**Epidemiology - Indications**

**References**

6 Caesarean Section

**23**(45):149-150

2016;**123**(5):667-670

2007;**176**(4):455-460

Education. 2013;**3**(3):e117

Surgery. 2017;**4**(3):555638

[1] WHO. WHO statement on caesarean section rates. Reproductive Health Matters. 2015;

[2] Betran A, Torloni M, Zhang J, et al. WHO statement on caesarean section rates. BJOG.

[3] Barber E, Lundsberg L, Belanger K, et al. Indications contributing to the increasing cesar-

[4] Liu S, Liston R, Joseph K, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ.

[5] Caughey A, Cahill A, Guise J, et al. Safe prevention of the primary cesarean delivery.

[6] Androutsopoulos G, Decavalas G. Perioperative internal iliac artery balloon occlusion in patients with abnormal placental invasion. Journal of Community Medicine and Health

[7] Androutsopoulos G, Decavalas G. Perioperative utilization of internal iliac artery balloons, does it really help in case of abnormal placental invasion? Open Access Journal of

[8] Ye J, Zhang J, Mikolajczyk R, et al. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: A worldwide population-based

ean delivery rate. Obstetrics and Gynecology. 2011;**118**(1):29-38

American Journal of Obstetrics and Gynecology. 2014;**210**(3):179-193

ecological study with longitudinal data. BJOG. 2016;**123**(5):745-753

**Chapter 2**

**Provisional chapter**

**Trends in Cesarean Section**

**Trends in Cesarean Section**

http://dx.doi.org/10.5772/intechopen.77309

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

mayor issue to take care of in modern medicine.

request, medical autonomy

**1. Introduction**

DOI: 10.5772/intechopen.77309

Cesarean section (CS) is part of the standard of care in modern obstetrics. Its availability, practicity, high acceptance among patients, and the permanent improvement in surgical techniques, anesthesia, blood replacement, and neonatal care have popularized the procedure as a safe and reasonable alternative to vaginal delivery for any individual born in the twenty-first century. Beyond an established recommended rate of 15% for all births, presently the main challenge in obstetrical care is to limit its use to patients that need the procedure in order to keep an adequate perinatal outcome. The rate of CS has been used in many healthcare settings as an indicator of an individual or institutional obstetrical performance. The issue of overuse of CS as a birth alternative beyond clear maternal or fetal indications has received extensive analysis not only from the reproductive medicine point of view but also from neonatal, ethical, financial, and public health stakeholders. Its place in modern obstetrics, and its impact on short-and long-term maternal and neonatal outcomes, health financial budgets, and in public health policies, have positioned CS a

**Keywords:** cesarean, perinatal outcome, maternal outcome, cesarean upon maternal

Cesarean section (CS) is part of the standard of care in modern obstetrics. During the last 50 years, institutionalization of delivery pretended to make childbirth a safer event. The wide availability of cesarean section has been intended to favor maternal and neonatal outcomes in certain clinical situations in which vaginal delivery is not a safe alternative. Today, CS is an active part of obstetrical practice with aims to improve clinical performance and perinatal indicators. The indications for a cesarean section as an alternative to vaginal delivery have evolved over the centuries. From remote anecdotal references in the history of medicine, CS

> © 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.

Andres Sarmiento

Andres Sarmiento

**Abstract**

#### **Chapter 2 Provisional chapter**

#### **Trends in Cesarean Section Trends in Cesarean Section**

#### Andres Sarmiento Andres Sarmiento

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.77309

#### **Abstract**

Cesarean section (CS) is part of the standard of care in modern obstetrics. Its availability, practicity, high acceptance among patients, and the permanent improvement in surgical techniques, anesthesia, blood replacement, and neonatal care have popularized the procedure as a safe and reasonable alternative to vaginal delivery for any individual born in the twenty-first century. Beyond an established recommended rate of 15% for all births, presently the main challenge in obstetrical care is to limit its use to patients that need the procedure in order to keep an adequate perinatal outcome. The rate of CS has been used in many healthcare settings as an indicator of an individual or institutional obstetrical performance. The issue of overuse of CS as a birth alternative beyond clear maternal or fetal indications has received extensive analysis not only from the reproductive medicine point of view but also from neonatal, ethical, financial, and public health stakeholders. Its place in modern obstetrics, and its impact on short-and long-term maternal and neonatal outcomes, health financial budgets, and in public health policies, have positioned CS a mayor issue to take care of in modern medicine.

DOI: 10.5772/intechopen.77309

**Keywords:** cesarean, perinatal outcome, maternal outcome, cesarean upon maternal request, medical autonomy

#### **1. Introduction**

Cesarean section (CS) is part of the standard of care in modern obstetrics. During the last 50 years, institutionalization of delivery pretended to make childbirth a safer event. The wide availability of cesarean section has been intended to favor maternal and neonatal outcomes in certain clinical situations in which vaginal delivery is not a safe alternative. Today, CS is an active part of obstetrical practice with aims to improve clinical performance and perinatal indicators. The indications for a cesarean section as an alternative to vaginal delivery have evolved over the centuries. From remote anecdotal references in the history of medicine, CS

© 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.

has evolved to be part of the standard of obstetrical care today. Its practicity, disponibility, and apparent safeness have placed CS a first-line procedure in many clinical scenarios.

imposed on physicians who failed to make an attempt to save a soul in cases of maternal death. In the United States (1769–1833), it was mandatory for the Franciscan missionaries to have the

Trends in Cesarean Section

11

http://dx.doi.org/10.5772/intechopen.77309

Francois Roussette (1530–1603) was the first physician to refer cesarean section as a procedure for living women (Paris-1581: Traitté nouveau de l'hysterotomotokie, ou enfantement caesarien). His report included 10 cases, even though he only participated in six of them since he was not a surgeon. Roussette referred for historical purposes the story of Jacob Nufer (1500), a swine castrator from Switzerland, apparently was the first documented man to perform a successful CS. Elizabeth Alice Pachin, his wife had a prolonged and dystocic labor during her first pregnancy. The intervention of 13 midwives was not successful and Nufer, after two requests to the town's mayor, was authorized to proceed to operate. He performed an abdominal and uterine incision with a blade, extracted the fetus and sutured the abdominal wall. The patient survived and subsequently had

However, cesarean sections as a surgical option in cases of dystocia historically were delayed

Trautmann of Wittenberg (Nurtemberg, Germany-1610) practiced the first medically documented CS in a living woman. The patient died 25 days later due to sepsis. By 1865, the maternal mortality rate secondary to CS practiced for maternal indications was estimated to

In the historical evolution of CS practiced for maternal indications, some important mile-

• The description of a transverse incision technique by Ferdinand Adolf Lehrer (1881).

• Joseph Lister (UK-1860) description of the use of carbolic acid as an antiseptic.

• Use of silver and silk sutures for peritoneal closure by Max Sänger (1882).

• Abdominal incision by Hermann Johannes Pfannenstiel (1900).

• CS extra-peritoneal and transverse low by Krönig (1912).

• Eduardo Porro (Italy-1876) practiced the first CS with supravaginal hysterectomy.

• Munro Kerr (UK-1929) described the transversal incision on the uterine segment.

stones for the reduction of complications and increase in survival are: [3, 4].

vaginal deliveries, including twins. The newborn lived until the age of 77 years [5].

knowledge and dexterity of how to practice a section [2, 5].

in the practice of obstetrics due mainly to three elements:

(2) Infection, and (3) Hemorrhage.

be around 85% [2, 5].

(1) It was a late procedure in a patient already complicated,

**3. The evolution of the cesarean section**

The rate of CS has been used in many healthcare settings as an indicator of an individual or institutional obstetrical performance. However, the worldwide reported CS rate seems to draw back from the World Health Organization recommendation. Significant variations are apparent between first-and third-world economies, health models, the standard of obstetrical care, reimbursement, obstetrical risk factors, and cultural influences. Other factors related to the type of practice in modern obstetrics have contributed to the popularization of cesarean section: liberalization of the use of a relatively safe procedure under a pragmatic point of view, limited training in instrumented vaginal delivery among the younger generations of obstetricians, optimization of time, minimizing possible legal medical complications, and evident improvements in surgical and anesthetic safety. Finally, new phenomena like acceptance of CS upon maternal request without any medical indications as a valid indication and the loss of medical autonomy in the modern practice of obstetrics will be addressed in this chapter as contributors to changes in CS rates [1, 18].

Over the last decades, obstetrics has evidenced a notorious increase in the rate of cesarean sections. The progressive institutionalization of birth has resulted in evident improvements not only in fetal and neonatal care but also in a growing number of cesarean sections [1]. Trends in rates have evolved in the United States from one digit numbers, 5% in 1970, and into 32.7% for 2014 [1, 6]. Unfortunately, this growing trend has not always corresponded to a warrant of quality improvement in perinatal outcome indicators. This worldwide concerning phenomenon of a growing cesarean rate has been reported and analyzed not only from the perspective of reproductive medicine but also as a neonatal, financial, public health, legal, and ethical issue.

The indications for a cesarean section as an alternative to vaginal delivery have evolved over the centuries. From remote anecdotal references in the history of obstetrics, CS is reported in many clinical scenarios as the most common way to be born.

### **2. Historical background**

CS has been reported throughout the history of mankind. The term "*cesarean*" most probably comes from the Roman term "*caeso matris*," which meant cutting a fetus out of the maternal womb. The law *Lex Regia* (Numa Pompilius-715 BC) or *Lex Cesarea* ordered the fetal extraction out of the maternal uterus in case of maternal death for an individual burial. Jacques Guillemeau (1598) was the first author to use the term "section" to refer to the cesarean intervention as a birth choice.

The main indication for practicing a CS has not always been maternal and fetal health. There are reports of religious indications in ancient Egypt (3000 BC) and in India (1500 BC). The Jewish Mishnah (140 BC) established that for twins, birth by CS for both products had privileges to claim primogeniture. The Council of Colonia (1280) determined mandatory to perform cesarean section when the mother died. In the Republic of Venice (1608), penalties were imposed on physicians who failed to make an attempt to save a soul in cases of maternal death. In the United States (1769–1833), it was mandatory for the Franciscan missionaries to have the knowledge and dexterity of how to practice a section [2, 5].

#### **3. The evolution of the cesarean section**

Francois Roussette (1530–1603) was the first physician to refer cesarean section as a procedure for living women (Paris-1581: Traitté nouveau de l'hysterotomotokie, ou enfantement caesarien). His report included 10 cases, even though he only participated in six of them since he was not a surgeon. Roussette referred for historical purposes the story of Jacob Nufer (1500), a swine castrator from Switzerland, apparently was the first documented man to perform a successful CS. Elizabeth Alice Pachin, his wife had a prolonged and dystocic labor during her first pregnancy. The intervention of 13 midwives was not successful and Nufer, after two requests to the town's mayor, was authorized to proceed to operate. He performed an abdominal and uterine incision with a blade, extracted the fetus and sutured the abdominal wall. The patient survived and subsequently had vaginal deliveries, including twins. The newborn lived until the age of 77 years [5].

However, cesarean sections as a surgical option in cases of dystocia historically were delayed in the practice of obstetrics due mainly to three elements:


has evolved to be part of the standard of obstetrical care today. Its practicity, disponibility, and apparent safeness have placed CS a first-line procedure in many clinical scenarios.

The rate of CS has been used in many healthcare settings as an indicator of an individual or institutional obstetrical performance. However, the worldwide reported CS rate seems to draw back from the World Health Organization recommendation. Significant variations are apparent between first-and third-world economies, health models, the standard of obstetrical care, reimbursement, obstetrical risk factors, and cultural influences. Other factors related to the type of practice in modern obstetrics have contributed to the popularization of cesarean section: liberalization of the use of a relatively safe procedure under a pragmatic point of view, limited training in instrumented vaginal delivery among the younger generations of obstetricians, optimization of time, minimizing possible legal medical complications, and evident improvements in surgical and anesthetic safety. Finally, new phenomena like acceptance of CS upon maternal request without any medical indications as a valid indication and the loss of medical autonomy in the modern practice of obstetrics will be addressed in this

Over the last decades, obstetrics has evidenced a notorious increase in the rate of cesarean sections. The progressive institutionalization of birth has resulted in evident improvements not only in fetal and neonatal care but also in a growing number of cesarean sections [1]. Trends in rates have evolved in the United States from one digit numbers, 5% in 1970, and into 32.7% for 2014 [1, 6]. Unfortunately, this growing trend has not always corresponded to a warrant of quality improvement in perinatal outcome indicators. This worldwide concerning phenomenon of a growing cesarean rate has been reported and analyzed not only from the perspective of reproductive medicine but also as a neonatal, financial, public health, legal, and ethical issue. The indications for a cesarean section as an alternative to vaginal delivery have evolved over the centuries. From remote anecdotal references in the history of obstetrics, CS is reported in

CS has been reported throughout the history of mankind. The term "*cesarean*" most probably comes from the Roman term "*caeso matris*," which meant cutting a fetus out of the maternal womb. The law *Lex Regia* (Numa Pompilius-715 BC) or *Lex Cesarea* ordered the fetal extraction out of the maternal uterus in case of maternal death for an individual burial. Jacques Guillemeau (1598) was the first author to use the term "section" to refer to the cesarean inter-

The main indication for practicing a CS has not always been maternal and fetal health. There are reports of religious indications in ancient Egypt (3000 BC) and in India (1500 BC). The Jewish Mishnah (140 BC) established that for twins, birth by CS for both products had privileges to claim primogeniture. The Council of Colonia (1280) determined mandatory to perform cesarean section when the mother died. In the Republic of Venice (1608), penalties were

chapter as contributors to changes in CS rates [1, 18].

many clinical scenarios as the most common way to be born.

**2. Historical background**

10 Caesarean Section

vention as a birth choice.

(3) Hemorrhage.

Trautmann of Wittenberg (Nurtemberg, Germany-1610) practiced the first medically documented CS in a living woman. The patient died 25 days later due to sepsis. By 1865, the maternal mortality rate secondary to CS practiced for maternal indications was estimated to be around 85% [2, 5].

In the historical evolution of CS practiced for maternal indications, some important milestones for the reduction of complications and increase in survival are: [3, 4].


Later in medicine, the implementation and improvement of surgical techniques, anesthesia, blood transfusion, and antibiotics impacted positively in the performance and prognosis of CS as an alternative option to vaginal delivery.

The 10-group classification system−Robson groups [10]:

**5.** Previous cesarean, single cephalic ≥37 weeks.

**9.** All abnormal lies (including previous cesareans).

**7.** All multiparous breeches (including previous cesareans). **8.** All multiple pregnancies (including previous cesareans).

**10.** All single cephalic, ≤36 weeks (including previous cesareans).

labor.

ean before labor.

**6.** All nulliparous breeches.

more detailed analysis [10, 12].

section (57.5% in 2010 and 50.2% in 2016) [14].

in private versus public hospitals [16, 17].

the classification.

**1.** Nulliparous, single cephalic, ≥37 weeks, spontaneous labor.

**2.** Nulliparous, single cephalic, ≥37 weeks, induced or cesarean before labor.

**3.** Multiparous (excluding previous cesareans), single cephalic, ≥37 weeks, spontaneous

Trends in Cesarean Section

13

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**4.** Multiparous (excluding previous cesareans), single cephalic, ≥37 weeks, induced or cesar-

This system implies that the information collected must be clinically relevant, carefully defined and collected, and timely and permanently available. This information should be used to permanently audit and standardize indications for inductions and to practice cesarean sections. It should be used as a parameter for monthly critical analysis and reference in time and with other obstetrical units. Also, each parameter can be further subdivided for

In most studies, the main contributors to explain the increase in CS rates are groups 1, 2, and 5 [12].

This classification, however, only takes part of the variables of an obstetric population into account. Important information like maternal age or body mass index (BMI), are not part of

Although the 1985 WHO recommendation on the CS continues to be a referred indicator in obstetric literature, recent evidence based on demographic differences across the 194 WHO member countries suggest that the optimal global CS rate may be around 20% [13]. In countries like France, that have been successful in keeping CS rates stable, the main difference has been lowering sections before initiation of labor and in women with one previous cesarean

Other nonmedical factors have also been reported: supply-side demand induction, decision issues related to professional convenience, and optimization of time and predilection for CS

With the inclusion of obstetric protocols of systematic use of prenatal diagnosis and fetal surveillance techniques during pregnancy and delivery, the number of CS secondary to fetal indications has increased. Even though there is no evidence that the universal use of intrapartum

In 1846, at the Massachusetts General Hospital, the dentist William T.G. Morton was the first to used diethyl ether to operate a facial tumor. Since then analgesia-anesthesia was used for many surgical procedures. However, this did not happen so fast in obstetrics. The belief, according to the Biblical mandate, that women in compensation for Eve's sin should suffer "birth in pain" was popularized. This argument lost value when Queen Victoria of England, head of the English church received chloroform during the birth of their children Leopoldo (1853) and Beatriz (1857) [5].

From 1880 through 1925, several techniques of extra-peritoneal CS and vaginal cesarean were described in order to decrease infection. The need of these techniques disappeared after 1928, with the discovery of penicillin, which became available in 1940.

The CS rate in the United States has changed dramatically during the last 50 years [6, 8].

1970: 5%,

1990: 23.5%, and.

2016: 31.9% (low-risk patients: 26.9%).

Worldwide CS rates have nearly doubled since 1990 (from 14.5 to 27.2%) [11].

In 1985, the WHO stated that the CS should not exceed 15% in any population group [8]. In the last decades, an invariable upward trend has been evident mainly in low-and middle-income countries. China (64.1%), Colombia (46.4%), Dominican Republic (56.4%), Egypt (51.8%), Iran (47.9%), and Brazil (55.6%, 80% for second deliveries) – when the first was by cesarean, are some examples [7, 11, 15].

Among countries of the organization for economic cooperation and development (OECD) the rate varies widely from 45 to 50% (Mexico and Turkey) to 15–17% (Netherland, Sweden, and Norway). In other European countries like France the CS rate has been relatively stable: 20.4% in 2003, 21.1% in 2010, and 20.4% in 2016 [9, 11, 14].

Although CS is widely available, the main recommendation and challenge are to limit its practice to patients that may have a clear benefit from the intervention. Quality assurance in labor and delivery should be part of the standard of care in any clinical scenario and assure a reasonable CS rate.

In 2001, Robson [10] proposed to adopt a standard classification system so that CS rates would no longer be thought of as being too high or too low, but rather whether they are appropriate or not, in the context of all information about clinical variables, including maternal satisfaction. The 10-group classification system (TGCS or Robson classification) is a method that provides essential information regarding common factors for a determined obstetric population where perinatal events and outcomes can be established, measured, compared, and audited.

The 10 Robson classification groups have been thoroughly used by many research groups with the intention to standardize and eventually regulate the CS rate in a specific obstetric scenario.

The 10-group classification system−Robson groups [10]:


Later in medicine, the implementation and improvement of surgical techniques, anesthesia, blood transfusion, and antibiotics impacted positively in the performance and prognosis of

In 1846, at the Massachusetts General Hospital, the dentist William T.G. Morton was the first to used diethyl ether to operate a facial tumor. Since then analgesia-anesthesia was used for many surgical procedures. However, this did not happen so fast in obstetrics. The belief, according to the Biblical mandate, that women in compensation for Eve's sin should suffer "birth in pain" was popularized. This argument lost value when Queen Victoria of England, head of the English church received chloroform during the birth of their children Leopoldo

From 1880 through 1925, several techniques of extra-peritoneal CS and vaginal cesarean were described in order to decrease infection. The need of these techniques disappeared after 1928,

In 1985, the WHO stated that the CS should not exceed 15% in any population group [8]. In the last decades, an invariable upward trend has been evident mainly in low-and middle-income countries. China (64.1%), Colombia (46.4%), Dominican Republic (56.4%), Egypt (51.8%), Iran (47.9%), and Brazil (55.6%, 80% for second deliveries) – when the first was by cesarean, are

Among countries of the organization for economic cooperation and development (OECD) the rate varies widely from 45 to 50% (Mexico and Turkey) to 15–17% (Netherland, Sweden, and Norway). In other European countries like France the CS rate has been relatively stable: 20.4%

Although CS is widely available, the main recommendation and challenge are to limit its practice to patients that may have a clear benefit from the intervention. Quality assurance in labor and delivery should be part of the standard of care in any clinical scenario and assure a

In 2001, Robson [10] proposed to adopt a standard classification system so that CS rates would no longer be thought of as being too high or too low, but rather whether they are appropriate or not, in the context of all information about clinical variables, including maternal satisfaction. The 10-group classification system (TGCS or Robson classification) is a method that provides essential information regarding common factors for a determined obstetric population where perinatal events and outcomes can be established, measured, compared, and audited. The 10 Robson classification groups have been thoroughly used by many research groups with the intention to standardize and eventually regulate the CS rate in a specific obstetric scenario.

The CS rate in the United States has changed dramatically during the last 50 years [6, 8].

Worldwide CS rates have nearly doubled since 1990 (from 14.5 to 27.2%) [11].

CS as an alternative option to vaginal delivery.

with the discovery of penicillin, which became available in 1940.

(1853) and Beatriz (1857) [5].

2016: 31.9% (low-risk patients: 26.9%).

in 2003, 21.1% in 2010, and 20.4% in 2016 [9, 11, 14].

1970: 5%,

12 Caesarean Section

1990: 23.5%, and.

some examples [7, 11, 15].

reasonable CS rate.


This system implies that the information collected must be clinically relevant, carefully defined and collected, and timely and permanently available. This information should be used to permanently audit and standardize indications for inductions and to practice cesarean sections. It should be used as a parameter for monthly critical analysis and reference in time and with other obstetrical units. Also, each parameter can be further subdivided for more detailed analysis [10, 12].

In most studies, the main contributors to explain the increase in CS rates are groups 1, 2, and 5 [12].

This classification, however, only takes part of the variables of an obstetric population into account. Important information like maternal age or body mass index (BMI), are not part of the classification.

Although the 1985 WHO recommendation on the CS continues to be a referred indicator in obstetric literature, recent evidence based on demographic differences across the 194 WHO member countries suggest that the optimal global CS rate may be around 20% [13]. In countries like France, that have been successful in keeping CS rates stable, the main difference has been lowering sections before initiation of labor and in women with one previous cesarean section (57.5% in 2010 and 50.2% in 2016) [14].

Other nonmedical factors have also been reported: supply-side demand induction, decision issues related to professional convenience, and optimization of time and predilection for CS in private versus public hospitals [16, 17].

With the inclusion of obstetric protocols of systematic use of prenatal diagnosis and fetal surveillance techniques during pregnancy and delivery, the number of CS secondary to fetal indications has increased. Even though there is no evidence that the universal use of intrapartum fetal surveillance has had a positive impact on perinatal morbidity and mortality in low-risk obstetric population in the last 30 years, its use is part of the daily routine in any obstetrical ward [16, 29, 30].

a prospective observational setting, the following results: (a) multiple maternal outcomes among low-risk women who intended to have CSMR versus vaginal delivery, and (b) multiple neonatal outcomes derived from the same obstetric population. We hypothesized to find the different frequency of maternal and neonatal outcomes between CSMR and vaginal deliv-

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We developed a prospective observational study that included obstetric patients aged 18–45 with low-risk term pregnancies that delivered at our hospital. Previous board ethical committee approval, patients requesting CSMR were individualized to receive further information, after what all of them signed an information consent form before being admitted to the study. The presence of any of 5 pre-specified adverse maternal outcomes and of any of 17 pre-specified adverse neonatal outcomes was compared between CSMR and vaginal births. Induced vaginal births were analyzed separately. All recruited patients were offered the same standard of medical care. The effect of confounders was adjusted using multivariate logistic regression. The demographic characteristics of our participants showed healthy, actively working women, mostly in their early 1930s, married, and with private health insurance cov-

The study incorporated 214 patients with CSMR, 341 with spontaneous vaginal delivery (SVD), and 376 with induced vaginal delivery (IVD). Relative to the spontaneous delivery arm, the multivariate-adjusted odds ratios for adverse maternal outcomes were 0.21 (95% CI: 0.05–0.97) in the CSMR group and 0.93 (95% CI: 0.42–2.06) in the IVD arm. The multivariate ORs for adverse neonatal outcomes were 0.59 (95% CI: 0.36–0.93) for CSMR and 0.84 (95% CI: 0.59–1.21) for IVD. The frequency of hospital admission for the newborn was lowest in the cesarean delivery group (10.3% compared to 15.8% for spontaneous deliveries and 16.2% for

Our preliminary results suggested that among low-risk pregnancy patients that received a standardized obstetric care protocol, CSMR was associated with a lower rate of adverse perinatal outcomes when compared to spontaneous vaginal delivery. Due to our limited number and type of population additional studies are needed to assess the long-term safety of CSMR. Despite that all three groups were very similar at inclusion we found a lower absolute rate of adverse maternal and neonatal outcomes among obstetric patients who chose CSMR over a vaginal delivery. Furthermore, when the effects of variables with the highest potential were adjusted to be considered confounders, this result continued to be significant, in some cases yielding even lower estimates of the odds ratio. Despite the perception that cesarean sections implied longer hospitalizations, the absolute difference in the total days of hospital admission between the CSMR and spontaneous vaginal birth groups was on average 0.5 days, a differ-

In the same way, the rate of primary neonatal poor outcome was also lower for the CSMR group, a difference that also persisted after correction with multivariate models. We consider this a noteworthy result since multiple related adverse neonatal outcomes were identified and registered. Moreover, newborns from CSMR women were admitted significantly less and had slightly higher APGAR scores than those born vaginally. Stunningly, our results

erage, who presented for delivery with a term, low-risk pregnancy.

eries in our low-risk obstetric population.

induced vaginal deliveries).

ence that has minimal clinical implications.

Unfortunately, high CS rates are not always correlated to better maternal-fetal outcomes. Several systematic reviews have shown that, although CS can be a truly life-saving procedure in some cases, it's also associated with anomalous short-term immune response in the newborn, and a greater risk of developing immune-mediated diseases such as asthma, allergies, or DM type 1. From a financial perspective, globally, the cost of practicing CS without a clear medical indication has been estimated at \$2.32 billion [15, 16].

## **4. Cesarean delivery under maternal request**

An important contributor to the rising trend of CS worldwide, and particularly in Latin America, is the surge of cesarean section upon maternal request (CSMR). The most accepted definition of this indication is a CS performed in an obstetric patient with a singleton, term pregnancy, by maternal request, and with no medical indication [19]. The performance of this surgery without any medical indication has given rise to in-depth medical, legal, ethical, and financial debates, especially when the use of limited health resources is a concerning issue for an elective and frequent procedure [20]. Despite a presumable under-registered data, CSMR is estimated to correspond to 4–15% of all deliveries in the United States. As much as 82% of obstetricians in the United States recognize having performed at least one CSMR [21, 22]. In addition, a high degree of variation in the use of CSMR, ranging between 6% in the United Kingdom and up to 80% of deliveries in Brazil has been reported [23, 24].

Diverse factors including patients and health providers have been reported as contributors to the increase in CSMR. Referred patient factors are fear of pain, a sense of safeness, and confidence, a hypothetic control over a somewhat unpredictable event, and a false perception of a reduced risk of urinary incontinence in the obstetric patient and/or hypoxic encephalopathy in the newborn [25]. Factors depending on medical personal include a pragmatic view of birth, efficiency in working time, and finally a hypothetical avoidance of medical and legal complains. Advances in surgical and anesthetic protocols may also be important issues in safety matters [26].

Presently there is controversy deeming the safety of CSMR for both, the mother, and the neonate. A summary of the evidence was presented by the United States National Institutes of Health, referring that CSMR might be associated to a diminished risk of bleeding or need for transfusion, and a lower risk of trauma and organ damage. However, there is still uncertainty about the short-term impact of CSMR on perinatal outcomes, as well as in future pregnancies [26]. Direct evidence about the risks of CSMR, particularly when compared to cesarean sections, is limited.

On behalf of these facts and since the evidence to recommend or ban the practice of CSMR is mostly based on retrospective analyses, our group realized a 4-year period research study based in our hospital obstetric low-risk population [18]. Our objectives were to compare, in a prospective observational setting, the following results: (a) multiple maternal outcomes among low-risk women who intended to have CSMR versus vaginal delivery, and (b) multiple neonatal outcomes derived from the same obstetric population. We hypothesized to find the different frequency of maternal and neonatal outcomes between CSMR and vaginal deliveries in our low-risk obstetric population.

fetal surveillance has had a positive impact on perinatal morbidity and mortality in low-risk obstetric population in the last 30 years, its use is part of the daily routine in any obstetrical

Unfortunately, high CS rates are not always correlated to better maternal-fetal outcomes. Several systematic reviews have shown that, although CS can be a truly life-saving procedure in some cases, it's also associated with anomalous short-term immune response in the newborn, and a greater risk of developing immune-mediated diseases such as asthma, allergies, or DM type 1. From a financial perspective, globally, the cost of practicing CS without a clear

An important contributor to the rising trend of CS worldwide, and particularly in Latin America, is the surge of cesarean section upon maternal request (CSMR). The most accepted definition of this indication is a CS performed in an obstetric patient with a singleton, term pregnancy, by maternal request, and with no medical indication [19]. The performance of this surgery without any medical indication has given rise to in-depth medical, legal, ethical, and financial debates, especially when the use of limited health resources is a concerning issue for an elective and frequent procedure [20]. Despite a presumable under-registered data, CSMR is estimated to correspond to 4–15% of all deliveries in the United States. As much as 82% of obstetricians in the United States recognize having performed at least one CSMR [21, 22]. In addition, a high degree of variation in the use of CSMR, ranging between 6% in the United

Diverse factors including patients and health providers have been reported as contributors to the increase in CSMR. Referred patient factors are fear of pain, a sense of safeness, and confidence, a hypothetic control over a somewhat unpredictable event, and a false perception of a reduced risk of urinary incontinence in the obstetric patient and/or hypoxic encephalopathy in the newborn [25]. Factors depending on medical personal include a pragmatic view of birth, efficiency in working time, and finally a hypothetical avoidance of medical and legal complains. Advances in surgical and anesthetic protocols may also be important issues in

Presently there is controversy deeming the safety of CSMR for both, the mother, and the neonate. A summary of the evidence was presented by the United States National Institutes of Health, referring that CSMR might be associated to a diminished risk of bleeding or need for transfusion, and a lower risk of trauma and organ damage. However, there is still uncertainty about the short-term impact of CSMR on perinatal outcomes, as well as in future pregnancies [26]. Direct evidence about the risks of CSMR, particularly when compared to cesarean sections, is limited. On behalf of these facts and since the evidence to recommend or ban the practice of CSMR is mostly based on retrospective analyses, our group realized a 4-year period research study based in our hospital obstetric low-risk population [18]. Our objectives were to compare, in

medical indication has been estimated at \$2.32 billion [15, 16].

