrictor effect without affecting the placental flow.

Another complication is headache by puncture of the arachnoid hard membranes that cause an escape of cerebrospinal fluid with loss of cushioning effect. It is solved with the application of a blood patch in the epidural space.

Finally, there may be a total blockage causing a respiratory arrest that forces to handle the airway with the difficulties that this implies in the pregnant patient.

General anesthesia presents the failed airway intubation as a main problem secondary to the difficulty implied by the pregnant woman due to an increase in body mass and decreased functional lung capacity. In most cases, it is resolved by temporarily deferring the surgery initiating 100% lime oxygenation with a face mask and the appropriate position of the head and neck. However, the deferral of the cesarean section, most of the time, it may not be possible due to the urgent indication of it.

Another complication of general anesthesia is the chemical pneumonitis by aspiration of gastric contents which has an unfavorable prognosis [33–37].

Fetal lesions with the scalpel when the uterus impinges are reported with a very low frequency, on average of less than 1%, and most of the occasions occur when there is an indication to extract the fetus with urgency. This frequency is higher in school hospitals due to the lack of experience of the obstetric surgeon in training [38].

#### **4. Early postsurgical complications**

#### **4.1. Hemorrhage**

Postsurgical hemorrhage occurs mainly due to hypotonia or uterine atony that is managed with sustained uterotonic medications during the following hours after the surgery; however, when there is no favorable response, the same sequence of treatment of trans-surgical hemorrhage must be followed. Less frequently, it is due to a poor technique in the repair of the surgical planes, favoring the formation of bruises that, when they extend, can dissect the adjacent tissues in an important way. Another cause is the defects in the coagulation either by the pathology previous to the event as in the case of preeclampsia or due to the consumption of factors when a severe hemorrhage occurs. Finally, in few occasions, it can be due to the retention of placental remains, which is managed with the extraction by means of an instrumental curettage of the uterine cavity [1, 2, 7, 12, 14].

#### **4.2. Infection**

The infection in most of the times is the result of a reciprocal action between the defenses of the host and the virulence of the germs, nevertheless in obstetrics unlike the other specialties, the immune state acts only in rare occasions as a factor of important selection. The increase in the number of leukocytes that occurs in pregnancy is maximum at the end of it, increasing the defenses and also has a higher bactericidal activity than in the non-pregnant women.

Most patients become infected with their own microflora, which depends on factors such as duration of labor, time of rupture of the chorioamniotic membranes, multiple vaginal examinations, nutritional status of the patient, deficient aseptic techniques and surgical time. Infection during cesarean section is one of the most frequent complications, and the main reason for hospital re-admission, which consequently increasing costs [39–44].

Almost 30 years after completing two centuries in which Ignatz Semmelweis established his concepts about asepsis in obstetrics and importantly in surgery, we are still surprised that the deficient asepsis, in most of the times due to excess of confidence acquired from the beginning of the antibiotic era, continues to be a risk factor for the appearance of obstetric infection, mainly during cesarean section [45].

It is well known that postpartum endometritis occurs approximately 5–20 times more frequently and with greater severity in the cesarean section than in vaginal delivery, thus becoming the major risk factor mainly due to situations involving uterine manipulation, instrumental contamination and sutures that cause ischemia and tissue necrosis, which favors the development of an infection.

The infection of the surgical site before called surgical wound infection is caused by contamination, being the most frequent germ the coagulase-negative *Staphylococcus*. It occurs in a range of 3–15%. Cesarean section is considered contaminated when there is prolonged labor or rupture of membranes, in addition to various risk factors such as prolonged surgical time, poor tissue management, contaminated instruments, nutritional status and previous anemia

Complications of Cesarean Operation http://dx.doi.org/10.5772/intechopen.75901 89

**Figure 3** shows a sonographic image of pelvic abscesses after obstetric hysterectomy.

• Deep infection of the incision. It affects the aponeurotic fascia and the muscle.

Infection happen during the following 30 days of the intervention, and it is classified as

• Surface infection of the incision. It affects only the skin and the subcutaneous tissue at the

• Organ or space infection. It involves any part of the anatomy other than the open or ma-

or caused by surgery.

site of the incision.

nipulated incision during the surgery.

**Table 2.** Most frequent microorganisms in endometritis.

follows:

**Aerobic**:

Others

*Peptococcus Peptoestreptococcus* Gram-positive bacilli

*Clostridium*

Gram-negative bacilli *Bacteroides bivius Bacteroides fragilis*

*Corynebacterium vaginalis Neisseria gonorrhoeae* **Anaerobes**: Gram-positive cocci

Gram-positive cocci *Streptococcus Enterococcus Staphylococcus* Gram-negative *Escherichia coli Klebsiella pneumoniae Proteus mirabilis*

Endometritis has a multiple microbial origin, and more frequently, aerobic Gram-positive cocci and Gram-positive anaerobic bacilli are found. In **Table 2**, we observe the most frequent microorganisms.

The diagnosis is made by clinic where we find the presence of fever, hypogastric pain, fetid lochia and pain to the mobilization of the uterus, the laboratory shows a leukocytosis.

The treatment should be started once the culture samples have been taken, although most of the time, they are not very helpful because of the little reliable information they provide given the vaginal contamination and the delay in reporting.

The antibiotics of choice must be broad spectrum, in the majority of patients, the use of thirdgeneration cephalosporins achieves a good result, and in cases of penicillin allergy, clindamycin can be used either alone or in combination with some aminoglycoside.

Endometritis can occur accompanied by infection of the surgical site or urinary tract, and in these cases, the quinolones become a good treatment option.


**Table 2.** Most frequent microorganisms in endometritis.

factors when a severe hemorrhage occurs. Finally, in few occasions, it can be due to the retention of placental remains, which is managed with the extraction by means of an instrumental

The infection in most of the times is the result of a reciprocal action between the defenses of the host and the virulence of the germs, nevertheless in obstetrics unlike the other specialties, the immune state acts only in rare occasions as a factor of important selection. The increase in the number of leukocytes that occurs in pregnancy is maximum at the end of it, increasing the defenses and also has a higher bactericidal activity than in the non-pregnant

Most patients become infected with their own microflora, which depends on factors such as duration of labor, time of rupture of the chorioamniotic membranes, multiple vaginal examinations, nutritional status of the patient, deficient aseptic techniques and surgical time. Infection during cesarean section is one of the most frequent complications, and the main

Almost 30 years after completing two centuries in which Ignatz Semmelweis established his concepts about asepsis in obstetrics and importantly in surgery, we are still surprised that the deficient asepsis, in most of the times due to excess of confidence acquired from the beginning of the antibiotic era, continues to be a risk factor for the appearance of obstetric infection,

It is well known that postpartum endometritis occurs approximately 5–20 times more frequently and with greater severity in the cesarean section than in vaginal delivery, thus becoming the major risk factor mainly due to situations involving uterine manipulation, instrumental contamination and sutures that cause ischemia and tissue necrosis, which favors

Endometritis has a multiple microbial origin, and more frequently, aerobic Gram-positive cocci and Gram-positive anaerobic bacilli are found. In **Table 2**, we observe the most frequent

The diagnosis is made by clinic where we find the presence of fever, hypogastric pain, fetid

The treatment should be started once the culture samples have been taken, although most of the time, they are not very helpful because of the little reliable information they provide given the

The antibiotics of choice must be broad spectrum, in the majority of patients, the use of thirdgeneration cephalosporins achieves a good result, and in cases of penicillin allergy, clindamy-

Endometritis can occur accompanied by infection of the surgical site or urinary tract, and in

lochia and pain to the mobilization of the uterus, the laboratory shows a leukocytosis.

cin can be used either alone or in combination with some aminoglycoside.

these cases, the quinolones become a good treatment option.

reason for hospital re-admission, which consequently increasing costs [39–44].

curettage of the uterine cavity [1, 2, 7, 12, 14].

mainly during cesarean section [45].

the development of an infection.

vaginal contamination and the delay in reporting.

microorganisms.

**4.2. Infection**

88 Caesarean Section

women.

The infection of the surgical site before called surgical wound infection is caused by contamination, being the most frequent germ the coagulase-negative *Staphylococcus*. It occurs in a range of 3–15%. Cesarean section is considered contaminated when there is prolonged labor or rupture of membranes, in addition to various risk factors such as prolonged surgical time, poor tissue management, contaminated instruments, nutritional status and previous anemia or caused by surgery.

**Figure 3** shows a sonographic image of pelvic abscesses after obstetric hysterectomy.

Infection happen during the following 30 days of the intervention, and it is classified as follows:


middle incision seems the most suitable for obstetric approach although it has its esthetic

Complications of Cesarean Operation http://dx.doi.org/10.5772/intechopen.75901 91

The prognosis regarding the possibility of infection or dehiscence depends more on performing an adequate technique than on the type of incision, although controversy still exists in this regard. In which does exist an agreement is that the infection in transverse incisions evolves in

In **Figure 4**, we observed a transverse abdominal wound infected with purulent discharge at

Thromboembolisms are more frequent in the cesarean section than in the vaginal delivery and are favored by the triad relatively common to the gestational term of venous stasis, hypercoagulability and endothelial injury. Symptoms at the site of thrombus formation are usually minimal or absent until detached and manifest as a pulmonary or pelvic embolism. The diagnosis is usually made by exclusion in those patients who have insidious fever accompanied by tachycardia and an inadequate response to treatment with antibiotics most of the time

In the cases of pulmonary thromboembolism, the picture manifests suddenly with tachypnea, dyspnea, general malaise, severe chest pain and hemoptysis, and in severe forms, it

In the pelvic presentation, there is no local pain or malaise, and its manifestation is usually delayed, producing septic emboli mainly to the lung, manifesting initially as micropulmo-

The treatment consists of immediate anticoagulation to end the obstruction and avoid new emboli. Unfractionated heparin is used in necessary doses until the activated partial thromboplastin time is lengthened up to 1.5–2 times over the control time. Most of the time, the recovery is amazing only with anticoagulation; however; it is necessary to modify the antimicrobial treatment with a double scheme that covers both Gram-positive and Gram-negative bacteria.

In **Figure 5**, we observed a contrast tomographic image of a major pulmonary thrombosis.

Postoperative ileus rarely occurs in the obstetric patient since little is manipulated in the intestine due to the pregnant uterus, and when it occurs, with fasting, parenteral solutions and the

Fetal complications are rare, and the most frequent is respiratory distress syndrome in terms of newborns mainly in elective cesarean section. The immediate transition required by the fetal lung filled with fluid to change it by air at birth occupies physiological mechanisms that accelerate with labor, so in the absence of this, a dysfunction of these mechanisms occurs and

progresses to the state of shock with a high percentage of mortality.

Surgical intervention is rarely necessary to remove the clot [6, 39, 42, 52–56].

placement of a nasogastric tube is usually enough to solve it [4, 57].

more torpid form when the subaponeurotic plane is affected [39–44, 46–51].

disadvantages.

the edges.

**5. Thromboembolisms**

already established.

nary infarcts.

**Figure 3.** Pelvic abscess *after obstetric hysterectomy*.

The treatment is based on adequate drainage performed in the exploration and the use of broad-spectrum antibiotics.

Since the antibiotic era, a significant decrease in the infection in cesarean section is observed, especially with the use of prophylactic antibiotics evidenced through multiple studies, and it is almost universally accepted nowadays, in the same way, there is increasing evidence of better results with the application prior to the incision and not after clamping the umbilical cord, although there is still controversy in this regard. The recommended antibiotic continues to be the first-generation cephalosporins.

However, prophylaxis remains debatable in that, it does not prevent more serious infections such as thrombophlebitis and pelvic abscess, so its use should be limited to cases where there is a high risk of infection such as prolonged labor, the rupture of long-lasting membranes and the indication of cesarean section in urgent form.

The incision in the abdominal wall acquires a great importance in the presence of complications since the transverse incisions restrict the surgical field in such a way that the vertical

**Figure 4.** Transverse abdominal infected wound.

middle incision seems the most suitable for obstetric approach although it has its esthetic disadvantages.

The prognosis regarding the possibility of infection or dehiscence depends more on performing an adequate technique than on the type of incision, although controversy still exists in this regard. In which does exist an agreement is that the infection in transverse incisions evolves in more torpid form when the subaponeurotic plane is affected [39–44, 46–51].

In **Figure 4**, we observed a transverse abdominal wound infected with purulent discharge at the edges.

### **5. Thromboembolisms**

The treatment is based on adequate drainage performed in the exploration and the use of

Since the antibiotic era, a significant decrease in the infection in cesarean section is observed, especially with the use of prophylactic antibiotics evidenced through multiple studies, and it is almost universally accepted nowadays, in the same way, there is increasing evidence of better results with the application prior to the incision and not after clamping the umbilical cord, although there is still controversy in this regard. The recommended antibiotic continues

However, prophylaxis remains debatable in that, it does not prevent more serious infections such as thrombophlebitis and pelvic abscess, so its use should be limited to cases where there is a high risk of infection such as prolonged labor, the rupture of long-lasting membranes and

The incision in the abdominal wall acquires a great importance in the presence of complications since the transverse incisions restrict the surgical field in such a way that the vertical

broad-spectrum antibiotics.

90 Caesarean Section

to be the first-generation cephalosporins.

**Figure 3.** Pelvic abscess *after obstetric hysterectomy*.

**Figure 4.** Transverse abdominal infected wound.

the indication of cesarean section in urgent form.

Thromboembolisms are more frequent in the cesarean section than in the vaginal delivery and are favored by the triad relatively common to the gestational term of venous stasis, hypercoagulability and endothelial injury. Symptoms at the site of thrombus formation are usually minimal or absent until detached and manifest as a pulmonary or pelvic embolism. The diagnosis is usually made by exclusion in those patients who have insidious fever accompanied by tachycardia and an inadequate response to treatment with antibiotics most of the time already established.

In the cases of pulmonary thromboembolism, the picture manifests suddenly with tachypnea, dyspnea, general malaise, severe chest pain and hemoptysis, and in severe forms, it progresses to the state of shock with a high percentage of mortality.

In the pelvic presentation, there is no local pain or malaise, and its manifestation is usually delayed, producing septic emboli mainly to the lung, manifesting initially as micropulmonary infarcts.

The treatment consists of immediate anticoagulation to end the obstruction and avoid new emboli. Unfractionated heparin is used in necessary doses until the activated partial thromboplastin time is lengthened up to 1.5–2 times over the control time. Most of the time, the recovery is amazing only with anticoagulation; however; it is necessary to modify the antimicrobial treatment with a double scheme that covers both Gram-positive and Gram-negative bacteria. Surgical intervention is rarely necessary to remove the clot [6, 39, 42, 52–56].

In **Figure 5**, we observed a contrast tomographic image of a major pulmonary thrombosis.

Postoperative ileus rarely occurs in the obstetric patient since little is manipulated in the intestine due to the pregnant uterus, and when it occurs, with fasting, parenteral solutions and the placement of a nasogastric tube is usually enough to solve it [4, 57].

Fetal complications are rare, and the most frequent is respiratory distress syndrome in terms of newborns mainly in elective cesarean section. The immediate transition required by the fetal lung filled with fluid to change it by air at birth occupies physiological mechanisms that accelerate with labor, so in the absence of this, a dysfunction of these mechanisms occurs and

The surgical scar of the cesarean section is considered the main risk for low placenta insertion and placental accreta in subsequent pregnancies. It is also the main risk factor for uterine rupture when a labor test is performed, increasing the possibility of rupture by five times when

Complications of Cesarean Operation http://dx.doi.org/10.5772/intechopen.75901 93

It can be concluded that the best way to prevent complications in cesarean section is not to indicate an unnecessary one. It is a reality that the inevitable increase in the frequency of the operation worldwide and increasingly with new indications motivated by the most known factors such as better techniques and surgical concepts, surgical materials, the best hospital infrastructure, greater pressure in medical treatment for a high incidence of legal demands but also exist popular concepts that favor the request of completion of pregnancy through the abdomen, whether for esthetics, poorly understood comfort or some other medical justifica-

All of the above lead us to question the following: is the cesarean section performed by a justi-

There are also more and more situations around pregnancy that imply an increase in the risk of pregnancy itself such as the tendency to postpone the first pregnancy at a later age, obesity, treatments to promote fertility and others that go beyond the hand with an increase in risk in

When complications occur, the impact on cost is truly important not only because they affect maternal health, but also because of the psychological damage that occurs in the mother-child

The tendency to limit the number of cesarean sections must be considered seriously for the benefit of the patient since, in addition to preventing the complications that potentially exist in each event, they have a favorable impact on economic, social and reproductive aspects.

It will never be stopped insisting that the identified risk factors may not be so important if proper precautions are taken and a real responsibility is assumed, first in indicating the cesar-

Knowledge of the gestational pathophysiology gives us the ability to make appropriate decisions, and when the intervention is timely and accurate in most cases, the possibility of harm is avoided. For the abovementioned intervention, basic concepts such as the careful management of tissues, use of appropriate instruments and minimize surgical time should be kept in

relationship by prolonging hospital stay and altering home convalescence.

there are two previous cesarean sections compared to when there is only one.

tions that are enough to convince the obstetrician to perform it.

fied indication or by a justified concern?

case of indicating a cesarean section.

ean section and then when doing it.

**Author details**

Enrique Rosales Aujang

Aguascalientes, Mexico

mind as much as possible [1, 2, 4, 6, 8–10, 75].

Address all correspondence to: kikes1\_13@yahoo.com.mx

General Hospital of Zone #2, Mexican Social Security Institute, Aguascalientes,

**Figure 5.** Pulmonary thromboembolism.

with a probable failure of the action of pulmonary surfactant. In some cases, mechanical ventilation with supplemental oxygenation and surfactant administration is required until the aforementioned adaptation is achieved [58–61].

#### **6. Late postsurgical complications**

Late postsurgical complications include endometriosis of the abdominal wall in the surgical scar, the formation of adhesions, and as an important sequel, the high possibility of low placental insertion, placental accreta or uterine rupture in later pregnancies.

Endometriosis is defined as the ectopic presence of tissue, whose histological and functional characteristics are identical to the endometrium. Secondary endometrial transplantation is performed secondarily to the surgical incision site manually, with instruments or through sutures during cesarean section with a frequency of less than 0.5%. The diagnosis is made by the antecedent of cesarean section accompanied by cyclic pain and is confirmed by the histological study. Cabinet studies are only useful for deep localization of lesions. The treatment consists of the surgical removal of the lesion in its entirety. Medical management does not provide good results in these cases [62, 63].

