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Repeat cesarean birth

Repeat cesarean birth
Literature review current through: Jan 2024.
This topic last updated: Oct 16, 2023.

INTRODUCTION — After a primary cesarean birth, individuals who become pregnant again must decide between undergoing a repeat cesarean or a trial of labor. Issues specific to repeat cesarean birth will be discussed here. Primary cesarean birth, issues common to both primary and repeat cesareans, and trial of labor after a previous cesarean birth are reviewed separately.

(See "Choosing the route of delivery after cesarean birth".)

(See "Cesarean birth: Preoperative planning and patient preparation".)

(See "Cesarean birth: Surgical technique".)

(See "Cesarean birth: Postoperative care, complications, and long-term sequelae".)

(See "Cervical ripening and induction of labor after a prior cesarean birth".)

TIMING

Patients with a medical or obstetric indication for intervention in the current pregnancy — Timing of a medically or obstetrically indicated birth, whether by induction of labor or repeat cesarean, depends upon the particular medical or obstetric indication for delivery (eg, preeclampsia, fetal growth restriction, nonreassuring fetal testing, alloimmunization, cholestasis of pregnancy). The decision should be made by the obstetric care provider based on the disorder, with consideration of patient-specific factors (eg, severity of the disorder, comorbidities, patient values and preferences). (Refer to topic reviews on each disorder.)

A consensus panel of experts did not consider "soft" indications for intervention, such as suspected macrosomia in the absence of maternal diabetes or a problem in a previous pregnancy that has not recurred, reasonable medical indications for early delivery [1].

Patients with no medical or obstetric indication for intervention in the current pregnancy

General principles

Planned repeat cesarean birth is typically scheduled before the onset of labor to minimize the risk of an emergency delivery due to uterine rupture in the setting of labor and the associated risk for fetal demise.

Patient and physician convenience is another, but less important, factor.

The optimum gestational age for scheduling the birth balances these benefits with the potential risk of delivering a neonate who could benefit from additional maturation in utero. Since fetal exposure to labor (even if prior to cesarean birth) is associated with a lower rate of neonatal respiratory morbidity, it is particularly important to schedule planned cesarean births when gestational age-related respiratory morbidity is minimal [2].

The precise timing of cesarean birth before onset of labor depends on the location of previous hysterotomies, as described in the following sections.

Previous low-transverse uterine incision — In patients with one or more previous lower uterine segment transverse hysterotomies, the optimum time for planned repeat cesarean birth appears to be in the 39th week of gestation (39+0 to 39+6 weeks). We agree with the American College of Obstetricians and Gynecologists (ACOG) recommendation to not perform nonmedically indicated births before 39 weeks of gestation [3]. This recommendation is supported by a multicenter prospective study (Eunice Kennedy Shriver National Institute of Child Health and Human Development [NICHD] Maternal-Fetal Medicine Units Network) on timing of cesarean birth including over 24,000 repeat cesarean births at term, of which over 13,000 were planned [4-6]:

The incidence of the composite primary outcome (neonatal respiratory problems, hypoglycemia, sepsis, seizures, intensive care unit admission, hospitalization ≥5 days, etc) by gestational age at planned repeat cesarean birth was 15.3 percent at 37 weeks, 11 percent at 38 weeks, 8 percent at 39 weeks, 7.3 percent at 40 weeks, 11.3 percent at 41 weeks, and 19.5 percent at ≥42 weeks [4]. Thus, there was a higher incidence of adverse neonatal outcome before and after 39 to 40 weeks, and this difference was statistically significant.

Compared with pregnancy continuation, planned repeat cesarean birth at 37 and 38 weeks of gestation had a higher risk of adverse neonatal outcome (37 weeks: odds ratio [OR] 2.02, 95% CI 1.73-2.36; 38 weeks: OR 1.39, 95% CI 1.24-1.56) whereas delivery at 39 and 40 weeks had a lower risk (39 weeks: OR 0.79, 95% CI 0.68-0.92; 40 weeks: OR 0.57, 95% CI 0.43-0.75).

For the mother, compared with pregnancy continuation, planned repeat cesarean birth at 37 weeks of gestation had a higher risk of adverse maternal outcome (OR 1.56, 95% CI 1.06-2.31), while planned repeat cesarean at 39 weeks had a lower risk (OR 0.51, 95% CI 0.36-0.72) [5].

Similar findings were published in a study of data from the Dutch birth registry involving nearly 21,000 planned cesarean births at term [7]. The incidence of a primary composite of neonatal morbidity and mortality decreased from 20.6 percent at <38 weeks and 12.5 percent at <39 weeks to 9.5 percent at ≥39 weeks.