Kingdom and up to 80% of deliveries in Brazil has been reported [23, 24].

**4. Cesarean delivery under maternal request**

ward [16, 29, 30].

14 Caesarean Section

safety matters [26].

We developed a prospective observational study that included obstetric patients aged 18–45 with low-risk term pregnancies that delivered at our hospital. Previous board ethical committee approval, patients requesting CSMR were individualized to receive further information, after what all of them signed an information consent form before being admitted to the study. The presence of any of 5 pre-specified adverse maternal outcomes and of any of 17 pre-specified adverse neonatal outcomes was compared between CSMR and vaginal births. Induced vaginal births were analyzed separately. All recruited patients were offered the same standard of medical care. The effect of confounders was adjusted using multivariate logistic regression. The demographic characteristics of our participants showed healthy, actively working women, mostly in their early 1930s, married, and with private health insurance coverage, who presented for delivery with a term, low-risk pregnancy.

The study incorporated 214 patients with CSMR, 341 with spontaneous vaginal delivery (SVD), and 376 with induced vaginal delivery (IVD). Relative to the spontaneous delivery arm, the multivariate-adjusted odds ratios for adverse maternal outcomes were 0.21 (95% CI: 0.05–0.97) in the CSMR group and 0.93 (95% CI: 0.42–2.06) in the IVD arm. The multivariate ORs for adverse neonatal outcomes were 0.59 (95% CI: 0.36–0.93) for CSMR and 0.84 (95% CI: 0.59–1.21) for IVD. The frequency of hospital admission for the newborn was lowest in the cesarean delivery group (10.3% compared to 15.8% for spontaneous deliveries and 16.2% for induced vaginal deliveries).

Our preliminary results suggested that among low-risk pregnancy patients that received a standardized obstetric care protocol, CSMR was associated with a lower rate of adverse perinatal outcomes when compared to spontaneous vaginal delivery. Due to our limited number and type of population additional studies are needed to assess the long-term safety of CSMR.

Despite that all three groups were very similar at inclusion we found a lower absolute rate of adverse maternal and neonatal outcomes among obstetric patients who chose CSMR over a vaginal delivery. Furthermore, when the effects of variables with the highest potential were adjusted to be considered confounders, this result continued to be significant, in some cases yielding even lower estimates of the odds ratio. Despite the perception that cesarean sections implied longer hospitalizations, the absolute difference in the total days of hospital admission between the CSMR and spontaneous vaginal birth groups was on average 0.5 days, a difference that has minimal clinical implications.

In the same way, the rate of primary neonatal poor outcome was also lower for the CSMR group, a difference that also persisted after correction with multivariate models. We consider this a noteworthy result since multiple related adverse neonatal outcomes were identified and registered. Moreover, newborns from CSMR women were admitted significantly less and had slightly higher APGAR scores than those born vaginally. Stunningly, our results disagree with those of the WHO Global Survey on Maternal and Perinatal Health [27]. In their report, cesarean sections were associated with an increased risk of severe adverse maternal outcomes. An explanation for the result discrepancy may be the fact that in the WHO study as in many others, elective and emergency, term and preterm, low and high risk, cesarean sections have been included for analysis as a single group.

must not be used to suggest or advice CSMR as a first line alternative for childbirth. Our results have been used to launch a formal protocol in our hospital for cases of CSMR and to accurately inform our patients about birth options; their respective short-and long-term complications are a critical element in the consent form. In our hospital, all patients that request a CS are individualized for counsel and further information. It has discouraged hospital under recording of CS indications, has contributed to the exactness of surgical indications on medical records and has turned a previous individualize practice into a controlled institutional protocol of medical attention that is permanently audited and followed up. Also, this model has endorsed us to keep low indicators of maternal, neonatal, and anesthetic complications

Trends in Cesarean Section

17

http://dx.doi.org/10.5772/intechopen.77309

Medical autonomy is understood as the self-determination of professional behaviors, according to individual values based on professional ethics, supported by the best available scientific evidence, giving priority to the interests of the patient, and without external interference or coercion. The modern concept of autonomy is based on the ideas of Kant (1788), according to which morality is based on consciousness and reason as the fundamental elements and

On the other hand, the profession as a work activity derives its name from "professing" or

In the twenty-first century, professional autonomy is articulated by three factors such as:

Under this frame of reference, the behavior of the cesarean rate can be a magnificent example of the loss of medical autonomy in certain practice scenarios. The exercise of modern obstetrics within the current social paradigms becomes a very complex task. Modern times have imposed as a fundamental principle the fact that "time is money" for which we always live in a hurry, there is no time for communication or patient medical relationship, moral relativism, and pragmatism of behavior predominates. Thus, although birth is a profound and powerful

without a negative impact on financial issues.

declaring society a commitment to behavior.

(1) missionary and vocational activity,

(3) an ethical code of behavior, and

(2) responsible use of technology, and

"what man should do" [31].

(2) knowledge and expertise,

(4) self-regulation.

(3) financial factors.

**5. Loss of medical autonomy as a factor affecting CS**

Medicine as a profession is based on four fundamental elements:

(1) self-assessment and self-regulation of medical practice,

These three factors cannot conflict with the element of quality of care.

We recognized a low rate of obstetric hemorrhage requiring blood transfusion in all groups (0.3% in spontaneous vaginal, 1.3% in induced vaginal, and 0.5% in CSMR). In a retrospective review of more than 400,000 births, Holm et al. found a lower risk of severe post-partum hemorrhage with CSMR in both nulliparous patients and in those with a previous cesarean section [28]. There is evidence that the frequency of hemorrhage and obstetric shock is generally lower with elective sections, and that the overall risk of blood transfusion is low, except when associated with antepartum established anemia and placenta previa. In a Canadian population-based revision of vaginal delivery versus cesarean section practiced for breech presentation, maternal morbidity was similar between groups, but neonatal morbidity was lower among babies born by cesarean [20]. In the same way, in a retrospective analysis of almost 30,000 deliveries in the United States, the incidence of persistent pulmonary hypertension was 3.7/1000 live births among neonates born by elective section, but only 0.8/1000 live births among neonates delivered vaginally [22]. Part of the inconsistency among results from different studies may be explained in association with the role of gestational age as a confounding factor. This is shown by the fact that when elective cesarean sections are performed after 39 weeks, clinical variables of neonatal respiratory morbidity are not increased compared to vaginal delivery [23].

Our results seem to point out that under specific optimal low-risk obstetric population conditions, CSMR may be a clinical procedure with an equivalent impact on both mother and neonate compared to vaginal birth.

The main assets of our study embrace its prospective nature, the cautious and widespread documentation of outcomes and covariates, and the use of homogeneous high-quality care protocols that allow to better evaluate the advantages and disadvantages of each mode of delivery.

In contrast, our main methodological drawback lies in the undersized postpartum follow-up, which does not permit us to evaluate long-term postpartum complications. CSMR may be associated with numerous potential risks, which can be classified as immediate, late, and long-term. We did not find an added incidence of short-term risks (infection, hemorrhage, intra-operative genital/urinary lesions, other intra-abdominal complications, and anesthetic risks or death). However, we cannot rule out late (thromboembolic disease, prolonged recovery, hospital readmission, adhesions, and incisional hernias) or long-term (abnormal placental implantation, uterine scar dehiscence/rupture, hysterectomy, infertility, early fetal loss, ectopic pregnancy, and intrauterine growth retardation) complications in these patients. Undouble, extended prospective studies are needed in order to validate our results.

In conclusion, in this prospective investigation that only included the term, low-risk pregnancies of women with a very specific demography and chosen with strict inclusion criteria, CSMR was associated with a lower rate of adverse perinatal outcomes for both mother and newborn, compared to vaginal birth. While these results may look promising, this evidence must not be used to suggest or advice CSMR as a first line alternative for childbirth. Our results have been used to launch a formal protocol in our hospital for cases of CSMR and to accurately inform our patients about birth options; their respective short-and long-term complications are a critical element in the consent form. In our hospital, all patients that request a CS are individualized for counsel and further information. It has discouraged hospital under recording of CS indications, has contributed to the exactness of surgical indications on medical records and has turned a previous individualize practice into a controlled institutional protocol of medical attention that is permanently audited and followed up. Also, this model has endorsed us to keep low indicators of maternal, neonatal, and anesthetic complications without a negative impact on financial issues.

#### **5. Loss of medical autonomy as a factor affecting CS**

Medical autonomy is understood as the self-determination of professional behaviors, according to individual values based on professional ethics, supported by the best available scientific evidence, giving priority to the interests of the patient, and without external interference or coercion. The modern concept of autonomy is based on the ideas of Kant (1788), according to which morality is based on consciousness and reason as the fundamental elements and "what man should do" [31].

On the other hand, the profession as a work activity derives its name from "professing" or declaring society a commitment to behavior.

Medicine as a profession is based on four fundamental elements:


disagree with those of the WHO Global Survey on Maternal and Perinatal Health [27]. In their report, cesarean sections were associated with an increased risk of severe adverse maternal outcomes. An explanation for the result discrepancy may be the fact that in the WHO study as in many others, elective and emergency, term and preterm, low and high risk, cesarean

We recognized a low rate of obstetric hemorrhage requiring blood transfusion in all groups (0.3% in spontaneous vaginal, 1.3% in induced vaginal, and 0.5% in CSMR). In a retrospective review of more than 400,000 births, Holm et al. found a lower risk of severe post-partum hemorrhage with CSMR in both nulliparous patients and in those with a previous cesarean section [28]. There is evidence that the frequency of hemorrhage and obstetric shock is generally lower with elective sections, and that the overall risk of blood transfusion is low, except when associated with antepartum established anemia and placenta previa. In a Canadian population-based revision of vaginal delivery versus cesarean section practiced for breech presentation, maternal morbidity was similar between groups, but neonatal morbidity was lower among babies born by cesarean [20]. In the same way, in a retrospective analysis of almost 30,000 deliveries in the United States, the incidence of persistent pulmonary hypertension was 3.7/1000 live births among neonates born by elective section, but only 0.8/1000 live births among neonates delivered vaginally [22]. Part of the inconsistency among results from different studies may be explained in association with the role of gestational age as a confounding factor. This is shown by the fact that when elective cesarean sections are performed after 39 weeks, clinical variables of neonatal respiratory morbidity are not increased

Our results seem to point out that under specific optimal low-risk obstetric population conditions, CSMR may be a clinical procedure with an equivalent impact on both mother and

The main assets of our study embrace its prospective nature, the cautious and widespread documentation of outcomes and covariates, and the use of homogeneous high-quality care protocols that allow to better evaluate the advantages and disadvantages of each mode of delivery.

In contrast, our main methodological drawback lies in the undersized postpartum follow-up, which does not permit us to evaluate long-term postpartum complications. CSMR may be associated with numerous potential risks, which can be classified as immediate, late, and long-term. We did not find an added incidence of short-term risks (infection, hemorrhage, intra-operative genital/urinary lesions, other intra-abdominal complications, and anesthetic risks or death). However, we cannot rule out late (thromboembolic disease, prolonged recovery, hospital readmission, adhesions, and incisional hernias) or long-term (abnormal placental implantation, uterine scar dehiscence/rupture, hysterectomy, infertility, early fetal loss, ectopic pregnancy, and intrauterine growth retardation) complications in these patients.

Undouble, extended prospective studies are needed in order to validate our results.

In conclusion, in this prospective investigation that only included the term, low-risk pregnancies of women with a very specific demography and chosen with strict inclusion criteria, CSMR was associated with a lower rate of adverse perinatal outcomes for both mother and newborn, compared to vaginal birth. While these results may look promising, this evidence

sections have been included for analysis as a single group.

compared to vaginal delivery [23].

16 Caesarean Section

neonate compared to vaginal birth.


These three factors cannot conflict with the element of quality of care.

Under this frame of reference, the behavior of the cesarean rate can be a magnificent example of the loss of medical autonomy in certain practice scenarios. The exercise of modern obstetrics within the current social paradigms becomes a very complex task. Modern times have imposed as a fundamental principle the fact that "time is money" for which we always live in a hurry, there is no time for communication or patient medical relationship, moral relativism, and pragmatism of behavior predominates. Thus, although birth is a profound and powerful human experience and for women generates feelings of empowerment, success and personal achievement, the excessive increase in the cesarean rate is a consequence of the medicalization of birth and a change in attitude of the patient and the doctor within the new social model that undoubtedly impacts professional practice.

Medicine is a moral activity, exercised by individuals who adhere to a code of behavior. Medical autonomy should be the result of the balance of the factors that affect the practice. Trust is the fundamental principle of medical professionalism and the basis of the social con-

Trends in Cesarean Section

19

http://dx.doi.org/10.5772/intechopen.77309

The indications for the cesarean section have changed throughout history. They have been shaped by religious, cultural, economic, professional, and technological reasons that have impacted medicine. CS originated as a precept for saving the soul, if not the life of the fetus. From the nineteenth century, it changed to save the obstetric patient. Finally, since the end of twentieth century, Western obstetric medicine has focused on the maternal and fetal benefits of the procedure. In the last 30 years, the fetal indications of the procedure have triggered its

Attempts to reduce CS rates in underdeveloped countries have not been efficient. Its place in today's obstetric practice, its impact on short-and long-term maternal and neonatal outcomes, health financial budgets, and in public health policies, has positioned CS a major issue in

Our goal as health providers is to assure that CS is practiced on patients and neonates that will benefit from it. Women should be adequately informed and brought into the conversation about the benefits and disadvantages, both short and long term, of birth by cesarean

[1] Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. NCHS

[2] National Library of Medicine. Caesarean Section – A Brief History. 1993

[3] Kerr JMM. Journal of Obstetrics and Gynecology. 1926;**12**:729-734

[5] Boley JP. The history of caesarean section. CMAJ. 1991;**145**(4):319-322

[4] Pfannenstiel HJ. Samml Klin Vortr. 1900;**268**:1735-1756

frequency with a definite impact on the model of modern obstetric practice.

Address all correspondence to: ansarmie@uniandes.edu.co

Universidad de los Andes, Bogotá, Colombia

Data Brief. 2010;**35**:1-8

tract between the obstetrician and the society [32].

**6. Conclusion**

modern obstetrics.

delivery [13].

**Author details**

Andres Sarmiento

**References**

Undoubtedly, any of the above may have a medical field of discussion in the indication and relevance; however, the last two are the ones that generate great controversy today due to the laxity in its acceptance, its underreporting in the clinical history, and ethical considerations in your practice. The rate of CS in Colombia reached 46% in 2014, moving further away from the universal recommendation of 15% of the WHO. Having a preference for its practice in specific geographical areas where it can reach percentages greater than 70% and with a clear predilection for private institutions.

Medical autonomy is being affected by a series of factors that threaten the full exercise of obstetrics. Optimization of time, remuneration, disinformation of the patient with inappropriate use of their autonomy, fear of legal medical suits, the misuse of medical technology, therapeutic pragmatism, and finally poor medical training with limitations in the expertise of the care of the vaginal delivery. In addition to these factors that undermine medical autonomy, others that can contribute to understanding this phenomenon are the aforementioned loss of the physicianpatient relationship, the model of medicalized care, demographic changes (the role of women in today's society), the standard of obstetric care with the programming of birth, and the negative perspective about the vaginal delivery that new generations of patients and obstetricians have.

A separate mention deserves the media who have contributed through inaccurate information or decontextualized cultural and social myths about supposed benefits of surgical delivery that feed a social behavior that tends to be replicated.

Highlighting the value of informed consent, explained and discussed with the patient in a quiet environment during prenatal care and never on the scenario of a delivery room, is that it rationalizes the decision, informs objectively, and allows the patient to choose the right decision, which is not always the easiest.

Proposals for intervention to regain medical autonomy in obstetric practice:


Medicine is a moral activity, exercised by individuals who adhere to a code of behavior. Medical autonomy should be the result of the balance of the factors that affect the practice. Trust is the fundamental principle of medical professionalism and the basis of the social contract between the obstetrician and the society [32].

#### **6. Conclusion**

human experience and for women generates feelings of empowerment, success and personal achievement, the excessive increase in the cesarean rate is a consequence of the medicalization of birth and a change in attitude of the patient and the doctor within the new social model that

Undoubtedly, any of the above may have a medical field of discussion in the indication and relevance; however, the last two are the ones that generate great controversy today due to the laxity in its acceptance, its underreporting in the clinical history, and ethical considerations in your practice. The rate of CS in Colombia reached 46% in 2014, moving further away from the universal recommendation of 15% of the WHO. Having a preference for its practice in specific geographical areas where it can reach percentages greater than 70% and with a clear

Medical autonomy is being affected by a series of factors that threaten the full exercise of obstetrics. Optimization of time, remuneration, disinformation of the patient with inappropriate use of their autonomy, fear of legal medical suits, the misuse of medical technology, therapeutic pragmatism, and finally poor medical training with limitations in the expertise of the care of the vaginal delivery. In addition to these factors that undermine medical autonomy, others that can contribute to understanding this phenomenon are the aforementioned loss of the physicianpatient relationship, the model of medicalized care, demographic changes (the role of women in today's society), the standard of obstetric care with the programming of birth, and the negative perspective about the vaginal delivery that new generations of patients and obstetricians have. A separate mention deserves the media who have contributed through inaccurate information or decontextualized cultural and social myths about supposed benefits of surgical deliv-

Highlighting the value of informed consent, explained and discussed with the patient in a quiet environment during prenatal care and never on the scenario of a delivery room, is that it rationalizes the decision, informs objectively, and allows the patient to choose the right

Proposals for intervention to regain medical autonomy in obstetric practice:

**1.** Institutionalization of obstetric care: follow-up indicators and protocols,

undoubtedly impacts professional practice.

18 Caesarean Section

predilection for private institutions.

ery that feed a social behavior that tends to be replicated.

decision, which is not always the easiest.

**5.** Routine use of informed consent,

**6.** Patient education,

**10.** Working with the media.

**2.** Health team practice supported by midwives, **3.** Training of residents and health personnel, **4.** Rational use of methods of fetal surveillance,

**7.** Permanent availability of analgesia and anesthesia,

**9.** Vaginal delivery as a public health policy, and

**8.** Individualized care of cases of CS by maternal request,

The indications for the cesarean section have changed throughout history. They have been shaped by religious, cultural, economic, professional, and technological reasons that have impacted medicine. CS originated as a precept for saving the soul, if not the life of the fetus. From the nineteenth century, it changed to save the obstetric patient. Finally, since the end of twentieth century, Western obstetric medicine has focused on the maternal and fetal benefits of the procedure. In the last 30 years, the fetal indications of the procedure have triggered its frequency with a definite impact on the model of modern obstetric practice.

Attempts to reduce CS rates in underdeveloped countries have not been efficient. Its place in today's obstetric practice, its impact on short-and long-term maternal and neonatal outcomes, health financial budgets, and in public health policies, has positioned CS a major issue in modern obstetrics.

Our goal as health providers is to assure that CS is practiced on patients and neonates that will benefit from it. Women should be adequately informed and brought into the conversation about the benefits and disadvantages, both short and long term, of birth by cesarean delivery [13].

#### **Author details**

Andres Sarmiento

Address all correspondence to: ansarmie@uniandes.edu.co

Universidad de los Andes, Bogotá, Colombia

#### **References**


[6] Recent Trends in Cesarean Delivery in the United States. NCHS Data Brief, September 2017

[21] Bettes BA. Cesarean delivery on maternarequest: Obstetrician-gynecologis ts' knowledge, perception, and practice patterns. Obstetrics and Gynecology. 2007;**109**:57-66 [22] MacDorman MF. Cesarean birth in the United States: Epidemiology, trends, and out-

Trends in Cesarean Section

21

http://dx.doi.org/10.5772/intechopen.77309

[23] Section C. National Institute of Health and Clinical Excellence Guideline. 2nd ed.

[24] Potter JE et al. Unwanted caesarean sections among public and private patients in Brazil:

[25] Hofberg K. Fear of childbirth, tocophobia, and mental health in mothers: The obstetric-

[26] Ecker J. Elective cesarean delivery on maternal request. Journal of the American Medical

[27] Souza JP et al. WHO global survey on maternal and perinatal Health Research Group. Caesarean section without medical indications is associated with an increased risk of adverse short- term maternal outcomes: The 2004-2008 WHO global survey on maternal

[28] Holm C. Severe postpartum hemorrhage and mode of delivery: A retrospective cohort study. BJOG : An International Journal of Obstetrics and Gynaecology. 2012;**119**:596-604

[29] Sartwelle Th.. American College of Legal Medicine Electronic Fetal Monitoring; a Bridge

[30] U.S. Preventive Services Task Force. Screening for intrapartum electronic fetal monitoring. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsiefm.htm.,

[32] Wojtczak H. Profesionalismo médico: una problemática global. Educational Medicine.

psychiatric interface. Clinical Obstetrics and Gynecology. 2004;**47**:527-534

comes. Clinics in Perinatology. 2008;**35**:293-307

Prospective study. BMJ. 2001;**323**:1155-1158

and perinatal health. BMC Medicine. 2010;**8**:71

too Far. The Journal of Legal Medicine. 2012;**33**:313-379

[31] Hashimoto N. Medical autonomy. JMAJ. 2006;**49**(3):125-127

Association. 2013;**309**:1930-1936

London: RCOG; 2011

2010

2006;**9**:144-145


[21] Bettes BA. Cesarean delivery on maternarequest: Obstetrician-gynecologis ts' knowledge, perception, and practice patterns. Obstetrics and Gynecology. 2007;**109**:57-66

[6] Recent Trends in Cesarean Delivery in the United States. NCHS Data Brief, September

[7] Vital Statistics DANE. Public Health Analysis Room. Bogota: Universidad de los Andes;

[9] WHO Statement on Caesarean Section Rates: World Health Organization; 2015. Available online at: http://apps.who.int/iris/bitstream/10665/161442/1/WHO\_RHR\_15.02\_eng.pdf?ua=1

[10] Robson M., Can we reduce the caesarean section rate? Best Practice & Research Clinical

[11] Betrán AP. The increasing trend in caesarean section rates: Global, regional and national

[12] Robson M. Quality assurance: The 10-group classification system (Robson classification), induction of labor, and cesarean delivery. International Journal of Gynecology &

[13] Robson SJ. Thirty years of the WHO target caesarean section rate: Time to move on. The

[14] Blondel B. Trends in perinatal health in metropolitan France from 1995 to 2016: Results from the French National Perinatal Surveys. Journal of Gynecology Obstetrics and

[15] Beogo I. Determinants and materno-fetal outcomes related to cesarean section delivery in private and public hospitals in low- and middle-income countries: A systematic

[16] Gibbons L. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. In: World Health Report (2010) Background Paper, 30. WHO; 2010: http://www.who.int/healthsys-

tems/topics/financing/healthreport/30C-sectioncosts.pdf. Accessed May 11, 2016 [17] Robson M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Practice & Research. Clinical Obstetrics & Gynaecology. 2013;**27**(2):297-308 [18] Sarmiento-Rodríguez A. Impacto perinatal de la cesárea por solicitud materna comparada con el parto vaginal en embarazos de bajo riesgo en un Hospital Universitario: estudio observacional prospectivo en Bogotá, Colombia Revista Colombiana de Ginecologia

[19] ACOG. Committee opinion no. 559. Cesarean delivery on maternal request. Obstetrics

[20] Dahlgren L. Caesarean section on maternal request: Risks and benefits in healthy nulliparous women and their infants. Journal of Obstetrics and Gynaecology Canada.

review and meta-analysis protocol. BMC. Systematic Reviews. 2017;**6**:5

[8] Chalmers B. Appropriate technology for birth. Lancet. 1985;**2**:436-437

Obstetrics & Gynaecology Vol. 15, No. 1, pp. 179±194, 2001

estimates: 1990-2014. PLoS One. 2016;**11**:e0148343

Medical Journal of Australia. 2017 Mar 6;**206**(4):181-185

2017

20 Caesarean Section

2016

[Accessed: September 15, 2016]

Obstetrics. 2015;**131**:S23-S27

Human Reproduction. 2017;**46**:701-713

y Obstetrician Vol 68, No 1 2017

and Gynecology. 2013;**121**:904-907

2009;**31**:808-817


**Chapter 3**

**Provisional chapter**

**Value of Caesarian Section in HIV-Positive Women**

**Value of Caesarian Section in HIV-Positive Women**

DOI: 10.5772/intechopen.76883

The international main goal is to reduce mother-to-child HIV transmission. The appropriate birth delivery for seropositive woman has been analyzed since the beginning of the twenty-first century. Although at the beginning of HIV pandemic delivery by caesarian section (C-section) was considered mandatory in many studies and meta-analyses, recent information reveal limited benefits. Mother-to-child transmission is higher when mothers are diagnosed late during pregnancy, in advanced stages with a high HIV viral load, and labor with membranes ruptured for more than 4 h, especially when the antiretroviral treatment is not respected. During vaginal delivery, the risk of HIV transmitting to infant is due to microtransfusions during uterine contractions or by newborn exposure to cervicovaginal secretions or blood. Although the indication of C-section in HIV-positive women is controversial, there are some situations in which C-section remains mandatory. In mothers diagnosed late during pregnancy, in situation in which HIV viral load is not affordable in real time in the last trimester of pregnancy, and in mothers with poor adherence to antiretroviral treatment, C-section remains one of the most important mea-

Human immunodeficiency virus (HIV) continues to be an important European public health problem, especially in low-to-medium income countries, such as Romania. UAIDS declared in 2016 between 6100 and 7500 women aged 15 and over as being diagnosed with HIV in our country [1]. The medical system crisis and poverty are the two most important reasons of remaining underdiagnosed. Therefore, the unofficial number is much higher. Worldwide 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.

Simona Claudia Cambrea and Anca Daniela Pinzaru

sures of prevention for HIV mother-to-child transmission.

**Keywords:** HIV, delivery, C-section, newborn, HIV viral load

Simona Claudia Cambrea and Anca Daniela Pinzaru

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.76883

**Abstract**

**1. Introduction**

number is significantly higher.

#### **Value of Caesarian Section in HIV-Positive Women Value of Caesarian Section in HIV-Positive Women**

DOI: 10.5772/intechopen.76883

Simona Claudia Cambrea and Anca Daniela Pinzaru Simona Claudia Cambrea and Anca Daniela Pinzaru

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.76883

#### **Abstract**

The international main goal is to reduce mother-to-child HIV transmission. The appropriate birth delivery for seropositive woman has been analyzed since the beginning of the twenty-first century. Although at the beginning of HIV pandemic delivery by caesarian section (C-section) was considered mandatory in many studies and meta-analyses, recent information reveal limited benefits. Mother-to-child transmission is higher when mothers are diagnosed late during pregnancy, in advanced stages with a high HIV viral load, and labor with membranes ruptured for more than 4 h, especially when the antiretroviral treatment is not respected. During vaginal delivery, the risk of HIV transmitting to infant is due to microtransfusions during uterine contractions or by newborn exposure to cervicovaginal secretions or blood. Although the indication of C-section in HIV-positive women is controversial, there are some situations in which C-section remains mandatory. In mothers diagnosed late during pregnancy, in situation in which HIV viral load is not affordable in real time in the last trimester of pregnancy, and in mothers with poor adherence to antiretroviral treatment, C-section remains one of the most important measures of prevention for HIV mother-to-child transmission.

**Keywords:** HIV, delivery, C-section, newborn, HIV viral load

#### **1. Introduction**

Human immunodeficiency virus (HIV) continues to be an important European public health problem, especially in low-to-medium income countries, such as Romania. UAIDS declared in 2016 between 6100 and 7500 women aged 15 and over as being diagnosed with HIV in our country [1]. The medical system crisis and poverty are the two most important reasons of remaining underdiagnosed. Therefore, the unofficial number is much higher. Worldwide the number is significantly higher.

© 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.

Pregnancy in HIV-positive females is a challenge due to its risk and fatal complications.

Mother-to-child transmission is particularly analyzed in preventing HIV spreading. The type of birth management in HIV-positive women makes the difference between healthy infants or future new HIV infection sources. Assessing the risks and benefits of every type of birth should be analyzed at the beginning of every pregnancy [2].

affinity for some types of HIV serotypes. The lack of medical education or poverty could interfere with periodical gynecological examination. Females may present multiple entry points for HIV infection, such as ulceration or inflammation of the vaginal mucosae facilitating the entry and multiplication of the virus. Cofactors of transmission are considered the

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 25

Cultural or religious beliefs could make the women an easier target to sexually transmitted infections. In some communities women are discriminated, are not included in healthcare programs, and do not undergo to periodical gynecological examination. In some situation, women are regarded as "sinners" and blamed for being ill. Social status sometimes prevents

Due to poverty or sexual inequality, women are involved in illicit commercial sex work. Promiscuity is the main reason in HIV explosion, especially in poor, uneducated environ-

HIV pandemic has been intensely epidemiologically analyzed. The main purpose was to determine the viable method on reducing mother-to-child transmission. Since the beginning of the twenty-first century until the beginning of the twenty-second century, discussing the more effective method of birth offered contradictory data. In 1999 a European clinical trial underlined the benefits of elective caesarian section in transmitting vertical HIV [5, 11].