Adhesions that occur during abdominal surgeries tend to occur with a high frequency, and there is increasing evidence of long-term morbidity that results in intestinal obstruction as a more severe sequel, chronic pelvic pain and infertility, and in the case of later surgeries, difficulty in carrying them out increasing their morbidity.

In our case, there is important evidence that the greater the number of cesarean sections, the greater the possibility of developing adhesions, although a single cesarean section is not exempt in fact. The presence of adhesions becomes more important when the indication for gynecological causes of performing a hysterectomy appears since it increases morbidity.

Modifications to surgical techniques have not yet been adequately evaluated in the long term such as the decision not to close the peritoneum, and more conclusive evidence is needed regarding the formation or not of adhesions [64–73].

The surgical scar of the cesarean section is considered the main risk for low placenta insertion and placental accreta in subsequent pregnancies. It is also the main risk factor for uterine rupture when a labor test is performed, increasing the possibility of rupture by five times when there are two previous cesarean sections compared to when there is only one.

It can be concluded that the best way to prevent complications in cesarean section is not to indicate an unnecessary one. It is a reality that the inevitable increase in the frequency of the operation worldwide and increasingly with new indications motivated by the most known factors such as better techniques and surgical concepts, surgical materials, the best hospital infrastructure, greater pressure in medical treatment for a high incidence of legal demands but also exist popular concepts that favor the request of completion of pregnancy through the abdomen, whether for esthetics, poorly understood comfort or some other medical justifications that are enough to convince the obstetrician to perform it.

All of the above lead us to question the following: is the cesarean section performed by a justified indication or by a justified concern?

There are also more and more situations around pregnancy that imply an increase in the risk of pregnancy itself such as the tendency to postpone the first pregnancy at a later age, obesity, treatments to promote fertility and others that go beyond the hand with an increase in risk in case of indicating a cesarean section.

When complications occur, the impact on cost is truly important not only because they affect maternal health, but also because of the psychological damage that occurs in the mother-child relationship by prolonging hospital stay and altering home convalescence.

The tendency to limit the number of cesarean sections must be considered seriously for the benefit of the patient since, in addition to preventing the complications that potentially exist in each event, they have a favorable impact on economic, social and reproductive aspects.

It will never be stopped insisting that the identified risk factors may not be so important if proper precautions are taken and a real responsibility is assumed, first in indicating the cesarean section and then when doing it.

Knowledge of the gestational pathophysiology gives us the ability to make appropriate decisions, and when the intervention is timely and accurate in most cases, the possibility of harm is avoided. For the abovementioned intervention, basic concepts such as the careful management of tissues, use of appropriate instruments and minimize surgical time should be kept in mind as much as possible [1, 2, 4, 6, 8–10, 75].

#### **Author details**

with a probable failure of the action of pulmonary surfactant. In some cases, mechanical ventilation with supplemental oxygenation and surfactant administration is required until the

Late postsurgical complications include endometriosis of the abdominal wall in the surgical scar, the formation of adhesions, and as an important sequel, the high possibility of low pla-

Endometriosis is defined as the ectopic presence of tissue, whose histological and functional characteristics are identical to the endometrium. Secondary endometrial transplantation is performed secondarily to the surgical incision site manually, with instruments or through sutures during cesarean section with a frequency of less than 0.5%. The diagnosis is made by the antecedent of cesarean section accompanied by cyclic pain and is confirmed by the histological study. Cabinet studies are only useful for deep localization of lesions. The treatment consists of the surgical removal of the lesion in its entirety. Medical management does not

Adhesions that occur during abdominal surgeries tend to occur with a high frequency, and there is increasing evidence of long-term morbidity that results in intestinal obstruction as a more severe sequel, chronic pelvic pain and infertility, and in the case of later surgeries, dif-

In our case, there is important evidence that the greater the number of cesarean sections, the greater the possibility of developing adhesions, although a single cesarean section is not exempt in fact. The presence of adhesions becomes more important when the indication for gynecological causes of performing a hysterectomy appears since it increases morbidity.

Modifications to surgical techniques have not yet been adequately evaluated in the long term such as the decision not to close the peritoneum, and more conclusive evidence is needed

cental insertion, placental accreta or uterine rupture in later pregnancies.

aforementioned adaptation is achieved [58–61].

**6. Late postsurgical complications**

**Figure 5.** Pulmonary thromboembolism.

92 Caesarean Section

provide good results in these cases [62, 63].

ficulty in carrying them out increasing their morbidity.

regarding the formation or not of adhesions [64–73].

Enrique Rosales Aujang

Address all correspondence to: kikes1\_13@yahoo.com.mx

General Hospital of Zone #2, Mexican Social Security Institute, Aguascalientes, Aguascalientes, Mexico

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[51] Skjeldestad FE et al. The effect of antibiotic prophylaxis guidelines on surgical siteinfections associated with cesarean delivery. International Journal of Gynecology &

[52] Mora VJA. Septic pelvic thrombophlebitis. Revista Médica de Costa Rica y Centroamerica.

[53] Pantoja GM et al. Maternalñ death due to amniotic fluid embolism after cesarean section. Obstetric pathology with high morbimortality. Ginecologia Y Obstetricia De Mexico.

[54] Rojas SA et al. Pulmonary thromboembolism during pregnancy and puerperium.

[56] Wang HC et al. Perioperative risk factors for postpartum pulmonary embolism in Taiwanese cesarean section women. Asian Journal of Anesthesiology. 2017;**55**:35-40.

[57] Horowitz R, Rock JA. Postanesthetic and postoperative care. In: Thompson JD, Rock JA, editors. Te Linde's Operative Gynecology. 7a ed. Editorial Médica Panamericana; 1993.

[58] Bazán G et al. The work of previous caesarean section birth protects against transient tachypnea of the newborn. Archivos de Pediatría del Uruguay. 2012;**83**(1):13-20

[59] Ceriani CJ et al. Births by caesarean section at the end in low-risk pregnancies: Effects on

[60] Jonguitud AA. Elective caesarean section: Impact on neonatal respiratory evolution.

neonatal morbidity. Archivos Argentinos de Pediatría. 2010;**108**(1):17-23

[55] Vanoni S. Pregnancy and pulmonary thromboembolism. RAMR. 2004;**1**:6-11

Reviews. 2014;**12**:CD009516. DOI: 10.1002/14651858.CD009516.pub2

Obstetrics. 2015;**128**:126-130. DOI: 10.1016/j.ijgo.2014.08.018

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[46] Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics for caesarean section: A systematic review and meta-analysis. BJOG. 2013;**120**:661-669. DOI: 10.1111/1471-0528.12036

[30] Castro CA, Muller EA, González CV. Chemical peritonitis after injury of bladder during caesarean section. Case report and review of the literature. Ginecología y Obstetricia de

[31] Salman L et al. Urinary bladder injury during casarean delivery: Maternal outcome from a contemporary large case series. European Journal of Obstetrics, Gynecology, and

[32] Yossepowitch O, Baniel J, Livne PM. Urological injuries during cesarean section: Intraoperative diagnosis and management. The Journal of Urology. 2004;**172**:196-199.

[33] Köhnenkampf CR, Nazar JG, Lacassie QH. General anesthesia for cesarean: Benefits, risks and associated complications. Revista Chilena de Anestesia. 2011;**40**:335-343 [34] Montoya BB, Oliveros WC, Moreno MD. Management of hypotension induced by spinal anesthesia for cesarean section. Revista Colombiana de Anestesiología. 2009;**37**:131-140

[35] Páez JJ, Navarro VR. Anaesthesia regional versus general para parto por cesárea. Revista Colombiana de Anestesiología. 2012;**4**:203-206. DOI: 10.1016/j.rca.2012.05.008

[36] Rueda FJV, Pinzón FCE, Vasco RM. Anesthetic management for urgent caesarean: Systematic review of the literature of anesthetics techniques for emergency cesarean section. Revista Colombiana de Anestesiología. 2012;**40**:273-286. DOI: 10.1016/j.rca.2012.08.001

[37] Yeoh SB, Li SJ. Anaesthesia for emergency caesarean section. Trends in Anaesthesia and

[38] Shah-Becker S, Oberman BS, May JG. Scalping of a newborn: Complication during cesarean section. International Journa of Pediatric Otorhinolaryngology Extra. 2015;**10**:53-55.

[39] Bezares B, Sanz O, Jiménez I. Puerperal pathology. Anales del Sistema Sanitario de

[40] Caraballo LS, García RY, Núñez AA. Infectious complications in the caesarean section: Previous classification and use of antibiotics. Revista Cubana de Medicina Tropical.

[41] Santalla A et al. Infection of the surgical wound. Prevention and treatment. Clínica e

[42] Simm A, Mathew D. Caesarean section: Techniques and complications. Obstetrics,

[43] Tyner JE, Rayburn WF. Emergency cesarean delivery: Special precautions. Obstetrics & Gynecology Clinics of North America. 2013;**40**:37-45. DOI: 10.1016/j.ogc.2012.11.003

[44] Zuarez-easton S et al. Postcesarean wound infection: Prevalence, impact, prevention, and management challenges. International Journal of Women's Health. 2017:81-88 [45] Salaverry GO. Institutional iatrogenesis and maternal death. Semmelweis and puerperal fever. Revista Peruana de Medicina Experimental y Salud Pública. 2013;**30**(3):512-517

Critical Care. 2013;**3**:157-161. DOI: 10.1016/j.tacc.2013.02.007

Investigación en Ginecología y Obstetricia 2007;**34**:189-196

Gynaecology and Reproductive Medicine. 2008;**18**:93-98

México. 2015;**83**:120-124

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Reproductive Biology. 2017;**213**:26-30

DOI: 10.1097/01.ju.0000128632.29421.87

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Navarra. 2009;**32**(1):169-175

2001;**53**(2):106-110


[61] Sananès N et al. Pilot randomized controlled trial comparing the risk of neonatal respiratory distress in elective caesarean section at 38 weeks' gestation following a course of corticosteroids versus caesarean at 39 weeks. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;**212**:54-59. DOI: 10.1016/j.ejogrb.2017.03.020

**Section 5**

**Future Considerations**


## **Future Considerations**

[61] Sananès N et al. Pilot randomized controlled trial comparing the risk of neonatal respiratory distress in elective caesarean section at 38 weeks' gestation following a course of corticosteroids versus caesarean at 39 weeks. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;**212**:54-59. DOI: 10.1016/j.ejogrb.2017.03.020

[62] Grigore M et al. Abdominal wall endometriosis: An update in clinical, imagistic features, and management options. Medical Ultrasonography. 2017;**19**(4):430-437. DOI: 10.11152/

[63] Gupta P. Gupta S-scar endometriosis: A case report with literature review. Acta Medica

[64] Bamigboye AA, Hofmeyr G. Closure versus non-closure of the peritoneum at caesarean section: Short-and long-term outcomes. Cochrane Database of Systematic Reviews.

[65] Biler A et al. Is it safe to have multiple repeat cesarean sections? A high volume tertiary care center experience. Pakistan Journal of Medical Sciences. 2017;**33**:1074-1079. DOI:

[66] Bogani G et al. Hysterectomy in patients with previous cesarean section: Comparison between laparoscopic and vaginal approaches. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2015;**184**:53-57. DOI: 10.1016/j.ejogrb.2014.11.005 [67] Clark EA, Silver RM. Long-term maternal morbidity associated with repeat casarean delivery. American Journal of Obstetrics and Gynecology. 2011;**205**:S2-S10. DOI: 10.1016/j.

[68] Gasim T et al. Multiple repeat cesarean sections: Operative difficulties, maternal complications and outcome. The Journal of Reproductive Medicine. 2013;**58**:312-318

[69] Hesselman S, Högberg U, Jonsson M. Effect of remote cesarean delivery on complications during hysterectomy: A cohort study. American Journal of Obstetrics and Gynecology.

[70] Leon CI et al. Postoperative complications in caesarean section without suture of perito-

[71] Lyell DJ. Adhesions and perioperative complications of repeat cesarean delivery. American Journal of Obstetrics and Gynecology. 2011;**205**:S11-S18. DOI: 10.1016/j.ajog.

[72] Silver RM. Delivery after previous cesarean: Long-term maternal outcomes. Seminars in

[73] Tulandi T et al. Adhesion development and morbidity after repeat cesarean delivery. American Journal of Obstetrics and Gynecology. 2009;**201**:56.e1-56.e6. DOI: 10.1016/j.

[74] Caughey AB et al. Rate of uterine rupture during a trial of labor in woman with one or two prior cesarean deliveries. American Journal of Obstetrics and Gynecology.

[75] Rosales AE, Felguérez FA. Demographic impact of caesarean section. Ginecología y

neal plane. Revista Cubana de Obstetricia y Ginecología. 2010;**36**:333-343

Perinatology. 2010;**34**:258-266. DOI: 10.1053/j.semperi.2010.03.006

2014;**8**:CD000163. DOI: 10.1002/14651858.CD000163.pub2

2017;**217**:564.e1-564.e8. DOI: 10.1016/j.ajog.2017.07.021

mu-1248

98 Caesarean Section

Iranica. 2015;**53**:793-795

10.12669/pjms.335.12899

ajog.2011.09.028

2011.09.029

ajog.2009.04.039

1999;**181**(4):872-876

Obstetricia de México. 2009;**77**(8):362-366

**Chapter 7**

**Provisional chapter**

**Caesarean Section: Reasons for and Actions to Prevent**

**Caesarean Section: Reasons for and Actions to Prevent** 

According to data from 150 countries, the worldwide caesarean section rate increased from 7% in 1990 to 19% in 2014. Latin America and the Caribbean region reported the highest CS rate 42%, followed by North America 32%, Oceania 31%, Europe 25%, Asia 19%, and Africa 7%. This trend is accompanied by increasing reports of severe adverse outcomes, such as invasive placenta, peripartum hysterectomy, and massive obstetric bleeding. The World Health Organization stated in 2015 that caesareans are effective in saving maternal and infant lives only when they are required for medically indicated reasons and that caesarean rates higher than 10–15% at a population level are not associated with reduced maternal or newborn mortality rates. More than 90% of women claim that they want to give birth in a natural way. In contrast, recent studies suggest that the majority of planned caesareans are carried out for psychosocial or nonmedical reasons. Knowledge about the indications for caesareans is a prerequisite in order to define actions to prevent unnecessary caesareans. The aim of this chapter was to present a review of the history behind, and to evaluate the indications for, caesarean sections in order to suggest

**Keywords:** caesarean section, complication, delivery, fear, fetal distress, indication,

Caesarean section (CS) rates continue to rise, particularly in middle- and high-income countries without evidence for maternal and perinatal benefits from the increase. According to

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.76582

**Unnecessary Caesareans**

**Unnecessary Caesareans**

http://dx.doi.org/10.5772/intechopen.76582

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

appropriate actions to prevent unnecessary caesareans.

Ylva Vladic Stjernholm

Ylva Vladic Stjernholm

**Abstract**

labor, team

**1.1. Caesarean section rates**

**1. Introduction**

#### **Caesarean Section: Reasons for and Actions to Prevent Unnecessary Caesareans Caesarean Section: Reasons for and Actions to Prevent Unnecessary Caesareans**

DOI: 10.5772/intechopen.76582

Ylva Vladic Stjernholm Ylva Vladic Stjernholm

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76582

#### **Abstract**

According to data from 150 countries, the worldwide caesarean section rate increased from 7% in 1990 to 19% in 2014. Latin America and the Caribbean region reported the highest CS rate 42%, followed by North America 32%, Oceania 31%, Europe 25%, Asia 19%, and Africa 7%. This trend is accompanied by increasing reports of severe adverse outcomes, such as invasive placenta, peripartum hysterectomy, and massive obstetric bleeding. The World Health Organization stated in 2015 that caesareans are effective in saving maternal and infant lives only when they are required for medically indicated reasons and that caesarean rates higher than 10–15% at a population level are not associated with reduced maternal or newborn mortality rates. More than 90% of women claim that they want to give birth in a natural way. In contrast, recent studies suggest that the majority of planned caesareans are carried out for psychosocial or nonmedical reasons. Knowledge about the indications for caesareans is a prerequisite in order to define actions to prevent unnecessary caesareans. The aim of this chapter was to present a review of the history behind, and to evaluate the indications for, caesarean sections in order to suggest appropriate actions to prevent unnecessary caesareans.

**Keywords:** caesarean section, complication, delivery, fear, fetal distress, indication, labor, team

#### **1. Introduction**

#### **1.1. Caesarean section rates**

Caesarean section (CS) rates continue to rise, particularly in middle- and high-income countries without evidence for maternal and perinatal benefits from the increase. According to

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

data from 150 countries, the worldwide CS rate increased from 7% in 1990 to 19% in 2014. Latin America and the Caribbean region reported the highest CS rate, 42%, followed by North America, 32%, Oceania, 31%, Europe, 25%, Asia, 19%, and Africa, 7% (**Figure 1**) [1] .

classification would be the optimal system. Proposed in 2001, the Robson system classifies women into 10 groups based on their obstetric characteristics—parity, gestational age, onset of labor, fetal presentation, previous CS and the number of fetuses. The system can be applied prospectively and every woman who is admitted for delivery can be classified based on these

Caesarean Section: Reasons for and Actions to Prevent Unnecessary Caesareans

http://dx.doi.org/10.5772/intechopen.76582

103

Referrals to abdominal delivery appear in the Indian epos *Ayurveda* (Knowledge of Life), 3300 BC, as well as in scriptures and pictures from ancient Persia, Egypt and China. Evidence that CS was performed arises from legal texts, such as a tablet describing the adoption of a

The ancient Jewish scriptures Talmud and Mishna, the collection of ancient Jewish laws (200 BC–600 AD), describe caesareans on living women who survived the operation.

