**3. Discussion**

Today Cragin's opinion "once a Caesarean, always a Caesarean" [23] is proved by highly increasing CS rate worldwide.

In the last decades, the number of Cesarean Sections increased steadily [24]. One of the reasons is the promoting of Cesarean Section by request of the mother [25].

As a result, more placental implantation pathologies occur [26], and certainly more problems related to scar dehiscence following repeated pregnancies following Cesarean Sections.

The best way to prevent these complications is certainly by reducing the number of Cesarean Sections, mainly at low-risk pregnancies. In our group, it was successfully achieved by asking for a documented second opinion for each non-emergency Cesarean Section.

When a Cesarean Section is done, it is important to perform the operation in a way that the full thickness of the uterine wall, as well as its strength, will be preserved.

It is important to analyze what are the reasons for uterine wall defects and how are they related to the surgical method.

It was shown by Di Spiezio et al. that one or two layers suturing of the uterine wall do not make any difference concerning the incidence of Cesarean scar defects as well as the uterine dehiscence and rate of ruptures in subsequent pregnancies [27].

Although a second layer did not show any benefit concerning the thickness of the uterine wall [28].

If one or two layers of sutures are not the etiology of dehiscence in subsequent pregnancies, it is important to analyze the relevant reason.

It is known that sutured muscle tissue will never regain its original strength, in contrary to fibrous tissue. Therefore, the less muscle tissue to be cut the better are the chances for a stronger scar.

*Rorie* analyzed the histological structure of the uterus and found out that the amount of smooth muscle in the upper third of the cervix is 28%, and in the body of the uterus 68.8% [29].

It means the lower the incision in the uterus, the less damage to the uterine wall.

As a result, it is important to incise the urine bladder plica, push the bladder down, and cut the uterine wall as low as possible. This is in contrary to the nowadays practice to open the uterus above the plica [30].

The uterus contracts immediately after delivery, and after a few weeks regains its original size. The sutures cannot contract together with the uterus, and their function is to enhance hemostasis in the first hours. Thereafter, the more stitching material is left the more foreign body reaction occurs which might weaken the scar.

Therefore, in order to leave as little suturing material as possible, it is important to use big needles as possible [31].

Technique of this Cesarean section and advantages was described in earlier publications [31–36] with systematic review of literature [37].

This will result in less suture material left behind. We believe that opening the uterus in the lower segment and suture the uterus with one layer using a big needle will reduce the scar dehiscence in future pregnancies.

#### **4. Conclusions**

The cesarean scar is a significant risk factor for the following pregnancies and especially deliveries. In this chapter, we discussed the diagnosis, incidence, detection, manifestations, and prognosis of pregnancy and delivery with cesarean scars.

**61**

*Cesarean Scar Defect Manifestations during Pregnancy and Delivery*

big needle preferable by Stark technique of Cesarean section.

inestimable assistance of the manuscript preparation.

A systematic review of current literature showed that a manifestation of cesarean scars during the following pregnancies is not predictable, in general, although modern visualization technologies could reveal some specific features of scar defects that are associated with complications during pregnancy and delivery. However, there is no factor, which could serve as the main prognostic guide for obstetricians to make a decision for VBAC, thus Edwin Cragin's phrase "once a cesarean, always a cesarean" has represented the essential health care issue over the century. At the moment, the most reasonable measurements to prevent uterine scar complications are reducing the rate of Cesarean Sections, opening the uterus transversely in the lower segment, and stitching the uterus with one layer only continuously using a

The authors would like to sincerely thank Mrs. Maya A. Bessarabova for her

*DOI: http://dx.doi.org/10.5772/intechopen.90775*

**Acknowledgements**

**Conflict of interest**

No conflict of interest exists.

*Cesarean Scar Defect Manifestations during Pregnancy and Delivery DOI: http://dx.doi.org/10.5772/intechopen.90775*

A systematic review of current literature showed that a manifestation of cesarean scars during the following pregnancies is not predictable, in general, although modern visualization technologies could reveal some specific features of scar defects that are associated with complications during pregnancy and delivery. However, there is no factor, which could serve as the main prognostic guide for obstetricians to make a decision for VBAC, thus Edwin Cragin's phrase "once a cesarean, always a cesarean" has represented the essential health care issue over the century. At the moment, the most reasonable measurements to prevent uterine scar complications are reducing the rate of Cesarean Sections, opening the uterus transversely in the lower segment, and stitching the uterus with one layer only continuously using a big needle preferable by Stark technique of Cesarean section.