HIV could be acquired during blood transfusion or contact with contaminated fluids, dental extractions, vertical transmission, or unprotected sexual intercourse. It is one of the most

Vertical transmission could occur before or in different stages of pregnancy or postpartum. Pregnancy, labor with membranes ruptured for more than 4 h, infected blood contact or cervicovaginal secretions, and breastfeeding are key points in preventing HIV. Premasticated food could be another method of contamination. In undiagnosed women, the vertical transmission

Infants born from seropositive females should be tested immediately after birth, at 14–21 days, 1–2 months, and 4–6 months. International guidelines recommend viral assay—HIV RNA and HIV DNA. Detection of antibodies is not recommended in children less than 12–18 months due to the presence of residual mother's antibodies. Mothers diagnosed after birth or incompliant to treatment or with high viral load have a higher risk of HIV transmission. Their infants must be tested at 2–4 weeks from caesarian delivery or antiretroviral prophylaxis. At infants the positive diagnosis is established based on two consecutive positive virologic assays (>1 month and >4 months of life). In children >12–18 months, the HIV antibody tests will be used [16]. HIV genomes had been discovered in different fractions of human milk; therefore breastfeeding should be forbidden. Breastfeeding is not allowed even in women undergoing retroviral treatment because the infected genome could still be present. Replacement formulas are the recommended alternative. If the mother already breastfeeds the infant, without knowing

other sexually transmitted diseases (chlamydia, syphilis) [12–15].

women in asking and receiving proper treatment [12–15].

**3. Epidemiology and risk factors**

severe sexually transmitted diseases.

is evaluated at 30% [6, 10].

ments [15].

The proper method of delivery in HIV-positive female has been analyzed since the beginning of the twenty-first century [3]. Villari et al. in 1993 elaborated an important meta-analysis about six cohort studies regarding the elective caesarian benefits in HIV females. It underlined only a slight effectiveness of C-section in reducing vertical HIV transmission [3, 4]. Until 1999 the international literature was uncertain. A randomized clinical study providing certain information regarding the necessity of selective C-section in preventing HIV transmission was published [5].

In undiagnosed women the vertical transmission is evaluated at 30%. The risk could be higher, depending on the disease evolution/stage and treatment effectiveness [6].

Vaginal birth could lead to newborn infection, increased mortality, and morbidity, especially in undiagnosed or untreated females [6, 7]. To minimize the transmission risk, elective caesarian section (before labor settles or membrane ruptures) is considered the most important method [3].

A scheduled C-section, for the 38th week of pregnancy, to prevent mother-to-child transmission is recommended in women with unknown of high viral load near the delivery time [8]. HIV-positive pregnant women should start their antiretroviral treatment as soon as possible for their own health and to protect their baby [8].

#### **2. Etiology**

HIV could be induced in humans by two entities: HIV-1 (with three representative groups: M, major; O, outlier; and N, new) and HIV-2, both from the Retroviridae family. The enzymatic proteins and the most part of the structure are encoded by three genes (gag, pol, and env). HIV-1 is the most frequent. Regarding the expression and infectious release of the virus, there are other six genes involved (regulatory = tat and rev and accessory: vif, vpr, vpu, and nef). On the host cellular membranes, the envelope glycoprotein has contact with CD4, CD1, and CD2 major receptors. HIV-1, a RNA virus, during its replication, enzyme called reverse transcriptase transformed it into a DNA virus. Viral DNA is integrated as proviral DNA. Then, during transcription, proviral DNA is transformed in mRNA, which during translation synthesize immature viral proteins. Assembly viral proteins create mature viral particles and then during budding the new viral particles will be release and they will infect the new cells. HIV-2 is less encountered as HIV-1. It has a slower clinical course, but the outcome is similar to type 1 [9–11].

The key of infection with HIV is cellular dysfunction, humoral immune dysfunction, and aberrant lymphocyte turnover [9, 10].

The male-female ratio in acquiring HIV infection is 2:3, due to women particular anatomy. After unprotected sexual intercourse, envelope glycoprotein gp120 with the infected particles remains on mucosae surface for a period. Langerhans cells from the cervix have an important affinity for some types of HIV serotypes. The lack of medical education or poverty could interfere with periodical gynecological examination. Females may present multiple entry points for HIV infection, such as ulceration or inflammation of the vaginal mucosae facilitating the entry and multiplication of the virus. Cofactors of transmission are considered the other sexually transmitted diseases (chlamydia, syphilis) [12–15].

Cultural or religious beliefs could make the women an easier target to sexually transmitted infections. In some communities women are discriminated, are not included in healthcare programs, and do not undergo to periodical gynecological examination. In some situation, women are regarded as "sinners" and blamed for being ill. Social status sometimes prevents women in asking and receiving proper treatment [12–15].

Due to poverty or sexual inequality, women are involved in illicit commercial sex work. Promiscuity is the main reason in HIV explosion, especially in poor, uneducated environments [15].

## **3. Epidemiology and risk factors**

Pregnancy in HIV-positive females is a challenge due to its risk and fatal complications.

should be analyzed at the beginning of every pregnancy [2].

for their own health and to protect their baby [8].

aberrant lymphocyte turnover [9, 10].

**2. Etiology**

24 Caesarean Section

depending on the disease evolution/stage and treatment effectiveness [6].

Mother-to-child transmission is particularly analyzed in preventing HIV spreading. The type of birth management in HIV-positive women makes the difference between healthy infants or future new HIV infection sources. Assessing the risks and benefits of every type of birth

The proper method of delivery in HIV-positive female has been analyzed since the beginning of the twenty-first century [3]. Villari et al. in 1993 elaborated an important meta-analysis about six cohort studies regarding the elective caesarian benefits in HIV females. It underlined only a slight effectiveness of C-section in reducing vertical HIV transmission [3, 4]. Until 1999 the international literature was uncertain. A randomized clinical study providing certain information regarding the necessity of selective C-section in preventing HIV transmission was published [5]. In undiagnosed women the vertical transmission is evaluated at 30%. The risk could be higher,

Vaginal birth could lead to newborn infection, increased mortality, and morbidity, especially in undiagnosed or untreated females [6, 7]. To minimize the transmission risk, elective caesarian section (before labor settles or membrane ruptures) is considered the most important method [3]. A scheduled C-section, for the 38th week of pregnancy, to prevent mother-to-child transmission is recommended in women with unknown of high viral load near the delivery time [8]. HIV-positive pregnant women should start their antiretroviral treatment as soon as possible

HIV could be induced in humans by two entities: HIV-1 (with three representative groups: M, major; O, outlier; and N, new) and HIV-2, both from the Retroviridae family. The enzymatic proteins and the most part of the structure are encoded by three genes (gag, pol, and env). HIV-1 is the most frequent. Regarding the expression and infectious release of the virus, there are other six genes involved (regulatory = tat and rev and accessory: vif, vpr, vpu, and nef). On the host cellular membranes, the envelope glycoprotein has contact with CD4, CD1, and CD2 major receptors. HIV-1, a RNA virus, during its replication, enzyme called reverse transcriptase transformed it into a DNA virus. Viral DNA is integrated as proviral DNA. Then, during transcription, proviral DNA is transformed in mRNA, which during translation synthesize immature viral proteins. Assembly viral proteins create mature viral particles and then during budding the new viral particles will be release and they will infect the new cells. HIV-2 is less encountered as HIV-1. It has a slower clinical course, but the outcome is similar to type 1 [9–11]. The key of infection with HIV is cellular dysfunction, humoral immune dysfunction, and

The male-female ratio in acquiring HIV infection is 2:3, due to women particular anatomy. After unprotected sexual intercourse, envelope glycoprotein gp120 with the infected particles remains on mucosae surface for a period. Langerhans cells from the cervix have an important HIV pandemic has been intensely epidemiologically analyzed. The main purpose was to determine the viable method on reducing mother-to-child transmission. Since the beginning of the twenty-first century until the beginning of the twenty-second century, discussing the more effective method of birth offered contradictory data. In 1999 a European clinical trial underlined the benefits of elective caesarian section in transmitting vertical HIV [5, 11].

HIV could be acquired during blood transfusion or contact with contaminated fluids, dental extractions, vertical transmission, or unprotected sexual intercourse. It is one of the most severe sexually transmitted diseases.

Vertical transmission could occur before or in different stages of pregnancy or postpartum. Pregnancy, labor with membranes ruptured for more than 4 h, infected blood contact or cervicovaginal secretions, and breastfeeding are key points in preventing HIV. Premasticated food could be another method of contamination. In undiagnosed women, the vertical transmission is evaluated at 30% [6, 10].

Infants born from seropositive females should be tested immediately after birth, at 14–21 days, 1–2 months, and 4–6 months. International guidelines recommend viral assay—HIV RNA and HIV DNA. Detection of antibodies is not recommended in children less than 12–18 months due to the presence of residual mother's antibodies. Mothers diagnosed after birth or incompliant to treatment or with high viral load have a higher risk of HIV transmission. Their infants must be tested at 2–4 weeks from caesarian delivery or antiretroviral prophylaxis. At infants the positive diagnosis is established based on two consecutive positive virologic assays (>1 month and >4 months of life). In children >12–18 months, the HIV antibody tests will be used [16].

HIV genomes had been discovered in different fractions of human milk; therefore breastfeeding should be forbidden. Breastfeeding is not allowed even in women undergoing retroviral treatment because the infected genome could still be present. Replacement formulas are the recommended alternative. If the mother already breastfeeds the infant, without knowing her health status, it is recommended to begin of prophylaxis. Infants born from HIV-positive mother are tested in the first 4–6 weeks of life. Complementary food is offered at 6 months, according to international guidelines [10, 11].

and intrauterine devices). An important discussion subject is represented by the effectiveness of every contraceptive method. There are still uncertain data regarding oral or injectable contraceptive. International studies have not established exactly a connection between hormonal changes—vaginal flora—and mucosae modification and an increased risk of HIV transmission. The Mombasa study underlined a higher predisposition of HIV infection in women undergoing oral or injectable contraceptive therapy, but Beaten et al. in a different cohort could not establish a certain connection. Mombasa study revealed that other sexual transmitted diseases (chlamydia) had a higher incidence and the viral load was higher [17–20].

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 27

The international guidelines underline the necessity of thorough blood evaluation in women who desire to conceive before pregnancy. The same indication is recommended to male partners. The purpose is to eliminate any transmitted diseases to the future child. HIV diagnosis as early as possible before pregnancy or during pregnancy leads to a proper antiretroviral

Step 1: Complete medical checkup for both parents. Viral load determination is essential.

Step 2: Establishing the correct antiretroviral treatment. Respecting the doses and clinical

Step 3: Gynecological evaluation, ultrasound, and cervicovaginal cultures should be done

Step 4: Discussing and analyzing the prober birth method to prevent or minimize mother-to-

HIV infection is characterized by cellular and immune dysfunction and aberrant lymphocyte turnover. Pregnancy is regarded as period of decreased immunity due to reduced levels of immunoglobulin or complement. Viral load remains the main tool of viral turnover. Concerns were induced by the impact of pregnancy on HIV progression. Evidence of pregnancy influencing the HIV evolution was noticed in untreated patients or in advanced/complicated stages of disease. Bordeaux University Hospital (France) issued a prospective cohort study on 57 pregnant women that are HIV positive. It revealed that pregnancy had not influence the natural immunosuppression evolution [15, 17–19, 22]. Madeline Y. Sutton et al. analyzed the immune response (Interleukin-2 low levels secondary determines CD4+ T lymphocyte levels to drop exposing the HIV-positive organism to opportunistic infection) at HIV patients. Sixtyone women were divided in four large groups: 39 pregnant women (20 HIV positive and 19 HIV negative) and 22 nonpregnant equal HIV positive and negative. There were some differences regarding IL-2 production between HIV-positive and HIV-negative pregnant women, but during the third trimester, the differences were insignificant. Therefore, pregnancy does

Preexisting diseases in HIV-positive women could alter the natural pregnancy evolution. Tuberculosis or other pulmonary infections (*Pneumocystis carinii*), urinary tract infections, and parasite infections (*Toxocara canis*) should be mandatorily evaluated or registered in the

treatment and a close follow-up, reducing the risk of vertical transmission [21]:

periodically, as the medical team recommends.

**5. Pregnancy evolution in HIV-positive women**

not influence the natural evolution of HIV [15, 22–24].

follow-up.

child HIV transmission.

During vaginal delivery, the risk of transmitting HIV to infant is due to microtransfusions during uterine contractions or to exposure to cervicovaginal secretions or blood [3].

Risk factors in HIV vertical transmission were:


The actual data sustain that vertical transmission could be encountered at any maternal viral load, but the risk is lower <1000 copies/ml. The risk is higher when CD4+ count is under 700/mm3 [9, 15].

Establishing the exact moment of contamination is essential in minimizing the risk of vertical transmission. The longer the mother is left untreated, the higher the risk of transmission to her child. In utero contamination had been observed after histological analysis of fetal or placenta tissue. The presence of p24 antigen in fetal tissue represents in utero transmission of the HIV infection [15].

In mother-to-child transmission, the minimum period until clinical manifestations are present is between 12 and 18 months. However, exceptions are frequently encountered, but rarely the diagnosis is established in adolescents [10].

#### **4. Pregnancy planning in HIV-positive women**

HIV-positive women are as fertile as healthy ones. The difference is made by the impact of the active virus on the female organism. Therefore, subfertility, underweight, associated diseases (sexually transmitted diseases, respiratory infections), and illicit drug abuse are the reasons of fertility problems or abortion in this social category [17].

HIV-positive women should be guided through a correct contraceptive method (male or female condom, diaphragms, vaginal cups, progesterone injections, transdermal implants, and intrauterine devices). An important discussion subject is represented by the effectiveness of every contraceptive method. There are still uncertain data regarding oral or injectable contraceptive. International studies have not established exactly a connection between hormonal changes—vaginal flora—and mucosae modification and an increased risk of HIV transmission. The Mombasa study underlined a higher predisposition of HIV infection in women undergoing oral or injectable contraceptive therapy, but Beaten et al. in a different cohort could not establish a certain connection. Mombasa study revealed that other sexual transmitted diseases (chlamydia) had a higher incidence and the viral load was higher [17–20].

The international guidelines underline the necessity of thorough blood evaluation in women who desire to conceive before pregnancy. The same indication is recommended to male partners. The purpose is to eliminate any transmitted diseases to the future child. HIV diagnosis as early as possible before pregnancy or during pregnancy leads to a proper antiretroviral treatment and a close follow-up, reducing the risk of vertical transmission [21]:

Step 1: Complete medical checkup for both parents. Viral load determination is essential.

Step 2: Establishing the correct antiretroviral treatment. Respecting the doses and clinical follow-up.

Step 3: Gynecological evaluation, ultrasound, and cervicovaginal cultures should be done periodically, as the medical team recommends.

Step 4: Discussing and analyzing the prober birth method to prevent or minimize mother-tochild HIV transmission.

#### **5. Pregnancy evolution in HIV-positive women**

her health status, it is recommended to begin of prophylaxis. Infants born from HIV-positive mother are tested in the first 4–6 weeks of life. Complementary food is offered at 6 months,

During vaginal delivery, the risk of transmitting HIV to infant is due to microtransfusions

• Maternal viral load (a higher viral load reflects a lower CD4 T lymphocyte, therefore a

• Period of exposure (undiagnosed before or during the pregnancy, vaginal birth with labor

• Treatment compliance (incompliant mother to antiretroviral treatment has a higher viral

The actual data sustain that vertical transmission could be encountered at any maternal viral load, but the risk is lower <1000 copies/ml. The risk is higher when CD4+ count is under

Establishing the exact moment of contamination is essential in minimizing the risk of vertical transmission. The longer the mother is left untreated, the higher the risk of transmission to her child. In utero contamination had been observed after histological analysis of fetal or placenta tissue. The presence of p24 antigen in fetal tissue represents in utero transmission of

In mother-to-child transmission, the minimum period until clinical manifestations are present is between 12 and 18 months. However, exceptions are frequently encountered, but rarely the

HIV-positive women are as fertile as healthy ones. The difference is made by the impact of the active virus on the female organism. Therefore, subfertility, underweight, associated diseases (sexually transmitted diseases, respiratory infections), and illicit drug abuse are the reasons of

HIV-positive women should be guided through a correct contraceptive method (male or female condom, diaphragms, vaginal cups, progesterone injections, transdermal implants,

• Type of delivery, preterm delivery; membrane ruptures more than 4 h.

during uterine contractions or to exposure to cervicovaginal secretions or blood [3].

according to international guidelines [10, 11].

Risk factors in HIV vertical transmission were:

and membranes ruptured, breastfeeding).

• Mother's nutritional and clinical status.

diagnosis is established in adolescents [10].

**4. Pregnancy planning in HIV-positive women**

fertility problems or abortion in this social category [17].

• Breastfeeding, premasticated food.

• Behavioral attitude [15].

[9, 15].

the HIV infection [15].

more advanced clinical stage).

load).

26 Caesarean Section

700/mm3

HIV infection is characterized by cellular and immune dysfunction and aberrant lymphocyte turnover. Pregnancy is regarded as period of decreased immunity due to reduced levels of immunoglobulin or complement. Viral load remains the main tool of viral turnover. Concerns were induced by the impact of pregnancy on HIV progression. Evidence of pregnancy influencing the HIV evolution was noticed in untreated patients or in advanced/complicated stages of disease. Bordeaux University Hospital (France) issued a prospective cohort study on 57 pregnant women that are HIV positive. It revealed that pregnancy had not influence the natural immunosuppression evolution [15, 17–19, 22]. Madeline Y. Sutton et al. analyzed the immune response (Interleukin-2 low levels secondary determines CD4+ T lymphocyte levels to drop exposing the HIV-positive organism to opportunistic infection) at HIV patients. Sixtyone women were divided in four large groups: 39 pregnant women (20 HIV positive and 19 HIV negative) and 22 nonpregnant equal HIV positive and negative. There were some differences regarding IL-2 production between HIV-positive and HIV-negative pregnant women, but during the third trimester, the differences were insignificant. Therefore, pregnancy does not influence the natural evolution of HIV [15, 22–24].

Preexisting diseases in HIV-positive women could alter the natural pregnancy evolution. Tuberculosis or other pulmonary infections (*Pneumocystis carinii*), urinary tract infections, and parasite infections (*Toxocara canis*) should be mandatorily evaluated or registered in the personal history of the patients. Immunosuppression induced both by the HIV and pregnancy could lead to certain complications that are life-threatening for the mother and fetus [15, 25].

Birmingham. It concluded that under the antiretroviral treatment and preterm delivery with ruptured membranes over 4 h, the risk of vertical transmission is minimal. Only two infants whose mother did not receive antiretroviral therapy were seropositive. To reduce to zero, the risk of HIV transmission from mother to child, elective caesarian is the proper attitude [15, 31].

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 29

The main purpose of antiretroviral therapy is to minimize the transmission and to decrease HIV evolution. Diagnosis timing is essential. Seropositive women antepartum should undergo strict blood count and antiretroviral therapy. Intrapartum or postpartum HIV infection benefits on the same medical steps, underlining that the second category could have a better evolution if the diagnosis is established soon after contamination. Seropositive female

The goal of antiretroviral treatment during pregnancy is to drop viral load to undetectability and to maintain it. Secondary risk of transmitting HIV to fetus is minimum. Through the placenta, the antiretroviral drugs are transported to child. In year 2005, in France, a prospective multicenter perinatal cohort, evaluated 8075 HIV+ mother/infant couples over a period of 11 years. Mothers received treatment during pregnancy, they did not breastfeed and viral load was determined. It concluded that the risk of vertical transmitting HIV is zero if antiretroviral

Establishing the moment of HIV contamination is essential in preventing mother-to-child transmission. An English retrospective multicenter cohort study (Read et al.) evaluated 378 pregnancies undergoing retroviral therapy. After analyzing age of gestation, the start of drug therapy, CD4+ count, and viral load, it underlined the following data: if the viral load was under 10,000 copies/ml until a gestational age of 26.3 weeks, the purpose to achieve 50 copies/ml could be reached. When the viral load was more than 10,000 copies/ml before 20.4 weeks of gestation, the purpose to obtain less than 50 copies/ml until birth was compromised. The level

Zidovudine (dideoxynucleoside reverse transcriptase inhibitors) is the most used antiretroviral drug during pregnancy. Even if there are other types of dideoxynucleoside reverse transcriptase inhibitors (didanosine, zalcitabine, stavudine, lamivudine) with the same action

therapy is started before pregnancy and the viral load is suppressed [33, 34].

of 50 copies/ml was obtained in 292 pregnancies from a total number of 378 [35].

may present antiretroviral resistance and lower CD4+ levels [32, 33]. Establishing the correct antiretroviral therapy should be guided by:

• Age of the mother and immunity/clinical status

**6. Antiretroviral therapy**

• Treatment compliance

• HIV viral load

• Comorbidities associated

• Possible teratogenic effects [32, 33]

Tuberculosis is considered the most frequent coinfection in seropositive females. Halichidis et al. presented a case report of a 21-year-old pregnant HIV-positive female presenting at admission severe infection signs (fever, right cervical and submandibular painful adenopathy persistent, dry cough). After sputum analysis it established the diagnosis of acute miliary TB. Adequate therapy for both pathologies was implemented. Mother refused abortion, the treatment, and admission. After 20 days she was again admitted but with more severe symptoms. After undergoing emergency caesarian at 30 weeks, she gave birth to a male child (1000 g, small for gestation age) who lived 5 days. One week later the mother died. After biopsy the following diagnosis was established: acute disseminated miliary TB with meningoencephalitis, tuberculoma of the brain, pulmonary edema, acute interstitial nephritis, cardiomyopathy, and atrophic gastritis. The association between these two pathologies has a poor prognosis. It affects the mother and the child; furthermore the drug therapy side effects are multiple and could lead to morbidity or mortality in a high percentage [26].

Spontaneous abortion is higher in HIV seropositive women than in healthy population. It is link to opportunistic infections, anogenital contamination with other sexually transmitted diseases, drug abuse, smoking, and alcohol use [25].

HIV infection can predispose the human host to opportunistic infections and comorbidities. Reitter et al. evaluated 312 pregnant HIV-positive females (Frankfurt HIV cohort) and monitored them over an 11-year period. Complications encountered gestational diabetes mellitus, preeclampsia, and preterm delivery [27].

The type of delivery is also influenced by coexisting urogenital infections. HIV-seropositive females come from promiscuous environments, with unprotected sexual activity, poverty, and lack of medical healthcare systems or medical education. HIV induces an important immunosuppression predisposing to severe forms of sexual transmitted diseases, especially trichomoniasis, gonorrhea, syphilis, and bacterial or fungus vaginitis. The risk of coexisting infections is the same as in healthy women, but its evolution is more severe making it difficult to be eradicated. Group B *Streptococcus* dominates bacterial urogenital infections. Preinvasive lesions such as different types of neoplasia or inflammatory pelvic disease could be tied to the immunosuppression. Evaluating CIN incidents in 305 HIV-positive females, Ahr et al. underlined its higher prevalence than in healthy women. Human papilloma virus is the frequent responsible agent [24, 28, 29].

A Romanian study evaluated 98 unpregnant HIV-positive female undergoing antiretroviral therapy for cytological modification. Babes-Papanicolau test was performed to determine if there was a connection between immunosuppression and cervical lesions. 73.58% had cervical cytology abnormal results, estimating that squamous cell lesions in seropositive females with peripheral viral load lower than 500 cell/μl are more often encountered than in healthy population (p < 0.02) [30].

Preterm delivery (<37 weeks) and premature birth are two important risk factors in transmitting HIV from mother to child. Kjersti et al. analyzed 219 seropositive pregnant women from Birmingham. It concluded that under the antiretroviral treatment and preterm delivery with ruptured membranes over 4 h, the risk of vertical transmission is minimal. Only two infants whose mother did not receive antiretroviral therapy were seropositive. To reduce to zero, the risk of HIV transmission from mother to child, elective caesarian is the proper attitude [15, 31].

### **6. Antiretroviral therapy**

personal history of the patients. Immunosuppression induced both by the HIV and pregnancy could lead to certain complications that are life-threatening for the mother and fetus [15, 25]. Tuberculosis is considered the most frequent coinfection in seropositive females. Halichidis et al. presented a case report of a 21-year-old pregnant HIV-positive female presenting at admission severe infection signs (fever, right cervical and submandibular painful adenopathy persistent, dry cough). After sputum analysis it established the diagnosis of acute miliary TB. Adequate therapy for both pathologies was implemented. Mother refused abortion, the treatment, and admission. After 20 days she was again admitted but with more severe symptoms. After undergoing emergency caesarian at 30 weeks, she gave birth to a male child (1000 g, small for gestation age) who lived 5 days. One week later the mother died. After biopsy the following diagnosis was established: acute disseminated miliary TB with meningoencephalitis, tuberculoma of the brain, pulmonary edema, acute interstitial nephritis, cardiomyopathy, and atrophic gastritis. The association between these two pathologies has a poor prognosis. It affects the mother and the child; furthermore the drug therapy side effects

are multiple and could lead to morbidity or mortality in a high percentage [26].

diseases, drug abuse, smoking, and alcohol use [25].

preeclampsia, and preterm delivery [27].

28 Caesarean Section

responsible agent [24, 28, 29].

population (p < 0.02) [30].

Spontaneous abortion is higher in HIV seropositive women than in healthy population. It is link to opportunistic infections, anogenital contamination with other sexually transmitted

HIV infection can predispose the human host to opportunistic infections and comorbidities. Reitter et al. evaluated 312 pregnant HIV-positive females (Frankfurt HIV cohort) and monitored them over an 11-year period. Complications encountered gestational diabetes mellitus,

The type of delivery is also influenced by coexisting urogenital infections. HIV-seropositive females come from promiscuous environments, with unprotected sexual activity, poverty, and lack of medical healthcare systems or medical education. HIV induces an important immunosuppression predisposing to severe forms of sexual transmitted diseases, especially trichomoniasis, gonorrhea, syphilis, and bacterial or fungus vaginitis. The risk of coexisting infections is the same as in healthy women, but its evolution is more severe making it difficult to be eradicated. Group B *Streptococcus* dominates bacterial urogenital infections. Preinvasive lesions such as different types of neoplasia or inflammatory pelvic disease could be tied to the immunosuppression. Evaluating CIN incidents in 305 HIV-positive females, Ahr et al. underlined its higher prevalence than in healthy women. Human papilloma virus is the frequent

A Romanian study evaluated 98 unpregnant HIV-positive female undergoing antiretroviral therapy for cytological modification. Babes-Papanicolau test was performed to determine if there was a connection between immunosuppression and cervical lesions. 73.58% had cervical cytology abnormal results, estimating that squamous cell lesions in seropositive females with peripheral viral load lower than 500 cell/μl are more often encountered than in healthy

Preterm delivery (<37 weeks) and premature birth are two important risk factors in transmitting HIV from mother to child. Kjersti et al. analyzed 219 seropositive pregnant women from The main purpose of antiretroviral therapy is to minimize the transmission and to decrease HIV evolution. Diagnosis timing is essential. Seropositive women antepartum should undergo strict blood count and antiretroviral therapy. Intrapartum or postpartum HIV infection benefits on the same medical steps, underlining that the second category could have a better evolution if the diagnosis is established soon after contamination. Seropositive female may present antiretroviral resistance and lower CD4+ levels [32, 33].

Establishing the correct antiretroviral therapy should be guided by:


The goal of antiretroviral treatment during pregnancy is to drop viral load to undetectability and to maintain it. Secondary risk of transmitting HIV to fetus is minimum. Through the placenta, the antiretroviral drugs are transported to child. In year 2005, in France, a prospective multicenter perinatal cohort, evaluated 8075 HIV+ mother/infant couples over a period of 11 years. Mothers received treatment during pregnancy, they did not breastfeed and viral load was determined. It concluded that the risk of vertical transmitting HIV is zero if antiretroviral therapy is started before pregnancy and the viral load is suppressed [33, 34].

Establishing the moment of HIV contamination is essential in preventing mother-to-child transmission. An English retrospective multicenter cohort study (Read et al.) evaluated 378 pregnancies undergoing retroviral therapy. After analyzing age of gestation, the start of drug therapy, CD4+ count, and viral load, it underlined the following data: if the viral load was under 10,000 copies/ml until a gestational age of 26.3 weeks, the purpose to achieve 50 copies/ml could be reached. When the viral load was more than 10,000 copies/ml before 20.4 weeks of gestation, the purpose to obtain less than 50 copies/ml until birth was compromised. The level of 50 copies/ml was obtained in 292 pregnancies from a total number of 378 [35].

Zidovudine (dideoxynucleoside reverse transcriptase inhibitors) is the most used antiretroviral drug during pregnancy. Even if there are other types of dideoxynucleoside reverse transcriptase inhibitors (didanosine, zalcitabine, stavudine, lamivudine) with the same action mechanism, they are differentiated by the intracellular phosphorylation and kinetics which lead to other types of side effects/toxicity [36].

**8. Personal contribution**

section.

child transmission, there were 480 cases reported [42].

and 3% single, and 2% have never received treatment.

ian 160 cases and vaginal birth 28 cases.

child were declared healthy.

seven were HIV positive.

Romania continues to have a high percentage of HIV infection. In June 2017 UNAID reported a total number of 9074 seropositive women. Data were collected between 1985 and 2017. The group age 15–39 years is presenting the higher incidence—2147 cases. Regarding mother-to-

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 31

We conducted a 10-year (January 2008–December 2017) retrospective study on 203 pregnant seropositive women, ages between 15 and 41 (average age 24 years), under surveillance at the Hospital for Infectious Diseases, Constanta County. The HIV rate of transmission was 5.8%. From all HIV-positive children, 11 were birth by vaginal delivery and just 1 by caesarian

The main purpose was to establish new ways of preventing mother-to-child transmission and to encourage HIV testing as a normal routine screening during pregnancy, even in healthy women. Health status was compromised in all females included in evaluation; 100% had anemia (laboratory inferior limit is 11.7 mg/dl); 32 had values under 8 mg/dl. Coinfection with human papilloma virus (14) and toxoplasmosis (1) was detected in 7.02%. During the third trimester, only four women had undetectable peripheral blood viral load. Levels of CD4+ had values under 500 copies/ml in 116 cases. The HIV stage during pregnancy had been A1, 14 cases; A2, 15 cases; A3, 2 cases; B1, 16 cases; B2, 26 cases; B3, 5 cases; C1, 40 cases; C2, 51 cases; and C3, 27 cases. Seventy-five percent underwent triple antiretroviral therapy, 20% double,

Not all patients had reported to the scheduled evaluation; therefore, only in 188 pregnant seropositive females we collected concrete data. Delivery management was divided in caesar-

Analyzing our patients regarding coinfections, we noticed one HIV pregnant women with

Caesarian section was elected in 28 seropositive women with HCV or HBV coinfection. Two HIV-positive women with coinfection elected vaginal birth. All 30 children were healthy with no viral infections. Caesarian was elected as the proper method of delivery in genital warts and syphilis coinfection. In order to minimize the risk of syphilis transmission, the newborn and mother received Penicillin G treatment. After receiving the correct treatment, mother and

In eight cases children were breastfed after delivery. One was HIV negative and the other

As we analyzed in the previous discussions, preterm delivery is frequently encountered. In our study in 60 cases, the delivery was under 37 weeks. Fifty four had weight under 2500 g (the normal inferior weight limit), 28 were preterm, and 26 were declared small for gestational age (it represents the infants born over 37 weeks but with weight under the inferior normal limit). Nine mothers had died due to HIV complications and lack of treatment compliance, after a medium period of 32 months after birth. Nine infants had died (one at 1 day,

syphilis, other three with genital warts, six with HCV, and 24 with HBV.