The Roman *Leges Regiae* (Royal Laws) from 600 BC forbids the burial of a pregnant woman before extraction of the child from the uterus. When Rome became the Roman Empire, the law was named *"Lex caesarea."* According to Greek mythology, Asclepius, founder of the medicine cult, was removed from his mother Coronis´ abdomen by his father Apollo. [5]. The origin of *caesarean* is commonly believed to be derived from the surgical birth of Julius Caesar (100–44 BC), which has been considered unlikely since his mother was reported to have lived to hear of her son's invasion of Britain. Other possible Latin origins include the verb *caedare*, to cut, and the term *caesones* for infants born by postmortem operations

In the early medieval period, a CS was often performed by midwives [7]. Postmortem caesarean section was encouraged in order to secure baptism of the child. The Catholic theologian and philosopher St. Thomas Aquinas (1225–1274) stated that the mother must not be killed in order to deliver the child [8]. Islamic authorities favored postmortem caesareans, according to Imam Abu Hanifeh (699–767) . However, there are no referrals to caesareans in "The book of enabling him to manage who cannot cope with the complications" by Albucasis (Abul Qasim

In 1500, a successful caesarean on a living woman who survived the operation was reported performed by Jacob Nufer, Switzerland. The woman (his wife) was unable to deliver her baby

Al-Zahrawi, 936–1013), a leading book of surgery in Europe during five centuries.

little boy during the 23rd year of the Babylonian king Hammurabi (1795–1750 BC).

characteristics [2, 3].

**2.1. Ancient cultures**

(**Figure 2**) [6].

**2.2. The medieval period**

**2.3. Renaissance and modern ages**

**2. Historic background**

Postmortem caesareans were also performed [4].

#### **1.2. Definition**

A CS is the delivery of a fetus through an abdominal incision (laparotomy) followed by a uterine incision (uterotomy), regardless of whether the fetus is alive or dead.

#### **1.3. Categorization**

A CS is categorized as planned (elective) when performed 8 h or more after the decision, usually before labor onset, and urgent when carried out between 30 min and 8 h after decision. Immediate caesareans are performed within 15–30 min due to an immediate threat to maternal or fetal health.

#### **1.4. The Robson classification system**

The lack of a standardized classification system to monitor and compare CS rates between obstetric units, regions and countries has hindered a better understanding of the increasing trend. In 2011, a systematic review of classifications for CS concluded that the Robson

**Figure 1.** Worldwide caesarean section rates. From Betrán et al. [1].

classification would be the optimal system. Proposed in 2001, the Robson system classifies women into 10 groups based on their obstetric characteristics—parity, gestational age, onset of labor, fetal presentation, previous CS and the number of fetuses. The system can be applied prospectively and every woman who is admitted for delivery can be classified based on these characteristics [2, 3].

### **2. Historic background**

#### **2.1. Ancient cultures**

data from 150 countries, the worldwide CS rate increased from 7% in 1990 to 19% in 2014. Latin America and the Caribbean region reported the highest CS rate, 42%, followed by North

A CS is the delivery of a fetus through an abdominal incision (laparotomy) followed by a

A CS is categorized as planned (elective) when performed 8 h or more after the decision, usually before labor onset, and urgent when carried out between 30 min and 8 h after decision. Immediate caesareans are performed within 15–30 min due to an immediate threat to

The lack of a standardized classification system to monitor and compare CS rates between obstetric units, regions and countries has hindered a better understanding of the increasing trend. In 2011, a systematic review of classifications for CS concluded that the Robson

America, 32%, Oceania, 31%, Europe, 25%, Asia, 19%, and Africa, 7% (**Figure 1**) [1] .

uterine incision (uterotomy), regardless of whether the fetus is alive or dead.

**1.2. Definition**

102 Caesarean Section

**1.3. Categorization**

maternal or fetal health.

**1.4. The Robson classification system**

**Figure 1.** Worldwide caesarean section rates. From Betrán et al. [1].

Referrals to abdominal delivery appear in the Indian epos *Ayurveda* (Knowledge of Life), 3300 BC, as well as in scriptures and pictures from ancient Persia, Egypt and China. Evidence that CS was performed arises from legal texts, such as a tablet describing the adoption of a little boy during the 23rd year of the Babylonian king Hammurabi (1795–1750 BC).

The ancient Jewish scriptures Talmud and Mishna, the collection of ancient Jewish laws (200 BC–600 AD), describe caesareans on living women who survived the operation. Postmortem caesareans were also performed [4].

The Roman *Leges Regiae* (Royal Laws) from 600 BC forbids the burial of a pregnant woman before extraction of the child from the uterus. When Rome became the Roman Empire, the law was named *"Lex caesarea."* According to Greek mythology, Asclepius, founder of the medicine cult, was removed from his mother Coronis´ abdomen by his father Apollo. [5]. The origin of *caesarean* is commonly believed to be derived from the surgical birth of Julius Caesar (100–44 BC), which has been considered unlikely since his mother was reported to have lived to hear of her son's invasion of Britain. Other possible Latin origins include the verb *caedare*, to cut, and the term *caesones* for infants born by postmortem operations (**Figure 2**) [6].

#### **2.2. The medieval period**

In the early medieval period, a CS was often performed by midwives [7]. Postmortem caesarean section was encouraged in order to secure baptism of the child. The Catholic theologian and philosopher St. Thomas Aquinas (1225–1274) stated that the mother must not be killed in order to deliver the child [8]. Islamic authorities favored postmortem caesareans, according to Imam Abu Hanifeh (699–767) . However, there are no referrals to caesareans in "The book of enabling him to manage who cannot cope with the complications" by Albucasis (Abul Qasim Al-Zahrawi, 936–1013), a leading book of surgery in Europe during five centuries.

#### **2.3. Renaissance and modern ages**

In 1500, a successful caesarean on a living woman who survived the operation was reported performed by Jacob Nufer, Switzerland. The woman (his wife) was unable to deliver her baby

which caused vitamin D deficiency and rachitis. Still, at the early 1900s, women commonly died in childbirth due to rachitic pelvis. When pasteurized milk became available in the 1930s,

Caesarean Section: Reasons for and Actions to Prevent Unnecessary Caesareans

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105

In Uganda, 1879, the catholic missionary Robert Felkin observed a caesarean [14]. He concluded that the operative technique was well developed and had been used for a long time. The surgeons used anesthesia and antiseptics (banana wine), a low abdominal midline incision and a blunt uterine incision with the assistant holding up the sides of the abdomen wall with two fingers into the uterus. The child was removed, the cord cut and the child handed to an assistant. The placenta was removed, the cervix manually dilated allowing for blood to escape, manual compression of the uterus was carried out without suturing it and red irons were used to coagulate bleeding points. The peritoneum, abdominal wall and skin were approximated and closed with seven iron needles, which were removed within 1 week. A root paste was applied over the wound and covered by a cloth bandage. Felkin observed the woman for 11 days, and when he left the mother and infant both were alive and well. Similar reports are known from other African regions, where botanical preparations were also used to anesthetize the woman and promote wound

**2.6. Centralization of obstetric care, mobilization, blood transfusion, antibiotics,** 

Since the 1940s, the trend toward medically managed pregnancy and childbirth has proceeded. Centralization of obstetric and neonatal care has led to decreasing maternal and perinatal mortality. In Sweden, 1900, approximately 10% of births took place in hospitals, which increased to 75% in the 1940s [15]. Maternal mortality declined when early mobilization after childbirth was practiced and after the introduction of blood transfusions, uterotonics, antibi-

*Mobilization:* Maternal mortality due to pulmonary embolism declined when early mobiliza-

*Blood transfusions:* The main blood groups A, B and O were distinguished by the biologist and immunologist Karl Landsteiner, 1900. Based on these findings, the first successful blood

*Antibiotics:* Sulfonamide drugs were introduced as the first antibiotics in the 1930s. Penicillin was generally available in the 1940s after its discovery by Fleming in United Kingdom, 1928,

*Uterotonics:* Ergometrine has been the most important drug for treatment of postpartum hemorrhage, a major cause of maternal mortality. "Ergot of rye has been known to possess deleterious and poisonous qualities for more than 800 years, and it has been used on the continent by female midwives as a promoter of labor pains for nearly 150 years," according to Francis Ramsbotham, founder of the Obstetrical Society of London 1841. In 1954, the uterotonic octapeptide amide oxytocin was described by Vincent du Vigneaud in the United

tion instead of bed rest during 1–2 weeks after childbirth was advised.

transfusion was performed in 1907 in the United States [16].

States, and 1 year later oxytocin was synthesized [18].

insufficient bone growth became less common [13].

**2.5. Africa**

healing.

**uterotonics and anesthesia**

otics and anesthesia.

and subsequent purification [17].

**Figure 2.** The extraction of Asclepius from his mother Coronis´ abdomen by his father Apollo. Woodcut from De Re Medica (1549) Alessandro Beneditti.

after several days in obstructed labor and despite help from many midwives. Her desperate husband gained permission from the local authorities to attempt a caesarean. The mother survived and subsequently went through several deliveries. The caesarean child lived until an older age. Success factors were that the caesarean was performed at an early opening stage, that it was performed in the house and that Nufer must have had anatomical knowledge because of his work with animal care. The story was not recorded until 1582; its accuracy has been questioned [9]. In 1581, the French physician François Rousset published a book with the subtitle "The extraction of a child through a lateral incision of the abdomen and the uterus of a pregnant woman who cannot otherwise give birth. And that without endangering the life of the one or another and without preventing subsequent fertility," where he suggested caesareans on living women for indications such as large fetus, dead fetus, twins, malpresentation, extremely young or elderly mother or narrow pelvis. In support of this proposal were 10 observations, of which he personally took part in a few without operating, as he was not a surgeon [10].

In the early 1500s, the British Chamberlen clan introduced instrumental forceps delivery to pull the fetus from the birth canal during obstructed labor. During the following 300 years, the male midwife and obstetrician gradually wrested influence over deliveries from female midwives [9, 11].

Until the 1600s, the procedure was known as a caesarean operation. In a book on midwifery, 1598, published by the French surgeon Jacques Guillimeau, the term "section" was introduced and thereafter replaced "operation" [12].

#### **2.4. Industrialization and malnutrition in Western countries increase the need for caesareans**

Increasing urbanization due to industrialization in Western countries in the 1800s led to an increased need for caesareans. City children suffered from malnutrition and lack of sunlight, which caused vitamin D deficiency and rachitis. Still, at the early 1900s, women commonly died in childbirth due to rachitic pelvis. When pasteurized milk became available in the 1930s, insufficient bone growth became less common [13].

#### **2.5. Africa**

after several days in obstructed labor and despite help from many midwives. Her desperate husband gained permission from the local authorities to attempt a caesarean. The mother survived and subsequently went through several deliveries. The caesarean child lived until an older age. Success factors were that the caesarean was performed at an early opening stage, that it was performed in the house and that Nufer must have had anatomical knowledge because of his work with animal care. The story was not recorded until 1582; its accuracy has been questioned [9]. In 1581, the French physician François Rousset published a book with the subtitle "The extraction of a child through a lateral incision of the abdomen and the uterus of a pregnant woman who cannot otherwise give birth. And that without endangering the life of the one or another and without preventing subsequent fertility," where he suggested caesareans on living women for indications such as large fetus, dead fetus, twins, malpresentation, extremely young or elderly mother or narrow pelvis. In support of this proposal were 10 observations, of

**Figure 2.** The extraction of Asclepius from his mother Coronis´ abdomen by his father Apollo. Woodcut from De Re

which he personally took part in a few without operating, as he was not a surgeon [10].

**2.4. Industrialization and malnutrition in Western countries increase the need for** 

midwives [9, 11].

Medica (1549) Alessandro Beneditti.

104 Caesarean Section

**caesareans**

duced and thereafter replaced "operation" [12].

In the early 1500s, the British Chamberlen clan introduced instrumental forceps delivery to pull the fetus from the birth canal during obstructed labor. During the following 300 years, the male midwife and obstetrician gradually wrested influence over deliveries from female

Until the 1600s, the procedure was known as a caesarean operation. In a book on midwifery, 1598, published by the French surgeon Jacques Guillimeau, the term "section" was intro-

Increasing urbanization due to industrialization in Western countries in the 1800s led to an increased need for caesareans. City children suffered from malnutrition and lack of sunlight, In Uganda, 1879, the catholic missionary Robert Felkin observed a caesarean [14]. He concluded that the operative technique was well developed and had been used for a long time. The surgeons used anesthesia and antiseptics (banana wine), a low abdominal midline incision and a blunt uterine incision with the assistant holding up the sides of the abdomen wall with two fingers into the uterus. The child was removed, the cord cut and the child handed to an assistant. The placenta was removed, the cervix manually dilated allowing for blood to escape, manual compression of the uterus was carried out without suturing it and red irons were used to coagulate bleeding points. The peritoneum, abdominal wall and skin were approximated and closed with seven iron needles, which were removed within 1 week. A root paste was applied over the wound and covered by a cloth bandage. Felkin observed the woman for 11 days, and when he left the mother and infant both were alive and well. Similar reports are known from other African regions, where botanical preparations were also used to anesthetize the woman and promote wound healing.

#### **2.6. Centralization of obstetric care, mobilization, blood transfusion, antibiotics, uterotonics and anesthesia**

Since the 1940s, the trend toward medically managed pregnancy and childbirth has proceeded. Centralization of obstetric and neonatal care has led to decreasing maternal and perinatal mortality. In Sweden, 1900, approximately 10% of births took place in hospitals, which increased to 75% in the 1940s [15]. Maternal mortality declined when early mobilization after childbirth was practiced and after the introduction of blood transfusions, uterotonics, antibiotics and anesthesia.

*Mobilization:* Maternal mortality due to pulmonary embolism declined when early mobilization instead of bed rest during 1–2 weeks after childbirth was advised.

*Blood transfusions:* The main blood groups A, B and O were distinguished by the biologist and immunologist Karl Landsteiner, 1900. Based on these findings, the first successful blood transfusion was performed in 1907 in the United States [16].

*Antibiotics:* Sulfonamide drugs were introduced as the first antibiotics in the 1930s. Penicillin was generally available in the 1940s after its discovery by Fleming in United Kingdom, 1928, and subsequent purification [17].

*Uterotonics:* Ergometrine has been the most important drug for treatment of postpartum hemorrhage, a major cause of maternal mortality. "Ergot of rye has been known to possess deleterious and poisonous qualities for more than 800 years, and it has been used on the continent by female midwives as a promoter of labor pains for nearly 150 years," according to Francis Ramsbotham, founder of the Obstetrical Society of London 1841. In 1954, the uterotonic octapeptide amide oxytocin was described by Vincent du Vigneaud in the United States, and 1 year later oxytocin was synthesized [18].

*Anesthesia:* Nitrous oxide (laughing gas) was used as an anesthetic, 1799, and ether was demonstrated in 1846. Chloroform/ether was introduced in obstetrics, 1847, by Sir James Young Simpson, Professor in Midwifery in Edinburgh, Scotland, after self-experimentation and despite the criticism from many obstetricians in Europe and the United States. Anesthesia was often provided by nurses, of whom many were recruited among nuns from the convents [19]. In the 1900s, regional anesthesia and the general anesthetic halothane became available after being tumultuously developed with self-experiments. The initial enthusiasm was followed by skepticism and development of new drugs from the 1930s to 1950s [20].

pregnancy. It was combined either with a low midline or a transverse abdominal incision,

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In 1972, Joel-Cohen and colleagues reported a new method for CS, which had first been used for hysterectomy, with a transverse laparotomy 5 cm above the symphysis pubis and blunt dissection of the abdominal wall. In the 1990s, one layer suture of the uterus and nonclosure of the peritoneum were recommended [25, 26]. This technique was first evaluated by Stark and colleagues in 1995 and was named after the Misgav Ladach Hospital in Jerusalem, Israel, where it was developed [27]. Today, many clinicians practice a modified Misgav Ladach method, with a skin incision 3–4 cm above the symphysis pubis. This technique reduces the risk of bladder

*Uterine closure:* The idea to close the uterus was introduced by Lebas in France in the 1700s, suggested in certain situations by Harris in the Unites States in the 1800s, and first reported in 1882 by Max Sanger (Saumlnger) in Germany. Uterine closure with silver and silk sutures reduced maternal mortality significantly [29]. Silver threads had been launched into the gynecological field by the American surgeon James Marion Sims, who performed experimental surgery on postdelivery vesico-vaginal fistulas on enslaved, unanesthesized women in

The role of a single- or double-layer uterine closure for reducing subsequent uterine rupture has long been debated. According to randomized trials, the short-term complications are similar with either technique, but long-term follow-up is missing [30–32]. Locked sutures shall not be used, since they increase the risk of uterine ischemia and dehiscence [30, 33]. A singlelayer suture of the uterotomy has been recommended by several authors [32]. However, a

known as the Pfannenstiel-Kerr procedure, and gained acceptance in the 1940s [24].

injury, bleeding and pain compared with the Pfannenstiel method (**Figure 3**) [28].

**Figure 3.** The Joel-Cohen, Midline and Pfannenstiel abdominal wall incisions.

**3.5. The Misgav Ladach method**

Alabama, United States.

#### **3. Operative techniques**

As anesthesia and aseptics developed, obstetricians were able to concentrate on improvement of the operative techniques for cesareans.

#### **3.1. Classical caesarean**

Until the 1800s, caesareans were performed with midline laparotomy and vertical corporal uterotomy without closing the uterus, which resulted in mortality rates of 85–100% among women delivered by caesarean. The main reasons for caesareans were obstructed labor, often for days with a dead fetus. The main reasons for maternal mortality were hemorrhage, "exhaustion," septicemia and eclampsia [21].

#### **3.2. The Porro technique**

In 1876, the Italian obstetrician Eduardo Porro suggested a caesarean technique performing a subtotal hysterectomy with extirpation of the ovaries after delivery of the infant, in order to reduce hemorrhage and infection. This method claimed to result in more than 50% maternal survival [22].

#### **3.3. Vaginal cesarean**

Between the 1880s and 1925, surgeons suggested transverse incisions in the lower uterine segment. Also, vaginal caesareans were carried out, in order to reduce peritonitis and septicemia. The need for vaginal caesareans ceased after World War II by the development of antibiotics [9].

#### **3.4. The Pfannenstiel-Kerr method**

In 1897, Johannes Pfannenstiel in Germany documented a transverse abdominal incision just above the symphysis pubis [23]. In 1926, the British obstetrician John Munro Kerr reported a low transverse uterine incision, double-layer uterine sutures and peritoneal closure. This technique reduced maternal mortality and lowered the risk for uterine rupture in a subsequent pregnancy. It was combined either with a low midline or a transverse abdominal incision, known as the Pfannenstiel-Kerr procedure, and gained acceptance in the 1940s [24].