Two potential disadvantages of waiting until 39 weeks are the risks of antepartum stillbirth and onset of spontaneous labor, but neither of these risks appear to be clinically meaningful. When only risk of stillbirth is considered, others have found that the reduction in nonmedically indicated early term births in favor of birth at ≥39 weeks was not associated with an increase in the rate of stillbirth in the United States [8,9]. In a clinical trial, approximately 13 percent (82 of 638) of participants went into spontaneous labor before planned cesarean at 39+3 weeks, and these patients did not have a high rate of adverse outcomes [10].

Multiple previous low-transverse uterine incisions — Patients with multiple prior low-transverse cesarean births show a trend toward increased risk of rupture compared with a single prior cesarean [11,12]. For patients with ≥3 prior cesarean births, this author's practice is to perform planned repeat cesarean birth at 38+0 to 38+6 weeks to reduce the chances of rupture [11], but there is no consensus on best practice and others have advocated planned repeat cesarean at 39+0 to 39+6 weeks to reduce the chances of newborn morbidity from early term birth [13].

On uterine scar imaging, a thin scar is not highly predictive of rupture; therefore, imaging of the scar is not commonly performed as a component of delivery-planning. Antepartum incisional imaging and possible findings are reviewed separately. (See "Uterine rupture: After previous cesarean birth", section on 'Predicting uterine rupture' and "Uterine rupture: After previous cesarean birth", section on 'Antepartum uterine dehiscence'.)

Previous low-vertical uterine incision — In patients with a prior lower segment vertical incision, we perform planned repeat cesarean birth in the 39th week of gestation (39+0 to 39+6 weeks). However, if review of the prior operative report, patient report, or clinical setting of the previous birth suggests that the thick muscular part of the uterus (active segment) was likely involved in the otherwise low-vertical incision, then we perform repeat cesarean at 37+0 to 37+6 weeks.

Timing of repeat cesarean birth in patients with a prior low-vertical uterine incision is controversial. No trials have compared different gestational ages for repeat cesarean. In a review of 10 studies that included complete information about pregnancy outcome in 372 patients with prior low-vertical cesarean births and subsequent trial of labor, four uterine ruptures (1.05 percent) were reported, but only one of these occurred after a single prior low segment vertical cesarean incision that did not extend into the upper segment [14]. Two ruptures occurred elsewhere on the lateral or posterior aspect of the uterus in subsequent pregnancies, and the fourth rupture occurred at the juncture of prior low-vertical and -transverse incisions. We agree with the authors of this report who concluded that, in an otherwise uncomplicated pregnancy, a patient with one previous nonextended lower uterine segment vertical cesarean incision should receive the same care, counseling, and caution as a patient with a prior low-transverse incision.

Previous classical uterine incision — In the stable patient with a previous classical uterine incision, we schedule repeat cesarean at 37+0 weeks. The ACOG recommendation for delivery is at 36+0 to 37+0 weeks of gestation [15].

No randomized trials have evaluated the optimum timing of birth in patients with a prior classical hysterotomy incision. Intervention before 39+0 weeks of gestation reduces the chances of birth after spontaneous labor has begun and the associated risk of uterine rupture. However, intervention before 39+0 weeks of gestation can also lead to newborn complications from being born before fully mature, and it may not fully prevent uterine rupture since it has been reported as early as the second trimester and up to 50 percent of uterine ruptures will occur prior to labor onset.

A decision analysis attempted to address the issue of timing delivery after a previous classical hysterotomy incision by analyzing the following four options [16]:

Delivery at 36 weeks of gestation without amniocentesis

Amniocentesis at 36 weeks of gestation with delivery if the fetus is mature and 48 hours after antenatal corticosteroids if the fetus is immature

Weekly amniocentesis starting at 36 weeks of gestation with delivery upon fetal lung maturity

Delivery at 39 weeks of gestation

The authors concluded that the strategy of delivery at 36 weeks of gestation without amniocentesis provided the lowest risk of a maternal-neonatal catastrophic outcome associated with uterine rupture. Their rationale was that, although complications of prematurity at 36 weeks of gestation occur more frequently than uterine rupture, these complications are often minor and transient and are, therefore, not as detrimental to maternal-neonatal quality of life as uterine rupture. In this model, there was no benefit of offering fetal lung maturity testing because it would lead, in cases of negative results, to further expectant management in an already risky situation.