Conner et al. evaluated 477 pregnant women seropositive undergoing antiretroviral therapy with zidovudine (antepartum, 100 mg, orally for 5 days; intrapartum 2 mg/kg intravenously until birth). The infant received Zidovudine as well (2 mg/kg, orally for 6 weeks daily). The conclusion is the reducing risk of vertical transmission by 2/3 (70%) of the cases [15, 32, 33, 37].

#### **7. Caesarian vs. natural birth**

At the beginning of the twenty-first century, international study tries to evaluate the adequate pathways to minimize the risk of mother-to-child transmission. In an epidemic period in lowincome countries, death prevalence due to HIV was increasing.

Previous study results had yield contradictory results. Caesarian section after 4 h since the membranes are ruptured could lead to microtransfusion with mother's blood to fetus, increasing the risk of HIV transmission. Ignoring the antiretroviral treatment or late diagnosis made it difficult to affirm that caesarian section could or would drop the risk of HIV transmission [2, 38–40].

The idea of caesarian as method of reducing the risk of transmitting started in France. Duliege et al. observed that in twin pregnancies, the first child to be born has a higher risk of being infected than the second child. One hundred and fifteen twin pairs from HIV-positive females born vaginally or through caesarian section had developed HIV in the following order: vaginal birth, twin A 35% and twin B 15%, and caesarian section, twin A 16% and twin B 8%. The first born from vaginal birth is passing through birth canal in a longer period that the second one. Caesarian section eliminates the risk of contact with blood and vaginal secretions. The main conclusion was that caesarian is a safer method to give birth, preventing the mother-tochild transmission of HIV [36, 40].

International Perinatal HIV Group after analyzing 8533 mother-child pairs established that delivery through caesarian section dropped the risk of HIV transmission with 50% compared with other types of delivery. The percentage was even higher if the seropositive female followed antiretroviral therapy correctly. The combination antiretroviral therapy plus caesarian section before or shortly after membrane ruptures had dropped the transmission with 87% [3].

European Mode of Delivery Collaboration in 1999 after evaluating 370 infants from mothers without any type of delivery indication underlined an 80% reduction of the risk of transmitting HIV in females who gave birth through elective caesarian section [5].

American College of Obstetricians and Gynecologists recommended caesarian section as a prompt intervention in diminishing the mother-to-child transmitting HIV, especially when the peripheral blood count is greater than 1000 copies/ml. The intervention should be established at exact 38 weeks (1 week earlier as in healthy pregnancies), preventing labor or ruptured membranes. Viral load would be analyzed at every 3 months or every time the therapy is changing. Amniocentesis should be avoided in HIV pregnant women [41].

## **8. Personal contribution**

mechanism, they are differentiated by the intracellular phosphorylation and kinetics which

Conner et al. evaluated 477 pregnant women seropositive undergoing antiretroviral therapy with zidovudine (antepartum, 100 mg, orally for 5 days; intrapartum 2 mg/kg intravenously until birth). The infant received Zidovudine as well (2 mg/kg, orally for 6 weeks daily). The conclusion is the reducing risk of vertical transmission by 2/3 (70%) of the cases [15, 32, 33, 37].

At the beginning of the twenty-first century, international study tries to evaluate the adequate pathways to minimize the risk of mother-to-child transmission. In an epidemic period in low-

Previous study results had yield contradictory results. Caesarian section after 4 h since the membranes are ruptured could lead to microtransfusion with mother's blood to fetus, increasing the risk of HIV transmission. Ignoring the antiretroviral treatment or late diagnosis made it difficult to affirm that caesarian section could or would drop the risk of HIV transmission

The idea of caesarian as method of reducing the risk of transmitting started in France. Duliege et al. observed that in twin pregnancies, the first child to be born has a higher risk of being infected than the second child. One hundred and fifteen twin pairs from HIV-positive females born vaginally or through caesarian section had developed HIV in the following order: vaginal birth, twin A 35% and twin B 15%, and caesarian section, twin A 16% and twin B 8%. The first born from vaginal birth is passing through birth canal in a longer period that the second one. Caesarian section eliminates the risk of contact with blood and vaginal secretions. The main conclusion was that caesarian is a safer method to give birth, preventing the mother-to-

International Perinatal HIV Group after analyzing 8533 mother-child pairs established that delivery through caesarian section dropped the risk of HIV transmission with 50% compared with other types of delivery. The percentage was even higher if the seropositive female followed antiretroviral therapy correctly. The combination antiretroviral therapy plus caesarian section before or shortly after membrane ruptures had dropped the transmission with 87% [3]. European Mode of Delivery Collaboration in 1999 after evaluating 370 infants from mothers without any type of delivery indication underlined an 80% reduction of the risk of transmit-

American College of Obstetricians and Gynecologists recommended caesarian section as a prompt intervention in diminishing the mother-to-child transmitting HIV, especially when the peripheral blood count is greater than 1000 copies/ml. The intervention should be established at exact 38 weeks (1 week earlier as in healthy pregnancies), preventing labor or ruptured membranes. Viral load would be analyzed at every 3 months or every time the therapy

ting HIV in females who gave birth through elective caesarian section [5].

is changing. Amniocentesis should be avoided in HIV pregnant women [41].

lead to other types of side effects/toxicity [36].

income countries, death prevalence due to HIV was increasing.

**7. Caesarian vs. natural birth**

child transmission of HIV [36, 40].

[2, 38–40].

30 Caesarean Section

Romania continues to have a high percentage of HIV infection. In June 2017 UNAID reported a total number of 9074 seropositive women. Data were collected between 1985 and 2017. The group age 15–39 years is presenting the higher incidence—2147 cases. Regarding mother-tochild transmission, there were 480 cases reported [42].

We conducted a 10-year (January 2008–December 2017) retrospective study on 203 pregnant seropositive women, ages between 15 and 41 (average age 24 years), under surveillance at the Hospital for Infectious Diseases, Constanta County. The HIV rate of transmission was 5.8%. From all HIV-positive children, 11 were birth by vaginal delivery and just 1 by caesarian section.

The main purpose was to establish new ways of preventing mother-to-child transmission and to encourage HIV testing as a normal routine screening during pregnancy, even in healthy women. Health status was compromised in all females included in evaluation; 100% had anemia (laboratory inferior limit is 11.7 mg/dl); 32 had values under 8 mg/dl. Coinfection with human papilloma virus (14) and toxoplasmosis (1) was detected in 7.02%. During the third trimester, only four women had undetectable peripheral blood viral load. Levels of CD4+ had values under 500 copies/ml in 116 cases. The HIV stage during pregnancy had been A1, 14 cases; A2, 15 cases; A3, 2 cases; B1, 16 cases; B2, 26 cases; B3, 5 cases; C1, 40 cases; C2, 51 cases; and C3, 27 cases. Seventy-five percent underwent triple antiretroviral therapy, 20% double, and 3% single, and 2% have never received treatment.

Not all patients had reported to the scheduled evaluation; therefore, only in 188 pregnant seropositive females we collected concrete data. Delivery management was divided in caesarian 160 cases and vaginal birth 28 cases.

Analyzing our patients regarding coinfections, we noticed one HIV pregnant women with syphilis, other three with genital warts, six with HCV, and 24 with HBV.

Caesarian section was elected in 28 seropositive women with HCV or HBV coinfection. Two HIV-positive women with coinfection elected vaginal birth. All 30 children were healthy with no viral infections. Caesarian was elected as the proper method of delivery in genital warts and syphilis coinfection. In order to minimize the risk of syphilis transmission, the newborn and mother received Penicillin G treatment. After receiving the correct treatment, mother and child were declared healthy.

In eight cases children were breastfed after delivery. One was HIV negative and the other seven were HIV positive.

As we analyzed in the previous discussions, preterm delivery is frequently encountered. In our study in 60 cases, the delivery was under 37 weeks. Fifty four had weight under 2500 g (the normal inferior weight limit), 28 were preterm, and 26 were declared small for gestational age (it represents the infants born over 37 weeks but with weight under the inferior normal limit). Nine mothers had died due to HIV complications and lack of treatment compliance, after a medium period of 32 months after birth. Nine infants had died (one at 1 day, one at 12 days, four at 1 month, two at 27 months, and one at 7 months). In eight cases of vaginal birth, the infants' viral load was >10,000 copies/ml. In caesarian section the medium viral load was <50 copies/ml. In two cases we encountered values over 500 copies/ml. In those two situations, mother presented vaginal coinfections, and compliance to treatment is doubtful. In four cases infants were breastfed; three of them were born vaginally, and their mother even if they underwent triple antiretroviral therapy had peripheral viral load over 10,000 copies/ml.

In a study performed between January 2008 and August 2013, we analyze 124 HIV-positive mothers and their newborns. In the studied period, the maternal-fetal rate of HIV transmission was 4.8%.

The mortality rate for children was 5.6% and for mothers was 7.2%. Around 97.5% of the children received antiretroviral treatment after birth, and 93.1% of the mothers received antiretroviral treatment during pregnancy.

The proper health status evaluation in children is by growth charts. It provides information regarding the weight, length, and cranial perimeter. In this study, 22.76% were under the tenth percentile for length and weight, underlying the improper development during in utero life—small for gestational age. In 11.38% we encountered a symmetrical intrauterine delay, represented by weight, length, and cranial perimeter positioned under the tenth percentile.

In this study, we performed a linear regression to find if some parameters of the mothers correlate with difficulties in intrauterine growth appreciate below the level of tenth percentile. We found that the cranial perimeter of children under the percentile of tenth correlates with the hemoglobin value in pregnancy (p = 0.027), the CD4 value in the last trimester of pregnancy (p = 0.003), and the Apgar score (p < 0.0001). The weight of children under the tenth percentile correlates with the CD4 value in the last trimester of pregnancy (p = 0.011), as well as the Apgar score (p < 0.0001). The height of children under the percentile of tenth correlates with the hemoglobin value in pregnancy (p = 0.05), the CD4 value in the last trimester (p = 0.05), and the Apgar score (p < 0.0001). In this study cART duration in pregnancy, duration of gestation, type of delivery (C-section or vaginal delivery), and HIV viral load value do not influence the newborn parameters: weight, length, and cranial perimeter related with tenth percentiles of growth.

Intrauterine growth restriction is often encountered in seropositive females. Our data are sustained by the international literature. Cailhol and Dreyfuss obtained the same results [43–45].

The study performed on 124 children (66 males and 58 females) underlined a mean hemoglobin level of 10.37 mg/dl in male children, with a 1.33 mg/dl standard deviation. In female children, the mean hemoglobin was 10.32 mg/dl with a standard deviation of 1.32 mg/dl (**Figure 1**).

of 35.1 (**Figure 2**). There are no significant differences between the mean CD4 values of the two groups [t = 0.151; df = 122; p = 0.880; the IC 95% for the average is (−81,046; 94,418)].

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 33

The mean cART duration in male children was 28.33 weeks with a standard deviation of 14.095, and in female children, the mean cART duration was 26.74 weeks with a standard deviation of 14.81 (**Figure 3**). There are no significant differences of the mean cART duration between the

two groups [t = 0.613; df = 122; p = 0.541; the IC 95% for the average is (−3551; 6735)].

**Figure 1.** Mean hemoglobin level in pregnancy according with newborn sex.

**Figure 2.** Mean CD4 count in mothers according with newborn sex.

There are significant differences between the mean hemoglobin values of the two groups [p = 0.196; df = 122; p = 0.845; the 95% confidence interval (IC) for the average is (−0.42; 0.51)].

The mean CD4 value in male children was 421.15 cells/mmc with a standard deviation of 27.83, and in female children, the mean CD4 was 414.46 cells/mmc with a standard deviation

**Figure 1.** Mean hemoglobin level in pregnancy according with newborn sex.

one at 12 days, four at 1 month, two at 27 months, and one at 7 months). In eight cases of vaginal birth, the infants' viral load was >10,000 copies/ml. In caesarian section the medium viral load was <50 copies/ml. In two cases we encountered values over 500 copies/ml. In those two situations, mother presented vaginal coinfections, and compliance to treatment is doubtful. In four cases infants were breastfed; three of them were born vaginally, and their mother even if they underwent triple antiretroviral therapy had peripheral viral load over

In a study performed between January 2008 and August 2013, we analyze 124 HIV-positive mothers and their newborns. In the studied period, the maternal-fetal rate of HIV transmis-

The mortality rate for children was 5.6% and for mothers was 7.2%. Around 97.5% of the children received antiretroviral treatment after birth, and 93.1% of the mothers received anti-

The proper health status evaluation in children is by growth charts. It provides information regarding the weight, length, and cranial perimeter. In this study, 22.76% were under the tenth percentile for length and weight, underlying the improper development during in utero life—small for gestational age. In 11.38% we encountered a symmetrical intrauterine delay, represented by weight, length, and cranial perimeter positioned under the tenth

In this study, we performed a linear regression to find if some parameters of the mothers correlate with difficulties in intrauterine growth appreciate below the level of tenth percentile. We found that the cranial perimeter of children under the percentile of tenth correlates with the hemoglobin value in pregnancy (p = 0.027), the CD4 value in the last trimester of pregnancy (p = 0.003), and the Apgar score (p < 0.0001). The weight of children under the tenth percentile correlates with the CD4 value in the last trimester of pregnancy (p = 0.011), as well as the Apgar score (p < 0.0001). The height of children under the percentile of tenth correlates with the hemoglobin value in pregnancy (p = 0.05), the CD4 value in the last trimester (p = 0.05), and the Apgar score (p < 0.0001). In this study cART duration in pregnancy, duration of gestation, type of delivery (C-section or vaginal delivery), and HIV viral load value do not influence the newborn parameters: weight, length, and cranial perimeter related with

Intrauterine growth restriction is often encountered in seropositive females. Our data are sustained by the international literature. Cailhol and Dreyfuss obtained the same results [43–45]. The study performed on 124 children (66 males and 58 females) underlined a mean hemoglobin level of 10.37 mg/dl in male children, with a 1.33 mg/dl standard deviation. In female children, the mean hemoglobin was 10.32 mg/dl with a standard deviation of 1.32 mg/dl (**Figure 1**).

There are significant differences between the mean hemoglobin values of the two groups [p = 0.196; df = 122; p = 0.845; the 95% confidence interval (IC) for the average is (−0.42; 0.51)]. The mean CD4 value in male children was 421.15 cells/mmc with a standard deviation of 27.83, and in female children, the mean CD4 was 414.46 cells/mmc with a standard deviation

10,000 copies/ml.

32 Caesarean Section

sion was 4.8%.

percentile.

tenth percentiles of growth.

retroviral treatment during pregnancy.

**Figure 2.** Mean CD4 count in mothers according with newborn sex.

of 35.1 (**Figure 2**). There are no significant differences between the mean CD4 values of the two groups [t = 0.151; df = 122; p = 0.880; the IC 95% for the average is (−81,046; 94,418)].

The mean cART duration in male children was 28.33 weeks with a standard deviation of 14.095, and in female children, the mean cART duration was 26.74 weeks with a standard deviation of 14.81 (**Figure 3**). There are no significant differences of the mean cART duration between the two groups [t = 0.613; df = 122; p = 0.541; the IC 95% for the average is (−3551; 6735)].

**Figure 3.** Mean cART duration in pregnancy according with newborn sex.

**Figure 4.** Cranial perimeter according with newborn sex.

The mean cranial perimeter in all studied newborn was 32.5 cm with a standard deviation of 2.13939. In male children the mean cranial perimeter was 32.5 cm with a standard deviation of 1.95503, and in female children, the mean cranial perimeter was 32.5 cm with a standard deviation of 2.34895 (**Figure 4**). The obtained cranial perimeters correspond to 3–5th percentiles on growth charts.

The mean length in newborn from HIV-positive mothers was 47.7258, with a standard deviation of 2.67885. In male children it was 47.9 cm with a standard deviation of 2,66,445, and in female children it was 47.51 cm with a standard deviation of 2.70309 (**Figure 5**). These length

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 35

values correspond to 10–25th percentiles on growth charts.

**Figure 5.** Length according with newborn sex.

**Figure 6.** Weight according with newborn sex.

**Figure 5.** Length according with newborn sex.

**Figure 6.** Weight according with newborn sex.

The mean cranial perimeter in all studied newborn was 32.5 cm with a standard deviation of 2.13939. In male children the mean cranial perimeter was 32.5 cm with a standard deviation of 1.95503, and in female children, the mean cranial perimeter was 32.5 cm with a standard deviation of 2.34895 (**Figure 4**). The obtained cranial perimeters correspond to 3–5th percen-

tiles on growth charts.

34 Caesarean Section

**Figure 4.** Cranial perimeter according with newborn sex.

**Figure 3.** Mean cART duration in pregnancy according with newborn sex.

The mean length in newborn from HIV-positive mothers was 47.7258, with a standard deviation of 2.67885. In male children it was 47.9 cm with a standard deviation of 2,66,445, and in female children it was 47.51 cm with a standard deviation of 2.70309 (**Figure 5**). These length values correspond to 10–25th percentiles on growth charts.

The mean weight in male children was 2734.69 g with a standard deviation of 436,65,942, and in female children, the mean weight perimeter was 2677,4138 g with a standard deviation of 542,33,918 (**Figure 6**). These weight values correspond to 5–10th percentiles on growth charts.

[4] Villari P, Spino C, Chalmers TC, Lau J, Sacks HS. Cesarean section to reduce perinatal transmission of human immunodeficiency virus. A metaanalysis. The Online Journal of

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 37

[5] European Mode of Delivery Collaboration. Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: A randomised clinical trial.

[6] Ashley T Peterson. HIV in pregnancy. https://emedicine.medscape.com/article/1385488-

[7] World Health Organization. WHO Statement on Caesarean Section Rates 2015. Geneva, Switzerland: WHO; 2015. http://apps.who.int/iris/bitstream/10665/161442/1/WHO\_RHR\_

[8] https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/24/70/hiv-medicines-

[9] Committee on Infectious Diseases American Academy of Pediatrics, Reed Book, 2012 Report of the committee on infectious diseases 29th Edition, ISSN No. 1080-0131, ISBN

[10] Fauci AS. Pathogenesis of HIV disease: Opportunities for new prevention interventions. Clinical Infectious Diseases. 15 December 2007;**45**(Supplement 4):S206-S212. DOI:

[11] WHO PMTCT Guidelines 2014. https://www.google.cm/?gws\_rd=cr&ei=Y5Q4VvvuIaf9 ywOBzoK4DQ#q=who+pmtct+guidelines+2014 [Accessed: February 20, 2018, 20:35]

[12] Downs AM, De Vincenzi I. Probability of heterosexual transmission of HIV: Relationship to number of unprotected sexual contacts. European Study Group in Heterosexual Transmission of HIV. Journal of Acquired Immune Deficiency Syndromes.

[13] Royce RA, Sena A, Cates W, Cohen M. Sexual transmission of HIV. The New England

[14] Soto-Ramirez LE, Renjifo B, McLane MF, et al. HIV-1 Langerhans' cell tropism associ-

[15] McIntyre J. HIV in pregnancy: A review, WHO/RHT/98.24 UNAIDS/98.44 Distr.: General

[16] Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Diagnosis of HIV Infection in Infants and Children. Last Updated: November 15, 2017; Last Reviewed: November 15, 2017, https://aidsinfo.nih.gov/guidelines/html/2/pediatric-arv/55/diagno-

sis-of-hiv-infection-in-infants-and-children [Accessed: February 25, 2018, 08:20]

Transmitted Infections. 2004;**80**:167-173. DOI: 10.1136/sti.2003.008441

[17] Mitchell HS, Stephens E. Contraception choice for HIV positive women. Sexually

ated with heterosexual transmission of HIV. Science. 1996;**271**:1291-1293

Current Clinical Trials. 1993 Jul 8;Doc No 74:[5107 words; 46 paragraphs]

overview, Updated in September 2017 [Accessed: February 19, 2018, 19:14]

15.02\_eng.pdf?ua=1 [Accessed: February 19, 2018, 20:03]

Lancet. 1999 Mar 27;**353**(9158):1035-1039

during-pregnancy-and-childbirth

10.1086/522540

1996;**11**:388-395

No. 978-1-58110-703-6 MA0625, pp. 418-439

Journal of Medicine. 1997;**336**(15):1072-1078

#### **9. Conclusions**

HIV infection continues to be an important public health problem worldwide due to its cost, morbidity, and mortality. Antenatal screening for HIV should be implemented for every woman as the easier method available to reduce transmission, especially mother-to-child transmission.

Although in our study C-section did not make a clear delimitation between HIV-positive and HIV-negative children, it seems that in children born from HIV-positive mothers with high HIV viral load, delivery by C-section is mandatory.

Although the indication of C-section in HIV-positive women is controversial, in situations in which HIV viral load is high or is not affordable near the time of delivery, and in mothers with poor adherence to antiretroviral treatment, C-section remains one of the most important measures of prevention for HIV mother-to-child transmission.

### **Author details**

Simona Claudia Cambrea\* and Anca Daniela Pinzaru

\*Address all correspondence to: cambrea.claudia@gmail.com

Faculty of Medicine, Ovidius University, Constanta, Romania

#### **References**


[4] Villari P, Spino C, Chalmers TC, Lau J, Sacks HS. Cesarean section to reduce perinatal transmission of human immunodeficiency virus. A metaanalysis. The Online Journal of Current Clinical Trials. 1993 Jul 8;Doc No 74:[5107 words; 46 paragraphs]

The mean weight in male children was 2734.69 g with a standard deviation of 436,65,942, and in female children, the mean weight perimeter was 2677,4138 g with a standard deviation of 542,33,918 (**Figure 6**). These weight values correspond to 5–10th percentiles on growth

HIV infection continues to be an important public health problem worldwide due to its cost, morbidity, and mortality. Antenatal screening for HIV should be implemented for every woman as the easier method available to reduce transmission, especially mother-to-child

Although in our study C-section did not make a clear delimitation between HIV-positive and HIV-negative children, it seems that in children born from HIV-positive mothers with high

Although the indication of C-section in HIV-positive women is controversial, in situations in which HIV viral load is high or is not affordable near the time of delivery, and in mothers with poor adherence to antiretroviral treatment, C-section remains one of the most important

[1] UNAIDS. Country factsheets. Romania 2016. http://www.unaids.org/en/regionscoun-

[2] Read JS, Newell MK. Efficacy and safety of cesarean delivery for prevention of mother-tochild transmission of HIV-1. Cochrane Database of Systematic Reviews. 2005;**4**:CD005479 [3] International Perinatal HIV Group, Andiman W, Bryson Y, de Martino M, Fowler M, Harris D, Hutto C, Korber B, Kovacs A, Landesman S, Lindsay M, Lapointe N, Mandelbrot L, Newell M-L, Peavy H, Read J, Rudin C, Semprini A, Simonds R, Tuomala R. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1—A meta-analysis of 15 prospective cohort studies. The New England Journal of

charts.

36 Caesarean Section

**9. Conclusions**

transmission.

**Author details**

**References**

HIV viral load, delivery by C-section is mandatory.

Simona Claudia Cambrea\* and Anca Daniela Pinzaru

Medicine. 1999 Apr 1;**340**(13):977-987

\*Address all correspondence to: cambrea.claudia@gmail.com Faculty of Medicine, Ovidius University, Constanta, Romania

tries/countries/romania [Accessed: February 19, 2018, 18:52]

measures of prevention for HIV mother-to-child transmission.


[18] Morrison CS, Richardson BA, Mmiro F, Chipato T, Celentano DD, Luoto J, Mugerwa R, Padian N, Rugpao S, Brown JM, Cornelisse P, Salata RA, Hormonal Contraception and the Risk of HIV Acquisition (HC-HIV) Study Group. Hormonal contraception and the risk of HIV acquisition. AIDS. 2007 Jan 2;**21**(1):85-95. https://www.ncbi.nlm.nih.gov/ pubmed/17148972/ [Accessed: February 20, 2018, 22:24]

[29] Ahr A, Rody A, Cimposiau C, Faul-Burbes C, Kissler S, Kaufmann M, Gätje R. Cervical cancer screening of HIV-positive women: Is a prolongation of the screening interval

Value of Caesarian Section in HIV-Positive Women http://dx.doi.org/10.5772/intechopen.76883 39

[30] Halichidis S, Cambrea SC, Resul G, Mocanu L, Costandache I, Ceamitru N, Arghir OC. Correlations between Babes Papanicolaou's findings and immunosuppression in human immunodeficiency virus infected women. Gyneco.eu. 2013;**9**(3):122-127, ISSN:

[31] Aagaard-Tillery KM, Lin MG, Lupo V, Buchbinder A, Ramsey PS. Preterm premature rupture of membranes in human immunodeficiency virus-infected women: A novel case series. Infectious Diseases in Obstetrics and Gynecology. 2006;**2006**:53234. Published

[32] Panel on treatment of HIV-infected pregnant women and prevention of perinatal transmission. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Oct 24, 2016. Available from: http://aidsinfo.nih.gov/contentfiles/

lvguidelines/AdultandAdolescentGL.pdf [Accessed: February 21, 2018, 22:25]

[33] Madhu Chhanda Choudhary, Antiretroviral therapy (ART) in pregnant women with HIV infection overview of HIV antiretroviral therapy (ART) in pregnancy. https://emedicine.medscape.com/article/2042311-overview#a2 [Accessed: February 21, 2018, 22:26]

[34] Mandelbrot L, Tubiana R, Le Chenadec J, Dollfus C, Faye A, Pannier E, Matheron S, Khuong MA, Garrait V, Reliquet V, Devidas A, Berrebi A, Allisy C, Elleau C, Arvieux C, Rouzioux C, Warszawski J, Blanche S, ANRS-EPF Study Group. No perinatal HIV-1 transmission from women with effective antiretroviral therapy starting before conception. Clinical Infectious Diseases. 2015 Dec 1;**61**(11):1715-1725. DOI: 10.1093/cid/civ578.

[35] Read PJ, Mandalia S, Khan P, Harrisson U, Naftalin C, Gilleece Y, Anderson J, Hawkins DA, Taylor GP, de Ruiter A, London HIV Perinatal Research Group. When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery?

[36] Sperling R.Zidovudine. Infectious Diseases in Obstetrics and Gynecology. 1998;**6**:197-203.

[37] Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O'Sullivan MJ, VanDyke R, Bey M, Shearer W, Jacobson RL. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. The New England Journal of Medicine. 1994;**331**(18):

[38] Denise J. Jamieson, Jennifer S. Read, Athena P. Kourtis, Tonji M. Durant, Margaret A. Lampe, Kenneth L. Dominguez. Cesarean delivery for HIV-infected women: Recommendations and controversies. Supplement to September 2007. http://www.ajog.org/

article/S0002-9378(07)00270-0/pdf [Accessed: February 23, 2018, 00:08]

AIDS. 2012 Jun 1;**26**(9):1095-1103. DOI: 10.1097/QAD.0b013e3283536a6c

meaningful? Zentralblatt für Gynäkologie. 2006 Oct;**128**(5):242-245

online 2006 Apr 20. DOI: 10.1155/IDOG/2006/53234

1841-4435

Epub 2015 Jul 21

Wiley-Liss, Inc

1173-1180. (ISSN: 0028-4793)


[29] Ahr A, Rody A, Cimposiau C, Faul-Burbes C, Kissler S, Kaufmann M, Gätje R. Cervical cancer screening of HIV-positive women: Is a prolongation of the screening interval meaningful? Zentralblatt für Gynäkologie. 2006 Oct;**128**(5):242-245

[18] Morrison CS, Richardson BA, Mmiro F, Chipato T, Celentano DD, Luoto J, Mugerwa R, Padian N, Rugpao S, Brown JM, Cornelisse P, Salata RA, Hormonal Contraception and the Risk of HIV Acquisition (HC-HIV) Study Group. Hormonal contraception and the risk of HIV acquisition. AIDS. 2007 Jan 2;**21**(1):85-95. https://www.ncbi.nlm.nih.gov/

[19] Baeten JM, Lavreys L, Sagar M, Kreiss JK, Richardson BA, Chohan B, Panteleeff D, Mandaliya K, Ndinya-Achola JO, Overbaugh J, Farley T, Mwachari C, Cohen C, Chipato T, Jaisamrarn U, Kiriwat O, Duerr A. Effect of contraceptive methods on natural history of HIV: Studies from the Mombasa cohort. Journal of Acquired Immune Deficiency Syndromes. 2005 Mar;**38**(Suppl 1):S18-S21. https://www.ncbi.nlm.nih.gov/

[20] Stringer E, Antonsen E. Hormonal contraception and HIV disease progression. Clinical

[21] World Health Organization. HIV among Pregnant Women, Infants, and Children. https:// www.cdc.gov/hiv/group/gender/pregnantwomen/index.html [Accessed: February 19,

[22] Hocke C, Chene G, Dequae L, Dabis F. Prospective cohort study of the effect of pregnancy on the progression of human immunodeficiency virus infection. Obstetrics &

[23] Sutton MY, Holland B, Denny TN, Garcia A, Garcia Z, Stein D, Bardeguez AD. Effect of pregnancy and human immunodeficiency virus infection on intracellular interleukin-2 production patterns. Clinical and Diagnostic Laboratory Immunology. 2004 Jul;**11**(4):

[24] Joao EC, Gouvêa MI, Menezes JA, Matos HJ, Cruz ML, Rodrigues CA, de Souza MJ, Fracalanzza SE, Botelho AC, Calvet GA, Grinsztejn BG. Group B *Streptococcus* in a cohort of HIV-infected pregnant women: Prevalence of colonization, identification and antimicrobial susceptibility profile. Scandinavian Journal of Infectious Diseases. 2011

[25] Minnar A, Bodkin C. The Pocket Guide for HIV and AIDS Nursing Care, HIV in

[26] Halichidis S, Cambrea SC, Ilie MM, Irimiea L, Arghir OC. Clinical and ethical issue regarding early cesarean section in HIV young woman with severe TB disease. Gyneco.