#### **3.5. The Misgav Ladach method**

*Anesthesia:* Nitrous oxide (laughing gas) was used as an anesthetic, 1799, and ether was demonstrated in 1846. Chloroform/ether was introduced in obstetrics, 1847, by Sir James Young Simpson, Professor in Midwifery in Edinburgh, Scotland, after self-experimentation and despite the criticism from many obstetricians in Europe and the United States. Anesthesia was often provided by nurses, of whom many were recruited among nuns from the convents [19]. In the 1900s, regional anesthesia and the general anesthetic halothane became available after being tumultuously developed with self-experiments. The initial enthusiasm was followed by skepticism and development of new drugs from the 1930s to

As anesthesia and aseptics developed, obstetricians were able to concentrate on improvement

Until the 1800s, caesareans were performed with midline laparotomy and vertical corporal uterotomy without closing the uterus, which resulted in mortality rates of 85–100% among women delivered by caesarean. The main reasons for caesareans were obstructed labor, often for days with a dead fetus. The main reasons for maternal mortality were hemorrhage,

In 1876, the Italian obstetrician Eduardo Porro suggested a caesarean technique performing a subtotal hysterectomy with extirpation of the ovaries after delivery of the infant, in order to reduce hemorrhage and infection. This method claimed to result in more than 50% maternal

Between the 1880s and 1925, surgeons suggested transverse incisions in the lower uterine segment. Also, vaginal caesareans were carried out, in order to reduce peritonitis and septicemia. The need for vaginal caesareans ceased after World War II by the development of

In 1897, Johannes Pfannenstiel in Germany documented a transverse abdominal incision just above the symphysis pubis [23]. In 1926, the British obstetrician John Munro Kerr reported a low transverse uterine incision, double-layer uterine sutures and peritoneal closure. This technique reduced maternal mortality and lowered the risk for uterine rupture in a subsequent

1950s [20].

106 Caesarean Section

**3. Operative techniques**

**3.1. Classical caesarean**

**3.2. The Porro technique**

survival [22].

antibiotics [9].

**3.3. Vaginal cesarean**

**3.4. The Pfannenstiel-Kerr method**

of the operative techniques for cesareans.

"exhaustion," septicemia and eclampsia [21].

In 1972, Joel-Cohen and colleagues reported a new method for CS, which had first been used for hysterectomy, with a transverse laparotomy 5 cm above the symphysis pubis and blunt dissection of the abdominal wall. In the 1990s, one layer suture of the uterus and nonclosure of the peritoneum were recommended [25, 26]. This technique was first evaluated by Stark and colleagues in 1995 and was named after the Misgav Ladach Hospital in Jerusalem, Israel, where it was developed [27]. Today, many clinicians practice a modified Misgav Ladach method, with a skin incision 3–4 cm above the symphysis pubis. This technique reduces the risk of bladder injury, bleeding and pain compared with the Pfannenstiel method (**Figure 3**) [28].

*Uterine closure:* The idea to close the uterus was introduced by Lebas in France in the 1700s, suggested in certain situations by Harris in the Unites States in the 1800s, and first reported in 1882 by Max Sanger (Saumlnger) in Germany. Uterine closure with silver and silk sutures reduced maternal mortality significantly [29]. Silver threads had been launched into the gynecological field by the American surgeon James Marion Sims, who performed experimental surgery on postdelivery vesico-vaginal fistulas on enslaved, unanesthesized women in Alabama, United States.

The role of a single- or double-layer uterine closure for reducing subsequent uterine rupture has long been debated. According to randomized trials, the short-term complications are similar with either technique, but long-term follow-up is missing [30–32]. Locked sutures shall not be used, since they increase the risk of uterine ischemia and dehiscence [30, 33]. A singlelayer suture of the uterotomy has been recommended by several authors [32]. However, a

**Figure 3.** The Joel-Cohen, Midline and Pfannenstiel abdominal wall incisions.

double-layer closure is related to a 4-fold reduction of subsequent uterine rupture compared with a single-layer closure [34]. Also, ultrasound investigations show a higher myometrial thickness after a double-layer closure [35, 36]. It is noted that besides the uterine closure technique several factors influence the risk of subsequent uterine rupture, such as labor progress [37]*,* increasing maternal age and body mass index (BMI) [38, 39], short interpregnancy interval [40]; induced labor and method for labor induction [40–43] as well as fetal weight [38, 44].

**4.1. Planned caesareans**

**4.2. Urgent caesareans**

[37, 54, 55, 62, 67].

**4.3. Immediate caesareans**

eclampsia [55, 62, 67].

**4.4. Preterm caesareans**

a low-transverse uterine incision [70].

Historically, the primary indications for planned caesareans have been malpresentation, previous uterine scar, narrow pelvis and twin pregnancies with the first twin in a breech presentation [54, 57]. According to recent studies, the most common indications today appear to be psychosocial/nonmedical reasons, defined as fear of vaginal birth or maternal request without any co-existing medical indication in women with simplex cephalic pregnancy at a normal gestational age [54, 55]. Secondary fear of vaginal delivery after a negative birth experience was reported by 60% of these women (2.7% of all deliveries), primary fear of vaginal delivery by 34% (1.5%), whereas 5% (0.2%) was related to a pre-existing psychiatric health disorder such as severe depression, bipolar disease or an attention deficit disorder, and 1% (0.04%) was carried out on maternal request without further explanation. Fear of vaginal delivery is related to psychosocial burdens such as anxiety, depression, abuse, violence and a negative birth experience [53, 56, 58, 59]. The dominant Robson Classification Groups in Sweden 2015 were Group 2 (primiparous women with single cephalic pregnancy 37 weeks or more, who either had labor induced or were delivered by CS before labor) and Group 5 (multiparous women with single cephalic pregnancy 37 weeks or more and at least one previous uterine scar) [60].

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Most urgent caesareans are carried out because of prolonged labor (labor dystocia) [54, 55, 61–64]. Prolonged labor is related to fetal malpresentations such as occipital posterior presentation or asynklitism in approximately 15% [55, 62]. Lack of support during delivery, high maternal age, high BMI and induced labor are risk factors for prolonged labor [39, 65, 66]. The second most common reported indication for urgent caesareans is imminent fetal distress

Immediate caesareans are performed because of immediate threats to maternal or fetal health, which include signs of immediate fetal distress according to cardiotocography (CTG) or fetal scalp blood lactate sampling, placental abruption, umbilical cord prolapse and severe pre-

The rate of preterm caesareans has increased during the 2000s as a result of altered clinical guidelines recommending referral of women with threatening preterm birth to a tertiary hospital and active management including urgent caesareans at an earlier gestational age [68]. This development motivates long-term follow-up of maternal and child health, since preterm caesareans between 24 and 33 weeks reduce neonatal mortality and morbidity only when performed because of urgent fetal distress or a breech presentation [69]. Preterm caesareans more often require a high uterine corporal myometrial incision than term caesareans, due to an inadequately developed lower uterine segment in preterm gestation. This technique increases the risk of subsequent pathological placentation and uterine rupture compared with

*Removal of the placenta:* External compression of the uterus at caesarean, rather than manual removal of the placenta is recommended to reduce bleeding. The risk of postoperative endometritis was comparable with the two techniques and independent of whether the uterus was externalized or not during surgery. Manual or instrumental dilatation of the cervix did not reduce the risk of postoperative endometritis. Hematometra was not evaluated in the studies [31, 32].

*Closure of the abdominal wall:* Historically, both the urterovisceral and parietal peritoneum were closed during caesarean. This strategy was abandoned when it was shown that nonclosure of the peritoneum results in short-term advantages, such as shorter operative time, reduced risk of intra-abdominal hematomas and adhesions, postoperative analgetic requirement and shorter hospital stay [45, 46]. However, adaptation of the rectus muscle reduces the risk of rectus diastasis and may also reduce the risk of adhesions between the uterus and abdominal wall [46]. Closure of the external fascia of the abdominal wall with resorbable PDS suture is recommended to minimalize the risk of abdominal wall hernias [47]. Closure of the subcutaneous fat regardless of thickness reduces the risk of hematomas [48]. Skin closure of a transversal skin incision with sutures reduces the risk of wound complications as compared to staples. However, a midline laparotomy requires a robust closing technique [49].

*Uterotonics:* Low-dose oxytocin 2.5 U reduces preoperative bleeding during caesarean as efficiently as a high dose of 15 U. Oxytocin must be administered with care, because of the risk for cardiac arrhythmias, heart incompensation and pulmonary edema, particularly after doses of 30 U or more [50].

*Prophylactic antibiotics:* The effectiveness of prophylactic antibiotics depends on their presence in adequate concentrations during the operative period. Prophylactic antibiotic administration is recommended during emergency and immediate caesareans and by some authors also at elective caesareans. A single dose of cephalosporin is as effective as repeated doses of broad-spectrum antibiotics [51]. Preoperative administration within 15 min − 2 h before surgery is associated with a lower incidence of endometritis and wound infection as compared to intraoperative administration. It is noted that *in utero* exposure of a fetus to antibiotics is related to the development of allergy during infancy [52].

#### **4. Indications for caesarean section**

More than 90% of pregnant women claim that they want to give birth in a natural way [53]. In contrast, recent studies suggest that the majority of planned caesareans are carried out for psychosocial or nonmedical reasons [54, 55]. Interestingly, 80% of women who experience obstetric complications neither consider the birth a negative overall experience nor develop fear of vaginal delivery [56].

#### **4.1. Planned caesareans**

double-layer closure is related to a 4-fold reduction of subsequent uterine rupture compared with a single-layer closure [34]. Also, ultrasound investigations show a higher myometrial thickness after a double-layer closure [35, 36]. It is noted that besides the uterine closure technique several factors influence the risk of subsequent uterine rupture, such as labor progress [37]*,* increasing maternal age and body mass index (BMI) [38, 39], short interpregnancy interval [40]; induced labor and method for labor induction [40–43] as well as fetal weight [38, 44]. *Removal of the placenta:* External compression of the uterus at caesarean, rather than manual removal of the placenta is recommended to reduce bleeding. The risk of postoperative endometritis was comparable with the two techniques and independent of whether the uterus was externalized or not during surgery. Manual or instrumental dilatation of the cervix did not reduce the risk of postoperative endometritis. Hematometra was not evaluated in the studies [31, 32]. *Closure of the abdominal wall:* Historically, both the urterovisceral and parietal peritoneum were closed during caesarean. This strategy was abandoned when it was shown that nonclosure of the peritoneum results in short-term advantages, such as shorter operative time, reduced risk of intra-abdominal hematomas and adhesions, postoperative analgetic requirement and shorter hospital stay [45, 46]. However, adaptation of the rectus muscle reduces the risk of rectus diastasis and may also reduce the risk of adhesions between the uterus and abdominal wall [46]. Closure of the external fascia of the abdominal wall with resorbable PDS suture is recommended to minimalize the risk of abdominal wall hernias [47]. Closure of the subcutaneous fat regardless of thickness reduces the risk of hematomas [48]. Skin closure of a transversal skin incision with sutures reduces the risk of wound complications as compared

to staples. However, a midline laparotomy requires a robust closing technique [49].

doses of 30 U or more [50].

108 Caesarean Section

fear of vaginal delivery [56].

related to the development of allergy during infancy [52].

**4. Indications for caesarean section**

*Uterotonics:* Low-dose oxytocin 2.5 U reduces preoperative bleeding during caesarean as efficiently as a high dose of 15 U. Oxytocin must be administered with care, because of the risk for cardiac arrhythmias, heart incompensation and pulmonary edema, particularly after

*Prophylactic antibiotics:* The effectiveness of prophylactic antibiotics depends on their presence in adequate concentrations during the operative period. Prophylactic antibiotic administration is recommended during emergency and immediate caesareans and by some authors also at elective caesareans. A single dose of cephalosporin is as effective as repeated doses of broad-spectrum antibiotics [51]. Preoperative administration within 15 min − 2 h before surgery is associated with a lower incidence of endometritis and wound infection as compared to intraoperative administration. It is noted that *in utero* exposure of a fetus to antibiotics is

More than 90% of pregnant women claim that they want to give birth in a natural way [53]. In contrast, recent studies suggest that the majority of planned caesareans are carried out for psychosocial or nonmedical reasons [54, 55]. Interestingly, 80% of women who experience obstetric complications neither consider the birth a negative overall experience nor develop Historically, the primary indications for planned caesareans have been malpresentation, previous uterine scar, narrow pelvis and twin pregnancies with the first twin in a breech presentation [54, 57]. According to recent studies, the most common indications today appear to be psychosocial/nonmedical reasons, defined as fear of vaginal birth or maternal request without any co-existing medical indication in women with simplex cephalic pregnancy at a normal gestational age [54, 55]. Secondary fear of vaginal delivery after a negative birth experience was reported by 60% of these women (2.7% of all deliveries), primary fear of vaginal delivery by 34% (1.5%), whereas 5% (0.2%) was related to a pre-existing psychiatric health disorder such as severe depression, bipolar disease or an attention deficit disorder, and 1% (0.04%) was carried out on maternal request without further explanation. Fear of vaginal delivery is related to psychosocial burdens such as anxiety, depression, abuse, violence and a negative birth experience [53, 56, 58, 59]. The dominant Robson Classification Groups in Sweden 2015 were Group 2 (primiparous women with single cephalic pregnancy 37 weeks or more, who either had labor induced or were delivered by CS before labor) and Group 5 (multiparous women with single cephalic pregnancy 37 weeks or more and at least one previous uterine scar) [60].

#### **4.2. Urgent caesareans**

Most urgent caesareans are carried out because of prolonged labor (labor dystocia) [54, 55, 61–64]. Prolonged labor is related to fetal malpresentations such as occipital posterior presentation or asynklitism in approximately 15% [55, 62]. Lack of support during delivery, high maternal age, high BMI and induced labor are risk factors for prolonged labor [39, 65, 66]. The second most common reported indication for urgent caesareans is imminent fetal distress [37, 54, 55, 62, 67].

#### **4.3. Immediate caesareans**

Immediate caesareans are performed because of immediate threats to maternal or fetal health, which include signs of immediate fetal distress according to cardiotocography (CTG) or fetal scalp blood lactate sampling, placental abruption, umbilical cord prolapse and severe preeclampsia [55, 62, 67].

#### **4.4. Preterm caesareans**

The rate of preterm caesareans has increased during the 2000s as a result of altered clinical guidelines recommending referral of women with threatening preterm birth to a tertiary hospital and active management including urgent caesareans at an earlier gestational age [68]. This development motivates long-term follow-up of maternal and child health, since preterm caesareans between 24 and 33 weeks reduce neonatal mortality and morbidity only when performed because of urgent fetal distress or a breech presentation [69]. Preterm caesareans more often require a high uterine corporal myometrial incision than term caesareans, due to an inadequately developed lower uterine segment in preterm gestation. This technique increases the risk of subsequent pathological placentation and uterine rupture compared with a low-transverse uterine incision [70].

#### **5. Vaginal birth after caesarean**

By the quote "once a caesarean, always a caesarean," 1916, the American physician Edwin Craigin urged his colleagues to avoid unnecessary caesareans and emphasized that one of the risks of a primary caesarean is that repeat operations might be required [71]. This piece of advice is more actual than ever in today's obstetric care, when the rate of vaginal birth after caesarean (VBAC) is less than 10% in some countries [55, 63, 64, 72]. Trial of VBAC after one CS results in successful vaginal delivery in 80% with a 0.5–1% risk of uterine rupture as compared to a 0.05% risk of uterine rupture among women without a previous caesarean. The success rate is as high as 90% if the woman has a previous vaginal birth [43, 73, 74]. The risk of uterine rupture is increased by an interdelivery interval of less than 16 months [40]. Trial of VBAC is possible in most situations except after two situations, a high corporal uterine incision or three previous caesareans. The success rate of VBAC after two caesareans is approximately 70%, and the risk of uterine rupture may be higher, 1.5–2%, after 2 previous caesareans than after 1 previous caesarean [73, 75, 76].

*6.1.2. Neonatal*

*6.2.1. Woman*

sareans [85, 86].

mon after CS compared to vaginal delivery [82].

1 caesarean and 2% after 2 caesareans [80].

markedly after three caesareans to 2–3% [80].

uterine rupture (**Figure 4**) [37] .

**6.2. Long-term complications**

*Breast feeding:* The onset of breast feeding is slower, and breast complications are more com-

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*Neonatal breathing disturbances:* Neonatal breathing disturbances are five times more common after caesarean (3.7 per 1000) compared with vaginal birth (0.7 per 1000). The risk diminishes if a planned CS is performed by 39 completed gestational weeks rather than earlier [83, 84].

*Abdominal adhesions:* The risk of intra-abdominal adhesions increases with the number of cae-

*Placenta praevia:* The risk of *placenta praevia*, where the placenta implants in the low uterine segment, covers the internal orifice of the uterine cervix (or internal os), through which the uterine cervix communicates with the uterine cavity and hinders vaginal delivery, increases with the number of scars in the lower uterine segment, mostly after caesarean section, vacuum aspiration or in vitro fertilization. The rate of *placenta praevia* increases from 0.5–1% after

*Placenta accrete:* Placental implantation in the lower uterine segment, which is composed mainly of connective tissue in contrast to the dominating smooth muscle in the uterine corpus, is the primary risk factor for abnormally invasive placenta *(placenta accreta).* This severe obstetric complication comprises a high risk of massive obstetric bleeding, complicated surgery and peripartum hysterectomy. Abnormally invasive placenta includes several types of trophoblast invasions into the uterine wall, in 70% invasion into less than 50% of the wall (*placenta accreta*), in 30% invasion in more than 50% of the wall (*increta*) or through the uterine wall (*percreta*) perhaps into adjacent organs such as the urinary bladder, abdominal wall or intestine [80, 87]. The rate of *placenta accreta* has increased during the past 30 years and is reported in 2–90 per 10,000 births [87]. The prevalence of *placenta accreta* among women with *placenta praevia* is 3% after 1 caesarean, 11% after 2 caesareans and 40% after 3 caesareans [80]. *Peripartum hysterectomy:* The reported prevalence of emergency peripartum hysterectomy, primarily because of abnormally invasive placenta, secondly because of atonic bleeding and thirdly uterine rupture, in the Nordic countries is 3–4 per 10,000 births, as compared to 7 per 10,000 births in Germany and 23 per 10,000 births in the United States [88]. The risk of peripartum hysterectomy due to *placenta accreta* increases with the number of caesareans, rising

*Uterine rupture:* The risk of uterine rupture during delivery is estimated to 0.05% among women without a previous caesarean, 0.5% after 1 caesarean and 1.5% after 2 caesareans [73]. Prolonged opening stage after 6–7 cm cervical dilatation was related to an increased risk of

#### **6. Complications after caesarean**

#### **6.1. Short-term complications**

#### *6.1.1. Maternal*

*Mortality:* A WHO global survey on maternal and perinatal health found that all caesareans including antepartum CS without medical indications are associated with severe maternal outcomes, such as an increased risk of death, admission to intensive care unit, blood transfusion and hysterectomy, as compared to vaginal delivery. In addition, this association is stronger in Africa, as compared to Asia and Latin America [77].