Unknown location of previous uterine incision — When the location of the prior uterine incision is unknown (eg, no operative note is available, patient was not told incision site), the clinician and patient should review the past obstetric history (gestational age at birth, birth weight, presentation, pregnancy and/or delivery complications, surgeon's comments about the delivery to patient and/or family). If the patient reports a previous term cesarean birth of a newborn weighing more than 5 pounds (2.3 kg) in an otherwise uncomplicated pregnancy, then based on clinical experience and expert opinion, there is a high probability that the uterine incision was low transverse, especially if the skin incision is transverse. As a result, it is reasonable to schedule the repeat cesarean in the 39th week of gestation (39+0 to 39+6 weeks).

A classical hysterotomy should be suspected if the lower uterine segment was likely to be poorly developed at the time of the previous cesarean birth (eg, delivery before 28 weeks of gestation) or the patient had known pathology of the lower uterine segment (eg, large leiomyoma). In one large study, 50 percent of participants who underwent cesarean birth at 23 to 26 weeks had a classical hysterotomy [17].

This approach is supported by studies of patients who underwent a trial of labor after one or more previous cesarean births [18,19]. Patients in whom the type of prior uterine incision was unknown had comparable uterine rupture rates as those with a known prior low-transverse incision. In the latter study, exclusions included multifetal gestation, previous myomectomy, any prostaglandin use, and birth weight <500 grams (1.1 pound).

Previous uterine rupture — Pregnant patients who have had a uterine rupture and a previous cesarean should undergo repeat cesarean birth to minimize the risk of another rupture. The author generally schedules the birth between 34+0 and 35+6 weeks of gestation. In a decision analysis to determine the optimal gestational age of delivery in patients with prior uterine rupture, a Monte Carlo simulation supported this approach, demonstrating that delivery at 35 weeks was the optimal strategy 37 percent of the time and 34 weeks was the optimal strategy 17 percent of the time [20]. ACOG suggests managing these patients similar to those with a previous classical hysterotomy and thus scheduling delivery between 36+0 and 37+0 weeks of gestation, with individualization based on the clinical setting [21]. For example, if the prior rupture occurred prior to 36 weeks, earlier delivery would be warranted, possibly after a course of antenatal corticosteroids. (See "Uterine rupture: After previous cesarean birth", section on 'Recurrence risk'.)

Suboptimally dated pregnancies — Confidence in the estimation of gestational age is based on standard criteria (table 1). Pregnancies without a sonographic examination before 22+0 weeks that confirms or revises the estimated date of delivery are considered suboptimally dated [22]. ACOG has opined that there is no role for scheduled delivery in most patients with a suboptimally dated pregnancy in the absence of a medical or obstetric complication that warrants intervention [22]. In these patients, repeat cesarean birth should be performed as soon as feasible after the onset of labor.

However, if the patient with a suboptimally dated pregnancy has a history of a prior classical hysterotomy, an unknown uterine incision that has a high likelihood of being a classical incision, or a previous uterine rupture, then the best estimate of gestational age should be made using the patient's last menstrual period (if known), and the earliest ultrasound available. Once estimated, timing of delivery can be planned as discussed above. (See 'Previous classical uterine incision' above and 'Unknown location of previous uterine incision' above and 'Previous uterine rupture' above.)

GROUP B STREPTOCOCCUS SCREENING AND PROPHYLAXIS — Patients with GBS rectovaginal colonization who undergo planned cesarean birth in the absence of labor or rupture of membranes are at very low risk of GBS transmission to the fetus/newborn; therefore, these patients do not require GBS prophylaxis at any gestational age.  

Both onset of labor and prelabor rupture of membranes increase the risk of GBS transmission and, therefore, would be an indication for intrapartum GBS antibiotic prophylaxis in patients with GBS rectovaginal colonization even though cesarean birth is performed. Many cesarean antibiotic prophylaxis regimens (eg, cefazolin, ampicillin, vancomycin) have activity against GBS, so a change in the usual regimen is usually not required. (See "Prevention of early-onset group B streptococcal disease in neonates".)

PREOPERATIVE PREPARATION

Routine cases — Preoperative issues (eg, duration of fasting, aspiration prophylaxis, infection prophylaxis, thromboembolism prophylaxis) are generally similar to those for primary cesarean birth, with some exceptions. (See "Cesarean birth: Preoperative planning and patient preparation".)

Informed consent should include a discussion of the risk of injury to viscera (bowel, urinary system), transfusion, placenta accreta, and cesarean hysterectomy that takes into account the number of cesareans that the patient has undergone. An example of these risks as determined in one study is provided in the table (table 2). (See "Informed consent in obstetrics".)