[27] Reitter A, Stücker AU, Linde R, Königs C, Knecht G, Herrmann E, Schlößer R, Louwen F, Haberl A. Pregnancy complications in HIV-positive women: 11-year data from the Frankfurt HIV cohort. HIV Medicine. 2014 Oct;**15**(9):525-536. DOI: 10.1111/hiv.12142.

[28] Mbu ER, Kongnyuy EJ, Mbopi-Keou FX, Tonye RN, Nana PN, Leke RJ. Gynaecological morbidity among HIV positive pregnant women in Cameroon. Reproductive Health.

Sep;**43**(9):742-746. DOI: 10.3109/00365548.2011.585178. Epub 2011 Jun 15

Pregnancy. Cape Town, South Africa: Juta and Co; 2006. pp. 124-131

pubmed/17148972/ [Accessed: February 20, 2018, 22:24]

pubmed/15867603/ [Accessed: February 20, 2018, 22:25]

Gynecology. December 1995;**86**(6):886-891

780-785. DOI: 10.1128/CDLI.11.4.780-785.2004

eu. 2013;**9**(3):142-144, ISSN: 1841-4435

2008 Jul 3;**5**:3. DOI: 10.1186/1742-4755-5-3

Epub 2014 Mar 6

2018, 22:37]

38 Caesarean Section

Infectious Diseases. 2008 Oct 1;**47**(7):945-951. DOI: 10.1086/591697


[39] Zeichner S, Read S. Paediatric HIV Care—Caesarian Section before Labor and Ruptured Membranes. New York, US: Cambridge University Press; 2006. pp. 120-126

**Section 3**

**Surgical Technique**


**Section 3**

**Surgical Technique**

[39] Zeichner S, Read S. Paediatric HIV Care—Caesarian Section before Labor and Ruptured

[40] Duliège AM, Amos CI, Felton S, Biggar RJ, Goedert JJ. Birth order, delivery route, and concordance in the transmission of human immunodeficiency virus type 1 from mothers to twins. International registry of HIV-exposed twins. The Journal of Pediatrics. 1995

[41] American College of Obstetricians and Gynecologists. Scheduled cesarean delivery and the prevention of vertical transmission of HIV infection: ACOG committee opinion no.: 219: Committee on obstetric practice. International Journal of Gynaecology and

[42] HIV/AIDS infection in Romania 30 June 2017. The data is collected from the HIV/AIDS confirmation charts, sent by the nine Regional Centers for Evaluation and Monitoring of HIV/AIDS Data and further processed by Compartment for Monitoring and Evaluation of HIV/AIDS data in Romania, in National Institute for Infectious Diseases "Prof. Dr. Matei Bals". http://www.cnlas.ro/images/doc/30062017\_eng.pdf [Accessed: February 24,

[43] Caihol J, Jourdain G, Coeur SL, Traisathit P, Boonrod K, Prommas S, Putiyaaun C, Kanajanasing A, Lallemant M. Association of low CD4 cell count and intrauterine growth retardation in Thailand. Journal of Acquired Immune Deficiency Syndromes.

[44] Dreyfuss ML, Msamanga GI, Spiegelman D, Hunter DJ, Urassa EJ, Hertzmark E, Fawzi WW. Determinants of low birth weight among HIV infected pregnant women in

[45] Cambrea SC, Tanase DE, Ilie MM, Diaconu S, MArcas C, Carp DS, Halichidis S, Petcu CL. Can HIV cause an intrauterine growth restriction? BMC Infectious Diseases.

Tanzania. The American Journal of Clinical Nutrition. 2001;**74**(6):814-826

2009;**50**(4):409-413. DOI: 10.1097/QAI.0b013e3181958560

2013;**13**(Suppl 1):O5. DOI: 10.1186/1471-2334-13-S1-O5

Membranes. New York, US: Cambridge University Press; 2006. pp. 120-126

Apr;**126**(4):625-632

40 Caesarean Section

2018, 00:41]

Obstetrics. 1999;**66**:305-306

**Chapter 4**

**Provisional chapter**

**The Surgical Technique of Caesarean Section: What is**

**The Surgical Technique of Caesarean Section: What is** 

Caesarean section is the most frequent obstetric operation which is associated with increased maternal morbidity and mortality. Although these risks are low, affected women may suffer from severe consequences and this may affect subsequent pregnancies and deliveries. A variety of surgical approaches have been described, however, on low evidence level. The objective of this chapter is therefore to systematically search the literature and analyse the available evidence including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin. We systematically searched for meta-analysis, systematic reviews, and big studies and evaluated the evi-

**Keywords:** techniques of caesarean section, level of evidence, meta-analysis,

A caesarean section is a common surgical procedure indicated when complications arise during pregnancy or labour such as suspected foetal distress, breech presentation, failure to progress in labour in macrosomia or in some cases of previous caesarean section. Although maternal and foetal mortality and morbidity have become low, it is associated with substantial short- and long-term maternal and neonatal risks such as bleeding, thrombosis and

> © 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.78040

**Evidence Based?**

**Evidence Based?**

Jan-Simon Lanowski and Constantin S. von Kaisenberg

**Abstract**

Jan-Simon Lanowski and Constantin S. von Kaisenberg

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.78040

dence for each individual step.

**1. Various approaches of caesarean section**

systematic review

#### **The Surgical Technique of Caesarean Section: What is Evidence Based? The Surgical Technique of Caesarean Section: What is Evidence Based?**

DOI: 10.5772/intechopen.78040

Jan-Simon Lanowski and Constantin S. von Kaisenberg Jan-Simon Lanowski and Constantin S. von Kaisenberg

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.78040

#### **Abstract**

Caesarean section is the most frequent obstetric operation which is associated with increased maternal morbidity and mortality. Although these risks are low, affected women may suffer from severe consequences and this may affect subsequent pregnancies and deliveries. A variety of surgical approaches have been described, however, on low evidence level. The objective of this chapter is therefore to systematically search the literature and analyse the available evidence including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin. We systematically searched for meta-analysis, systematic reviews, and big studies and evaluated the evidence for each individual step.

**Keywords:** techniques of caesarean section, level of evidence, meta-analysis, systematic review

#### **1. Various approaches of caesarean section**

A caesarean section is a common surgical procedure indicated when complications arise during pregnancy or labour such as suspected foetal distress, breech presentation, failure to progress in labour in macrosomia or in some cases of previous caesarean section. Although maternal and foetal mortality and morbidity have become low, it is associated with substantial short- and long-term maternal and neonatal risks such as bleeding, thrombosis and

© 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.

embolism, infection and sepsis, and injury to the bladder and bowel. Caesarean section also has the potential for major complications in subsequent pregnancies, in particular uterine scar rupture, placenta praevia totalis, placenta percreta, and placental abruption [1, 2]. But most importantly and of major interest are increased risks for the baby such as asthma up to the age of 12 years and obesity up to the age of 5 years. Also the risks for miscarriage and stillbirth are increased, but not perinatal mortality [2].

The frequency of caesarean sections has increased dramatically worldwide within the last two to three decades, especially in middle- and high-income countries [3]. The reasons are multifactorial and factors such as fear of pain, loss of the preservation of the love channel, the misconception that CS is safer for the baby, convenience for both health professionals and the mother and family, increasing fear of medical litigation, and reduced tolerance of complications or adverse outcomes other than the perfect baby [4]. Improvements in surgical techniques, availability of blood products, anaesthesia, and infection control have reduced the threshold to indicate caesarean section [5].

Recent rates of caesarean sections have been reported with 24.5% in Western Europe, 32% in North America, and 41% in South America [1, 6].

Although one of the most commonly practiced operation a consensus on the most appropriate technique has not yet been reached, mostly because well-designed studies and solid evidence have been sparse.

**Figure 1.** This is a 37 year old IG0P at 38 weeks and 5 days.

The Surgical Technique of Caesarean Section: What is Evidence Based?

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45

**Figure 2.** Indicates the skin incision.

There are different techniques described such as the classic Pfannenstiel-Kerr technique, the Joel-Cohen method, and the Misgav Ladach technique [7].

There are many ways to perform a caesarean section. The **Pfannenstiel-Kerr** technique consists of the Pfannenstiel incision (**Figures 1**–**3**), which is a transverse skin incision, two fingers above the symphysis pubis, which is extended in the direction of the anterior superior iliac spine (ASIS), and ends 2–3 cm medial to ASIS on both sides [8]. The subcutaneous layer is opened via sharp dissection followed by a sharp extension of the fascia, a sharp superficial uterine incision, and then blunt entry. The placenta is removed manually, and the uterine closure is made by an interrupted single layer closure. The peritoneum is closed, and the fascia is interruptedly closed, followed by omittance of suturing of the subcutaneous layer and continuous suture of the skin.

In the **Joel-Cohen** technique, the skin incision is placed 3 cm above the original Pfannenstiel incision, the subcutaneous tissue is incised only in the three most medial centimetres, and the lateral tissue is separated manually, before the fascia is divided bluntly with both index fingers inserted in the deep fascial space created by the knife. Then, the peritoneum is opened bluntly with fingers, the uterine cavity is incised, and the incision is extended bluntly laterally by two fingers [9]. The placenta is delivered spontaneously, after delivery of the baby [10]. The uterine closure is made by a single interrupted layer, the peritoneal closure is omitted, and the fascial closure is also interrupted. The subcutaneous suture is omitted, and the skin is sutured continuously (**Figures 4** and **5**). The Joel-Cohen technique is claimed to be faster to The Surgical Technique of Caesarean Section: What is Evidence Based? http://dx.doi.org/10.5772/intechopen.78040 45

**Figure 1.** This is a 37 year old IG0P at 38 weeks and 5 days.

embolism, infection and sepsis, and injury to the bladder and bowel. Caesarean section also has the potential for major complications in subsequent pregnancies, in particular uterine scar rupture, placenta praevia totalis, placenta percreta, and placental abruption [1, 2]. But most importantly and of major interest are increased risks for the baby such as asthma up to the age of 12 years and obesity up to the age of 5 years. Also the risks for miscarriage and stillbirth are

The frequency of caesarean sections has increased dramatically worldwide within the last two to three decades, especially in middle- and high-income countries [3]. The reasons are multifactorial and factors such as fear of pain, loss of the preservation of the love channel, the misconception that CS is safer for the baby, convenience for both health professionals and the mother and family, increasing fear of medical litigation, and reduced tolerance of complications or adverse outcomes other than the perfect baby [4]. Improvements in surgical techniques, availability of blood products, anaesthesia, and infection control have reduced the

Recent rates of caesarean sections have been reported with 24.5% in Western Europe, 32% in

Although one of the most commonly practiced operation a consensus on the most appropriate technique has not yet been reached, mostly because well-designed studies and solid evidence

There are different techniques described such as the classic Pfannenstiel-Kerr technique, the

There are many ways to perform a caesarean section. The **Pfannenstiel-Kerr** technique consists of the Pfannenstiel incision (**Figures 1**–**3**), which is a transverse skin incision, two fingers above the symphysis pubis, which is extended in the direction of the anterior superior iliac spine (ASIS), and ends 2–3 cm medial to ASIS on both sides [8]. The subcutaneous layer is opened via sharp dissection followed by a sharp extension of the fascia, a sharp superficial uterine incision, and then blunt entry. The placenta is removed manually, and the uterine closure is made by an interrupted single layer closure. The peritoneum is closed, and the fascia is interruptedly closed, followed by omittance of suturing of the subcutaneous layer

In the **Joel-Cohen** technique, the skin incision is placed 3 cm above the original Pfannenstiel incision, the subcutaneous tissue is incised only in the three most medial centimetres, and the lateral tissue is separated manually, before the fascia is divided bluntly with both index fingers inserted in the deep fascial space created by the knife. Then, the peritoneum is opened bluntly with fingers, the uterine cavity is incised, and the incision is extended bluntly laterally by two fingers [9]. The placenta is delivered spontaneously, after delivery of the baby [10]. The uterine closure is made by a single interrupted layer, the peritoneal closure is omitted, and the fascial closure is also interrupted. The subcutaneous suture is omitted, and the skin is sutured continuously (**Figures 4** and **5**). The Joel-Cohen technique is claimed to be faster to

increased, but not perinatal mortality [2].

threshold to indicate caesarean section [5].

and continuous suture of the skin.

have been sparse.

44 Caesarean Section

North America, and 41% in South America [1, 6].

Joel-Cohen method, and the Misgav Ladach technique [7].

**Figure 2.** Indicates the skin incision.

**Figure 3.** The skin is fully incised.

The **Misgav Ladach** technique for caesarean section was first described by Michael Stark, based on the Joel-Cohen incision. It was initially introduced at Misgav Ladach hospital in Israel [12]. The procedure includes a transverse skin incision 5 cm above the symphysis pubis and blunt dissection of all abdominal walls after sharp superficial incision of the fascia (**Figures 6** and **7**) and uterus (**Figure 8**). The placenta is removed manually after delivery of the baby. One running layer suturing the uterus (**Figures 9** and **10**) [13] and non-closure of the peritoneum were also considered acceptable by many during 1990s [14]. The fascia is closed continuously, the subcutaneous layer is not sutured, and the skin is closed with a mattress suture. A modification of the Misgav Ladach technique was suggested by Stark in

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47

The Misgav Ladach technique is claimed to have several advantages compared with the Pfannenstiel-Kerr technique. Major differences are digital manual manipulation instead of using sharp instruments which is associated with the least possible trauma to the tissues, less blood loss, faster recovery, shorter anaesthetic time, and using less suture material [16]. A reduced level of antibiotic and narcotic use, faster return of normal bowel function, shorter maternal hospital stay and less postoperative adhesion formation as well as lower incidence of fever, and urinary tract infection has been suggested for that technique. The Misgav Ladach technique is suitable for both elective and emergency caesarean

The modified Misgav Ladach technique, other than the original Misgav Ladach technique, uses a Pfannenstiel skin incision, a spontaneous delivery of the placenta, a peritoneal closure,

1995 [15].

section [17].

and a continuous closure of the skin [7].

**Figure 5.** View cesarean section completed.

**Figure 4.** The skin is being closed following the cesarean section.

perform, causes less blood loss, less postoperative pain, shorter hospital stay, less postoperative infection, is more economic, and saves more staff time, and utilises less anaesthesia in comparison with the Pfannenstiel-Kerr technique [11].

**Figure 5.** View cesarean section completed.

perform, causes less blood loss, less postoperative pain, shorter hospital stay, less postoperative infection, is more economic, and saves more staff time, and utilises less anaesthesia in

comparison with the Pfannenstiel-Kerr technique [11].

**Figure 4.** The skin is being closed following the cesarean section.

**Figure 3.** The skin is fully incised.

46 Caesarean Section

The **Misgav Ladach** technique for caesarean section was first described by Michael Stark, based on the Joel-Cohen incision. It was initially introduced at Misgav Ladach hospital in Israel [12]. The procedure includes a transverse skin incision 5 cm above the symphysis pubis and blunt dissection of all abdominal walls after sharp superficial incision of the fascia (**Figures 6** and **7**) and uterus (**Figure 8**). The placenta is removed manually after delivery of the baby. One running layer suturing the uterus (**Figures 9** and **10**) [13] and non-closure of the peritoneum were also considered acceptable by many during 1990s [14]. The fascia is closed continuously, the subcutaneous layer is not sutured, and the skin is closed with a mattress suture. A modification of the Misgav Ladach technique was suggested by Stark in 1995 [15].

The Misgav Ladach technique is claimed to have several advantages compared with the Pfannenstiel-Kerr technique. Major differences are digital manual manipulation instead of using sharp instruments which is associated with the least possible trauma to the tissues, less blood loss, faster recovery, shorter anaesthetic time, and using less suture material [16]. A reduced level of antibiotic and narcotic use, faster return of normal bowel function, shorter maternal hospital stay and less postoperative adhesion formation as well as lower incidence of fever, and urinary tract infection has been suggested for that technique. The Misgav Ladach technique is suitable for both elective and emergency caesarean section [17].

The modified Misgav Ladach technique, other than the original Misgav Ladach technique, uses a Pfannenstiel skin incision, a spontaneous delivery of the placenta, a peritoneal closure, and a continuous closure of the skin [7].

**Figure 8.** Dilatation of myometrium after uterine incision.

**Figure 9.** The baby has been removed, the edges are secured, continuous uterine suture is to commence.

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49

**Figure 6.** Dissection of the fascia and blunt dilatation of abdominal rectus muscles.

**Figure 7.** Further digital preparation cranially.

**Figure 8.** Dilatation of myometrium after uterine incision.

**Figure 6.** Dissection of the fascia and blunt dilatation of abdominal rectus muscles.

**Figure 7.** Further digital preparation cranially.

48 Caesarean Section

**Figure 9.** The baby has been removed, the edges are secured, continuous uterine suture is to commence.

**Exclusion** criteria: comments, letters to the editor, personal communications, and case reports.

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51

The author selected the articles first through focused review of abstracts. Eligible studies

We excluded 4532 studies for not meeting either the inclusion criteria, for meeting the exclu-

The resulting number of studies was analysed (abstract: 61, whole paper were downloaded: 60).

The references of the most important studies were again checked for eligibility as part of the

Data from the randomised controlled trials and Cochrane systematic reviews were extracted,

Potential outcomes were: the technique/procedure which should be used, should not be used,

Thus, the result of this chapter is a summary of the conclusions of each one of the individual

From the abstracts retrieved by our search, we identified 49 studies and 12 Cochrane systematic reviews. All manuscripts were retrieved in electronic pdf format and analysed in detail.

Wound infection and postpartum endometritis following caesarean section are a frequent problem associated with maternal morbidity and mortality. Caesarean section is the most important risk factor for puerperal infection, and the incidence varies worldwide between 2.5 and 20.5% [18]. The infection is mostly polymicrobial involving a spectrum of Grampositive and Gram-negative bacteria, anaerobes, *Gardnerella vaginalis*, and genital myco-

Antibiotic prophylaxis is generally recommended for preventing infection after caesarean section. The administration of antibiotic prophylaxis should be effective, safe, and convenient. The route of administrating antibiotic prophylaxis can either be intravenous, orally or by antibiotic irrigation (washing with a saline solution containing antibiotics). Nine studies compared the administration of intravenous antibiotics with antibiotic irrigation and were analysed in a Cochrane systematic review [20]. The differences in the frequency of endometritis and wound infection between intravenous antibiotics and irrigation following caesarean

delivery were not significant, but the evidence was of low quality.

and each step of the operation was discussed using the available evidence.

underwent full text review.

search strategy.

We identified a total of 4593 studies.

sion criteria or for not answering the question.

no/low evidence available to answer the question.

steps to perform a caesarean section.

**3. Preoperative preparation**

**3.1. Prophylactic antibiotics**

plasmas [19].

**Figure 10.** Completion of uterine suture.

It is important that surgeons use techniques which have been shown to be associated with low rates of maternal morbidity and mortality. Therefore, the objective of this chapter is to systematically search the literature and analyse the available evidence for robustness including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin.

#### **2. Data collection**

We did a systematic literature review of PubMed and the Cochrane Database in English. Search terms used were techniques of caesarean section, randomised controlled trials, metaanalysis, systematic reviews, Cochrane systematic review, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization, skin incision types, dissection of fascia off the rectus muscles, bladder flap, uterine incision, removal of the placenta, cervical dilatation, closure of the uterine incision, closure of the peritoneum, subcutaneous closure, prophylactic drainage, and skin closure.

Before the search, we defined inclusion criteria and exclusion criteria:

**Inclusion** criteria: randomised controlled trials, cohort, case-control, systematic review, metaanalysis, and the above search terms.

**Exclusion** criteria: comments, letters to the editor, personal communications, and case reports.

The author selected the articles first through focused review of abstracts. Eligible studies underwent full text review.

We identified a total of 4593 studies.

We excluded 4532 studies for not meeting either the inclusion criteria, for meeting the exclusion criteria or for not answering the question.

The resulting number of studies was analysed (abstract: 61, whole paper were downloaded: 60).

The references of the most important studies were again checked for eligibility as part of the search strategy.

Data from the randomised controlled trials and Cochrane systematic reviews were extracted, and each step of the operation was discussed using the available evidence.

Potential outcomes were: the technique/procedure which should be used, should not be used, no/low evidence available to answer the question.

Thus, the result of this chapter is a summary of the conclusions of each one of the individual steps to perform a caesarean section.

From the abstracts retrieved by our search, we identified 49 studies and 12 Cochrane systematic reviews. All manuscripts were retrieved in electronic pdf format and analysed in detail.

#### **3. Preoperative preparation**

#### **3.1. Prophylactic antibiotics**

It is important that surgeons use techniques which have been shown to be associated with low rates of maternal morbidity and mortality. Therefore, the objective of this chapter is to systematically search the literature and analyse the available evidence for robustness including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin.

We did a systematic literature review of PubMed and the Cochrane Database in English. Search terms used were techniques of caesarean section, randomised controlled trials, metaanalysis, systematic reviews, Cochrane systematic review, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization, skin incision types, dissection of fascia off the rectus muscles, bladder flap, uterine incision, removal of the placenta, cervical dilatation, closure of the uterine incision, closure of the peritoneum, subcutaneous closure, prophylactic

**Inclusion** criteria: randomised controlled trials, cohort, case-control, systematic review, meta-

Before the search, we defined inclusion criteria and exclusion criteria:

**2. Data collection**

**Figure 10.** Completion of uterine suture.

50 Caesarean Section

drainage, and skin closure.

analysis, and the above search terms.

Wound infection and postpartum endometritis following caesarean section are a frequent problem associated with maternal morbidity and mortality. Caesarean section is the most important risk factor for puerperal infection, and the incidence varies worldwide between 2.5 and 20.5% [18]. The infection is mostly polymicrobial involving a spectrum of Grampositive and Gram-negative bacteria, anaerobes, *Gardnerella vaginalis*, and genital mycoplasmas [19].

Antibiotic prophylaxis is generally recommended for preventing infection after caesarean section. The administration of antibiotic prophylaxis should be effective, safe, and convenient. The route of administrating antibiotic prophylaxis can either be intravenous, orally or by antibiotic irrigation (washing with a saline solution containing antibiotics). Nine studies compared the administration of intravenous antibiotics with antibiotic irrigation and were analysed in a Cochrane systematic review [20]. The differences in the frequency of endometritis and wound infection between intravenous antibiotics and irrigation following caesarean delivery were not significant, but the evidence was of low quality.

Other studies have evaluated different prophylactic antibiotic regimens and compared single dose antibiotics with extended spectrum coverage. Ampicillin/sulbactam [21], triple antibiotic (ampicillin, gentamicin, and metronidazole) [22], and penicillin and cephalothin [23] were compared with standard cephalosporin prophylaxis. There was no improvement shown in giving an extended spectrum coverage compared to a single drug. Thus, a single dose of ampicillin or first generation cephalosporin should be administered as a prophylaxis in women undergoing caesarean delivery. The level of evidence was high.

**3.3. Preoperative bladder catheterization**

mortality [33].

moderate.

**4. Intraoperative techniques**

**4.1. Skin incision types**

Bladder evacuation with an indwelling catheter is a common preoperative procedure prior to CS. Alleged advantages of using catheters include a maintaining bladder drainage that may improve visualisation during surgery and minimise bladder injury. It is also linked with less retention of urine after operation with decreased incidence of postpartum haemorrhage due to uterine atony. But urinary catheters are associated with an increased risk of urinary tract infections, and the prevalence varies from 6 to 80% [32]. Catheter-associated urinary tract infections can lead to such complications as cystitis, pyelonephritis, and septicaemia which are uncomfortable for women and cause prolonged hospital stay, increased cost, and

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A Cochrane review for indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section included five studies of moderate quality [34]. Interestingly, urinary tract infection as defined by trialists was not different between the catheterised and non-catheterised group. There was also no difference shown in the incidence of postpartum haemorrhage (PPH) due to uterine atony. Given the low incidence of bladder or ureteral injury reported in the literature [35], these trials were underpowered to detect a difference in these outcomes. On the other hand, discomfort due to catheterisation or at first voiding and longer hospitalisation favoured the no catheter group, but there was marked heterogeneity among the included studies. Based on the Cochrane review, there is insufficient evidence to assess the routine use of indwelling urinary catheters for intra- and postoperative care in patients undergoing caesarean delivery [34]. The level of evidence was

Different types of skin incisions of the abdominal wall can be used for caesarean section. Patterns include vertical (midline and paramedian) incisions and transverse incisions (Pfannenstiel-Kerr, Joel-Cohen, Misgav Ladach, and Modified Misgav Ladach). Traditionally, vertical incisions were used for caesarean delivery [36], but the disadvantages of a vertical incision are greater risk of postoperative wound dehiscence and development of incisional hernia as well as cosmetical inconvenience. Nowadays, the lower abdominal transverse incision is adequate for the majority of caesarean operations because of the minimal risk of postoperative disruption, less incisional hernia, and cosmetic approval. Pfannenstiel and Joel-Cohen incision are described above and were analysed in a Cochrane review. Two trials [37–39] including 411 women compared the Joel-Cohen incision with Pfannenstiel incision, whereas all other aspects of surgery in these two trials were identical [40]. In the Cochrane review was shown that postoperative febrile morbidity and postoperative analgesic requirements were less, the operating time, the delivery time, the total dose of analgesia, the estimated blood loss, and the postoperative hospital stay for the mother were reduced in the Joel-Cohen group

The timing of antibiotic administration is also discussed in the literature. Some authors claim that antibiotic prophylaxis should be given preoperative, whereas others recommend it after cord clamping. In a Cochrane systematic review, 10 studies were analysed showing that antibiotics given to women before caesarean delivery nearly halved the risks of combined infections (43%), wound infection (41%), and endometritis (46%), compared to giving the antibiotics after clamping the umbilical cord [24]. Urinary and lung infections, febrile illness, and pelvic abscess did not differ in the two groups, nor did adverse effects in newborns. A meta-analysis of 5 RCT's showed that preoperative administration should be given 15–60 min prior to skin incision to reduce the risk of postpartum infection [25].

Antibiotic prophylaxis should therefore be given prior to the operation. The evidence was of high quality.

#### **3.2. Skin disinfection**

Women who give birth by caesarean section are exposed to surgical site infections. The rate of post caesarean infection has been estimated to be 10 times greater than that after vaginal birth [26]. The incidence of wound infection following caesarean section ranges from 3 to 15%. Risk factors for a wound infection are obesity, diabetes, immunosuppressive disorders (HIV infection), and chorioamnionitis during labour, anaemia, or women taking corticosteroids [27]. In order to reduce the risk of postpartum infection, adequate preparation of the skin before the incision is mandatory and is recommended by bodies such as the Royal College of Surgeons of England [28] and the Center for Disease Control and Prevention [29]. An application of an antiseptic is necessary to reduce or remove bacteria. Commonly used antiseptics include chlorhexidine, parachlorometaxylenol, iodine or povidone-iodine, and alcohol. They can be applied as liquids or powders, scrubs or on impregnated drapes. The antiseptic and the type of application given should be broadspectrum and fast acting.

A Cochrane review of skin preparations for clean surgery [30] found that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of surgical site infections following clean surgery, than alcohol-based povidone-iodine, but the evidence of two studies was low. A more recent Cochrane review for skin preparation for preventing infection following caesarean section of six trials found no advantage in either one of the techniques used [31]. Only one trial showed that chlorhexidine gluconate, compared with iodine alone, was associated with lower rates of bacterial growth after caesarean section, but the quality of evidence was very low. More high quality research is necessary to answer the question of the most sufficient preoperative skin preparation.

#### **3.3. Preoperative bladder catheterization**

Other studies have evaluated different prophylactic antibiotic regimens and compared single dose antibiotics with extended spectrum coverage. Ampicillin/sulbactam [21], triple antibiotic (ampicillin, gentamicin, and metronidazole) [22], and penicillin and cephalothin [23] were compared with standard cephalosporin prophylaxis. There was no improvement shown in giving an extended spectrum coverage compared to a single drug. Thus, a single dose of ampicillin or first generation cephalosporin should be administered as a prophylaxis in

The timing of antibiotic administration is also discussed in the literature. Some authors claim that antibiotic prophylaxis should be given preoperative, whereas others recommend it after cord clamping. In a Cochrane systematic review, 10 studies were analysed showing that antibiotics given to women before caesarean delivery nearly halved the risks of combined infections (43%), wound infection (41%), and endometritis (46%), compared to giving the antibiotics after clamping the umbilical cord [24]. Urinary and lung infections, febrile illness, and pelvic abscess did not differ in the two groups, nor did adverse effects in newborns. A meta-analysis of 5 RCT's showed that preoperative administration should be given 15–60 min

Antibiotic prophylaxis should therefore be given prior to the operation. The evidence was of

Women who give birth by caesarean section are exposed to surgical site infections. The rate of post caesarean infection has been estimated to be 10 times greater than that after vaginal birth [26]. The incidence of wound infection following caesarean section ranges from 3 to 15%. Risk factors for a wound infection are obesity, diabetes, immunosuppressive disorders (HIV infection), and chorioamnionitis during labour, anaemia, or women taking corticosteroids [27]. In order to reduce the risk of postpartum infection, adequate preparation of the skin before the incision is mandatory and is recommended by bodies such as the Royal College of Surgeons of England [28] and the Center for Disease Control and Prevention [29]. An application of an antiseptic is necessary to reduce or remove bacteria. Commonly used antiseptics include chlorhexidine, parachlorometaxylenol, iodine or povidone-iodine, and alcohol. They can be applied as liquids or powders, scrubs or on impregnated drapes. The antiseptic and the type

A Cochrane review of skin preparations for clean surgery [30] found that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of surgical site infections following clean surgery, than alcohol-based povidone-iodine, but the evidence of two studies was low. A more recent Cochrane review for skin preparation for preventing infection following caesarean section of six trials found no advantage in either one of the techniques used [31]. Only one trial showed that chlorhexidine gluconate, compared with iodine alone, was associated with lower rates of bacterial growth after caesarean section, but the quality of evidence was very low. More high quality research is necessary to answer

women undergoing caesarean delivery. The level of evidence was high.

prior to skin incision to reduce the risk of postpartum infection [25].

of application given should be broadspectrum and fast acting.

the question of the most sufficient preoperative skin preparation.

high quality.