*Amniotic fluid embolism:* The risk for amnion fluid embolus is 2–5 times higher after CS compared with vaginal delivery [78].

*Venous thromboembolism:* The risk of venous thromboembolism increases by 10–15 times from early pregnancy, and further 2–8 times during caesarean, more during urgent CS in general anesthesia than planned CS in regional anesthesia [79].

*Infections:* Infections such as endometritis, urinary tract infection and wound infection are more common after caesarean than vaginal delivery [52].

*Traumatic injury of bladder or intestine:* Intraoperative traumatic bladder or intestine injury occurs in less than 1%, and the risk increases with increasing number of caesareans [80].

*Postoperative pain:* Postoperative pain after caesarean is shown to be more intense and persistent than was previously presumed [81].

#### *6.1.2. Neonatal*

**5. Vaginal birth after caesarean**

110 Caesarean Section

than after 1 previous caesarean [73, 75, 76].

**6. Complications after caesarean**

ger in Africa, as compared to Asia and Latin America [77].

anesthesia than planned CS in regional anesthesia [79].

more common after caesarean than vaginal delivery [52].

**6.1. Short-term complications**

pared with vaginal delivery [78].

tent than was previously presumed [81].

*6.1.1. Maternal*

By the quote "once a caesarean, always a caesarean," 1916, the American physician Edwin Craigin urged his colleagues to avoid unnecessary caesareans and emphasized that one of the risks of a primary caesarean is that repeat operations might be required [71]. This piece of advice is more actual than ever in today's obstetric care, when the rate of vaginal birth after caesarean (VBAC) is less than 10% in some countries [55, 63, 64, 72]. Trial of VBAC after one CS results in successful vaginal delivery in 80% with a 0.5–1% risk of uterine rupture as compared to a 0.05% risk of uterine rupture among women without a previous caesarean. The success rate is as high as 90% if the woman has a previous vaginal birth [43, 73, 74]. The risk of uterine rupture is increased by an interdelivery interval of less than 16 months [40]. Trial of VBAC is possible in most situations except after two situations, a high corporal uterine incision or three previous caesareans. The success rate of VBAC after two caesareans is approximately 70%, and the risk of uterine rupture may be higher, 1.5–2%, after 2 previous caesareans

*Mortality:* A WHO global survey on maternal and perinatal health found that all caesareans including antepartum CS without medical indications are associated with severe maternal outcomes, such as an increased risk of death, admission to intensive care unit, blood transfusion and hysterectomy, as compared to vaginal delivery. In addition, this association is stron-

*Amniotic fluid embolism:* The risk for amnion fluid embolus is 2–5 times higher after CS com-

*Venous thromboembolism:* The risk of venous thromboembolism increases by 10–15 times from early pregnancy, and further 2–8 times during caesarean, more during urgent CS in general

*Infections:* Infections such as endometritis, urinary tract infection and wound infection are

*Traumatic injury of bladder or intestine:* Intraoperative traumatic bladder or intestine injury occurs in less than 1%, and the risk increases with increasing number of caesareans [80].

*Postoperative pain:* Postoperative pain after caesarean is shown to be more intense and persis-

*Breast feeding:* The onset of breast feeding is slower, and breast complications are more common after CS compared to vaginal delivery [82].

*Neonatal breathing disturbances:* Neonatal breathing disturbances are five times more common after caesarean (3.7 per 1000) compared with vaginal birth (0.7 per 1000). The risk diminishes if a planned CS is performed by 39 completed gestational weeks rather than earlier [83, 84].

#### **6.2. Long-term complications**

#### *6.2.1. Woman*

*Abdominal adhesions:* The risk of intra-abdominal adhesions increases with the number of caesareans [85, 86].

*Placenta praevia:* The risk of *placenta praevia*, where the placenta implants in the low uterine segment, covers the internal orifice of the uterine cervix (or internal os), through which the uterine cervix communicates with the uterine cavity and hinders vaginal delivery, increases with the number of scars in the lower uterine segment, mostly after caesarean section, vacuum aspiration or in vitro fertilization. The rate of *placenta praevia* increases from 0.5–1% after 1 caesarean and 2% after 2 caesareans [80].

*Placenta accrete:* Placental implantation in the lower uterine segment, which is composed mainly of connective tissue in contrast to the dominating smooth muscle in the uterine corpus, is the primary risk factor for abnormally invasive placenta *(placenta accreta).* This severe obstetric complication comprises a high risk of massive obstetric bleeding, complicated surgery and peripartum hysterectomy. Abnormally invasive placenta includes several types of trophoblast invasions into the uterine wall, in 70% invasion into less than 50% of the wall (*placenta accreta*), in 30% invasion in more than 50% of the wall (*increta*) or through the uterine wall (*percreta*) perhaps into adjacent organs such as the urinary bladder, abdominal wall or intestine [80, 87]. The rate of *placenta accreta* has increased during the past 30 years and is reported in 2–90 per 10,000 births [87]. The prevalence of *placenta accreta* among women with *placenta praevia* is 3% after 1 caesarean, 11% after 2 caesareans and 40% after 3 caesareans [80].

*Peripartum hysterectomy:* The reported prevalence of emergency peripartum hysterectomy, primarily because of abnormally invasive placenta, secondly because of atonic bleeding and thirdly uterine rupture, in the Nordic countries is 3–4 per 10,000 births, as compared to 7 per 10,000 births in Germany and 23 per 10,000 births in the United States [88]. The risk of peripartum hysterectomy due to *placenta accreta* increases with the number of caesareans, rising markedly after three caesareans to 2–3% [80].

*Uterine rupture:* The risk of uterine rupture during delivery is estimated to 0.05% among women without a previous caesarean, 0.5% after 1 caesarean and 1.5% after 2 caesareans [73]. Prolonged opening stage after 6–7 cm cervical dilatation was related to an increased risk of uterine rupture (**Figure 4**) [37] .

reasons and previous uterine scar [54, 55, 62, 72]. Recent studies have shown that normal labor progress during the opening stage is slower than 1 cm/h in all women, which was suggested by Emmanuel Friedman in the United States in the 1950s. Therefore, a slower progress than 1 cm/h is during the first stage of labor, which is not an indication for emergency caesarean in the absence of signs of fetal or maternal distress (**Figure 5**)

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Evidence-based management of labor, structured support during delivery, reduced labor induction and developed ability to perform instrumental deliveries instead of caesareans could be achieved through systematic theoretical education and team training programs on labor progress, fetal monitoring and delivery skills [55, 67, 96]. Such actions, taken together with structured counseling and support during pregnancy, would reduce planned caesareans due to psychosocial/nonmedical reasons or previous uterine scar. An increasing amount of evidence show that pregnancy-related anxiety is common and increasing with advancing pregnancy. A standardized definition of fear of vaginal delivery including an evidence-based scale for assessment of fear has been suggested [97]. Recommended systematic counseling and support for women fearing vaginal delivery include repeated meetings with a psychosocial team during pregnancy, objective information about benefits and risks related to different delivery modes including the influence on future reproductive health as well as support during delivery and planned follow-up after a negative birth

Importantly, the attitudes among midwives and obstetricians influence a patient's choice [100]. A "coping attitude" rather than an "autonomy attitude" is strongly associated with a

change in desire for a caesarean in women fearing vaginal delivery [59, 101].

[63, 64, 95].

experience [65, 98, 99].

**Figure 5.** Average labor curves. From Zhang et al. [63].

**Figure 4.** Placenta previa and abnormally invasive placenta, here *placenta percreta*. Source: Wikipedia.

*Urinary and bowel incontinence:* The prevalence of postpartum stress urinary incontinence is similar following spontaneous vaginal delivery and caesarean section performed for obstructed labor. It is quite possible that pelvic floor injury in such cases is already too extensive to be prevented by surgical intervention. Antepartal caesarean section was found to be associated with a lower rate of stress urinary incontinence. There is no difference between the groups after 2 years, and there is no difference at menopause between women with a previous vaginal delivery and women who never gave birth. It has been concluded that the pregnancy in itself leads to distension of pelvic ligaments and tissues. Caesareans do not protect against bowel incontinence [89, 90].

#### *6.2.2. Child*

*Intestinal microbiota and obesity:* Mode of delivery influences gut microbiota. Infants born by CS are exposed mainly to their mother's skin bacteria, in contrast to infants born vaginally, who become exposed to their mother's vaginal and intestinal microbiota. Thus, infants born by caesarean harbor more staphylococci and less bacterial diversity in the intestinal microbiota colonization. Such a pattern is linked with increased capacity for energy harvest and risk of overweight and obesity that persists throughout early adult life [91].

*Allergy, diabetes mellitus and other autoimmune diseases:* Delivery by CS has been associated with increased prevalence of asthma, allergies, diabetes mellitus, gluten intolerance and leukemia [92, 93]. Epigenetic changes of the genome have been suggested as possible molecular mechanisms for perinatal contributions to the later disease. It has been shown that infants born by CS exhibit higher DNA methylation in leucocytes compared with infants born with vaginal delivery [94].

#### **7. Prevention of unnecessary cesareans**

Actions to prevent unnecessary caesareans should focus on the main indications for caesarean sections' prolonged labor, imminent fetal distress, psychosocial/nonmedical reasons and previous uterine scar [54, 55, 62, 72]. Recent studies have shown that normal labor progress during the opening stage is slower than 1 cm/h in all women, which was suggested by Emmanuel Friedman in the United States in the 1950s. Therefore, a slower progress than 1 cm/h is during the first stage of labor, which is not an indication for emergency caesarean in the absence of signs of fetal or maternal distress (**Figure 5**) [63, 64, 95].

Evidence-based management of labor, structured support during delivery, reduced labor induction and developed ability to perform instrumental deliveries instead of caesareans could be achieved through systematic theoretical education and team training programs on labor progress, fetal monitoring and delivery skills [55, 67, 96]. Such actions, taken together with structured counseling and support during pregnancy, would reduce planned caesareans due to psychosocial/nonmedical reasons or previous uterine scar. An increasing amount of evidence show that pregnancy-related anxiety is common and increasing with advancing pregnancy. A standardized definition of fear of vaginal delivery including an evidence-based scale for assessment of fear has been suggested [97]. Recommended systematic counseling and support for women fearing vaginal delivery include repeated meetings with a psychosocial team during pregnancy, objective information about benefits and risks related to different delivery modes including the influence on future reproductive health as well as support during delivery and planned follow-up after a negative birth experience [65, 98, 99].

Importantly, the attitudes among midwives and obstetricians influence a patient's choice [100]. A "coping attitude" rather than an "autonomy attitude" is strongly associated with a change in desire for a caesarean in women fearing vaginal delivery [59, 101].

**Figure 5.** Average labor curves. From Zhang et al. [63].

*Urinary and bowel incontinence:* The prevalence of postpartum stress urinary incontinence is similar following spontaneous vaginal delivery and caesarean section performed for obstructed labor. It is quite possible that pelvic floor injury in such cases is already too extensive to be prevented by surgical intervention. Antepartal caesarean section was found to be associated with a lower rate of stress urinary incontinence. There is no difference between the groups after 2 years, and there is no difference at menopause between women with a previous vaginal delivery and women who never gave birth. It has been concluded that the pregnancy in itself leads to distension of pelvic ligaments and tissues. Caesareans do not protect against

**Figure 4.** Placenta previa and abnormally invasive placenta, here *placenta percreta*. Source: Wikipedia.

*Intestinal microbiota and obesity:* Mode of delivery influences gut microbiota. Infants born by CS are exposed mainly to their mother's skin bacteria, in contrast to infants born vaginally, who become exposed to their mother's vaginal and intestinal microbiota. Thus, infants born by caesarean harbor more staphylococci and less bacterial diversity in the intestinal microbiota colonization. Such a pattern is linked with increased capacity for energy harvest and risk of

*Allergy, diabetes mellitus and other autoimmune diseases:* Delivery by CS has been associated with increased prevalence of asthma, allergies, diabetes mellitus, gluten intolerance and leukemia [92, 93]. Epigenetic changes of the genome have been suggested as possible molecular mechanisms for perinatal contributions to the later disease. It has been shown that infants born by CS exhibit higher DNA methylation in leucocytes compared with infants born with vaginal delivery [94].

Actions to prevent unnecessary caesareans should focus on the main indications for caesarean sections' prolonged labor, imminent fetal distress, psychosocial/nonmedical

overweight and obesity that persists throughout early adult life [91].

**7. Prevention of unnecessary cesareans**

bowel incontinence [89, 90].

*6.2.2. Child*

112 Caesarean Section

#### **8. World Health Organization recommendations**

The World Health Organization (WHO) stated in 2015 that caesareans are effective in saving maternal and infant lives only when they are required for medically indicated reasons and that CS rates higher than 10–15% at a population level not associated with reduced maternal and newborn mortality rates [102].

[11] Patel R, Murphy D. Forceps delivery in modern obstetric practice. British Medical

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#### **Author details**

Ylva Vladic Stjernholm

Address all correspondence to: ylva.vladic-stjernholm@sll.se

Department of Women's and Children's Health, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden

#### **References**


[11] Patel R, Murphy D. Forceps delivery in modern obstetric practice. British Medical Journal. 2004;**328**:1302

**8. World Health Organization recommendations**

Address all correspondence to: ylva.vladic-stjernholm@sll.se

and newborn mortality rates [102].

Karolinska Institutet, Stockholm, Sweden

Obstetrics & Gynaecology. 2001;**15**:179

**Author details**

114 Caesarean Section

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Ylva Vladic Stjernholm

2016;**11**:e0148343

The World Health Organization (WHO) stated in 2015 that caesareans are effective in saving maternal and infant lives only when they are required for medically indicated reasons and that CS rates higher than 10–15% at a population level not associated with reduced maternal

Department of Women's and Children's Health, Karolinska University Hospital and

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study. British Journal of Obstetrics and Gynaecology. 2013;**120**:479

istry. American Journal of Obstetrics and Gynecology. 2010;**203**:406

newborns. Obstetrics and Gynecology. 2001;**97**:439

Journal of Obstetrics and Gynaecology. 2014;**123**:1348

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EBioMedicine. 2016;**9**:336

Paediatrica. 2009;**98**:1096

10.1111/1471-0528.14708

120 Caesarean Section


**Chapter 8**

**Provisional chapter**

**Improving Obstetrical Outcomes in Cesarean Sections,**

**Improving Obstetrical Outcomes in Cesarean Sections,** 

Cesarean sections are the most commonly performed surgery in the USA. Changing policies and clinical information have resulted in improved outcomes for both mothers and babies. We describe evidence-based best practices for a multi-strategy approach to reduce cesarean section rates, increasing safety and success of vaginal births after cesarean section, decreasing complication rates in higher order cesarean sections, and accurate estimations of blood loss. In addition, we present a novel approach of utilizing venous lactate levels to identify the need for blood transfusions in the resuscitation of women with postpartum hemorrhage. Given that pregnancy is a life event, we describe increased self-reported stress levels in women during pregnancy and after the birth. In summary, adoption of the best practices outlined herein will greatly enhance the safe practice of cesarean sections.

Cesarean sections are the most commonly performed surgical procedures in the USA, and account for approximately one-third of the 4 million annual live births. Cesarean sections can cause significant complications, disability or death, particularly in settings which lack the facilities to conduct safe surgeries or treat potential complications. Due to their increased cost, high rates of unnecessary cesarean sections can pull resources away from other services

The World Health Organization (WHO) recommends that medical practitioners should not undertake cesarean sections purely to meet a given target or rate, but rather focus on the

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.78667

**by Utilizing Evidence-Based Strategies**

**Keywords:** evidence based, best practices, cesarean section

**by Utilizing Evidence-Based Strategies**

Donald Morrish and Iffath A. Hoskins

Donald Morrish and Iffath A. Hoskins

http://dx.doi.org/10.5772/intechopen.78667

**Abstract**

**1. Introduction**

needs of patients.

in overloaded and weak health systems.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

#### **Improving Obstetrical Outcomes in Cesarean Sections, by Utilizing Evidence-Based Strategies Improving Obstetrical Outcomes in Cesarean Sections, by Utilizing Evidence-Based Strategies**

DOI: 10.5772/intechopen.78667

Donald Morrish and Iffath A. Hoskins Donald Morrish and Iffath A. Hoskins

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.78667

**Abstract**

Cesarean sections are the most commonly performed surgery in the USA. Changing policies and clinical information have resulted in improved outcomes for both mothers and babies. We describe evidence-based best practices for a multi-strategy approach to reduce cesarean section rates, increasing safety and success of vaginal births after cesarean section, decreasing complication rates in higher order cesarean sections, and accurate estimations of blood loss. In addition, we present a novel approach of utilizing venous lactate levels to identify the need for blood transfusions in the resuscitation of women with postpartum hemorrhage. Given that pregnancy is a life event, we describe increased self-reported stress levels in women during pregnancy and after the birth. In summary, adoption of the best practices outlined herein will greatly enhance the safe practice of cesarean sections.

**Keywords:** evidence based, best practices, cesarean section

#### **1. Introduction**

Cesarean sections are the most commonly performed surgical procedures in the USA, and account for approximately one-third of the 4 million annual live births. Cesarean sections can cause significant complications, disability or death, particularly in settings which lack the facilities to conduct safe surgeries or treat potential complications. Due to their increased cost, high rates of unnecessary cesarean sections can pull resources away from other services in overloaded and weak health systems.