Preoperative consultation with an anesthesiologist is recommended and may occur in the ambulatory setting or on the day of admission for the cesarean. The anesthesia team will assess the patient, discuss choice of anesthetic technique, and discuss preparations for anesthesia (eg, fasting, premedication, antacids, H2 receptor antagonists). (See "Anesthesia for cesarean delivery".)

In the absence of red blood cell antibodies or additional risk factors for intraoperative or postpartum hemorrhage, sending a clot to the blood bank for type and antibody screen is sufficient. Preoperative planning and management of patients at risk for postpartum hemorrhage are reviewed separately. (See "Overview of postpartum hemorrhage", section on 'Institutional planning and preparation'.)

Patients with more than one previous cesarean birth are at higher risk for complications. In a systematic review, maternal morbidity increased with an increasing number of cesarean births, even in the absence of a placental abnormality [23]. The rate of blood transfusions, adhesions, surgical injury, and hysterectomy all increased with increasing number of cesareans. Thus, the surgeon should be prepared to manage these complications. (See "Overview of postpartum hemorrhage" and "Postpartum hemorrhage: Management approaches requiring laparotomy".)

We place at least two large-bore intravenous lines in patients with more than one previous cesarean, particularly those with a history of dense adhesions since such adhesions increase the duration of surgery and blood loss. (See "Postoperative peritoneal adhesions in adults and their prevention", section on 'Incidence and burden'.)

Placement of a three-way bladder catheter can be useful in high-order repeat cesareans and other births where dense adhesions are suspected, given the increased risk of cystotomy in these settings.

Medications (oxytocin, methylergonovine maleate, carboprost, tranexamic acid) and physical interventions (intrauterine balloon for tamponade, uterine pack) to reduce intraoperative bleeding should be immediately available in case of hemorrhage. Topical hemostatic agents can also be useful when use of electrocautery or sutures for control of surgical bleeding is not ideal or safe [24]. (See "Overview of topical hemostatic agents and tissue adhesives".)

For patients with four or more prior cesarean births or with a history of intraoperative complications, consideration for planned surgical backup is advised in case the surgeon needs additional help.

Patients with suspected placenta previa or accreta spectrum — If placenta previa or placenta accreta spectrum is suspected sonographically, extensive preoperative counseling and preparation are needed. Delivery is typically scheduled before term (eg, 36+0 to 37+6 weeks for previa alone and 34+0 to 35+6 weeks for placenta accreta spectrum). (See "Placenta previa: Management" and "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences" and "Placenta accreta spectrum: Management".)

OPERATIVE ISSUES — Issues related to operative techniques common to both primary and repeat cesarean, including opening the abdomen, bladder flap, hysterotomy, fetal and placental extraction, closure, and prevention of adhesions, are reviewed separately. (See "Cesarean birth: Surgical technique".)

Specific issues for repeat cesarean births are discussed below.

Skin incision — We generally make a transverse incision at the site of the previous transverse skin incision. For patients with a prior vertical skin incision, we usually perform a transverse skin incision for the repeat cesarean, but use of the previous vertical incision site is also acceptable [25]. This is a shared decision with the patient, as they may have a preference.

We would consider making a midline vertical incision when it would provide more rapid exposure of the uterus. We would also consider a midline vertical or a Maylard incision in cases of suspected placenta previa or placenta accreta spectrum and in patients suspected to have extensive dense adhesions, as these incisions may provide better exposure. Patient body habitus is also a factor in determining the best skin incision. (See "Cesarean birth: Overview of issues for patients with obesity" and "Incisions for open abdominal surgery".)

Entering the pelvis — Formation of adhesions is common after cesarean birth, and the extent and density increase with increasing numbers of repeat cesarean births. The reported prevalence of adhesions is 12 to 46 percent of patients at their second cesarean and 26 to 75 percent of patients at their third cesarean [26-31].

Because adhesions are often present in patients with prior abdominal surgery, the fascia and peritoneum should be entered carefully to avoid injury to underlying, possibly adherent bowel or bladder. For example, opening the peritoneum by blunt rather than sharp dissection and opening laterally or using a paravesical or supravesical extraperitoneal approach should be considered. (See "Cesarean birth: Surgical technique", section on 'Avoiding visceral injury in patients with dense intraperitoneal adhesions'.)

A surgeon experienced in complex abdominal surgery should be present if meticulous dissection of dense adhesions involving important structures is required. Some clinicians find insertion of ureteral stents can be useful to facilitate intraoperative identification (and avoidance) of the ureters, especially in cases of placenta previa or suspected placenta accreta spectrum. (See "Placement and management of indwelling ureteral stents".)