52 Caesarean Section

**3.2. Skin disinfection**

Bladder evacuation with an indwelling catheter is a common preoperative procedure prior to CS. Alleged advantages of using catheters include a maintaining bladder drainage that may improve visualisation during surgery and minimise bladder injury. It is also linked with less retention of urine after operation with decreased incidence of postpartum haemorrhage due to uterine atony. But urinary catheters are associated with an increased risk of urinary tract infections, and the prevalence varies from 6 to 80% [32]. Catheter-associated urinary tract infections can lead to such complications as cystitis, pyelonephritis, and septicaemia which are uncomfortable for women and cause prolonged hospital stay, increased cost, and mortality [33].

A Cochrane review for indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section included five studies of moderate quality [34]. Interestingly, urinary tract infection as defined by trialists was not different between the catheterised and non-catheterised group. There was also no difference shown in the incidence of postpartum haemorrhage (PPH) due to uterine atony. Given the low incidence of bladder or ureteral injury reported in the literature [35], these trials were underpowered to detect a difference in these outcomes. On the other hand, discomfort due to catheterisation or at first voiding and longer hospitalisation favoured the no catheter group, but there was marked heterogeneity among the included studies. Based on the Cochrane review, there is insufficient evidence to assess the routine use of indwelling urinary catheters for intra- and postoperative care in patients undergoing caesarean delivery [34]. The level of evidence was moderate.

#### **4. Intraoperative techniques**

#### **4.1. Skin incision types**

Different types of skin incisions of the abdominal wall can be used for caesarean section. Patterns include vertical (midline and paramedian) incisions and transverse incisions (Pfannenstiel-Kerr, Joel-Cohen, Misgav Ladach, and Modified Misgav Ladach). Traditionally, vertical incisions were used for caesarean delivery [36], but the disadvantages of a vertical incision are greater risk of postoperative wound dehiscence and development of incisional hernia as well as cosmetical inconvenience. Nowadays, the lower abdominal transverse incision is adequate for the majority of caesarean operations because of the minimal risk of postoperative disruption, less incisional hernia, and cosmetic approval. Pfannenstiel and Joel-Cohen incision are described above and were analysed in a Cochrane review. Two trials [37–39] including 411 women compared the Joel-Cohen incision with Pfannenstiel incision, whereas all other aspects of surgery in these two trials were identical [40]. In the Cochrane review was shown that postoperative febrile morbidity and postoperative analgesic requirements were less, the operating time, the delivery time, the total dose of analgesia, the estimated blood loss, and the postoperative hospital stay for the mother were reduced in the Joel-Cohen group compared with the Pfannenstiel group [40]. Altogether, the Joel-Cohen incision is associated with some advantages compared with the Pfannenstiel incision and should be recommended, but is less popular with women for cosmetic reasons.

that there were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision, whereas mean blood loss and the need for blood were significantly lower following blunt extension, with no other significant differences identified in duration of operative procedure and maternal morbidity. No statistically significant difference was seen in the rate of neonatal injury. Therefore,

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The mode of placental delivery contributes to morbidity and determines blood loss during caesarean section [47]. Altogether there are two common methods used to deliver the placenta at caesarean section, by spontaneous delivery with mild cord traction and by manual removal. A Cochrane review compared the effects of manual removal of the placenta with cord traction at caesarean section, and 15 studies including 4694 women were analysed [48]. It was pointed out that the manual removal of the placenta was associated with more blood loss, more endometritis, and longer duration of hospital stay compared with cord traction. No significant differences were shown in fetomaternal haemorrhage, blood transfusion, and puerperal fever. Therefore, spontaneous delivery with cord traction should be used, and the

During elective, non-labour caesarean sections cervical dilatation by using finger, sponge forceps or other instruments are performed by some obstetricians after placental removal. On the one hand, it is discussed that an undilated cervix may cause obstruction of blood or lochia drainage, but on the other hand, mechanical cervical dilatation using a finger or instruments during caesarean section may result in contamination and increase the risk of infection or cervical trauma. One randomised controlled trial [49] and one Cochrane review analysing three trials with a total of 735 women [50] found insufficient evidence of mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperative morbidity. This does not justify cervical dilatation at present. Further, randomised controlled trials with adequate

The traditional approach to uterine suture is double layer closed [13], although a variety of techniques has been discussed in the literature. Haemostasis, wound healing, and possibly a reduced risk of uterine rupture in subsequent pregnancies are discussed as potential benefits of a double layer suture, whereas single layer closure may be associated with reduced operating time, reduced tissue disruption, and less suture material being absorbed in the

In a Cochrane systematic review, 19 studies were identified comparing single layer with double layer closure of the uterus [44], and data of 14 of the studies were analysed in a meta-analysis. The systematic review pointed out that there were no statistically significant differences

blunt extension should be recommended. The level of evidence is high.

**4.5. Removal of the placenta**

level of evidence was high.

methodological quality are needed.

**4.7. Closure of the uterine incision**

wound.

**4.6. Cervical dilatation**

The level of evidence was moderate.

#### **4.2. Dissection of fascia off the rectus muscles**

This question has been evaluated in a randomised controlled trial [41]. Non-dissection of the lower rectus fascia (pulling the fascia slowly manually apart) was associated with lower decline of pre- and post-surgical haemoglobin levels and less pain and should be recommended. The level of evidence was low.

#### **4.3. Bladder flap**

The bladder flap development (downwards removal of the bladder from the lower uterine segment) versus omission of the bladder flap has been investigated in a randomised controlled trial with 258 women. Omission of the bladder flap at caesarean delivery (primary and repeat) did not increase intraoperative or postoperative complications such as blood loss, postoperative micro haematuria, postoperative pain, hospital days, endometritis, or urinary tract infection but shortened incision to delivery time [42].

In another trial with 620 patients, it was shown that the visceral peritoneal closure of the bladder flap increased postpartum urinary frequency [43]. Because of those trials, the routine bladder flap development and closure of the visceral peritoneum of the bladder flap cannot be recommended, but trials have been underpowered to assess morbidity such as bladder injury and adhesion formation. The evidence was of moderate quality.

#### **4.4. Uterine incision**

A Cochrane review specifically assessed surgical techniques involving the uterus at the time of caesarean section and included the type of uterine incision (lower transverse uterine incision versus other types of uterine incision) and methods of performing the uterine incision ('sharp' uterine entry versus 'blunt' uterine entry) [44]. A transverse lower segment uterine incision, which is favoured by many obstetricians because of less vascularisation of the lower uterine segment, a better closure and less incidence of uterine dehiscence or rupture in subsequent pregnancies [45] is compared with other types of uterine incision (low vertical, 'classical', T-shaped or J-shaped incision). The Cochrane review did not identify any randomised controlled trials assessing the type of uterine incision to be used. But the ACOG stressed that uterine rupture is a significant risk in a subsequent pregnancy or labour, with estimates of occurrence being 4–9% for classical (uterine body and midline) caesarean incision, 4–9% for inverted T-shaped incisions, 1–7% for lower uterine segment vertical incisions, and 0.2–1.5% for lower uterine segment transverse incisions [46].

Methods of performing the uterine incision ('sharp' uterine entry versus 'blunt' uterine entry) were compared in five studies including 2141 women, and the Cochrane review pointed out that there were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision, whereas mean blood loss and the need for blood were significantly lower following blunt extension, with no other significant differences identified in duration of operative procedure and maternal morbidity. No statistically significant difference was seen in the rate of neonatal injury. Therefore, blunt extension should be recommended. The level of evidence is high.

#### **4.5. Removal of the placenta**

compared with the Pfannenstiel group [40]. Altogether, the Joel-Cohen incision is associated with some advantages compared with the Pfannenstiel incision and should be recommended,

This question has been evaluated in a randomised controlled trial [41]. Non-dissection of the lower rectus fascia (pulling the fascia slowly manually apart) was associated with lower decline of pre- and post-surgical haemoglobin levels and less pain and should be recom-

The bladder flap development (downwards removal of the bladder from the lower uterine segment) versus omission of the bladder flap has been investigated in a randomised controlled trial with 258 women. Omission of the bladder flap at caesarean delivery (primary and repeat) did not increase intraoperative or postoperative complications such as blood loss, postoperative micro haematuria, postoperative pain, hospital days, endometritis, or urinary

In another trial with 620 patients, it was shown that the visceral peritoneal closure of the bladder flap increased postpartum urinary frequency [43]. Because of those trials, the routine bladder flap development and closure of the visceral peritoneum of the bladder flap cannot be recommended, but trials have been underpowered to assess morbidity such as bladder injury

A Cochrane review specifically assessed surgical techniques involving the uterus at the time of caesarean section and included the type of uterine incision (lower transverse uterine incision versus other types of uterine incision) and methods of performing the uterine incision ('sharp' uterine entry versus 'blunt' uterine entry) [44]. A transverse lower segment uterine incision, which is favoured by many obstetricians because of less vascularisation of the lower uterine segment, a better closure and less incidence of uterine dehiscence or rupture in subsequent pregnancies [45] is compared with other types of uterine incision (low vertical, 'classical', T-shaped or J-shaped incision). The Cochrane review did not identify any randomised controlled trials assessing the type of uterine incision to be used. But the ACOG stressed that uterine rupture is a significant risk in a subsequent pregnancy or labour, with estimates of occurrence being 4–9% for classical (uterine body and midline) caesarean incision, 4–9% for inverted T-shaped incisions, 1–7% for lower uterine segment vertical incisions, and 0.2–1.5%

Methods of performing the uterine incision ('sharp' uterine entry versus 'blunt' uterine entry) were compared in five studies including 2141 women, and the Cochrane review pointed out

but is less popular with women for cosmetic reasons.

tract infection but shortened incision to delivery time [42].

and adhesion formation. The evidence was of moderate quality.

for lower uterine segment transverse incisions [46].

**4.2. Dissection of fascia off the rectus muscles**

The level of evidence was moderate.

mended. The level of evidence was low.

**4.3. Bladder flap**

54 Caesarean Section

**4.4. Uterine incision**

The mode of placental delivery contributes to morbidity and determines blood loss during caesarean section [47]. Altogether there are two common methods used to deliver the placenta at caesarean section, by spontaneous delivery with mild cord traction and by manual removal. A Cochrane review compared the effects of manual removal of the placenta with cord traction at caesarean section, and 15 studies including 4694 women were analysed [48]. It was pointed out that the manual removal of the placenta was associated with more blood loss, more endometritis, and longer duration of hospital stay compared with cord traction. No significant differences were shown in fetomaternal haemorrhage, blood transfusion, and puerperal fever. Therefore, spontaneous delivery with cord traction should be used, and the level of evidence was high.

#### **4.6. Cervical dilatation**

During elective, non-labour caesarean sections cervical dilatation by using finger, sponge forceps or other instruments are performed by some obstetricians after placental removal. On the one hand, it is discussed that an undilated cervix may cause obstruction of blood or lochia drainage, but on the other hand, mechanical cervical dilatation using a finger or instruments during caesarean section may result in contamination and increase the risk of infection or cervical trauma. One randomised controlled trial [49] and one Cochrane review analysing three trials with a total of 735 women [50] found insufficient evidence of mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperative morbidity. This does not justify cervical dilatation at present. Further, randomised controlled trials with adequate methodological quality are needed.

#### **4.7. Closure of the uterine incision**

The traditional approach to uterine suture is double layer closed [13], although a variety of techniques has been discussed in the literature. Haemostasis, wound healing, and possibly a reduced risk of uterine rupture in subsequent pregnancies are discussed as potential benefits of a double layer suture, whereas single layer closure may be associated with reduced operating time, reduced tissue disruption, and less suture material being absorbed in the wound.

In a Cochrane systematic review, 19 studies were identified comparing single layer with double layer closure of the uterus [44], and data of 14 of the studies were analysed in a meta-analysis. The systematic review pointed out that there were no statistically significant differences in febrile morbidity in both groups. They also found that mean blood loss was reduced in the single layer closure, but heterogeneity was high, and this limits the clinical applicability of the result. No statistically significant differences were also found for the risk of blood transfusion or other clinical outcomes.

visceral peritoneal non-closure group, but it was at high risk of bias, whereas one study

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Two studies with 573 women compared non-closure of parietal peritoneum only with closure of both parietal and visceral peritoneum and stressed that neither study reported on postoperative adhesion formation, but one study showed that there were no significant differences in endometritis, fever, wound infection, or hospital stay, but the operative time was reduced,

One study examined non-closure versus closure of visceral peritoneum when parietal peritoneum is closed and pointed out that there was reduction in urinary symptoms of frequency,

Altogether, there was a reduction in operative time across all the subgroups with the peritoneum left open, and there was no clear evidence on reduced adhesion formation for the peritoneum closure group. At the moment, there is insufficient evidence of advantages to

The Cochrane review stressed that quality of trials was variable, the results were in general consistent between the trials of better and poorer quality, and further studies are needed to

In a Cochrane review, 7 trials with 2056 women were analysed showing that the risk of haematoma or seroma was reduced with subcutaneous closure compared with non-closure but no difference in the risk of wound infection or other short-term outcomes was found [64]. A meta-analysis evaluating six randomised studies showed that prophylactic drainage was not associated with decreased wound infection, hematoma, or seroma and cannot be recom-

No difference was seen in the risk of wound infection between blunt needles and sharp needles, and no trials were found investigating suture techniques or materials for closure of the rectus sheath or subcutaneous fat. Closure of the subcutaneous fat may reduce wound complications, especially when subcutaneous fat is >2 cm, but further trials are needed which

The skin incision can be closed by subcuticular suture immediately below the skin layer, by an interrupted suture, or by staples. In a review of five randomised controlled trials and one prospective study, staple closure was associated with a two-times higher risk of wound infection or separation compared with subcuticular suture closure [66]. In contrast to this data, a Cochrane systematic review of eight studies stressed that wound complications and cosmetic outcomes were similar among both groups [67]. There is currently no conclusive evidence

are adequately powered to detect clinically important differences.

about how the skin should be closed after caesarean section.

urgency, and stress incontinence when the visceral peritoneum is left unsutured [63].

justify the additional time and use of suture material necessary for peritoneal closure.

showed a reduction in operating time and postoperative hospital days [61].

and a reduction of pain was seen in the non-closure group [62].

further assess all outcomes [60].

**4.9. Subcutaneous closure**

mended [65].

**4.10. Skin closure**

One study was identified comparing continuous versus interrupted single layer closure for the uterine incision, but no clinical or maternal outcome was assessed using either ultrasound or hysteroscopy [51].

In a separate meta-analysis, uterine exteriorization for hysterotomy repair was compared with intra-abdominal repair, and it was shown that febrile complications and surgical time were similar between both groups, and the decision should be provided by the surgeon's preference [52].

Closure with catgut was compared with polygactin-910 closure in 9544 women, where a significant reduction in the need for blood transfusion and a significant reduction in complications requiring relaparotomy were seen in the catgut closure group [53–58]; however, there was no significant difference in any other clinical outcome.

Altogether, there is limited high quality information available to suggest that one surgical technique of closing the uterine incision is superior to another, in particular regarding the chances of uterine rupture in subsequent vaginal birth following caesarean section (VBAC), and future randomised trials should be adequately powered to detect important differences in clinically relevant outcomes.

#### **4.8. Closure of the peritoneum**

Closure of the peritoneum at laparotomy has been a part of standard surgical practice. Possible advantages of closing the peritoneum after caesarean section include restoration of anatomy, reduction of infection, reduction of wound dehiscence, reducing haemorrhage, and a minimisation of adhesions [59], whereas the suturing of the peritoneum may cause peritoneal tissue ischaemia at the edges, which may delay healing and serve as a cause of intraperitoneal adhesions and febrile morbidity.

In a Cochrane systematic review, different types of the closure versus non-closure of the peritoneum during caesarean section were analysed [60].

We looked at the results of 16 studies including 15,480 women, when both parietal peritoneums were left unclosed versus when both peritoneal surfaces were closed. In four trials, no differences were seen in the postoperative adhesion formation, whereas there were a reduction of operating time, a reduction in hospital stay, and less chronic pelvic pain in the peritoneal non-closure group. No differences were seen in the occurrence of infectious morbidity, endometritis, and wound infection. The quality of the trials was variable with some of the outcomes demonstrating significant heterogeneity.

Three studies including 889 women investigated non-closure of visceral peritoneum versus closure of both peritoneal layers. In two trials, adhesion formation was increased in the visceral peritoneal non-closure group, but it was at high risk of bias, whereas one study showed a reduction in operating time and postoperative hospital days [61].

Two studies with 573 women compared non-closure of parietal peritoneum only with closure of both parietal and visceral peritoneum and stressed that neither study reported on postoperative adhesion formation, but one study showed that there were no significant differences in endometritis, fever, wound infection, or hospital stay, but the operative time was reduced, and a reduction of pain was seen in the non-closure group [62].

One study examined non-closure versus closure of visceral peritoneum when parietal peritoneum is closed and pointed out that there was reduction in urinary symptoms of frequency, urgency, and stress incontinence when the visceral peritoneum is left unsutured [63].

Altogether, there was a reduction in operative time across all the subgroups with the peritoneum left open, and there was no clear evidence on reduced adhesion formation for the peritoneum closure group. At the moment, there is insufficient evidence of advantages to justify the additional time and use of suture material necessary for peritoneal closure.

The Cochrane review stressed that quality of trials was variable, the results were in general consistent between the trials of better and poorer quality, and further studies are needed to further assess all outcomes [60].

#### **4.9. Subcutaneous closure**

in febrile morbidity in both groups. They also found that mean blood loss was reduced in the single layer closure, but heterogeneity was high, and this limits the clinical applicability of the result. No statistically significant differences were also found for the risk of blood transfusion

One study was identified comparing continuous versus interrupted single layer closure for the uterine incision, but no clinical or maternal outcome was assessed using either ultrasound

In a separate meta-analysis, uterine exteriorization for hysterotomy repair was compared with intra-abdominal repair, and it was shown that febrile complications and surgical time were similar between both groups, and the decision should be provided by the surgeon's

Closure with catgut was compared with polygactin-910 closure in 9544 women, where a significant reduction in the need for blood transfusion and a significant reduction in complications requiring relaparotomy were seen in the catgut closure group [53–58]; however, there

Altogether, there is limited high quality information available to suggest that one surgical technique of closing the uterine incision is superior to another, in particular regarding the chances of uterine rupture in subsequent vaginal birth following caesarean section (VBAC), and future randomised trials should be adequately powered to detect important differences

Closure of the peritoneum at laparotomy has been a part of standard surgical practice. Possible advantages of closing the peritoneum after caesarean section include restoration of anatomy, reduction of infection, reduction of wound dehiscence, reducing haemorrhage, and a minimisation of adhesions [59], whereas the suturing of the peritoneum may cause peritoneal tissue ischaemia at the edges, which may delay healing and serve as a cause of intraperitoneal

In a Cochrane systematic review, different types of the closure versus non-closure of the peri-

We looked at the results of 16 studies including 15,480 women, when both parietal peritoneums were left unclosed versus when both peritoneal surfaces were closed. In four trials, no differences were seen in the postoperative adhesion formation, whereas there were a reduction of operating time, a reduction in hospital stay, and less chronic pelvic pain in the peritoneal non-closure group. No differences were seen in the occurrence of infectious morbidity, endometritis, and wound infection. The quality of the trials was variable with some of the

Three studies including 889 women investigated non-closure of visceral peritoneum versus closure of both peritoneal layers. In two trials, adhesion formation was increased in the

was no significant difference in any other clinical outcome.

or other clinical outcomes.

in clinically relevant outcomes.

**4.8. Closure of the peritoneum**

adhesions and febrile morbidity.

toneum during caesarean section were analysed [60].

outcomes demonstrating significant heterogeneity.

or hysteroscopy [51].

56 Caesarean Section

preference [52].

In a Cochrane review, 7 trials with 2056 women were analysed showing that the risk of haematoma or seroma was reduced with subcutaneous closure compared with non-closure but no difference in the risk of wound infection or other short-term outcomes was found [64]. A meta-analysis evaluating six randomised studies showed that prophylactic drainage was not associated with decreased wound infection, hematoma, or seroma and cannot be recommended [65].

No difference was seen in the risk of wound infection between blunt needles and sharp needles, and no trials were found investigating suture techniques or materials for closure of the rectus sheath or subcutaneous fat. Closure of the subcutaneous fat may reduce wound complications, especially when subcutaneous fat is >2 cm, but further trials are needed which are adequately powered to detect clinically important differences.

#### **4.10. Skin closure**

The skin incision can be closed by subcuticular suture immediately below the skin layer, by an interrupted suture, or by staples. In a review of five randomised controlled trials and one prospective study, staple closure was associated with a two-times higher risk of wound infection or separation compared with subcuticular suture closure [66]. In contrast to this data, a Cochrane systematic review of eight studies stressed that wound complications and cosmetic outcomes were similar among both groups [67]. There is currently no conclusive evidence about how the skin should be closed after caesarean section.

## **5. Summary (suggested strategy/protocol)**

• **Prophylactic antibiotics**: yes, single dose, ampicillin or first-generation cephalosporin, 15–60 min prior to skin incision, LoE: high.

**References**

eCollection 2018 Jan

costs.pdf

S0140-6736(09)61870-5. [PubMed]

2013 Mar 1. Review. PMID: 23467047

online 2013 Dec 1. PMCID: PMC3935539

Gynecologica Scandinavica. 2001;**80**:91-92. PMID: 11167200

DOI: 10.1111/1471-0528.12971. Epub 2014 Aug 20

[1] Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990-2014. PLoS One.

The Surgical Technique of Caesarean Section: What is Evidence Based?

http://dx.doi.org/10.5772/intechopen.78040

59

[2] Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with caesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and metaanalysis. PLoS Medicine. 2018;**15**(1):e1002494. DOI: 10.1371/journal.pmed.1002494.

[3] Lumbiganon P, Laopaiboon M, Gulmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet. 2010;**375**(9713):490-499. DOI: 10.1016/

[4] Hellerstein S, Feldman S, Duan T. China's 50% caesarean delivery rate: Is it too high? BJOG : An International Journal of Obstetrics and Gynaecology. 2015;**122**(2):160-164.

[5] Vejnović TR, Costa SD, Ignatov A. New technique for caesarean section. Geburtshilfe

[6] Gibbons L, Belizan JM, Lauer JA, Betra AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Report. 2010. Background Paper, 30. http://www.who.int/healthsystems/topics/financing/healthreport/30C-section-

[7] Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidencebased surgery for caesarean delivery: an updated systematic review. American Journal of Obstetrics and Gynecology. 2013;**209**(4):294-306. DOI: 10.1016/j.ajog.2013.02.043. Epub

[8] Larry C, Matsumoto RR. Caesarean Delivery and Surgery in the Pregnant Patient (Operative obstet.). 2nd ed. Vol. 51. New York: McGraw-Hill Companies; 2002. p. 330. Chapter [9] Abuelghar WM, El-bishry G, Lamiaa H. Emam Caesarean deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled trial. Journal Of The Turkish-German Gynecological Association. 2013;**14**(4):194-200. DOI: 10.5152/jtgga.2013.75725. Published

[10] Holmgren G. Reply to: Comparative evaluation of the Misgav-Ladach caesarean section with two traditional techniques. The first four years' experience. Acta Obstetricia et

[11] Moreria P, Moreau JC, Faye ME, Ka S, Kane Gueye SM, Faye EO, et al. Comparison of two caesarean techniques: Classic versus Misgave Ladach caesarean. Journal of Gynecology

Obstetrics and Human Reproduction (Paris). 2002;**31**:572-576. PMID: 12407329

und Frauenheilkunde. 2012;**72**(9):840-845. DOI: 10.1055/s-0032-1315347

2016;**11**(2):e0148343. DOI: 10.1371/journal.pone.0148343. eCollection 2016


#### **Author details**

Jan-Simon Lanowski and Constantin S. von Kaisenberg\*

\*Address all correspondence to: vonkaisenberg.constantin@mh-hannover.de

Department of Obstetrics, Gynecology and Reproductive Medicine Hannover Medical School, Hannover, Germany

#### **References**

**5. Summary (suggested strategy/protocol)**

15–60 min prior to skin incision, LoE: high.

lower rectus fascia, LoE: low.

• **Bladder flap:** no, LoE: moderate.

low.

58 Caesarean Section

high.

moderate.

moderate.

**Author details**

School, Hannover, Germany

• **Prophylactic antibiotics**: yes, single dose, ampicillin or first-generation cephalosporin,

• **Skin disinfection**: yes, always, LoE: high; type of antiseptic chlorhexidine gluconate, LoE:

• **Preoperative bladder catheterization**: none or early removal, not enough evidence to

• **Skin incision types**: Joel-Cohen incision is associated with some advantages compared to

• **Dissection of fascia off the rectus muscles**: no, median incision and blunt dilatation of the

• **Uterine incision:** transverse lower uterine segment, LoE: moderate; blunt expansion, LoE:

• **Closure of the uterine incision:** single layer, LoE: high; continuous and unlocked, LoE:

• **Closure of the peritoneum**: no, generally not recommended, individual decision, LoE:

• **Removal of the placenta:** yes, spontaneous (with mild cord traction), LoE: high.

• **Subcutaneous drain:** no, does not reduce wound morbidity/infection, LoE: high.

• **Cervical dilatation**: no, does not reduce morbidity from infection, LoE: high.

• **Subcutaneous closure:** yes, if subcutaneous tissue >2 cm, LoE: high.

• **Skin closure:** staples or subcuticular suture possible, LoE: moderate.

\*Address all correspondence to: vonkaisenberg.constantin@mh-hannover.de

Department of Obstetrics, Gynecology and Reproductive Medicine Hannover Medical

Jan-Simon Lanowski and Constantin S. von Kaisenberg\*

assess the routine use of indwelling bladder catheters, LoE: moderate.

Pfannenstiel, but less popular for cosmetic reasons, LoE: moderate.


[12] Moradan S, Mirmohammadkhani M. Comparison of Misgav-Ladach and Pfannenstiel-Kerr techniques for caesarean section: A randomized controlled trial study. Middle East Journal of Rehabilitation and Health. 2016;**3**(4):e38541. Published online 2016 September 26. DOI: 10.17795/mejrh-38541

[25] Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for caesarean delivery: A meta-analysis. American Journal of Obstetrics and Gynecology.

The Surgical Technique of Caesarean Section: What is Evidence Based?

http://dx.doi.org/10.5772/intechopen.78040

61

[26] Henderson E, Love EJ. Incidence of hospital-acquired infections associated with caesar-

[27] Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD, et al. Puerperal infection. In: Williams Obstetrics. 22nd ed. New York: McGraw-Hill; 2005 [28] Leaper D, Orr K. Step: Inflammation and Infection. Royal College of Surgeons of

[29] Mangram JA, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection. Infection Control and Hospital Epidemiology. 1999;**20**:247-278

[30] Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews.

[31] Hadiati DR, Hakimi M, Nurdiati DS, Ota E. Skin preparation for preventing infection following caesarean section. Cochrane Database of Systematic Reviews. 2014;(9):CD007462.

[32] Li L, Wen J, Wang L, Li YP, Li Y. Is routine indwelling catheterisation of the bladder for caesarean section necessary? A systematic review. BJOG: An International Journal of

[33] Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care associated infections and deaths in U.S. hospitals. Public Health

[34] Abdel-Aleem H, Aboelnasr MF, Jayousi TM, Habib FA. Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section. Cochrane Database of Systematic Reviews. 2014;(4):CD010322. DOI: 10.1002/14651858.CD010322.

[35] Rajasekar D, Hall M. Urinary tract injuries during obstetric intervention. British Journal

[36] Myerscough PR. Caesarean section: Sterilization: Hysterectomy. In: Munro Kerr's

[37] Franchi M, Ghezzi F, Raio L, Di Naro E, Miglierina M, Agosti M, et al. Joel-Cohen or Pfannenstiel incision at caesarean delivery: Does it make a difference? Acta Obstetricia

[38] Ghezzi F, Franchi F, Raio L, Di Naro E, Balestreri D, Miglierina M, et al. Pfanenstiel or Joel-Cohen incision at caesarean delivery: A randomized clinical trial. American Journal

[39] Mathai M, Ambersheth S, George A. Comparison of two transverse abdominal incisions for caesarean delivery. International Journal of Gynecology & Obstetrics. 2002;**78**:47-49

Operative Obstetrics. 10th ed. London: Bailliere Tindall; 1982. pp. 295-319

ean section. Journal of Hospital Infection. 1995;**29**:245-255

2013;(3):1-45. DOI: 10.1002/14651858.CD003949.pub3

DOI: 10.1002/14651858.CD007462.pub3

Reports. 2007;**122**(2):160-166

pub2

Obstetrics & Gynaecology. 2011;**118**(4):400-409

of Obstetrics and Gynaecology. 1997;**104**:731-734

et Gynecologica Scandinavica. 2002;**81**:1040-1046

of Obstetrics and Gynecology. 2001;**184**(1):S166

2008;**199**:301.e1-301.e6

England, London; 2001


[25] Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for caesarean delivery: A meta-analysis. American Journal of Obstetrics and Gynecology. 2008;**199**:301.e1-301.e6

[12] Moradan S, Mirmohammadkhani M. Comparison of Misgav-Ladach and Pfannenstiel-Kerr techniques for caesarean section: A randomized controlled trial study. Middle East Journal of Rehabilitation and Health. 2016;**3**(4):e38541. Published online 2016 September

[13] Enkin MW, Wilkinson C. Single versus two layer suturing for closing the uterine incision at caesarean section. Cochrane Database of Systematic Reviews. 2000;(2):CD000192. Review. Update in: Cochrane Database Syst Rev. 2006;(3):CD000192. PMID: 10796177

[14] Wilkinson CS, Enkin MW. Peritoneal non-closure at caesarean section. Cochrane Database of Systematic Reviews. 2000;(2):CD000163. Review. Update in: Cochrane Database Syst

[15] Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR. Evaluation of combinations of procedures in caesarean section. International Journal of Gynaecology and Obstetrics.