The World Health Organization (WHO) recommends that medical practitioners should not undertake cesarean sections purely to meet a given target or rate, but rather focus on the needs of patients.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

follow the trajectory of the Friedman Curve. New evidence suggests that this method of tracking labor progress is no longer appropriate and applicable to contemporary labor practices. In their observational review entitled, Consortium on Safe Labor, Zhang et al. [4] presented the outcomes of 228,668 women, having 233,844 newborns, who were delivered at 12 US Clinical Centers. These included 19 hospitals of which 8 were University Teaching, 9 were Community Teaching, and 2 were Community non-Teaching. All had EMRs. The review encompassed 2002–2008. The overall C section rate was 30.5%, which matched the National rate. Of these, 31.2% were nulliparas, 30.9% were women undergoing scheduled repeat C sections. The Trial of Labor after C Section (TOLAC) rate was 28.8%, and of these, the Vaginal Birth after Cesarean (VBAC) rate was 57.1%. Induction of labor was the admission diagnosis in 43.8% of the women and the pre-operative diagnosis was Dystocia (≤6 cm dilation), in 50% of the patients. The investigators also found that many parturients did not have a clear pattern which would indicate an active phase of labor and that this phase likely did not commence until after the cervix was dilated to at least 6 cm, versus the previous beliefs of active phase of labor commencing at 4 cm dilation of the cervix. The total duration of labor was found to be longer than previously thought. Several factors were found to affect the overall progress and therefore the likelihood of a successful vaginal delivery. These included maternal obesity, medical conditions such as diabetes and hypertension, timing and dosage of epidural analgesia. Thus, this information helped to define the current practices of labor management and how best to manage labor in

Improving Obstetrical Outcomes in Cesarean Sections, by Utilizing Evidence-Based Strategies

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125

various patients with and without medical and other confounding complications.

tunities for reduction, without incurring compromise to mother and/or neonate.

to greatly increase their chances of undergoing a successful vaginal delivery.

Four specific interventions were rolled out, and consisted of:

While the ideal rate for C sections cannot be easily determined, several opportunities to safely decrease the rate currently exist. In the Executive Summary of the WHO Statement on Cesarean Section rates [1], the experts have stated that when medically justified, a C section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of a C section for women or infants who do not require the procedure. They state that at population level, C section rates higher than 10–15% are not associated with reductions in maternal and neonatal mortality. Therefore, clinical practices contributing to the higher rates (e.g., 31% US rate) should be carefully analyzed, in an attempt to identify oppor-

Spong et al. [5] in a joint statement with the National Institute of Child Health and Human Development (NICHHD), American College of Ob/Gyn (ACOG), and Society for Maternal Fetal Medicine (SMFM), described several opportunities for reducing the primary C section rate in an attempt to affect favorably, the overall C section rate. One of the most important suggested opportunities included allowing for longer than traditionally estimated times for normal latent and active phases of the first and second stages of labor, thus allowing women

We published our findings related to instituting a multi-strategy approach towards reducing cesarean section rates at an urban Community Hospital [6]. We initially calculated a target (reduced) cesarean section rate of 29%, which was a 10 point drop from the existing rate of 39%, which we deemed as unacceptably high for our Institution and patient demographics.

**2.1. Reducing the C section rate**

**Figure 1.** Evidence-based medicine (EBM).

Improved understanding of cesarean section rates has been hindered by the lack of a consistent, internationally accepted classification system to monitor, and compare cesarean section rates. To address this lack, WHO proposes the adoption of the Robson classification system, which can facilitate the comparison and analysis of cesarean rates within and between different facilities, and across countries and regions.

The World Health Organization (WHO) suggested rate is 10–15% [1], and the Healthy People 2020 recommends that the annual rate should decrease in low risk women with a singleton, term live born fetus with vertex presentation (STLV), from the current rate of 27–24% [2]. However, the US rate is much higher, being approximately 32% [3].

Utilizing evidence-based, best practices for the management of patients undergoing cesarean sections has contributed greatly to the improved outcomes in these clinical settings. This approach allows combining a patient's values and beliefs and the clinician's best judgments in addition to the relevant scientific evidence (**Figure 1**).

In this chapter, we outline several evidence-based best practices regarding the management of women who are undergoing cesarean sections so that they may have minimal morbidity and the safest outcomes possible.

#### **2. Current cesarean section practices**

Over the past several decades, clinicians have followed the progress of labor based upon the information that had been collected mainly from primiparous females who were undergoing labor with a singleton fetus at term. This information was compiled into the now ubiquitous Friedman Curve and patients were delivered by cesarean delivery if their labor progress did not follow the trajectory of the Friedman Curve. New evidence suggests that this method of tracking labor progress is no longer appropriate and applicable to contemporary labor practices. In their observational review entitled, Consortium on Safe Labor, Zhang et al. [4] presented the outcomes of 228,668 women, having 233,844 newborns, who were delivered at 12 US Clinical Centers. These included 19 hospitals of which 8 were University Teaching, 9 were Community Teaching, and 2 were Community non-Teaching. All had EMRs. The review encompassed 2002–2008. The overall C section rate was 30.5%, which matched the National rate. Of these, 31.2% were nulliparas, 30.9% were women undergoing scheduled repeat C sections. The Trial of Labor after C Section (TOLAC) rate was 28.8%, and of these, the Vaginal Birth after Cesarean (VBAC) rate was 57.1%. Induction of labor was the admission diagnosis in 43.8% of the women and the pre-operative diagnosis was Dystocia (≤6 cm dilation), in 50% of the patients. The investigators also found that many parturients did not have a clear pattern which would indicate an active phase of labor and that this phase likely did not commence until after the cervix was dilated to at least 6 cm, versus the previous beliefs of active phase of labor commencing at 4 cm dilation of the cervix. The total duration of labor was found to be longer than previously thought. Several factors were found to affect the overall progress and therefore the likelihood of a successful vaginal delivery. These included maternal obesity, medical conditions such as diabetes and hypertension, timing and dosage of epidural analgesia. Thus, this information helped to define the current practices of labor management and how best to manage labor in various patients with and without medical and other confounding complications.

#### **2.1. Reducing the C section rate**

Improved understanding of cesarean section rates has been hindered by the lack of a consistent, internationally accepted classification system to monitor, and compare cesarean section rates. To address this lack, WHO proposes the adoption of the Robson classification system, which can facilitate the comparison and analysis of cesarean rates within and between differ-

The World Health Organization (WHO) suggested rate is 10–15% [1], and the Healthy People 2020 recommends that the annual rate should decrease in low risk women with a singleton, term live born fetus with vertex presentation (STLV), from the current rate of 27–24% [2].

Utilizing evidence-based, best practices for the management of patients undergoing cesarean sections has contributed greatly to the improved outcomes in these clinical settings. This approach allows combining a patient's values and beliefs and the clinician's best judgments

In this chapter, we outline several evidence-based best practices regarding the management of women who are undergoing cesarean sections so that they may have minimal morbidity

Over the past several decades, clinicians have followed the progress of labor based upon the information that had been collected mainly from primiparous females who were undergoing labor with a singleton fetus at term. This information was compiled into the now ubiquitous Friedman Curve and patients were delivered by cesarean delivery if their labor progress did not

ent facilities, and across countries and regions.

**Figure 1.** Evidence-based medicine (EBM).

124 Caesarean Section

However, the US rate is much higher, being approximately 32% [3].

in addition to the relevant scientific evidence (**Figure 1**).

and the safest outcomes possible.

**2. Current cesarean section practices**

While the ideal rate for C sections cannot be easily determined, several opportunities to safely decrease the rate currently exist. In the Executive Summary of the WHO Statement on Cesarean Section rates [1], the experts have stated that when medically justified, a C section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of a C section for women or infants who do not require the procedure. They state that at population level, C section rates higher than 10–15% are not associated with reductions in maternal and neonatal mortality. Therefore, clinical practices contributing to the higher rates (e.g., 31% US rate) should be carefully analyzed, in an attempt to identify opportunities for reduction, without incurring compromise to mother and/or neonate.

Spong et al. [5] in a joint statement with the National Institute of Child Health and Human Development (NICHHD), American College of Ob/Gyn (ACOG), and Society for Maternal Fetal Medicine (SMFM), described several opportunities for reducing the primary C section rate in an attempt to affect favorably, the overall C section rate. One of the most important suggested opportunities included allowing for longer than traditionally estimated times for normal latent and active phases of the first and second stages of labor, thus allowing women to greatly increase their chances of undergoing a successful vaginal delivery.

We published our findings related to instituting a multi-strategy approach towards reducing cesarean section rates at an urban Community Hospital [6]. We initially calculated a target (reduced) cesarean section rate of 29%, which was a 10 point drop from the existing rate of 39%, which we deemed as unacceptably high for our Institution and patient demographics. Four specific interventions were rolled out, and consisted of:

**a.** Prior approval by the Chair or Obstetrics Service Chief was required for every scheduled cesarean section.

[8, 9] and the medicolegal climate. However, in a push toward increasing the VBAC rates for eligible women, several payers (Government and Private) adjusted the payments for cesarean sections and vaginal deliveries according to patients' eligibility for trials of labor and success-

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Roberts et al. [11] published the results of a survey of 227 Obstetric Care Hospitals regarding the availability of VBAC services after ACOG's statements regarding the need for having obstetrical emergency services readily available. The average number of deliveries per hospital was 811 per year. Approximately two-third of the hospitals (154 of the 224 responding hospitals) did not change their VBAC policy regardless of any "external" factors, including ACOG statements. However, one-third of the responding hospitals (68/229) had discontinued offering VBACs due to external factors, including the ACOG statements. Thus, the women receiving care in such facilities would be prevented from having this option, and unfortu-

Whenever a patient wishes to attempt a trial of labor, in order to achieve a VBAC, she should be made aware of the risks and complications of this plan. The discussion should include the risk of possible harm to mother and baby (uterine rupture, hemorrhage, injury to adjacent organs, severe fetal hypoxia or death). Additionally, the mother should be informed about the likelihood of success in this clinical setting. We published our findings regarding the effect, if any, of the extent of cervical dilation at cesarean delivery upon the subsequent VBAC rate [12]. Relevant records of the index pregnancy (Group 1) were reviewed for maximum cervical dilation at cesarean delivery and compared to the VBAC success rate of these patients in the subsequent pregnancy (Group 2). Of the 1917 patients, if the indication for a cesarean section in Group 1 was malpresentation, non-reassuring fetal heart rate tracing, and arrest disorder, the overall success rate of a subsequent VBAC was approximately 71%. However, in the subset of patients who had undergone the original cesarean section for arrest of descent (after achieving full dilation), the success rate was statistically significantly lower, being only 13%. Thus, patients who attempt a VBAC should be counseled about their reduced rates of a successful VBAC in situations where the prior cesarean delivery occurred when she was fully dilated.

One of the known consequences of a patient undergoing a cesarean section delivery is the higher than baseline rate that she will undergo a repeat cesarean section, either as a scheduled repeat or after a failed trial of labor. If patients choose to have more than three subsequent cesarean deliveries, there is a greater likelihood of serious morbidity to the mother and baby. Higher order cesarean sections have variously been described as >3 or >4 such procedures. Some investigators have described increased intraoperative and postoperative morbidity in these cases, whereas others have not found any increase in complications [13–16]. The complications included increased rates of hemorrhage, injury to adjacent organs, blood transfusions,

We retrospectively reviewed the complication rates of patients undergoing higher order cesarean deliveries at our Institution, in the setting of a unique program wherein a senior Obstetrician is always present 24/7 with the intent to assist with any surgery and/or manage complications [17]. The 826 patients who had undergone a higher order cesarean section

ful VBAC, hoping to maximize this option for management of a patient's birth [10].

nately, many of these facilities were in remote and underserved areas.

**2.3. Higher order cesarean sections**

longer hospital stays, and peripartum hysterectomies.


Over the study period, the overall cesarean section rate decreased to 29%, without any compromise in maternal or neonatal outcomes. An additional finding was that, regardless of the indications for the cesarean sections, the overall rates of the Service attendings had a statistically significant decrease, most likely due to the implementation of Items b and c which allowed for other colleagues to weigh in to the decision-making process and to encourage patients to also participate in their own obstetrical management due to having attended VBAC classes (**Table 1**).

#### **2.2. Rates of vaginal birth after cesarean section**

A large contributor to the overall cesarean section rate is the category of elective repeat cesarean sections, because the overall number of trials of labor after cesarean section is very low. Although, rates of vaginal birth after cesarean have fluctuated markedly over the past two decades, currently, women who attempt a trial of labor after cesarean delivery have a 60–80% success rate. Several factors have contributed to these outcomes. These include Craigin's dictum, "once a cesarean, always a cesarean," [7] the ACOG practice bulletin that allows elective cesarean delivery upon maternal request, and the document that states in order for a patient to attempt a trial of labor, anesthesia and surgical capabilities must be "immediately available,"


**Table 1.** Cesarean sections: private versus service attendings and indications.

[8, 9] and the medicolegal climate. However, in a push toward increasing the VBAC rates for eligible women, several payers (Government and Private) adjusted the payments for cesarean sections and vaginal deliveries according to patients' eligibility for trials of labor and successful VBAC, hoping to maximize this option for management of a patient's birth [10].

Roberts et al. [11] published the results of a survey of 227 Obstetric Care Hospitals regarding the availability of VBAC services after ACOG's statements regarding the need for having obstetrical emergency services readily available. The average number of deliveries per hospital was 811 per year. Approximately two-third of the hospitals (154 of the 224 responding hospitals) did not change their VBAC policy regardless of any "external" factors, including ACOG statements. However, one-third of the responding hospitals (68/229) had discontinued offering VBACs due to external factors, including the ACOG statements. Thus, the women receiving care in such facilities would be prevented from having this option, and unfortunately, many of these facilities were in remote and underserved areas.

Whenever a patient wishes to attempt a trial of labor, in order to achieve a VBAC, she should be made aware of the risks and complications of this plan. The discussion should include the risk of possible harm to mother and baby (uterine rupture, hemorrhage, injury to adjacent organs, severe fetal hypoxia or death). Additionally, the mother should be informed about the likelihood of success in this clinical setting. We published our findings regarding the effect, if any, of the extent of cervical dilation at cesarean delivery upon the subsequent VBAC rate [12]. Relevant records of the index pregnancy (Group 1) were reviewed for maximum cervical dilation at cesarean delivery and compared to the VBAC success rate of these patients in the subsequent pregnancy (Group 2). Of the 1917 patients, if the indication for a cesarean section in Group 1 was malpresentation, non-reassuring fetal heart rate tracing, and arrest disorder, the overall success rate of a subsequent VBAC was approximately 71%. However, in the subset of patients who had undergone the original cesarean section for arrest of descent (after achieving full dilation), the success rate was statistically significantly lower, being only 13%. Thus, patients who attempt a VBAC should be counseled about their reduced rates of a successful VBAC in situations where the prior cesarean delivery occurred when she was fully dilated.

#### **2.3. Higher order cesarean sections**

**a.** Prior approval by the Chair or Obstetrics Service Chief was required for every scheduled

**b.** All patients who had one or two prior cesarean sections were considered as candidates for a trial of labor in order to achieve a vaginal birth after cesarean delivery. Therefore, all patients had to receive information about VBAC either by attending a class taught by qualified midwives or by reading an ACOG approved patient education pamphlet regard-

**c.** All intrapartum cesarean sections required a second opinion. This was obtained by any clinician/colleague who was present on labor and delivery at the time the decision was made. If a difference of opinion occurred, the Director of Maternal Fetal Medicine reviewed the

**d.** Individual cesarean section rates of all providers were prominently displayed on labor and delivery. This resulted in healthy competition amongst attendings especially when

Over the study period, the overall cesarean section rate decreased to 29%, without any compromise in maternal or neonatal outcomes. An additional finding was that, regardless of the indications for the cesarean sections, the overall rates of the Service attendings had a statistically significant decrease, most likely due to the implementation of Items b and c which allowed for other colleagues to weigh in to the decision-making process and to encourage patients to also participate in their own obstetrical management due to having attended

A large contributor to the overall cesarean section rate is the category of elective repeat cesarean sections, because the overall number of trials of labor after cesarean section is very low. Although, rates of vaginal birth after cesarean have fluctuated markedly over the past two decades, currently, women who attempt a trial of labor after cesarean delivery have a 60–80% success rate. Several factors have contributed to these outcomes. These include Craigin's dictum, "once a cesarean, always a cesarean," [7] the ACOG practice bulletin that allows elective cesarean delivery upon maternal request, and the document that states in order for a patient to attempt a trial of labor, anesthesia and surgical capabilities must be "immediately available,"

**Control group Study group p Value**

**N = 1380 N = 993**

Private attendings 200 170 0.163 Service attendings 150\* 79\* 0.002\* Dystocia 424 (11.9%) 561 (16.4%) NS Non reassuring fetal tracings 225 (6.3%) 247 (7.2%) NS

**Table 1.** Cesarean sections: private versus service attendings and indications.

ing VBACs. This information was recorded into the patient's chart.

situation and made the ultimate decision.

**2.2. Rates of vaginal birth after cesarean section**

patient demographics and practice groups were similar.

cesarean section.

126 Caesarean Section

VBAC classes (**Table 1**).

\*

Statistically significant.

One of the known consequences of a patient undergoing a cesarean section delivery is the higher than baseline rate that she will undergo a repeat cesarean section, either as a scheduled repeat or after a failed trial of labor. If patients choose to have more than three subsequent cesarean deliveries, there is a greater likelihood of serious morbidity to the mother and baby. Higher order cesarean sections have variously been described as >3 or >4 such procedures. Some investigators have described increased intraoperative and postoperative morbidity in these cases, whereas others have not found any increase in complications [13–16]. The complications included increased rates of hemorrhage, injury to adjacent organs, blood transfusions, longer hospital stays, and peripartum hysterectomies.