Hysterotomy — Ideally, the hysterotomy is performed through a low-transverse incision, even if prior cesareans were performed using a classical or other type of uterine incision. Sometimes, a classical uterine incision cannot be avoided because of pathology, such as uterine myomas or dense adhesions involving the lower uterine segment. In one large study, among patients who had prior classical cesarean birth, 31 percent of repeat cesarean births were performed via a classical hysterotomy [32].

Management of dehiscence — Information on management of patients with a uterine dehiscence (incidental finding of an asymptomatic disruption of the myometrium that does not lead to any serious maternal or neonatal consequences) found at cesarean is limited to case reports. The term "uterine window" is also sometimes used, but uterine dehiscence is preferred.

Most dehiscences occur at the site of the prior uterine incision; they vary widely in length and depth. The amniotic sac remains intact.

The goals of repair are to ensure the integrity of the myometrium; adequate myometrial contraction, including the lower uterine segment; and avoidance of any further injury to the uterus and/or surrounding organs and vessels, especially the bladder. If the dehiscence is vertical, we close it in three layers with a baseball stitch (ie, continuous running stitch) for the superficial layer, as with a classical hysterotomy. If the dehiscence is transverse, we close it in two layers with an imbricating stitch for the superficial layer to reduce the risk of bladder adhesions [33].

If a significant uterine dehiscence is encountered at repeat cesarean birth and the patient desires to have additional children, we would consider planning repeat cesarean before 39+0 weeks. The precise timing depends on patient-specific factors (eg, severity of the dehiscence, appearance of the lower uterine segment on ultrasound).

Management of rupture — Management of uterine rupture is discussed in detail separately. (See "Uterine rupture: After previous cesarean birth", section on 'Management of patients with uterine rupture at laparotomy'.)

Repair of incidental operative injuries — Single cystotomy incisions in the dome of the bladder are often repaired by the obstetrician. Repair of multiple cystotomy incisions or injury to the trigone or ureter is more complex; consultation with a urologist, urogynecologist, or gynecologic oncologist can be helpful to evaluate the integrity of the urinary tract and assist with the repair. Similarly, if bowel injury occurs, a general surgeon may be consulted to evaluate the bowel and assist in the repair. Obstetricians proficient in these repairs may choose to undertake the repair without assistance. (See "Urinary tract injury in gynecologic surgery: Identification and management" and "Complications of gynecologic surgery", section on 'Bowel injury'.)

IS THERE AN UNSAFE NUMBER OF REPEAT CESAREAN BIRTHS? — Large observational studies have consistently shown that individuals who undergo multiple repeat cesarean births are at increased risk of maternal morbidity, and the risk increases with the number of cesarean births [23,34]. In one of the largest series (n >30,000 cesareans), the risks for blood transfusion, cystotomy, and hysterectomy were each >1 percent at and after the fourth cesarean (table 2) [35]. Nevertheless, there are insufficient data on which to base recommendations for the "safe" number of repeat cesarean births.

Issues to consider — Several issues should be considered and discussed when planning repeat cesarean birth:

Complications relating to abnormal placentation — An increasing number of prior cesarean births is strongly associated with an increased risk of abnormal placentation.

Placenta previa and morbidly adherent placenta – In a meta-analysis of observational studies [23]:

The incidence of placenta previa was 10/1000 deliveries in patients with one previous cesarean birth versus 28/1000 in those with ≥3 cesarean births, based on eight studies.

In patients with placenta previa undergoing cesarean birth, the incidence of placenta accreta was 3.3 to 4.0 percent in those with no previous cesarean births versus 50 to 67 percent in those with ≥4 previous cesarean births, based on two studies.

Both of these placental disorders increase the chances of hemorrhage and the need for blood transfusion and hysterectomy.

The largest prospective study of maternal morbidity associated with multiple cesarean births provides additional insights [35]. This study included 6201 first; 15,808 second; 6324 third; 1452 fourth; 258 fifth; and 89 sixth cesarean births. The frequency of placenta previa and accreta progressively increased with the number of cesarean births, and patients with placenta previa were at very high risk (11 to 67 percent) of also having placenta accreta (table 3). Accordingly, the frequency of peripartum hysterectomy at the fourth cesarean birth was approximately 1 in 40, increasing to approximately 1 in 11 at the sixth cesarean birth (table 2).

Abruption – Placental abruption is another example of a placental abnormality that occurs more often in patients with a prior cesarean birth [36-39]. In contrast to placenta previa and placenta accreta spectrum, the frequency of abruption does not appear to increase with an increasing number of prior cesarean births [40]. (See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences".)