[16] Holmgren G, Sjoholm L, Stark M. The Misgav-Ladach method for caesarean section: Method description. Acta Obstetricia et Gynecologica Scandinavica. 1999;**78**(7):615-621.

[17] Fatusic Z, Hudic I, Music A. Misgav-Ladach caesarean section: general consideration.

[18] Conroy K, Koenig AF, Yu YH, Courtney A, Lee HJ, Norwitz ER. Infectious morbidity after caesarean delivery: 10 strategies to reduce risk. Reviews in Obstetrics and

[19] Maharaj D. Puerperal pyrexia: A review. Part I. Obstetrical & Gynecological Survey.

[20] Nabhan AF, Allam NE, Hamed Abdel-Aziz Salama M. Routes of administration of antibiotic prophylaxis for preventing infection after caesarean section. Cochrane Database of

[21] Ziogos E, Tsiodras S, Matalliotakis I, Giamarellou H, Kanellakopoulou K. Ampicillin/ sulbactam versus cefuroxime as antimicrobial prophylaxis for caesarean delivery: A

[22] Alekwe LO, Kuti O, Orji EO, Ogunniyi SO. Comparison of ceftriaxone versus triple drug regimen in the prevention of caesarean section infectious morbidities. The Journal of

[23] Rudge MV, Atallah AN, Peracoli JC, Tristao Ada R, Mendonca Neto M. Randomized controlled trial on prevention of postcaesarean infection using penicillin and cephalo-

[24] Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK. Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing caesarean delivery. Cochrane Database of Systematic Reviews. 2014;(12):CD009516.

thin in Brazil. Acta Obstetricia et Gynecologica Scandinavica. 2006;**85**:945-948

Systematic Reviews. 2016;(6):CD011876. DOI: 10.1002/14651858.CD011876.pub2

Acta Clinica Croatica. 2011;**50**(1):95-99. [PubMed: 22034788]

randomized study. BMC Infectious Diseases. 2010;**10**:341

Maternal-Fetal & Neonatal Medicine. 2008;**21**:638-642

DOI: 10.1002/14651858.CD009516.pub2

26. DOI: 10.17795/mejrh-38541

60 Caesarean Section

Rev. 2003;(4):CD000163

1995;**48**(3):273-276

[PubMed: 10422908]

Gynecology. 2012;**5**(2):69-77

2007;Jun;**62**(6):393-399


[40] Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews. 2013;(5):CD004453. DOI: 10.1002/14651858. CD004453.pub3

[53] Brocklehurst P, for the CORONIS Trial Collaborative Group. The CORONIS Trial: International study of caesarean section surgical techniques: a randomised fractional factorial randomised trial. BJOG: An International Journal of Obstetrics & Gynaecology.

The Surgical Technique of Caesarean Section: What is Evidence Based?

http://dx.doi.org/10.5772/intechopen.78040

63

[54] CORONIS Collaborative Group. Caesarean section surgical techniques (CORONIS): A fractional, factorial, unmasked, randomised controlled trial. Lancet. 2013;**382**:234-248 [55] Glavind J, Uldbjerg N. Caesarean section: In good surgical skills we trust. Lancet. 2013;

[56] Juszczak E, Farrell B. The CORONIS Trial: International study of caesarean section sur-

[57] National Perinatal Epidemiology Unit. Prevention of Maternal Morbidity after Caesarean Section in Developing Countries: A Factorial RCT of Surgical Methods. Available from:

[58] The CORONIS Trial Collaborative Group. The CORONIS trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial. BMC

[59] Bamigboye AA, Buchman E, Hofmeyr GJ. Closure of peritoneum at laparotomy: a survey of gynecological practice. South African Medical Journal. 1999;**89**(3):332-335 [60] Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section: short- and long-termoutcomes. Cochrane Database of Systematic Reviews.

[61] Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al. Closure or non closure of the visceral peritoneum at caesarean delivery. American Journal of Obstetrics

[62] Pietrantoni M, Parsons MT, O'Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal closure or nonclosure at caesarean. Obstetrics & Gynecology. 1991;**77**:293-296

[63] Shahin AY, Hameed DA. Does visceral peritoneal closure affect post-caesarean urinary symptoms? A randomized clinical trial. International Urogynecology Journal.

[64] Anderson ER, Gates S. Techniques andmaterials for closure of the abdominal wall in caesarean section. Cochrane Database of Systematic Reviews. 2004;(4):CD004663. DOI:

[65] Hellums EK, Lin MG, Ramsey PS. Prophylactic subcutaneous drainage for prevention of wound complications after caesarean delivery—a metaanalysis. American Journal of

[66] Tuuli MG, Rampersad RM, Carbone JF, Stamilio D, Macones GA, Odibo AO. Staples compared with subcuticular suture for skin closure after caesarean delivery: A system-

[67] Mackeen AD, Berghella V, Larsen ML. Techniques and materials for skin closure in caesarean section. Cochrane Database of Systematic Reviews. 2012;(11):CD003577. DOI:

atic review and meta-analysis. Obstetrics and Gynecology. 2011;**117**:682-690

gical techniques. Trials. 2011;**112**(Suppl 1):A103

Pregnancy and Childbirth. 2007;**7**:24

and Gynecology. 1996;**174**:1366-1370

10.1002/14651858.CD004663.pub2

10.1002/14651858.CD003577.pub3

Obstetrics and Gynecology. 2007;**197**:229-235

2010;**21**(1):33-41

http://www.npeu.ox.ac.uk/coronis/ [Accessed: 2008]

2014;(8):CD000163. DOI: 10.1002/14651858.CD000163.pub2

2013;**120**(Suppl 1):3

**382**:188-189


[53] Brocklehurst P, for the CORONIS Trial Collaborative Group. The CORONIS Trial: International study of caesarean section surgical techniques: a randomised fractional factorial randomised trial. BJOG: An International Journal of Obstetrics & Gynaecology. 2013;**120**(Suppl 1):3

[40] Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews. 2013;(5):CD004453. DOI: 10.1002/14651858.

[41] Kadir RA, Khan A, Wilcock F, Chapman L. Is inferior dissection of the rectus sheath necessary during Pfannenstiel incision for lower segment caesarean section? A randomised controlled trial. European Journal of Obstetrics, Gynecology, and Reproductive Biology.

[42] Tuuli MG, Odibo AO, Macones GA. Utility of the bladder flap at caesarean delivery: a

[43] Shahin AY, Hameed DA. Does visceral peritoneal closure affect post-caesarean urinary symptoms? A randomized clinical trial. International Urogynecology Journal.

[44] Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database of Systematic

[45] Tahilramaney MP, Boucher M, Eglinton GS, Beall M, Phelan JP. Previous caesarean section and trial of labor. Factors related to uterine dehiscence. Journal of Reproductive

[46] Practice Bulletin ACOG. Vaginal birth after previous caesarean delivery. International

[47] Kamel A, El-Mazny A, Salah E, Ramadan W, Hussein AM, Hany A. Manual removal versus spontaneous delivery of the placenta at caesarean section in developing countries: a randomized controlled trial and review of literature. The Journal of Maternal-Fetal & Neonatal Medicine. 2017;**30**:1-6. DOI: 10.1080/14767058.2017.1369522. [Epub ahead of

[48] Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database of Systematic Reviews. 2008;(3):CD004737. DOI:

[49] Gungorduk K, Yildirim G, Ark C. Is routine cervical dilatation necessary during elective caesarean section? A randomised controlled trial. Australian and New Zealand Journal

[50] Liabsuetrakul T, Peeyananjarassri K. Mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperativemorbidity. Cochrane Database of Systematic

[51] Ceci O, Cantatore C, Scioscia M, Nardelli C, Ravi M, Vimercati A, et al. Ultrasonographic and hysteroscopic outcomes of uterine scar healing after caesarean section: Comparison of two types of single-layer suture. Journal of Obstetrics and Gynaecology Research.

[52] Walsh CA, Walsh SR. Extraabdominal vs intraabdominal uterine repair at caesarean delivery: A metaanalysis. American Journal of Obstetrics and Gynecology. 2009;**200**:625.

Reviews. 2011;(11):CD008019. DOI: 10.1002/14651858.CD008019.pub2

randomized controlled trial. Obstetrics and Gynecology. 2012;**120**:709

Reviews. 2014;(7):CD004732. DOI: 10.1002/14651858.CD004732.pub3

Journal of Gynecology & Obstetrics. 1999;**66**:197-204

CD004453.pub3

62 Caesarean Section

2006;**128**:262-266

2010;**21**:33-41

print]

Medicine. 1984;**29**(1):17-21

10.1002/14651858.CD004737.pub2

2012;**38**(11):1302-1307

e1-625.e8

of Obstetrics and Gynaecology. 2009;**49**:263-267


**Chapter 5**

**Provisional chapter**

**Pros and Cons of Myomectomy during Cesarean**

**Pros and Cons of Myomectomy during Cesarean** 

DOI: 10.5772/intechopen.75365

Additional surgical interventions apart from emergencies during cesarean section are not recommended in the textbooks; thus, surgical procedures like myomectomy as an adjunct to cesarean section remains a hot topic of discussion. There are many publications supporting serosal myomectomy during cesarean section, but studies published so far are poor in quality of evidence. To clarify the efficacy and safety of cesarean myomectomy, large-scale randomized controlled studies and studies explaining the mid-term and long-term outcomes of the cesarean myomectomy are required. Traditionally, cesarean myomectomy is performed from the uterine serosa as in the usual abdominal myomectomy. Although the surgical technique is the same as intracapsular myomectomy, a novel cesarean myomectomy technique, endometrial myomectomy, introduced into the obstetrics practice for minimizing the risk of adhesion formation and diminishing the blood loss during surgery. Further, strong studies are needed to overcome the contro-

**Keywords:** endometrial myomectomy, cesarean section, serosal myomectomy,

Among the benign uterine diseases, leiomyoma of the uterus seems to be the most common pathology. Though the endometrium is accepted as a dynamic tissue and myometrium is accepted as a silent muscular tissue, the reality is not that and it was understood from the studies that both endometrial processes and myometrial processes play a role in abnormal

> © 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.

Cengiz Tokgöz, Şafak Hatirnaz and Oğuz Güler

Cengiz Tokgöz, Şafak Hatirnaz and Oğuz Güler

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.75365

versy on cesarean myomectomy.

complications

**1. Introduction**

uterine bleeding.

**Abstract**

**Section**

**Section**

#### **Pros and Cons of Myomectomy during Cesarean Section Pros and Cons of Myomectomy during Cesarean Section**

DOI: 10.5772/intechopen.75365

Cengiz Tokgöz, Şafak Hatirnaz and Oğuz Güler Cengiz Tokgöz, Şafak Hatirnaz and Oğuz Güler

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.75365

#### **Abstract**

Additional surgical interventions apart from emergencies during cesarean section are not recommended in the textbooks; thus, surgical procedures like myomectomy as an adjunct to cesarean section remains a hot topic of discussion. There are many publications supporting serosal myomectomy during cesarean section, but studies published so far are poor in quality of evidence. To clarify the efficacy and safety of cesarean myomectomy, large-scale randomized controlled studies and studies explaining the mid-term and long-term outcomes of the cesarean myomectomy are required. Traditionally, cesarean myomectomy is performed from the uterine serosa as in the usual abdominal myomectomy. Although the surgical technique is the same as intracapsular myomectomy, a novel cesarean myomectomy technique, endometrial myomectomy, introduced into the obstetrics practice for minimizing the risk of adhesion formation and diminishing the blood loss during surgery. Further, strong studies are needed to overcome the controversy on cesarean myomectomy.

**Keywords:** endometrial myomectomy, cesarean section, serosal myomectomy, complications

#### **1. Introduction**

Among the benign uterine diseases, leiomyoma of the uterus seems to be the most common pathology. Though the endometrium is accepted as a dynamic tissue and myometrium is accepted as a silent muscular tissue, the reality is not that and it was understood from the studies that both endometrial processes and myometrial processes play a role in abnormal uterine bleeding.

© 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.

Uterine leiomyomas, also known as fibroids, are smooth muscle-derived benign masses ranging from millimeters to many centimeters. The investigation of pathological specimens of the uterus revealed that almost 80% of African Americans women and 70% of Caucasian women have detectable leiomyomas [1, 2]. The well-known risk factors for leiomyoma do not explain why racial difference is this much but genetic polymorphisms including increased aromatase activity and signal transducing genes showed that more severe phenotypic pattern may be seen in African Americans [3, 4].

Cesarean section is the most commonly performed procedure globally [18]. Due to more advanced age, pregnancies are more prevalent in developed countries, naturally encountering leiomyoma during cesarean section getting more prevalent as well. The prevalence of the

Pros and Cons of Myomectomy during Cesarean Section http://dx.doi.org/10.5772/intechopen.75365 67

Performing myomectomy during cesarean section is a controversial topic. The main concern is the potential risk of severe bleeding and increased morbidity when it is performed during cesarean section [22]. However, accumulating number of publications to support cesarean

In contrary to common belief, Tinelli et al. presented that serosal myomectomy has a minuscule impact on blood loss in the light of no difference in blood product transfusion rates when it performed during cesarean section [23]. Ramesh et al. investigated 21 cases of cesarean myomectomy retrospectively and concluded that myomectomy during cesarean section is not associated with intraoperative and postoperative complications [24]. Leiomyomas located at the cornual region were not removed in their study. Mangala et al. compared the blood loss in single fibroid in abdominal and cesarean myomectomy cases and concluded that there is no significant difference between the groups, and it is safe to remove the single leiomyoma during cesarean section [25]. Machado et al. studied eight cases in Oman for the safety of cesarean myomectomy and concluded that in selected patients, cesarean myomectomy is safe and efficient in the hands of experienced surgeons and in the tertiary healthcare facilities [26]. Kwon et al. investigated 165 pregnant women having myomas, and they evaluated the patients whose myomas are over 5 cm in size and concluded that the size of the myoma has no greater impact on the increased rates of complications [27]. Sparic et al. assessed 350 papers on cesarean myomectomy and 38 studies found to be eligible for their evaluation for review of cesarean myomectomy in modern obstetrics. The major risk is intraoperative bleeding ranging

leiomyomas during pregnancy varies from 0.37–12% in the current literature [19–21].

Potential indications of cesarean myomectomy are listed in **Table 1**.

Contraindications of cesarean myomectomy are listed in **Table 2**.

myomectomy in recent years is merging.

Symptomatic myomas (mild pelvic pain)

Myoma >5 cm Single myoma

Tumor previa

Anteriorly located myomas

Avoiding extra surgical procedure

**Table 1.** Potential indications of cesarean myomectomy.

Pedunculated myomas

Degenerative myomas

Patient's desire

Inadequacy of medical treatment and lack of understanding of molecular physiology and pathophysiological processes make the surgical treatment as the main therapeutic option for leiomyomas [5].

Leiomyomas of the uterus are highly vascular benign tumors, and their volume may increase 9% in 6-month period. Growth rate of the myomas decreases after the age of 35 among Caucasian women and almost all myomas carried to menopausal period without any symptoms shrink in size together with the shrinkage of the uterus [6].

There are only limited options for the treatment of leiomyomas of the uterus, and most of the time leiomyomas are asymptomatic and no treatment is necessary. For asymptomatic patients, menopause itself is a cure factor [7].

There are numerous medical treatment options for the treatment of leiomyoma of the uterus like OCPs, progestins, NSAIDs, androgenic compounds, antifibrinolytics and progestinloaded IUDs for symptom relief, and they are likely effective in at least a group of patients [8].

Other treatment options related to the use of GnRH agonists, GnRH antagonists and estrogen and progestin add back regimens may decrease the volume of the leiomyomas but after the cessation of medical treatment, leiomyomas resume their volume within 6 months of time [9–11].

Surgical therapy remains the definitive treatment option in symptomatic leiomyomas. Hysterectomy for the patients with no fertility problem increases the quality of the life of leiomyoma patients. Hysterectomy can be done by open surgery, laparoscopy or robotic-assisted surgery. Supracervical or subtotal hysterectomy is a controversial issue [12–14]. Abdominal myomectomy is the first surgical option for those who refuse to lose their uterus and who want to preserve their fertility for childbearing. Myomectomy can be done by open surgery, laparoscopic surgery and robotic-assisted surgery [15, 16]. For those who have submucous myomas, hysteroscopic resection is the gold standard treatment choice.

#### **2. Cesarean myomectomy**

One of the most controversial issues of obstetrics and gynecology is the presence of known or incidental leiomyomas during pregnancy and how to manage patients with myomas together with pregnancy. A total of 10–30% of the pregnancies develop some complications related to leiomyomas [17].

Cesarean section is the most commonly performed procedure globally [18]. Due to more advanced age, pregnancies are more prevalent in developed countries, naturally encountering leiomyoma during cesarean section getting more prevalent as well. The prevalence of the leiomyomas during pregnancy varies from 0.37–12% in the current literature [19–21].

Performing myomectomy during cesarean section is a controversial topic. The main concern is the potential risk of severe bleeding and increased morbidity when it is performed during cesarean section [22]. However, accumulating number of publications to support cesarean myomectomy in recent years is merging.

Potential indications of cesarean myomectomy are listed in **Table 1**.

Contraindications of cesarean myomectomy are listed in **Table 2**.

Uterine leiomyomas, also known as fibroids, are smooth muscle-derived benign masses ranging from millimeters to many centimeters. The investigation of pathological specimens of the uterus revealed that almost 80% of African Americans women and 70% of Caucasian women have detectable leiomyomas [1, 2]. The well-known risk factors for leiomyoma do not explain why racial difference is this much but genetic polymorphisms including increased aromatase activity and signal transducing genes showed that more severe phenotypic pattern may be

Inadequacy of medical treatment and lack of understanding of molecular physiology and pathophysiological processes make the surgical treatment as the main therapeutic option for

Leiomyomas of the uterus are highly vascular benign tumors, and their volume may increase 9% in 6-month period. Growth rate of the myomas decreases after the age of 35 among Caucasian women and almost all myomas carried to menopausal period without any symp-

There are only limited options for the treatment of leiomyomas of the uterus, and most of the time leiomyomas are asymptomatic and no treatment is necessary. For asymptomatic

There are numerous medical treatment options for the treatment of leiomyoma of the uterus like OCPs, progestins, NSAIDs, androgenic compounds, antifibrinolytics and progestinloaded IUDs for symptom relief, and they are likely effective in at least a group of patients [8]. Other treatment options related to the use of GnRH agonists, GnRH antagonists and estrogen and progestin add back regimens may decrease the volume of the leiomyomas but after the cessation of medical treatment, leiomyomas resume their volume within 6 months of time

Surgical therapy remains the definitive treatment option in symptomatic leiomyomas. Hysterectomy for the patients with no fertility problem increases the quality of the life of leiomyoma patients. Hysterectomy can be done by open surgery, laparoscopy or robotic-assisted surgery. Supracervical or subtotal hysterectomy is a controversial issue [12–14]. Abdominal myomectomy is the first surgical option for those who refuse to lose their uterus and who want to preserve their fertility for childbearing. Myomectomy can be done by open surgery, laparoscopic surgery and robotic-assisted surgery [15, 16]. For those who have submucous

One of the most controversial issues of obstetrics and gynecology is the presence of known or incidental leiomyomas during pregnancy and how to manage patients with myomas together with pregnancy. A total of 10–30% of the pregnancies develop some complications related to

myomas, hysteroscopic resection is the gold standard treatment choice.

toms shrink in size together with the shrinkage of the uterus [6].

patients, menopause itself is a cure factor [7].

**2. Cesarean myomectomy**

leiomyomas [17].

seen in African Americans [3, 4].

leiomyomas [5].

66 Caesarean Section

[9–11].

In contrary to common belief, Tinelli et al. presented that serosal myomectomy has a minuscule impact on blood loss in the light of no difference in blood product transfusion rates when it performed during cesarean section [23]. Ramesh et al. investigated 21 cases of cesarean myomectomy retrospectively and concluded that myomectomy during cesarean section is not associated with intraoperative and postoperative complications [24]. Leiomyomas located at the cornual region were not removed in their study. Mangala et al. compared the blood loss in single fibroid in abdominal and cesarean myomectomy cases and concluded that there is no significant difference between the groups, and it is safe to remove the single leiomyoma during cesarean section [25]. Machado et al. studied eight cases in Oman for the safety of cesarean myomectomy and concluded that in selected patients, cesarean myomectomy is safe and efficient in the hands of experienced surgeons and in the tertiary healthcare facilities [26]. Kwon et al. investigated 165 pregnant women having myomas, and they evaluated the patients whose myomas are over 5 cm in size and concluded that the size of the myoma has no greater impact on the increased rates of complications [27]. Sparic et al. assessed 350 papers on cesarean myomectomy and 38 studies found to be eligible for their evaluation for review of cesarean myomectomy in modern obstetrics. The major risk is intraoperative bleeding ranging


**Table 1.** Potential indications of cesarean myomectomy.


impact has no adverse effects [33]. Leiomyoma classified according to new myoma classification from type 0 (submucous myoma) to type 8 (Parasitic myomas) [34]. In this study, the

Pros and Cons of Myomectomy during Cesarean Section http://dx.doi.org/10.5772/intechopen.75365 69

The human uterus may increase in volume and weight, 1000 times and 20 times respectively throughout pregnancy [35, 36]. However, myomas can only grow one in fourth size during pregnancy. Thus, myomectomy during cesarean section produces less tissue damage compared to removal of a symptomatic myoma in normal sized uterus. Serosal scarring and myocyte damage during myomectomy in nonpregnant uterus is more than that of cesarean myomectomy especially endometrial myomectomy. After all cumulated publications about the safety of cesarean myomectomies, severe bleeding and possibility of cesarean hysterectomy still remain controversial issue though these two complications are no common. Conforti et al. described techniques for reducing hemorrhagic blood loss in their study published in *European Journal of Obstetrics & Gynecology and Reproductive Biology* including tourniquet, uterine artery ligation, uterine artery embolization, vasopressin, tranexamic acid and uterotonic agents like oxytocin, misoprostol and dinoprostone, GnRH analogs before the operation, recycling of lost blood during surgery and gelatin matrix [31]. Desai et al. described a novel technique for reducing the blood loss during myomectomy, and they used selective uterine devascularization in nine pregnant patients before myomectomy at the time of cesarean section. The ovarian vessels were ligated on both sides, and the ascending and the descending uterine artery branches were ligated bilaterally after the removal of baby and placental materials. All cases were managed successfully after the selective devascularization, and they found this technique as a safe and effective method [32]. Uterine artery ligation is lifesaving procedure during cesarean myomectomy of big-sized myomas as in the case reported by Ma et al. in *Taiwanese Journal of Obstetrics and Gynecology* [33]. Blood loss due to myomectomy following cesarean section is calculated by the weighing the swabs used during the surgery and volumetric measurement of aspirated blood and recorded. Loss of blood in cesarean section was not recorded but before beginning myomectomy, the uterus and lower uterine segment incision site were stabilized for any major or minor bleeding. In a meta-analysis conducted by Song et al., they searched many databases without language restriction and included only nine studies eligible for investigation and they concluded that though cesarean myomectomy can be a reasonable option, cesarean myomectomy remains still controversial because the

Literature search for cesarean myomectomies revealed many publications supporting the cesarean myomectomy. In the retrospective study conducted by Topcu et al., 76 cesarean myomectomy cases were compared with 60 cesarean only cases for blood loss, operation time, the need for transfusion and hospital stay and concluded that size of the myoma is not important and removal of corporal and subserous myomas is safe and feasible in some patients [36]. In a large group of cases in a university hospital setting, Li et al. investigated the efficacy of cesarean myomectomy of 1242 cases by comparing three groups of cases where 200 cases without myoma (group A), 145 cases with myoma but without myomectomy (group B) and 51 cases with myoma during pregnancy resulted in cesarean hysterectomy (group C), and they concluded that myomectomy during cesarean section is a safe and effective surgical method [37]. Sparic et al. analyzed the decision 289 making in cesarean myomectomy and concluded that

leiomyomas were in the range of type 2 and type 5.

data are not satisfactory [29].

**Table 2.** Contraindications of cesarean myomectomy.

from 0 to 35.3%. A potential late complication is the scar quality after the surgery. This may increase the risk of uterine rupture during the next pregnancy, but the literature lacks studies related to scar quality. However, Sparic et al. noted the advantages of cesarean myomectomy as smaller incision on the serosal surface, easy to perform during cesarean section, effortless suture placement and two operations in one. Another important advantage of cesarean myomectomy is the improved quality of life in affected women. However, they concluded that the risk benefit of cesarean myomectomy should be re-evaluated and further research is necessary [28]. Song et al. reviewed myomectomy during cesarean section through the database search and among 2500 studies they found nine studies eligible for their review and concluded that cesarean myomectomy may be a reasonable option in some leiomyoma patients but data driven from the meta-analysis were low quality, and definitive conclusion on this issue cannot be drawn [29].

Synchronous uterine contractions are mandatory for a healthy delivery. The uterus has no triggering mechanism as pacemaker in the heart, instead, uterine muscles have self- oscillators triggered by the changing membrane potentials happening in the pregnancy period and their contractility increases toward the end of the gestation [31]. Myocyte contractility also increased by the facilitation of prostaglandins and myocyte to myocyte connectivity and activated intracellular contractile mechanism, which eventually increase the intrauterine pressure that effaces and dilates the cervix for the babies to be delivered. Any leiomyoma or other uterine pathologies may have negative effect on the uterine contractility and also any surgical procedure related to the uterine musculature might have negative impact on the uterine contractility and may increase the risk of uterine rupture during delivery. Decreasing the myocyte damage during myomectomy should be taken into consideration during any myomectomy cases.

Uterine pathologies including the leiomyoma have negative impact on the implantation and placentation [32]. Submucosal and intramural myomas deforming the endometrial surface reduce the implantation rates and increase the risk of abortion and mallocated placentation. The intramural leiomyoma not affecting the endometrial cavity is still a question. Number, size and locations of the myomas determine their impact. Small leiomyoma without endometrial impact has no adverse effects [33]. Leiomyoma classified according to new myoma classification from type 0 (submucous myoma) to type 8 (Parasitic myomas) [34]. In this study, the leiomyomas were in the range of type 2 and type 5.

The human uterus may increase in volume and weight, 1000 times and 20 times respectively throughout pregnancy [35, 36]. However, myomas can only grow one in fourth size during pregnancy. Thus, myomectomy during cesarean section produces less tissue damage compared to removal of a symptomatic myoma in normal sized uterus. Serosal scarring and myocyte damage during myomectomy in nonpregnant uterus is more than that of cesarean myomectomy especially endometrial myomectomy. After all cumulated publications about the safety of cesarean myomectomies, severe bleeding and possibility of cesarean hysterectomy still remain controversial issue though these two complications are no common. Conforti et al. described techniques for reducing hemorrhagic blood loss in their study published in *European Journal of Obstetrics & Gynecology and Reproductive Biology* including tourniquet, uterine artery ligation, uterine artery embolization, vasopressin, tranexamic acid and uterotonic agents like oxytocin, misoprostol and dinoprostone, GnRH analogs before the operation, recycling of lost blood during surgery and gelatin matrix [31]. Desai et al. described a novel technique for reducing the blood loss during myomectomy, and they used selective uterine devascularization in nine pregnant patients before myomectomy at the time of cesarean section. The ovarian vessels were ligated on both sides, and the ascending and the descending uterine artery branches were ligated bilaterally after the removal of baby and placental materials. All cases were managed successfully after the selective devascularization, and they found this technique as a safe and effective method [32]. Uterine artery ligation is lifesaving procedure during cesarean myomectomy of big-sized myomas as in the case reported by Ma et al. in *Taiwanese Journal of Obstetrics and Gynecology* [33]. Blood loss due to myomectomy following cesarean section is calculated by the weighing the swabs used during the surgery and volumetric measurement of aspirated blood and recorded. Loss of blood in cesarean section was not recorded but before beginning myomectomy, the uterus and lower uterine segment incision site were stabilized for any major or minor bleeding. In a meta-analysis conducted by Song et al., they searched many databases without language restriction and included only nine studies eligible for investigation and they concluded that though cesarean myomectomy can be a reasonable option, cesarean myomectomy remains still controversial because the data are not satisfactory [29].

from 0 to 35.3%. A potential late complication is the scar quality after the surgery. This may increase the risk of uterine rupture during the next pregnancy, but the literature lacks studies related to scar quality. However, Sparic et al. noted the advantages of cesarean myomectomy as smaller incision on the serosal surface, easy to perform during cesarean section, effortless suture placement and two operations in one. Another important advantage of cesarean myomectomy is the improved quality of life in affected women. However, they concluded that the risk benefit of cesarean myomectomy should be re-evaluated and further research is necessary [28]. Song et al. reviewed myomectomy during cesarean section through the database search and among 2500 studies they found nine studies eligible for their review and concluded that cesarean myomectomy may be a reasonable option in some leiomyoma patients but data driven from the meta-analysis were low quality, and definitive conclusion on this issue cannot

Synchronous uterine contractions are mandatory for a healthy delivery. The uterus has no triggering mechanism as pacemaker in the heart, instead, uterine muscles have self- oscillators triggered by the changing membrane potentials happening in the pregnancy period and their contractility increases toward the end of the gestation [31]. Myocyte contractility also increased by the facilitation of prostaglandins and myocyte to myocyte connectivity and activated intracellular contractile mechanism, which eventually increase the intrauterine pressure that effaces and dilates the cervix for the babies to be delivered. Any leiomyoma or other uterine pathologies may have negative effect on the uterine contractility and also any surgical procedure related to the uterine musculature might have negative impact on the uterine contractility and may increase the risk of uterine rupture during delivery. Decreasing the myocyte damage during myomectomy should be taken into consideration during any

Uterine pathologies including the leiomyoma have negative impact on the implantation and placentation [32]. Submucosal and intramural myomas deforming the endometrial surface reduce the implantation rates and increase the risk of abortion and mallocated placentation. The intramural leiomyoma not affecting the endometrial cavity is still a question. Number, size and locations of the myomas determine their impact. Small leiomyoma without endometrial

be drawn [29].