We retrospectively reviewed the complication rates of patients undergoing higher order cesarean deliveries at our Institution, in the setting of a unique program wherein a senior Obstetrician is always present 24/7 with the intent to assist with any surgery and/or manage complications [17]. The 826 patients who had undergone a higher order cesarean section were divided into four groups according to the number of previous cesarean sections. The incidence of intraoperative complications (injury to adjacent organs) and length of hospital stay were not increased in patients undergoing higher order (≥3) cesarean sections. In the patients who had ≥3 prior cesarean sections, there was a statistically significant increase in total operating time, rate of blood transfusions, and peripartum hysterectomies. There were no differences in neonatal outcomes amongst the four groups (**Table 2**).

This standardized objective method of quantification of the blood loss at delivery revealed a mean value of 300 cc after uncomplicated vaginal delivery and 900 cc after uncomplicated cesarean section. These findings were similar to the estimated blood loss measurements that had been performed prior to instituting this approach and were consistent with findings in the literature (**Figure 2**). Thus, we suggested that the standard definition of partum hemorrhage of >1000 cc blood loss after a cesarean section could reliably be used as a trigger for the

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A major component of the management of postpartum hemorrhage is aggressive volume repletion. Serum lactate levels are used in the management of trauma patients because they reliably indicate tissue hypoperfusion [20]. However, their predictive role in the management

We reviewed the outcomes of 1314 patients with postpartum hemorrhage in whom the blood loss was ≥1500 cc [21]. As an initial step in their management, all patients received a second IV line for increased fluid administration. When this IV line was inserted, blood was initially drawn for a CBC, coagulation profile, and venous lactate level. All results were obtained within 30 min of blood draw. The venous lactate levels were "normal" (≤2), more than 93% were hemodynamically stable (no hypotension and no tachycardia) and only 9% required a blood transfusion. When the venous lactate levels were "elevated" (≥4), 68% demonstrated hemodynamic instability and 91% received 1 or more units of blood transfusion based on their clinical symptoms or ≥10 point drop in hematocrit (**Table 3**). We suggest that venous lactate levels are a reliable indicator of tissue hypo perfusion in obstetrical hemorrhage and should be used as a trigger for blood transfusions when resuscitating these patients regard-

of PPH for appropriateness of volume resuscitation remains to be elucidated.

occurrence of this serious complication.

less of the hemodynamic status or hematocrit levels.

**Figure 2.** Quantified blood loss at Cesarean delivery.

We attributed these "improved" outcomes to the presence of a 24/7 senior Obstetrician who was available to assist in prevention and management of complications in these high acuity clinical scenarios.

#### **2.4. Quantification of blood loss and resuscitation in postpartum hemorrhage**

Postpartum hemorrhage is one of the leading complications in a cesarean section. Therefore, accurate knowledge of the amount of postpartum blood loss is essential for the appropriate and safe management of these patients. Visual estimations of blood loss (EBL) are known to be incorrect by as much as 50%, with larger volumes of blood loss being underestimated and smaller volumes being overestimated. This inaccuracy in visual determinations of blood loss is known to be independent of the provider's age and clinical experience. [18].

We quantified blood loss (QBL) after delivery by actual measurements of the total blood lost [19]. During and after each delivery, trained Nursing personnel weighed all the blood soaked materials and blood clots and measured the amounts in the under-buttock drapes. Specially labeled weighing scales depicting pre-calculated dry weights of patient gowns and items such as towels, sheets that are commonly used to soak up blood, were all measured.


This standardized objective method of quantification of the blood loss at delivery revealed a mean value of 300 cc after uncomplicated vaginal delivery and 900 cc after uncomplicated cesarean section. These findings were similar to the estimated blood loss measurements that had been performed prior to instituting this approach and were consistent with findings in the literature (**Figure 2**). Thus, we suggested that the standard definition of partum hemorrhage of >1000 cc blood loss after a cesarean section could reliably be used as a trigger for the occurrence of this serious complication.

A major component of the management of postpartum hemorrhage is aggressive volume repletion. Serum lactate levels are used in the management of trauma patients because they reliably indicate tissue hypoperfusion [20]. However, their predictive role in the management of PPH for appropriateness of volume resuscitation remains to be elucidated.

We reviewed the outcomes of 1314 patients with postpartum hemorrhage in whom the blood loss was ≥1500 cc [21]. As an initial step in their management, all patients received a second IV line for increased fluid administration. When this IV line was inserted, blood was initially drawn for a CBC, coagulation profile, and venous lactate level. All results were obtained within 30 min of blood draw. The venous lactate levels were "normal" (≤2), more than 93% were hemodynamically stable (no hypotension and no tachycardia) and only 9% required a blood transfusion. When the venous lactate levels were "elevated" (≥4), 68% demonstrated hemodynamic instability and 91% received 1 or more units of blood transfusion based on their clinical symptoms or ≥10 point drop in hematocrit (**Table 3**). We suggest that venous lactate levels are a reliable indicator of tissue hypo perfusion in obstetrical hemorrhage and should be used as a trigger for blood transfusions when resuscitating these patients regardless of the hemodynamic status or hematocrit levels.

**Figure 2.** Quantified blood loss at Cesarean delivery.

were divided into four groups according to the number of previous cesarean sections. The incidence of intraoperative complications (injury to adjacent organs) and length of hospital stay were not increased in patients undergoing higher order (≥3) cesarean sections. In the patients who had ≥3 prior cesarean sections, there was a statistically significant increase in total operating time, rate of blood transfusions, and peripartum hysterectomies. There were

We attributed these "improved" outcomes to the presence of a 24/7 senior Obstetrician who was available to assist in prevention and management of complications in these high acuity

Postpartum hemorrhage is one of the leading complications in a cesarean section. Therefore, accurate knowledge of the amount of postpartum blood loss is essential for the appropriate and safe management of these patients. Visual estimations of blood loss (EBL) are known to be incorrect by as much as 50%, with larger volumes of blood loss being underestimated and smaller volumes being overestimated. This inaccuracy in visual determinations of blood loss

We quantified blood loss (QBL) after delivery by actual measurements of the total blood lost [19]. During and after each delivery, trained Nursing personnel weighed all the blood soaked materials and blood clots and measured the amounts in the under-buttock drapes. Specially labeled weighing scales depicting pre-calculated dry weights of patient gowns and items such as towels, sheets that are commonly used to soak up blood, were all measured.

no differences in neonatal outcomes amongst the four groups (**Table 2**).

**2.4. Quantification of blood loss and resuscitation in postpartum hemorrhage**

is known to be independent of the provider's age and clinical experience. [18].

**Table 2.** Maternal morbidity of patients in the four groups.

clinical scenarios.

128 Caesarean Section


The majority of patients self-reported high stress scores during the 1st trimester, likely due to fears and concerns about the pregnancy outcomes. The women reported lowest stress levels during the 2nd trimester, most likely due to their having a sense of wellbeing, especially in the absence of complications. Regardless of socioeconomic status, many women reported high stress levels during the postpartum period, likely due their concerns about their own recovery

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Given that cesarean sections are the most common surgical procedures performed in the USA, we suggest that applying the above mentioned evidence-based techniques and criteria, in the management of these operations, will greatly assist in ensuring safe and improved outcomes

in addition to addressing the needs of their newborns.

and Iffath A. Hoskins<sup>2</sup>

\*Address all correspondence to: iffath.hoskins@nyumc.org

[1] WHO, HRP. WHO ref # WHO/RHR/15.02; Apr 2015

& Health Promotion. HealthyPeople.gov; 2014

\*

1 Department of Obstetrics and Gynecology, St. John's Episcopal Hospital, NY,

2 Patient Safety and Quality, Department of Obstetrics and Gynecology, NYU School of

[2] Healthy People 2020. US Dept. of Health & Human Services. Office of Disease Prevention

[4] Zhang J, Troendle J, Reddy U, et al. Contemporary Cesarean delivery practice in the United States. Consortium on Safe Labor. American Journal of Obstetrics and Gynecology.

[5] Spong CY, Berghella V, Wenstrom K, et al. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National institute of Child Health and Human development, Society for Maternal Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstetrics and Gynecology. 2012;**120**(5):1181-1193

[3] Martin JA, Brady E, Hamilton BE, et al. Div Vital Statistics. CDC. 2017;**66**:1

**3. Conclusion**

in these patients.

**Author details**

Donald Morrish1

United States

**References**

Medicine, NY, United States

Oct 2010;326 e10

**Table 3.** Lactate levels as predictors for blood transfusions in PPH.

#### **2.5. Self-perceived stress during pregnancy**

Women experience different types of stresses during their lifetimes. Even though pregnancy and the postpartum period are universally considered to be a joyous event, it is paradoxically recognized as a stressful time in a woman's life. Psychological stress is known to have negative effects on maternal mental health, including depression and anxiety [22, 23]. This situation can be exacerbated when a woman is undergoing a cesarean section because of her concerns regarding her own recovery and also regarding the availability of support systems for her. We studied whether socioeconomic status affects a patient's self-perception of her own stress levels during the pregnancy and postpartum period, including in the setting of her undergoing a cesarean section [24]. There were 1006 patients with uncomplicated pregnancies, who were administered a validated questionnaire to assess stress levels at three study points: 1st trimester, 2nd trimester and at the 4–6 week postpartum visit.

The majority of patients self-reported high stress scores during the 1st trimester, likely due to fears and concerns about the pregnancy outcomes. The women reported lowest stress levels during the 2nd trimester, most likely due to their having a sense of wellbeing, especially in the absence of complications. Regardless of socioeconomic status, many women reported high stress levels during the postpartum period, likely due their concerns about their own recovery in addition to addressing the needs of their newborns.

#### **3. Conclusion**

Given that cesarean sections are the most common surgical procedures performed in the USA, we suggest that applying the above mentioned evidence-based techniques and criteria, in the management of these operations, will greatly assist in ensuring safe and improved outcomes in these patients.

### **Author details**

Donald Morrish1 and Iffath A. Hoskins<sup>2</sup> \*

\*Address all correspondence to: iffath.hoskins@nyumc.org

1 Department of Obstetrics and Gynecology, St. John's Episcopal Hospital, NY, United States

2 Patient Safety and Quality, Department of Obstetrics and Gynecology, NYU School of Medicine, NY, United States

#### **References**

**2.5. Self-perceived stress during pregnancy**

130 Caesarean Section

**Table 3.** Lactate levels as predictors for blood transfusions in PPH.

Women experience different types of stresses during their lifetimes. Even though pregnancy and the postpartum period are universally considered to be a joyous event, it is paradoxically recognized as a stressful time in a woman's life. Psychological stress is known to have negative effects on maternal mental health, including depression and anxiety [22, 23]. This situation can be exacerbated when a woman is undergoing a cesarean section because of her concerns regarding her own recovery and also regarding the availability of support systems for her. We studied whether socioeconomic status affects a patient's self-perception of her own stress levels during the pregnancy and postpartum period, including in the setting of her undergoing a cesarean section [24]. There were 1006 patients with uncomplicated pregnancies, who were administered a validated questionnaire to assess stress levels at three study

points: 1st trimester, 2nd trimester and at the 4–6 week postpartum visit.


[6] Hoskins IA, Elison TE, Ruggiero R. A multi-strategy approach for Cesarean section reduction at an urban community medical center. The Journal of Reproductive Medicine. 2017;**62**:1

[22] ACOG Committee Opinion #630. Screening for perinatal depression. Obstetrics and

Improving Obstetrical Outcomes in Cesarean Sections, by Utilizing Evidence-Based Strategies

http://dx.doi.org/10.5772/intechopen.78667

133

[23] Swanson LM, Pickett SM, Flynn H, et al. Relationships among depression, anxiety and insomnia symptoms in perinatal women seeking mental health treatment. Journal of

[24] Hoskins IA, Cerfolio N. Review of patients' self perception of stress associated with pregnancy: comparison across disparate socioeconomic strata. Journal of Reproductive

Medicine. Society for Gynecologic Investigation. Jan-Feb 2002;**9**(1 Suppl)313A

Gynecology. 2015;**125**(5):1268-1271

Women's Health. 2011;**20**(4):553-538


[22] ACOG Committee Opinion #630. Screening for perinatal depression. Obstetrics and Gynecology. 2015;**125**(5):1268-1271

[6] Hoskins IA, Elison TE, Ruggiero R. A multi-strategy approach for Cesarean section reduction at an urban community medical center. The Journal of Reproductive Medicine.

[7] Bangal VB, Giri PA, Shinde KK, et al. Vaginal birth after cesarean section. North American

[8] ACOG committee opinion no. 559: Cesarean delivery on maternal request. Obstet Gynecol.

[9] Practice Bulletin No. 184: Vaginal Birth after Cesarean Delivery. Obstet Gynecol. 2017

[10] The National Bureau of Economic Research, Gruber J, Mayzlin D, Kim J. Physician Fees and Procedure Intensity: The Case of Cesarean Delivery (NBER Working Paper No. 6744)

[11] Roberts RG, Deutchman M, King VJ, et al. Changing policies on vaginal birth after cesar-

[12] Hoskins IA, Gomez JL. Correlation between maximum cervical dilation at cesarean delivery and subsequent VBAC. Obstetrics and Gynecology. Apr 1997;**89**(4):591-593 [13] Rashid M, Rashid RS. Higher order repeat sections: How safe are five or more? BJOG: An International Journal of Obstetrics and Gynaecology. 2004 Oct;**111**(10):1090-1094 [14] Khashoggi TY. Higer order multiple repeat Cesarean sections: maternal and fetal out-

[15] Gassim T, Al Jama FE, Rahman MS, et al. Multiple repeat cesarean sections: Operative difficulties, maternal complications and outcome. The Journal of Reproductive Medicine.

[16] Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple

[17] Hoskins IA, Berg RE. Higher order (≥3) repeat cesarean sections: complications and outcomes in the setting of a unique Ob Safety Officer Program in an urban academic

[18] Larrson C, Sissel S, Wiklund I, et al. Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstetricia et

[19] Dolin C, Berg RE, Hoskins IA. Accuracy of the quantification of the blood loss after vaginal and cesarean deliveries. 1st World Congress of Neonatal and Maternal Health;

[20] Blomkalns A, Sperling M, Ronan S, et al. Serial venous point-of-care lactate measurements for the evaluation and triage of undifferentiated patients with blunt trauma. Point

[21] Hoskins IA, Berg RE. Correlation of blood lactate levels as a predictor for blood transfusions in postpartum hemorrhage. Presented at Annual Clinical Meeting, American

repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;**107**(6):1226-1232

medical center. Reproductive Sciences. Vol 23, Suppl 1; March 2016

Journal of Medical Sciences. 2013;**5**(2):140-144

ean: impact on access. Birth. 2007 Dec;**34**(4):316-322

comes. Annals of Saudi Medicine. 2003;**23**(5):278-282

Gynecologica Scandinavica. 2006;**85**(12):1448-1452

2017;**62**:1

132 Caesarean Section

2013 Apr;**121**(4):904-907

2013 Jul-Aug;**58**(7-8):312-318

London, England; 2017

of Care. 2009;**8**(1):4-7

College of Ob/Gyn. San Diego; 2017

Nov;**130**(5):e223


**Section 6**

**Necessary Measures**

**Section 6**

**Necessary Measures**

**Chapter 9**

**Provisional chapter**

**Vaginal Delivery after Cesarean Section**

**Vaginal Delivery after Cesarean Section**

DOI: 10.5772/intechopen.75900

Cesarean delivery is needed (indicated) for many reasons such as failure to progress, cephalopelvic disproportion, antepartum hemorrhage, preeclampsia, and repeated cesareans. The increase of the cesarean delivery rate is accompanied with an increase in the maternal and perinatal morbidities and increase in maternal mortality such as complications of anesthesia, injury to the nearby structure, respiratory distress syndrome, childhood allergy and childhood obesity. Vaginal delivery after cesarean section (VBAC) is one of the tools that aimed to reduce the rate of cesarean delivery. Here in this chapter we would like to highlight the different guidelines for VBAC, the success rate of VBAC, the determinant of the success rate, maternal and perinatal outcomes of VBAC. Then the arena of using oxytocic drugs in VBAC is discussed in

**Keywords:** cesarean section, trial of labour, uterine rupture, induced labour, oxytocin,

Childbirth is a special event in every woman's life and the occurrence marks the beginning of a new role of being a mother. In the past, individuals relied on the traditional vaginal birth method which sometimes ended up in fetal loss, maternal death or long term maternal morbidity in the form of perineal injuries and fistula formation. Fortunately, advancement in technology has revolutionized the healthcare industry and in particular, childbirth process

[1]. Cesarean delivery refers to child delivery through abdominal cut [2].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Zaheera Saadia, Nadiah AlHabardi and Ishag Adam

Zaheera Saadia, Nadiah AlHabardi and Ishag Adam

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75900

**Abstract**

details too.

**1. Introduction**

prostaglandins, misoprostol

#### **Vaginal Delivery after Cesarean Section Vaginal Delivery after Cesarean Section**

Zaheera Saadia, Nadiah AlHabardi and Ishag Adam Zaheera Saadia, Nadiah AlHabardi and Ishag Adam

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75900

**Abstract**

Cesarean delivery is needed (indicated) for many reasons such as failure to progress, cephalopelvic disproportion, antepartum hemorrhage, preeclampsia, and repeated cesareans. The increase of the cesarean delivery rate is accompanied with an increase in the maternal and perinatal morbidities and increase in maternal mortality such as complications of anesthesia, injury to the nearby structure, respiratory distress syndrome, childhood allergy and childhood obesity. Vaginal delivery after cesarean section (VBAC) is one of the tools that aimed to reduce the rate of cesarean delivery. Here in this chapter we would like to highlight the different guidelines for VBAC, the success rate of VBAC, the determinant of the success rate, maternal and perinatal outcomes of VBAC. Then the arena of using oxytocic drugs in VBAC is discussed in details too.

DOI: 10.5772/intechopen.75900

**Keywords:** cesarean section, trial of labour, uterine rupture, induced labour, oxytocin, prostaglandins, misoprostol

#### **1. Introduction**

Childbirth is a special event in every woman's life and the occurrence marks the beginning of a new role of being a mother. In the past, individuals relied on the traditional vaginal birth method which sometimes ended up in fetal loss, maternal death or long term maternal morbidity in the form of perineal injuries and fistula formation. Fortunately, advancement in technology has revolutionized the healthcare industry and in particular, childbirth process [1]. Cesarean delivery refers to child delivery through abdominal cut [2].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **2. Vaginal delivery after cesarean section**

#### **2.1. Indications for cesarean delivery**

There are various maternal and fetal indications for cesarean delivery (**Table 1**) [3–6].