Complications relating to adhesion formation — The degree of adhesion formation after abdominal surgery varies widely among individuals and is generally unpredictable. Adhesions might develop each time the abdomen is entered and increase with an increasing number of abdominal surgeries. In one study, adhesions in the operative field were identified in 7 percent of primary cesarean births and 68 percent of third cesarean births [41]. Some investigators have suggested that the sliding sign may help to identify significant intra-abdominal adhesions before repeat cesarean birth. On ultrasound examination in a sagittal plane lateral to the umbilicus, if the anterior uterine wall does not slide across the abdominal wall during maternal deep breathing, then the sliding sign is negative and moderate to severe intra-abdominal adhesions are likely to be present [42-48]. A positive sliding sign is associated with a low risk of dense adhesions. We do not use this sign given the limited available data, and most importantly, the lack of data that its use results in improved surgical outcomes.

Dense adhesions can make the surgical procedure and fetal extraction more difficult, prolong the time to fetal extraction, and increase the risk of surgical complications such as bladder or bowel injury and excessive blood loss [28,29,41,49,50]. Bladder injury is more common than bowel injury, and the frequency increases with an increasing number of cesarean births (table 2). Adhesions may cause the bladder to densely adhere to the lower uterine segment, eliminating the usual plane for blunt dissection, or they may distort the position of the bladder so that it is adherent to the midportion of the uterus. Cystotomy is more likely if an atypically located bladder is not recognized. (See "Cesarean birth: Surgical technique", section on 'Avoiding visceral injury in patients with dense intraperitoneal adhesions'.)

Postoperatively, adhesions are a common cause of small bowel obstruction. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults".)

Adhesions can also cause subfertility as a result of tubal distortion. There is no strong evidence of a causal relationship between a cesarean birth in a first pregnancy and subfertility [51]; however, the effect of multiple cesareans on fertility has not been evaluated. (See "Female infertility: Causes", section on 'Fallopian tube abnormalities/pelvic adhesions'.)

Complications relating to trial of labor in future pregnancies — The possible future desire for a vaginal birth after cesarean birth should also be considered by patients planning a repeat cesarean birth. There is a small risk of uterine rupture (although the event, when it occurs, is associated with adverse maternal and newborn outcomes). Patients with two prior cesarean births are generally considered to be acceptable candidates for a trial of labor after cesarean birth (TOLAC). Data are sparse for patients with three or more prior cesareans, and no consensus about the best approach. We often suggest repeat cesarean for these patients, but take into account other factors, such as prior vaginal births.  

The risks and benefits of TOLAC are discussed in more detail separately. (See "Choosing the route of delivery after cesarean birth" and "Uterine rupture: After previous cesarean birth".)

Other long-term complications relating to the abdominal and uterine incisions

The risk of incision-related complications, such as hernia or diastasis of rectus muscles, increases with increasing number of prior abdominal incisions. Attention to proper technique minimizes the risk of occurrence of these complications; however, if they do occur, we obtain surgical consultation for evaluation and repair. (See "Clinical features, diagnosis, and prevention of incisional hernias" and "Rectus abdominis diastasis".)

Other potential incisional complications include:

Cesarean scar pregnancy (See "Cesarean scar pregnancy".)

Numbness/pain in the area of the skin incision (see "Complications of abdominal surgical incisions", section on 'Nerve injury')

Incisional endometriosis (see "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact", section on 'Anatomy and staging')

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cesarean birth".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Cesarean birth (The Basics)")

Beyond the Basics topics (see "Patient education: C-section (cesarean delivery) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Timing

Previous low-transverse or low-vertical hysterotomy – In patients with a previous hysterotomy in the lower uterine segment and an uncomplicated pregnancy, we suggest scheduling repeat cesarean birth during the 39th week of gestation (39+0 to 39+6) rather than at 38+0 to 38+6 weeks (Grade 2C). This minimizes the risk of neonatal respiratory problems but accepts a low risk that spontaneous labor will occur before the scheduled date of surgery. (See 'Timing' above and 'Previous low-transverse uterine incision' above.)

Previous vertical hysterotomy extending into the fundus – If review of the operative report, patient report, or clinical setting of the previous birth suggests that the thick muscular part of the uterus was likely involved in an otherwise low-vertical hysterotomy incision, we perform repeat cesarean at 37 to 38 weeks. (See 'Previous low-vertical uterine incision' above.)