Age > 40 years Multiple myomas

68 Caesarean Section

Cornual located myomas Posteriorly located myomas Asymptomatic myomas

Previous history of uterine rupture

**Table 2.** Contraindications of cesarean myomectomy.

Tendency to bleed

myomectomy cases.

Literature search for cesarean myomectomies revealed many publications supporting the cesarean myomectomy. In the retrospective study conducted by Topcu et al., 76 cesarean myomectomy cases were compared with 60 cesarean only cases for blood loss, operation time, the need for transfusion and hospital stay and concluded that size of the myoma is not important and removal of corporal and subserous myomas is safe and feasible in some patients [36]. In a large group of cases in a university hospital setting, Li et al. investigated the efficacy of cesarean myomectomy of 1242 cases by comparing three groups of cases where 200 cases without myoma (group A), 145 cases with myoma but without myomectomy (group B) and 51 cases with myoma during pregnancy resulted in cesarean hysterectomy (group C), and they concluded that myomectomy during cesarean section is a safe and effective surgical method [37]. Sparic et al. analyzed the decision 289 making in cesarean myomectomy and concluded that surgical skills, age of the patient and type of the myomas are the most important predictors of cesarean myomectomy [38].

is the enlarged and well-vascularized uterus during cesarean section. Uterine involution squeezes the big vessels in the endometrial cavity, but the surface blood supply is not affected from the involution thus the risk of bleeding during serosal myomectomy is increased. Besides, the incision on the surface remains large which may have greater impact on the adhesion formation. In cases where multiple myoma removal is necessary, the number of incisions increases and the risk of bleeding and formation of adhesions increases. In serosal myomectomy, removal of posterior myomas and myomas close to the cornual region are not recommended. Myomas close to each other may be removed

Pros and Cons of Myomectomy during Cesarean Section http://dx.doi.org/10.5772/intechopen.75365 71

Following removal of baby and the placenta, the uterine cavity is swept by a gauze and incision site is controlled for any bleeding and lower uterine segment incision is closed with a running nonlocked no. 1 Vicryl suture. Uterine surface is evaluated for the locations and the sizes of the myomas present. Leiomyoma close to the low uterine segment incision site was taken out as described in endometrial myomectomy technique. Closed proximity of the leiomyomas was removed from a single incision to diminish the adhesion formation. Leiomyoma located in different locations is removed by incising each leiomyoma surface thus sutures and scarring on the surface of the uterus are prominent in classical technique. While removing the myoma, if myoma base carries a vascular pedicle, then the pedicle is clamped and sutured. The muscular layer is closed by separate no. 1 Vicryl sutures. The serosal surface is closed in either continuous locked no. 1 Vicryl sutures or a baseball suturing technique. After suturing a very hot sponge is placed on the suture line for a short time and then removed to see any bleeding foci. Any resistant bleeding not controlled by electrocautery may be controlled by no. 2 Vicryl U sutures or by figure of eight sutures around the suture line. No antiadhesion material is used for protection. After removal and suturing of all myomas, uterus is placed in the abdominal cavity and the serosal surface of the uterus and the tubes and ovaries are checked for bleeding and following hemostasis and clot removal the abdominal layers are closed according to the general principles. The long-term effect of this method is the adhesion formation, which makes the latter abdominal surgeries prone to complications. Hemostatic sutures for bleeding result in many suture

In 2013, **Cengiz Tokgöz M.D.** developed a new cesarean myomectomy technique which was named as **endometrial myomectomy**. The main aim of this novel technique is to minimalize the uterine scarring and eventual adhesion formation while using the uterine physiology as the main support for this surgical procedure. Until 2017, more than 30 cases were operated by this technique and 22 of the cases without posterior myomas were drilled into a retrospective study for publishing the preliminary outcomes of this novel technique. The technique was published in the *Journal of Maternal Fetal and Neonatal Medicine* as the first in the world and this study is the first and unique to compare one cesarean myomectomy technique(endometrial

All myomectomy cases were performed by the same team of surgeons and cesarean section technique and myomectomy techniques used in these surgeries were the same. After removal

from the same incision to diminish the adhesion formation.

nodes on the uterine surface and may prolong time of surgery.

myomectomy) with another one (serosal myomectomy).

**2.3. Technique of endometrial myomectomy**

Cesarean myomectomy has been consistently applied in our setting for 17 years. Beginning from 2013, endometrial myomectomy has been started and selected as the cesarean myomectomy of choice instead of classical serosal approach because in serosal myomectomy, the bleeding, operative time, myometrial damage and adhesion formation possibilities are higher as compared to endometrial myomectomy [30]. The rate of suturing the endometrium during surgery is very low and uterine involution itself shrinks the surgical site to a lesser size. The surgery raises the question whether the endometrial myomectomy increases the likelihood of intrauterine adhesions or Asherman syndrome. We performed ultrasound evaluation at seventh day postoperation and evaluated the myometrial defect and found totally normal appearance in 22 cases. Also we called all patients 40 days after the surgery for saline infusion sonohysterography (SIS) and SIS outcomes revealed that no single case experienced intrauterine adhesions at any level. SIS has been neglected for long time in infertility, but actually SIS is a simple and important investigation for intrauterine pathologies. Intrauterine adhesions can be verified by simple SIS as an adjunct to other diagnostic tools [39]. CS myomectomy from endometrial approach decreases loss of blood, total operation time and adhesion formation compared to classical cesarean myomectomy.

Hospital stay is no longer than classical myomectomies. Uterine serosa remains intact.

Endometrial myomectomy uses the principles of hysteroscopic myomectomy and supported by the physiological mechanism of uterine involution to decrease the blood loss and suturing during surgery. In this surgical method, unintentional opening of uterine serosa is accepted as complication because the main goal of this surgery is to remove all myomas from the endometrial layer without touching the serosal layer for preserving the uterus from dense adhesions and ease the future surgeries of the patient. All myomas located in anterior or posterior region and even the ones located close to cornual area can be safely removed by this surgical technique.

In the following section, we describe the techniques of serosal myomectomy and endometrial myomectomy in detail.

#### **2.1. Techniques of cesaraen myomectomy**

There are two approaches for removing the leiomyomas during cesarean section; one is the well-known serosal myomectomy and second is the novel technique recently published endometrial myomectomy. Both techniques use the same principle of intracapsular myoma removal, but the only difference is the route of myoma removal. Removing myomas by endometrial route have some advantages over the serosal myomectomy and both techniques are explained in the following section in detail.

#### **2.2. Technique of serosal myomectomy**

Serosal myomectomy is the removal of the leiomyomas as in abdominal or laparoscopic myomectomy where incisions were made on the surface of the uterus. The only difference is the enlarged and well-vascularized uterus during cesarean section. Uterine involution squeezes the big vessels in the endometrial cavity, but the surface blood supply is not affected from the involution thus the risk of bleeding during serosal myomectomy is increased. Besides, the incision on the surface remains large which may have greater impact on the adhesion formation. In cases where multiple myoma removal is necessary, the number of incisions increases and the risk of bleeding and formation of adhesions increases. In serosal myomectomy, removal of posterior myomas and myomas close to the cornual region are not recommended. Myomas close to each other may be removed from the same incision to diminish the adhesion formation.

Following removal of baby and the placenta, the uterine cavity is swept by a gauze and incision site is controlled for any bleeding and lower uterine segment incision is closed with a running nonlocked no. 1 Vicryl suture. Uterine surface is evaluated for the locations and the sizes of the myomas present. Leiomyoma close to the low uterine segment incision site was taken out as described in endometrial myomectomy technique. Closed proximity of the leiomyomas was removed from a single incision to diminish the adhesion formation. Leiomyoma located in different locations is removed by incising each leiomyoma surface thus sutures and scarring on the surface of the uterus are prominent in classical technique. While removing the myoma, if myoma base carries a vascular pedicle, then the pedicle is clamped and sutured. The muscular layer is closed by separate no. 1 Vicryl sutures. The serosal surface is closed in either continuous locked no. 1 Vicryl sutures or a baseball suturing technique. After suturing a very hot sponge is placed on the suture line for a short time and then removed to see any bleeding foci. Any resistant bleeding not controlled by electrocautery may be controlled by no. 2 Vicryl U sutures or by figure of eight sutures around the suture line. No antiadhesion material is used for protection. After removal and suturing of all myomas, uterus is placed in the abdominal cavity and the serosal surface of the uterus and the tubes and ovaries are checked for bleeding and following hemostasis and clot removal the abdominal layers are closed according to the general principles.

The long-term effect of this method is the adhesion formation, which makes the latter abdominal surgeries prone to complications. Hemostatic sutures for bleeding result in many suture nodes on the uterine surface and may prolong time of surgery.

In 2013, **Cengiz Tokgöz M.D.** developed a new cesarean myomectomy technique which was named as **endometrial myomectomy**. The main aim of this novel technique is to minimalize the uterine scarring and eventual adhesion formation while using the uterine physiology as the main support for this surgical procedure. Until 2017, more than 30 cases were operated by this technique and 22 of the cases without posterior myomas were drilled into a retrospective study for publishing the preliminary outcomes of this novel technique. The technique was published in the *Journal of Maternal Fetal and Neonatal Medicine* as the first in the world and this study is the first and unique to compare one cesarean myomectomy technique(endometrial myomectomy) with another one (serosal myomectomy).

#### **2.3. Technique of endometrial myomectomy**

surgical skills, age of the patient and type of the myomas are the most important predictors

Cesarean myomectomy has been consistently applied in our setting for 17 years. Beginning from 2013, endometrial myomectomy has been started and selected as the cesarean myomectomy of choice instead of classical serosal approach because in serosal myomectomy, the bleeding, operative time, myometrial damage and adhesion formation possibilities are higher as compared to endometrial myomectomy [30]. The rate of suturing the endometrium during surgery is very low and uterine involution itself shrinks the surgical site to a lesser size. The surgery raises the question whether the endometrial myomectomy increases the likelihood of intrauterine adhesions or Asherman syndrome. We performed ultrasound evaluation at seventh day postoperation and evaluated the myometrial defect and found totally normal appearance in 22 cases. Also we called all patients 40 days after the surgery for saline infusion sonohysterography (SIS) and SIS outcomes revealed that no single case experienced intrauterine adhesions at any level. SIS has been neglected for long time in infertility, but actually SIS is a simple and important investigation for intrauterine pathologies. Intrauterine adhesions can be verified by simple SIS as an adjunct to other diagnostic tools [39]. CS myomectomy from endometrial approach decreases loss of blood, total operation time and adhesion formation

Hospital stay is no longer than classical myomectomies. Uterine serosa remains intact.

Endometrial myomectomy uses the principles of hysteroscopic myomectomy and supported by the physiological mechanism of uterine involution to decrease the blood loss and suturing during surgery. In this surgical method, unintentional opening of uterine serosa is accepted as complication because the main goal of this surgery is to remove all myomas from the endometrial layer without touching the serosal layer for preserving the uterus from dense adhesions and ease the future surgeries of the patient. All myomas located in anterior or posterior region and even the ones located close to cornual area can be safely removed by this surgical

In the following section, we describe the techniques of serosal myomectomy and endometrial

There are two approaches for removing the leiomyomas during cesarean section; one is the well-known serosal myomectomy and second is the novel technique recently published endometrial myomectomy. Both techniques use the same principle of intracapsular myoma removal, but the only difference is the route of myoma removal. Removing myomas by endometrial route have some advantages over the serosal myomectomy and both techniques are

Serosal myomectomy is the removal of the leiomyomas as in abdominal or laparoscopic myomectomy where incisions were made on the surface of the uterus. The only difference

of cesarean myomectomy [38].

70 Caesarean Section

compared to classical cesarean myomectomy.

**2.1. Techniques of cesaraen myomectomy**

explained in the following section in detail.

**2.2. Technique of serosal myomectomy**

technique.

myomectomy in detail.

All myomectomy cases were performed by the same team of surgeons and cesarean section technique and myomectomy techniques used in these surgeries were the same. After removal of the baby and the placenta, the uterus is taken out from the abdominal cavity. The uterine cavity is swept by a gauze and uterine incision is controlled for any bleeding. Uterine surface and cavity are evaluated thoroughly for leiomyomas and anatomical locations and sizes are evaluated quickly. Those leiomyomas located close to the low uterine incision site (**Picture 1**) are removed from the incision line, which is neither a serosal nor an endometrial myomectomy, and in fact, the myoma (**Picture 3**) is removed from subendometrial-intramyometrial area (**Picture 2**). The death space is closed together with the low uterine incision line suturing thus no extra suturing is necessary in such conditions.

Courtesy of Şafak Hatırnaz M.D. & Oğuz Güler M.D.

major supporter in this technique.

Any vascular structures at the root of leiomyoma were clamped and sutured (**Picture 8**). If more than one leiomyoma are present and not close to each other, then all leiomyomas removed from one by one and endometrium is incised for each leiomyoma. However, the endometrium has the opportunity to involute rapidly and the endometria incisions diminish in size, which makes the endometrial scar smaller than the original incision. If the myoma removal site is not bleeding and the diameter of the incision on the endometrial layer <3 cm, no sutures are placed on the endometrial layer to minimalize the adhesion formation within the endometrial cavity. This is what is done in hysteroscopic submucous or intramural myoma resection where suturing is impossible to do. If suturing is necessary for bigger incisions or bleeding, the no. 1 rapid Vicryl separate or continuous sutures are placed on the endometrial incision sites. By this technique, almost all myomas located on the uterus can be easily removed from the endometrium including subserous non pedunculated leiomyomas. Subserous myoma removal from the endometrium may seem to be unnecessary, but serosa of the uterus remains intact and the myometrial tissue damage diminishes while uterus is involuted. Thus, the death space in the myometrial layer is not observed, and myometrial integrity is not affected too much following this surgical procedure. Uterine physiology is the

Pros and Cons of Myomectomy during Cesarean Section http://dx.doi.org/10.5772/intechopen.75365 73

Following bleeding control, any bleeding sites were sutured if present and if no major bleeding, myoma bed or death spaces are sutured with no. 1 Vicryl in a separated manner. Endometrium is sutured with an absorbable suture in cases where the defect site is bigger than 3 cm. Any serosal opening during subendometrial myomectomy is accepted as complication because the main goal of this surgical method is to keep the uterine serosa intact apart from cesarean lower uterine segment incision scar and by this way to minimize the adhesion formation which is a matter of fact in myomectomies. In cases where reaching myoma is difficult, the team preferred to use bivalves to open the endometrial cavity for a safe surgical procedure. Uterus itself is the major supporter of this surgery since the rapid physiological involution of the uterus diminishes the death spaces and suture sites thus endometrial scarring

Courtesy of Oğuz Güler M.D. & Cengiz Tokgöz M.D.

Following palpation and localization, leiomyomas (**Picture 4**) were pushed from the serosal site to be visible and palpable from endometrial site, then an endometrial-transmyometrial incision was made (**Picture 5**) to reach the leiomyoma by a scalpel or electrocautery knife and leiomyoma(**Picture 6**) was removed without its capsule (**Picture 7**) by blunt and sharp dissections.

Courtesy of Şafak Hatırnaz M.D. & Oğuz Güler M.D.

of the baby and the placenta, the uterus is taken out from the abdominal cavity. The uterine cavity is swept by a gauze and uterine incision is controlled for any bleeding. Uterine surface and cavity are evaluated thoroughly for leiomyomas and anatomical locations and sizes are evaluated quickly. Those leiomyomas located close to the low uterine incision site (**Picture 1**) are removed from the incision line, which is neither a serosal nor an endometrial myomectomy, and in fact, the myoma (**Picture 3**) is removed from subendometrial-intramyometrial area (**Picture 2**). The death space is closed together with the low uterine incision line suturing

Following palpation and localization, leiomyomas (**Picture 4**) were pushed from the serosal site to be visible and palpable from endometrial site, then an endometrial-transmyometrial incision was made (**Picture 5**) to reach the leiomyoma by a scalpel or electrocautery knife and leiomyoma(**Picture 6**) was removed without its capsule (**Picture 7**) by blunt and sharp

thus no extra suturing is necessary in such conditions.

Courtesy of Oğuz Güler M.D. & Cengiz Tokgöz M.D.

dissections.

72 Caesarean Section

Any vascular structures at the root of leiomyoma were clamped and sutured (**Picture 8**). If more than one leiomyoma are present and not close to each other, then all leiomyomas removed from one by one and endometrium is incised for each leiomyoma. However, the endometrium has the opportunity to involute rapidly and the endometria incisions diminish in size, which makes the endometrial scar smaller than the original incision. If the myoma removal site is not bleeding and the diameter of the incision on the endometrial layer <3 cm, no sutures are placed on the endometrial layer to minimalize the adhesion formation within the endometrial cavity. This is what is done in hysteroscopic submucous or intramural myoma resection where suturing is impossible to do. If suturing is necessary for bigger incisions or bleeding, the no. 1 rapid Vicryl separate or continuous sutures are placed on the endometrial incision sites. By this technique, almost all myomas located on the uterus can be easily removed from the endometrium including subserous non pedunculated leiomyomas. Subserous myoma removal from the endometrium may seem to be unnecessary, but serosa of the uterus remains intact and the myometrial tissue damage diminishes while uterus is involuted. Thus, the death space in the myometrial layer is not observed, and myometrial integrity is not affected too much following this surgical procedure. Uterine physiology is the major supporter in this technique.

Following bleeding control, any bleeding sites were sutured if present and if no major bleeding, myoma bed or death spaces are sutured with no. 1 Vicryl in a separated manner. Endometrium is sutured with an absorbable suture in cases where the defect site is bigger than 3 cm. Any serosal opening during subendometrial myomectomy is accepted as complication because the main goal of this surgical method is to keep the uterine serosa intact apart from cesarean lower uterine segment incision scar and by this way to minimize the adhesion formation which is a matter of fact in myomectomies. In cases where reaching myoma is difficult, the team preferred to use bivalves to open the endometrial cavity for a safe surgical procedure. Uterus itself is the major supporter of this surgery since the rapid physiological involution of the uterus diminishes the death spaces and suture sites thus endometrial scarring minimizes automatically. After inspection and hemostasis, lower uterine segment incision is closed and layers of the abdomen are closed carefully.

transabdominal ultrasound and recorded. Every single patient is called for saline infusion sonography (SIS) 40 days after the surgery (when the uterine involution is ended and the uterus reaches the normal size) for the evaluation of endometrial damage or adhesion formation routinely and SİS findings are also recorded. Asherman syndrome at any level was not recorded in studied cases. Among the studied 22 cases, four of them were operated for next cesarean section, and no leiomyoma formation or adhesion formation was observed during their next surgeries.

Pros and Cons of Myomectomy during Cesarean Section http://dx.doi.org/10.5772/intechopen.75365 75

Both techniques carry some risks and complications during and after surgery. The complica-

Cesarean myomectomy still remains a controversial issue in obstetrics practice and seems to continue to be debated in the future. Because none of the studies were performed as randomized controlled trials so far, and meta-analyses derived from those studies have weak outcomes to say that cesarean myomectomy is a safe and reliable procedure. The accumulating data, how-

Though this novel method of cesarean myomectomy, endometrial myomectomy, decreases the adhesion formation by keeping the uterine serosa intact, diminishes blood loss and reduce the operation time compared to serosal myomectomy, large-scale randomized controlled trials need to show mid-term and long-term outcomes of this novel approach. Much safer and technically easier methods may change the steady thoughts on the risks of cesarean myomec-

\* and Oğuz Güler<sup>1</sup>

1 Department of Obstetrics and Gynecology, Private Bilge Hospital, Istanbul, Turkey

2 IVF Center, Department of Obstetrics and Gynecology, Medicana International Hospital,

[1] Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. American

tions related to cesarean myomectomy are listed in **Table 3**.

**3. Conclusions**

tomy in future.

**Author details**

Cengiz Tokgöz<sup>1</sup>

Samsun, Turkey

**References**

A picture of SIS 40 days after the operation is depicted in **Figure 1**.

ever, diminished the fear of performing cesarean myomectomy.

, Şafak Hatirnaz<sup>2</sup>

\*Address all correspondence to: safakhatirnaz@gmail.com

Journal of Obstetrics and Gynecology. 2003;**188**(1):100-107

Postoperative care was not different from the cesarean section cases, and no additional treatment or follow-up was recommended for endometrial myomectomy cases.

Number of the leiomyomas, leiomyoma sizes, amount of blood lost during this procedure, serosal opening during surgery and operation time are all recorded. Leiomyomas are sent for pathological evaluation in all cases.

All patients are called 5 days after the hospital discharge for postoperative control and the uterus, the endometrium and the surgical sites of leiomyoma removal are evaluated carefully by


**Table 3.** Early and late complications of cesarean myomectomy.

**Figure 1.** Saline infusion sonohysterography (SIS) 40 days after endometrial myomectomy. Courtesy of Oğuz Güler M.D.

transabdominal ultrasound and recorded. Every single patient is called for saline infusion sonography (SIS) 40 days after the surgery (when the uterine involution is ended and the uterus reaches the normal size) for the evaluation of endometrial damage or adhesion formation routinely and SİS findings are also recorded. Asherman syndrome at any level was not recorded in studied cases.

Among the studied 22 cases, four of them were operated for next cesarean section, and no leiomyoma formation or adhesion formation was observed during their next surgeries.

Both techniques carry some risks and complications during and after surgery. The complications related to cesarean myomectomy are listed in **Table 3**.

A picture of SIS 40 days after the operation is depicted in **Figure 1**.

#### **3. Conclusions**

Cesarean myomectomy still remains a controversial issue in obstetrics practice and seems to continue to be debated in the future. Because none of the studies were performed as randomized controlled trials so far, and meta-analyses derived from those studies have weak outcomes to say that cesarean myomectomy is a safe and reliable procedure. The accumulating data, however, diminished the fear of performing cesarean myomectomy.

Though this novel method of cesarean myomectomy, endometrial myomectomy, decreases the adhesion formation by keeping the uterine serosa intact, diminishes blood loss and reduce the operation time compared to serosal myomectomy, large-scale randomized controlled trials need to show mid-term and long-term outcomes of this novel approach. Much safer and technically easier methods may change the steady thoughts on the risks of cesarean myomectomy in future.

#### **Author details**

Cengiz Tokgöz<sup>1</sup> , Şafak Hatirnaz<sup>2</sup> \* and Oğuz Güler<sup>1</sup>

\*Address all correspondence to: safakhatirnaz@gmail.com

1 Department of Obstetrics and Gynecology, Private Bilge Hospital, Istanbul, Turkey

2 IVF Center, Department of Obstetrics and Gynecology, Medicana International Hospital, Samsun, Turkey

#### **References**

**Figure 1.** Saline infusion sonohysterography (SIS) 40 days after endometrial myomectomy. Courtesy of Oğuz Güler M.D.

minimizes automatically. After inspection and hemostasis, lower uterine segment incision is

Postoperative care was not different from the cesarean section cases, and no additional treat-

Number of the leiomyomas, leiomyoma sizes, amount of blood lost during this procedure, serosal opening during surgery and operation time are all recorded. Leiomyomas are sent for

All patients are called 5 days after the hospital discharge for postoperative control and the uterus, the endometrium and the surgical sites of leiomyoma removal are evaluated carefully by

ment or follow-up was recommended for endometrial myomectomy cases.

closed and layers of the abdomen are closed carefully.

pathological evaluation in all cases.

Intraoperative bleeding Postoperative fever Blood transfusion Prolonged hospital stay Adhesion formation Asherman syndrome

74 Caesarean Section

Abnormal placental insertions

**Table 3.** Early and late complications of cesarean myomectomy.

Uterine rupture

[1] Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. American Journal of Obstetrics and Gynecology. 2003;**188**(1):100-107

[2] Cramer SF, Patel A. The frequency of uterine leiomyomas. American Journal of Clinical Pathology. 1990;**94**(4):435-438

[15] Mansour FW, Kives S, Urbach DR, Lefebvre G. Robotically assisted laparoscopic myomectomy: A canadian experience. Journal of Obstetrics and Gynaecology Canada.

Pros and Cons of Myomectomy during Cesarean Section http://dx.doi.org/10.5772/intechopen.75365 77

[16] Advincula AP, Xu X, Goudeau ST, Ransom SB. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: A comparison of short-term surgical outcomes and immediate costs. Journal of Minimally Invasive Gynecology. 2007;**14**(6):698-705 [17] Klatsky PC, Tran ND, Caughey AB, Fibroids FVY. reproductive outcomes: A systematic literature review from conception to delivery. American Journal of Obstetrics and

Gynecology. 2008 Apr;**198**(4):357-366. DOI: 10.1016/j.ajog.2007.12.039. Review

[18] Ma PC, Juan YC, Wang ID, Chen CH, Liu WM, Jeng CJ. A huge leiomyomsubjected to a myomectomy during a cesarean section. Taiwanese Journal of Obstetrics and

[19] Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: An ultrasound-screening study.

[20] Exacoustos C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in

[21] Kwawukume EY. Myomectomy during cesarean section. International Journal of

[22] Park BJ, Kim YW. Safety of cesarean myomectomy. The Journal of Obstetrics and

[23] Tinelli A, Malvasi A, Mynbaev OA, et al. The surgical outcome of intracapsular cesarean myomectomy: A match control study. The Journal of Maternal-Fetal & Neonatal

[24] Ramesh Kumar R, Patıl M, Sa S. The utility of cesarean myomectomy as a safe proce-

[25] Mangala KJ, Sudha S, Sarala S, Rajambal B, Usha MG, Sheejamol VS. Comparative study of cesarean myomectomy with abdominal myomectomy in terms of blood loss in single fibroid. The Journal of Obstetrics and Gynecology Of India. July-August

[26] Lovina SM Machado, Gowri V, Al-Riyami N, Al-Khurasi L. Cesarean myomectomy fea-

[27] Kwon DH, Song JE, Yoon KR, Lee KY. The safety of cesarean myomevtomy in woman

with large myomas. Obstetrics & Gynecology Science. 2014;**57**(5):367-372

dure. Journal of Clinical and Diagnostic Research. 2014 sep;**8**(9):0005-0008

2012;**34**(4):353-358

Gynecology. 2010;**49**:220-222

Obstetrics and Gynecology. 2009;**113**(3):630-635

Gynecology & Obstetrics. 2002;**76**:183-184

Gynaecology Research. 2009;**35**(5):906-911

Medicine. 2014;**27**:66-71

2016;**66**(4):287-291

pregnancy. Obstetrics and Gynecology. 1993;**82**(1):97-101

sibility and safety SQU MED J. May 2012;**12**(2):190-196


[15] Mansour FW, Kives S, Urbach DR, Lefebvre G. Robotically assisted laparoscopic myomectomy: A canadian experience. Journal of Obstetrics and Gynaecology Canada. 2012;**34**(4):353-358

[2] Cramer SF, Patel A. The frequency of uterine leiomyomas. American Journal of Clinical

[3] Ishikawa H, Reierstad S, Demura M, Rademaker AW, Kasai T, Inoue M, et al. High aromatase expression in uterine leiomyoma tissues of African-American women. The

[4] Pan Q, Luo X, Chegini N. Genomic and proteomic profiling I: Leiomyomas in African Americans and Caucasians. Reproductive Biology and Endocrinology. 2007;**5**:34

[5] Stewart EA, Nowak RA. Leiomyoma-related bleeding: A classic hypothesis updated for

[6] Peddala SD, Laughlin SK, Miner K, Guyon JP, Haneke K, Vahdat HL, et al. Growth of uterine leiomyomata among premenopausal black and White women. Proceedings of the National Academy of Sciences of the United States of America. 2008;**105**(50):19887-19892

[7] Şener AB, Seçkin NC, Ozmen S, Gokmen O, Doğu N, Ekici E.The effects of hormone replacement therapy on uterine fibroids in postmenopousal women. Fertility and

[8] Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. The Cochrane Database of Systematic Reviews. 2006 Apr 19;(2):CD003855. Review. Update in: The Cochrane Database of Systematic Reviews. 2016;**1**:CD003855

[9] Friedman AJ, Daly M, Juneau-Norcross M, Rein MS. Predictors of uterine volume reduction in women with myomas treated with a gonadotropin-releasing hormone agonist.

[10] Friedman AJ. Treatment of leiomyomata uteri with short-term leupro-lide followed by leuprolide plus estrogen-progestin hormone replacement therapy for 2 years: A pilot

[11] Fellerbaum RE, Germer U, Ludwig M, Riethmuller-Winzen H, Hiese S, Buttge I, et al. Treatment of uterine fibroids with a slow release formulation of a gonadotropin releas-

[12] Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study: I. Outcomes of

[13] Kjerulff KH, Rhodes JC, Langenberg PW, Harvey LA. Patient satisfaction with results of hysterectomy. American Journal of Obstetrics and Gynecology. 2000;**183**(6):1440-1447

[14] Owusu-Ansah R, Gatongi D, Chien PF. Health technology assessment of surgical therapies for benign gynecological disease, Best Practice & Research. Clinical Obstetrics &

ing hormone antagonist Cetrorelix. Human Reproduction. 1998;**13**(6):1660-1668

hysterectomy. Obstetrics and Gynecology. 1994;**83**(4):556-565

Journal of Clinical Endocrinology and Metabolism. 2009;**94**(5):1752-1756

the molecular era. Human Reproduction Update. 1996;**2**(4):295-306

Pathology. 1990;**94**(4):435-438

76 Caesarean Section

Sterility. 1996;**65**(2):354-357

Fertility and Sterility. 1992;**58**(2):413-415

Gynaecology. 2006;**20**(6):841-879

study. Fertility and Sterility. 1989;**51**(3):526-528


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

**Section 4**

**Complications**


**Section 4**