"a vaginal birth after cesarean delivery (VBAC)." It is one of the tools to decrease or avoid the rising rate of cesarean delivery. In general, good candidates for planned TOLAC are those women in whom the balance of risks (as low as possible) and chances of success (as high as

Vaginal Delivery after Cesarean Section http://dx.doi.org/10.5772/intechopen.75900 139

It is possible for women to have vaginal delivery even after a previous cesarean delivery. It has been shown 55–67% of women, who had previously delivered through cesarean delivery,

Primarily, the success of vaginal childbirth is dependent on different factors. When the procedure is handled by unqualified individuals, it can result in complications which can reduce

High success rates have been attained when the amniotic fluid does not contain meconium. In addition, vaginal birth should not be prioritized when a patient, who had given birth previously through cesarean delivery, has prolonged labor [11, 12]. Importantly, the characteristics of the cervical regions are crucial in ascertaining if a woman can give birth without necessary

Notably, studies have established that women that have given birth through the vaginal childbirth process are likely to show high success rate when compared to others that were

The rate of successful TOLAC by indication for prior cesarean delivery was higher when the fetal malpresentation was the indication compared with non-reassuring fetal heart rate pat-

Vaginal delivery before or after the cesarean delivery is the good sign for successful TOLAC.

Some ethnicity, e.g., Hispanic, African American, and Asian women are less likely to have a

Increasing maternal age, women with less education and high body mass are also having a

possible) are acceptable to the patient and obstetrician.

undergoing another cesarean section operation [11, 12].

**4. Factors affecting success rate of TOLAC**

had successful vaginal delivery afterward [11, 12].

the rate of successful delivery.

operated during the same process.

*4.1.1. Indication for prior cesarean delivery*

tern, and failure to progress (**Table 3**) [11–15].

reduced likelihood of successful TOLAC.

**4.1. Antepartum factors**

*4.1.2. Prior vaginal delivery*

**4.2. Demographic factors**

successful VBAC.

#### **2.2. Complications of cesarean delivery**

There are various complications of cesarean delivery (**Table 2**) [7–10].


**Table 1.** Indications of cesarean delivery.


**Table 2.** Complications of cesarean delivery.

#### **3. Vaginal birth after cesarean section**

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving the goal "a vaginal birth after cesarean delivery (VBAC)." It is one of the tools to decrease or avoid the rising rate of cesarean delivery. In general, good candidates for planned TOLAC are those women in whom the balance of risks (as low as possible) and chances of success (as high as possible) are acceptable to the patient and obstetrician.

It is possible for women to have vaginal delivery even after a previous cesarean delivery. It has been shown 55–67% of women, who had previously delivered through cesarean delivery, had successful vaginal delivery afterward [11, 12].

Primarily, the success of vaginal childbirth is dependent on different factors. When the procedure is handled by unqualified individuals, it can result in complications which can reduce the rate of successful delivery.

High success rates have been attained when the amniotic fluid does not contain meconium. In addition, vaginal birth should not be prioritized when a patient, who had given birth previously through cesarean delivery, has prolonged labor [11, 12]. Importantly, the characteristics of the cervical regions are crucial in ascertaining if a woman can give birth without necessary undergoing another cesarean section operation [11, 12].

Notably, studies have established that women that have given birth through the vaginal childbirth process are likely to show high success rate when compared to others that were operated during the same process.

### **4. Factors affecting success rate of TOLAC**

#### **4.1. Antepartum factors**

**2. Vaginal delivery after cesarean section**

**Maternal indications Fetal indications** Failed progress of labor Presentation of the fetus

Preeclampsia Preterm births Infection Fetal distress Repeated cesareans Precious baby

There are various maternal and fetal indications for cesarean delivery (**Table 1**) [3–6].

There are various complications of cesarean delivery (**Table 2**) [7–10].

Cephalopelvic disproportion Large size babies/fetal macrosomia Antepartum hemorrhage Higher order multiple pregnancies

**2.1. Indications for cesarean delivery**

**2.2. Complications of cesarean delivery**

**3. Vaginal birth after cesarean section**

**Table 2.** Complications of cesarean delivery.

**Table 1.** Indications of cesarean delivery.

Abnormal placentation Infertility issues

Maternal request

138 Caesarean Section

**Maternal complications Fetal complications** Complications of anesthesia Preterm delivery

Infections Childhood allergy Deep venous thrombosis Childhood obesity

Hemorrhage Respiratory distress syndrome Injury to the nearby structure Delayed initiation of breast feeding

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving the goal

#### *4.1.1. Indication for prior cesarean delivery*

The rate of successful TOLAC by indication for prior cesarean delivery was higher when the fetal malpresentation was the indication compared with non-reassuring fetal heart rate pattern, and failure to progress (**Table 3**) [11–15].

#### *4.1.2. Prior vaginal delivery*

Vaginal delivery before or after the cesarean delivery is the good sign for successful TOLAC.

#### **4.2. Demographic factors**

Some ethnicity, e.g., Hispanic, African American, and Asian women are less likely to have a successful VBAC.

Increasing maternal age, women with less education and high body mass are also having a reduced likelihood of successful TOLAC.


**Table 3.** Factors affecting success rate of TOLAC [11–15].

#### *4.2.1. Maternal medical disease*

Maternal medical disease such as hypertension, diabetes, asthma, renal disease, and heart disease have been reported to reduce the likelihood of successful TOLAC.

Compared to CS, women having a VBAC have [15–17].

**Maternal complications Perinatal complications**

Hemorrhage and transfusion Respiratory problems

Uterine rupture Hypoxic ischemic encephalopathy

Vaginal Delivery after Cesarean Section http://dx.doi.org/10.5772/intechopen.75900 141

Failure of the trial Mortality

Peripartum hysterectomy Others

Lower rates of hemorrhage, infection, deep vein thrombosis.

Enhanced mother-infant bonding, including the long term wellbeing of the infant.

a failed TOLAC is associated with more complications (**Table 4**) [15–17].

**6. Induction of labor after cesarean section pros and cons**

VBAC is associated with fewer complications than elective repeat cesarean delivery, whereas

Induction of labor is possible even after delivering a first child through the cesarean. However, the chances of a successful birth are dependent on whether a woman delivered through the vaginal process in an earlier pregnancy. Ideally, there are both pros and cons of labor induc-

One of the key advantages of induction of labor after cesarean section is that it allows a woman to give birth through the vaginal process. Induction is recommended, by professionals, once a woman reaches the 41 weeks of gestation. Induction reduces the likelihood of having meconium in the amniotic fluid. Significantly, precaution has to be taken given that labor induction, for instance, when dealing with women with past cesarean section experiences can be risky [18].

Fulfilling a patient's preference for vaginal delivery.

**Table 4.** Maternal and perinatal complication of VBAC and ERCS.

Shorter stays in hospital and recovery period.

**5.2. Potential risks of VBAC and TOLAC**

Avoid major abdominal surgery.

Lower maternal morbidity.

tion after cesarean section.

**6.1. Pros**

Infection

Pelvic floor injury

#### **4.3. Intrapartum factors**

#### *4.3.1. Admission labor status*

Women in spontaneous labor or with a high bishop score are more likely to have successful TOLAC than women who are being induced or who have low Bishop scores.

#### *4.3.2. Fetal macrosomia*

A fetus weighing more than 4000 g reduces the likelihood of successful TOLAC.

#### *4.3.3. Type of hospital*

University hospitals or those affiliated with obstetrics and gynecology residency program have higher rates of TOLAC and successful VBAC. Women who deliver at a private or rural hospital have a decreased likelihood that TOLAC will be attempted, and if attempted, a decreased rate of successful VBAC when compared to a tertiary care or perinatal center.

#### **5. Potential benefits and risk of VBAC**

#### **5.1. Potential benefits of VBAC**

In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and the expected complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level.


**Table 4.** Maternal and perinatal complication of VBAC and ERCS.

Compared to CS, women having a VBAC have [15–17].

Fulfilling a patient's preference for vaginal delivery.

Shorter stays in hospital and recovery period.

Avoid major abdominal surgery.

*4.2.1. Maternal medical disease*

**Table 3.** Factors affecting success rate of TOLAC [11–15].

Indication for prior cesarean delivery

Prior vaginal delivery Demographic factors Maternal medical disease Intrapartum factors Fetal macrosomia Type of hospital

140 Caesarean Section

**4.3. Intrapartum factors**

*4.3.2. Fetal macrosomia*

*4.3.3. Type of hospital*

**5. Potential benefits and risk of VBAC**

**5.1. Potential benefits of VBAC**

level.

*4.3.1. Admission labor status*

Maternal medical disease such as hypertension, diabetes, asthma, renal disease, and heart

Women in spontaneous labor or with a high bishop score are more likely to have successful

University hospitals or those affiliated with obstetrics and gynecology residency program have higher rates of TOLAC and successful VBAC. Women who deliver at a private or rural hospital have a decreased likelihood that TOLAC will be attempted, and if attempted, a decreased rate of successful VBAC when compared to a tertiary care or perinatal center.

In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and the expected complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population

disease have been reported to reduce the likelihood of successful TOLAC.

TOLAC than women who are being induced or who have low Bishop scores.

A fetus weighing more than 4000 g reduces the likelihood of successful TOLAC.

Lower rates of hemorrhage, infection, deep vein thrombosis.

Enhanced mother-infant bonding, including the long term wellbeing of the infant.

Lower maternal morbidity.

#### **5.2. Potential risks of VBAC and TOLAC**

VBAC is associated with fewer complications than elective repeat cesarean delivery, whereas a failed TOLAC is associated with more complications (**Table 4**) [15–17].

#### **6. Induction of labor after cesarean section pros and cons**

Induction of labor is possible even after delivering a first child through the cesarean. However, the chances of a successful birth are dependent on whether a woman delivered through the vaginal process in an earlier pregnancy. Ideally, there are both pros and cons of labor induction after cesarean section.

#### **6.1. Pros**

One of the key advantages of induction of labor after cesarean section is that it allows a woman to give birth through the vaginal process. Induction is recommended, by professionals, once a woman reaches the 41 weeks of gestation. Induction reduces the likelihood of having meconium in the amniotic fluid. Significantly, precaution has to be taken given that labor induction, for instance, when dealing with women with past cesarean section experiences can be risky [18].

#### **6.2. Cons**

Labor induction, among women that have delivered through the cesarean section, have been found to be risky and it can result in the rupture of the uterine walls [18]. Basically, this is because the process put pressure on the lower abdomen which could be having scars. Fortunately, the uterine rupture is not a major issue given that it occurs among four to five women in every 1000 operations [19]. However, the issue has to be addressed adequately to avoid further complications.

[2] Velho MB, Santos EK, Brüggemann OM, Camargo BV. Experience with vaginal birth versus cesarean childbirth: Integrative review of women's perceptions. Texto & Contexto –

Vaginal Delivery after Cesarean Section http://dx.doi.org/10.5772/intechopen.75900 143

[3] Jacob A. A Comprehensive Textbook of Midwifery and Gynecological Nursing. Jaypee

[6] Begum T, Rahman A, Nababan H, Hoque DME, Khan AF, Ali T, Anwar I. Indications and determinants of Cesarean section delivery: Evidence from a population-based study

[7] Kaplanoglu M, Karateke A, Un B, Akgor U, Baloğlu A. Complications and outcomes of repeat cesarean section in adolescent women. International Journal of Clinical and

[8] Mylonas I, Friese K. Indications for and risks of elective cesarean section. Deutsches

[9] Moshiri M, Osman S, Bhargava P, Maximin S, Robinson TJ, Katz DS. Imaging evaluation of maternal complications associated with repeat cesarean deliveries. Radiologic Clinics

[10] Caesarean Section. National Collaborating Centre for Women's and Children's Health

[11] Senturk MB, Cakmak Y, Atac H, Budak MS. Factors associated with successful vaginal birth after cesarean section and outcomes in rural area of Anatolia. International Journal

[12] Brill Y, Windrim R. Vaginal birth after Caesarean section: Review of antenatal predictors of success. Journal of Obstetrics and Gynecology Canada. Apr 30, 2003;**25**(4):275-286 [13] Gyamfi C, Juhasz G, Gyamfi P, Stone JL. Increased success of trial of labor after previous

[14] Grobman WA, Lai Y, Landon MB, et al. Development of a nomogram for prediction of vaginal birth after cesarean delivery. Obstetrics and Gynecology. 2007;**109**:806

[15] Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: New insights on maternal and neonatal outcomes. Obstetrics and Gynecology. 2010;**115**:1267-1278 [16] Guise JM, Eden K, Emeis C, Denman MA, Marshall N, Fu RR, Janik R, Nygren P, Walker M, McDonagh M. Vaginal birth after cesarean: New insights. Evidence Report/

[17] Guise JM, McDonagh MS, Hashima J, Kraemer DF, Eden KB, Berlin M, Nygren P, Osterweil P, Krages KP, Helfand M. Vaginal birth after cesarean (VBAC). Evidence

vaginal birth after cesarean. Obstetrics and Gynecology. 2004;**104**:715

[4] Goldman MB, Hatch MC, editors. Women and Health. Academic Press; Nov 23, 2000 [5] Becher L, Stokke S. Indications for cesarean section in St. Joseph Medical Hospital Moshi, Tanzania [Doctoral dissertation, Masters Dissertation, University of Oslo]. Oslo: DUO

Brothers Medical Publishers (December 1, 2005); Apr 1, 2012

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(UK). London: RCOG Press; Nov 2011. PMID: 23285498

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Besides this, complications can be registered when dealing with mothers that are diabetic. It is estimated that diabetes is the major cause of obstacles in 2–3% of all pregnancies [30]. The mentioned disease can derail the healing of scars in the uterine area. As a result, induction of labor and vaginal delivery in this group, even after a first successful cesarean section, can be risky and the effectiveness rates are lower when compared with other women without the similar condition [20].

Furthermore, considerations have to be made when dealing with obese mothers. Research indicates that obese mothers have a low rate of 13% of having children through the vaginal process after undergoing cesarean section in previous pregnancies [19]. The infection morbidity rate is considered to be high in obese women when judged against non-obese. In short, there are numerous disadvantages when an obese woman decides to give birth through the vaginal process after a past successful cesarean section.

In the end, the cesarean section has been a major boost in reducing child and mother mortality after birth. The process has been refined since its earlier inception ancient times. At present, it is a safe method of childbirth, especially, when a mother has health-related complications. Notably, parameters have to be observed when dealing with special groups, for instance, obese and diabetic pregnant women. Indeed, there are various indications and contradictions of cesarean section. Despite this, the process is fast and it has various advantages.

#### **Author details**

Zaheera Saadia1 , Nadiah AlHabardi2 and Ishag Adam2,3\*


#### **References**

[1] Flamm BL, Quilligan EJ, editors. Cesarean Section: Guidelines for Appropriate Utilization. New York: Springer-Verlag, Springer Science & Business Media; 1995:207-221

[2] Velho MB, Santos EK, Brüggemann OM, Camargo BV. Experience with vaginal birth versus cesarean childbirth: Integrative review of women's perceptions. Texto & Contexto – Enfermagem. 2012 Jun;**21**(2):458-466

**6.2. Cons**

142 Caesarean Section

avoid further complications.

similar condition [20].

**Author details**

Zaheera Saadia1

**References**

vaginal process after a past successful cesarean section.

, Nadiah AlHabardi2

\*Address all correspondence to: ishagadam@hotmail.com 1 Qassim University, College of Medicine, Saudi Arabia

3 Faculty of Medicine, University of Khartoum, Sudan

2 Unaizah College of Medicine, Qassim University, Saudi Arabia

Labor induction, among women that have delivered through the cesarean section, have been found to be risky and it can result in the rupture of the uterine walls [18]. Basically, this is because the process put pressure on the lower abdomen which could be having scars. Fortunately, the uterine rupture is not a major issue given that it occurs among four to five women in every 1000 operations [19]. However, the issue has to be addressed adequately to

Besides this, complications can be registered when dealing with mothers that are diabetic. It is estimated that diabetes is the major cause of obstacles in 2–3% of all pregnancies [30]. The mentioned disease can derail the healing of scars in the uterine area. As a result, induction of labor and vaginal delivery in this group, even after a first successful cesarean section, can be risky and the effectiveness rates are lower when compared with other women without the

Furthermore, considerations have to be made when dealing with obese mothers. Research indicates that obese mothers have a low rate of 13% of having children through the vaginal process after undergoing cesarean section in previous pregnancies [19]. The infection morbidity rate is considered to be high in obese women when judged against non-obese. In short, there are numerous disadvantages when an obese woman decides to give birth through the

In the end, the cesarean section has been a major boost in reducing child and mother mortality after birth. The process has been refined since its earlier inception ancient times. At present, it is a safe method of childbirth, especially, when a mother has health-related complications. Notably, parameters have to be observed when dealing with special groups, for instance, obese and diabetic pregnant women. Indeed, there are various indications and contradictions

and Ishag Adam2,3\*

[1] Flamm BL, Quilligan EJ, editors. Cesarean Section: Guidelines for Appropriate Utilization. New York: Springer-Verlag, Springer Science & Business Media; 1995:207-221

of cesarean section. Despite this, the process is fast and it has various advantages.


[18] Shatz L, Novack L, Mazor M, Weisel RB, Dukler D, Rafaeli-Yehudai T, Israeli O, Erez O. Induction of labor after a prior cesarean delivery: Lessons from a population-based

[19] Kurjak A, Chervenak FA, editors. Textbook of Perinatal Medicine. CRC Press, Taylor &

[20] Hollander D. Labor induction for vaginal birth after cesarean may lead to uterine rup-

study. Journal of Perinatal Medicine. Mar 1, 2013;**41**(2):171-179

ture. Family Planning Perspectives. 2001;**33**(6):287-288

Francis Group; Sep 25, 2006

144 Caesarean Section

## *Edited by Georgios Androutsopoulos*

In this book, we present recent advances in surgical techniques as well as the most common perioperative complications in patients that undergo a cesarean section. Moreover, we discuss appropriate measures to reduce unnecessary procedures.

Published in London, UK © 2018 IntechOpen © chompoosuppa / iStock

Caesarean Section

Caesarean Section