Previous classical hysterotomy – In stable patients with a previous classical (fundal) uterine incision, we suggest repeat cesarean birth at 36+0 to 37+6 weeks of gestation (Grade 2C). This minimizes the risk of uterine rupture related to onset of spontaneous labor but also reduces the risk of complications related to preterm birth <36 weeks. (See 'Previous classical uterine incision' above.)

Unknown hysterotomy incision – If documentation of the type of prior hysterotomy is not available, the clinician should obtain a thorough history of the delivery from the patient and use this information to estimate the most likely location of the prior incision. Timing of repeat cesarean is based on this estimate. (See 'Unknown location of previous uterine incision' above.)

Complications of multiple repeat cesarean births – There is no threshold below which the number of repeat cesarean births can be guaranteed to be uncomplicated. Our approach is to discuss the increasing risk of complications with increasing numbers of cesarean births (table 2 and table 3). We inform each patient that the risk of placenta accreta rises in direct proportion to the number of previous cesareans, and this risk is dramatically increased if placenta previa is also present. (See 'Is there an unsafe number of repeat cesarean births?' above.)

  1. Spong CY, Mercer BM, D'alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118:323.
  2. Kamath BD, Todd JK, Glazner JE, et al. Neonatal outcomes after elective cesarean delivery. Obstet Gynecol 2009; 113:1231.
  3. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 561: Nonmedically indicated early-term deliveries. Obstet Gynecol 2013; 121:911. Reaffirmed 2017.
  4. Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009; 360:111.
  5. Chiossi G, Lai Y, Landon MB, et al. Timing of delivery and adverse outcomes in term singleton repeat cesarean deliveries. Obstet Gynecol 2013; 121:561.
  6. Tita AT, Lai Y, Landon MB, et al. Timing of elective repeat cesarean delivery at term and maternal perioperative outcomes. Obstet Gynecol 2011; 117:280.
  7. Wilmink FA, Hukkelhoven CW, Lunshof S, et al. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. Am J Obstet Gynecol 2010; 202:250.e1.
  8. Little SE, Zera CA, Clapp MA, et al. A Multi-State Analysis of Early-Term Delivery Trends and the Association With Term Stillbirth. Obstet Gynecol 2015; 126:1138.
  9. MacDorman MF, Reddy UM, Silver RM. Trends in Stillbirth by Gestational Age in the United States, 2006-2012. Obstet Gynecol 2015; 126:1146.
  10. Glavind J, Kindberg SF, Uldbjerg N, et al. Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG 2013; 120:1123.
  11. Oliver EA, Rood KM, Daveri V, Berghella V. Risk of uterine rupture in women with three or more prior cesarean sections. Abstract, SMFM 40th Annual Meeting, Grapevine, Texas, February 2020.
  12. Landon MB, Spong CY, Thom E, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006; 108:12.
  13. Breslin N, Vander Haar E, Friedman AM, et al. Impact of timing of delivery on maternal and neonatal outcomes for women after three previous caesarean deliveries; a secondary analysis of the caesarean section registry. BJOG 2019; 126:1008.
  14. Martin JN Jr, Perry KG Jr, Roberts WE, Meydrech EF. The case for trial of labor in the patient with a prior low-segment vertical cesarean incision. Am J Obstet Gynecol 1997; 177:144.
  15. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee Opinion, Number 831. Obstet Gynecol 2021; 138:e35.
  16. Stotland NE, Lipschitz LS, Caughey AB. Delivery strategies for women with a previous classic cesarean delivery: a decision analysis. Am J Obstet Gynecol 2002; 187:1203.
  17. Osmundson SS, Garabedian MJ, Lyell DJ. Risk factors for classical hysterotomy by gestational age. Obstet Gynecol 2013; 122:845.
  18. Pruett KM, Kirshon B, Cotton DB. Unknown uterine scar and trial of labor. Am J Obstet Gynecol 1988; 159:807.
  19. Smith D, Stringer E, Vladutiu CJ, et al. Risk of uterine rupture among women attempting vaginal birth after cesarean with an unknown uterine scar. Am J Obstet Gynecol 2015; 213:80.e1.
  20. Frank ZC, Lee VR, Hersh AR, et al. Timing of delivery in women with prior uterine rupture: a decision analysis. J Matern Fetal Neonatal Med 2021; 34:238.
  21. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol 2019; 133:e110.
  22. Committee on Obstetric Practice. Committee Opinion No. 688: Management of Suboptimally Dated Pregnancies. Obstet Gynecol 2017; 129:e29. Reaffirmed 2019.
  23. Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: A systematic review. Am J Obstet Gynecol 2011; 205:262.e1.
  24. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. Topical Hemostatic Agents at Time of Obstetric and Gynecologic Surgery: ACOG Committee Opinion, Number 812. Obstet Gynecol 2020; 136:e81.
  25. Puttanavijarn L, Phupong V. Comparisons of the morbidity outcomes in repeated cesarean sections using midline and Pfannenstiel incisions. J Obstet Gynaecol Res 2013; 39:1555.
  26. Tulandi T, Agdi M, Zarei A, et al. Adhesion development and morbidity after repeat cesarean delivery. Am J Obstet Gynecol 2009; 201:56.e1.
  27. Soltan MH, Al Nuaim L, Khashoggi T, et al. Sequelae of repeat cesarean sections. Int J Gynaecol Obstet 1996; 52:127.
  28. Makoha FW, Felimban HM, Fathuddien MA, et al. Multiple cesarean section morbidity. Int J Gynaecol Obstet 2004; 87:227.
  29. Morales KJ, Gordon MC, Bates GW Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007; 196:461.e1.
  30. Uygur D, Gun O, Kelekci S, et al. Multiple repeat caesarean section: Is it safe? Eur J Obstet Gynecol Reprod Biol 2005; 119:171.
  31. Hesselman S, Högberg U, Råssjö EB, et al. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study. BJOG 2018; 125:597.
  32. Thompson BB, Reddy UM, Burn M, et al. Maternal Outcomes in Subsequent Pregnancies After Classical Cesarean Delivery. Obstet Gynecol 2022; 140:212.
  33. Blumenfeld YJ, Caughey AB, El-Sayed YY, et al. Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG 2010; 117:690.
  34. Cook JR, Jarvis S, Knight M, Dhanjal MK. Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. BJOG 2013; 120:85.
  35. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
  36. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First-birth cesarean and placental abruption or previa at second birth(1). Obstet Gynecol 2001; 97:765.
  37. Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006; 107:771.
  38. Yang Q, Wen SW, Oppenheimer L, et al. Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. BJOG 2007; 114:609.
  39. Jackson S, Fleege L, Fridman M, et al. Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Am J Obstet Gynecol 2012; 206:139.e1.
  40. National Institutes of Health Consensus Development Conference Statement. NIH consensus development conference: Vaginal birth after cesarean: New insights. March 8–10, 2010.
  41. Rossouw JN, Hall D, Harvey J. Time between skin incision and delivery during cesarean. Int J Gynaecol Obstet 2013; 121:82.
  42. Shafti V, Azarboo A, Ghaemi M, et al. Prediction of intraperitoneal adhesions in repeated cesarean sections: A Systematic review and Meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 287:97.
  43. Drukker L, Sela HY, Reichman O, et al. Sliding Sign for Intra-abdominal Adhesion Prediction Before Repeat Cesarean Delivery. Obstet Gynecol 2018; 131:529.
  44. Charernjiratragul K, Suntharasaj T, Pranpanus S, et al. Preoperative sonographic sliding sign for prediction of intra-abdominal adhesions before repeat cesarean delivery. Int J Gynaecol Obstet 2023; 161:250.
  45. Shu W. Predicting Intra-abdominal Adhesions for Repeat Cesarean Delivery with the Ultrasound Sliding Sign. J Obstet Gynaecol Can 2021; 43:1274.
  46. Baron J, Tirosh D, Mastrolia SA, et al. Sliding sign in third-trimester sonographic evaluation of intra-abdominal adhesions in women undergoing repeat Cesarean section: a novel technique. Ultrasound Obstet Gynecol 2018; 52:662.
  47. Yosef AH, Youssef AEA, Abbas AM, et al. The use of ultrasound sliding sign for prediction of adhesions in women undergoing repeated caesarean section. J Obstet Gynaecol 2023; 43:2114333.
  48. Mayibennye M. OC02.08: Preoperative prediction of severe intraperitoneal adhesions in women undergoing repeat Caesarean section using clinical signs and the sliding sign. Ultrasound Obstet Gynecol 2023; 62:6.
  49. Nisenblat V, Barak S, Griness OB, et al. Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol 2006; 108:21.
  50. Sikirica V, Broder MS, Chang E, et al. Clinical and economic impact of adhesiolysis during repeat cesarean delivery. Acta Obstet Gynecol Scand 2012; 91:719.
  51. Eijsink JJ, van der Leeuw-Harmsen L, van der Linden PJ. Pregnancy after caesarean section: Fewer or later? Hum Reprod 2008; 23:543.
Topic 4457 Version 55.0

References

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