For most of this century,"once a cesarean, always a cesarean" was the rule in the United States. In the 1980s, vaginal birth after cesarean grew in popularity and the pendulum began to swing away from routine repeat cesarean delivery. Recently, the wisdom of this transition has been questioned. As the 20th century comes to a close, the treatment of the patient with a prior cesarean delivery remains controversial.

OBJECTIVE This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR]= 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.

BACKGROUND To assess pregnancy course and outcome after conservative treatment of a cesarean scar pregnancy. METHODS During an 8-year period, 15 cases of cesarean scar pregnancies were diagnosed at our institution. Seven of the 14 patients for whom we successfully preserved the uterus became pregnant within 3 years after termination of the scar pregnancy. The year of diagnosis, conservative method and gestational age for these five patients were recorded. Delivery method, time interval between the scar pregnancy and subsequent pregnancy, and maternal and neonatal outcome were evaluated. RESULTS Seven pregnancies (eight live and one dead baby) were noted. The mean interval between the ectopic pregnancy and subsequent pregnancy was 13.3 months (range 0-34 months). One patient, who became pregnant 3 months after the scar pregnancy was found, suffered uterine rupture at 38.3 weeks' gestational age. Two patients with placental accrete, and one of them who continued the existing intrauterine twin pregnancy after transvaginal sono-guided aspiration of the scar pregnancy received a cesarean hysterectomy at 32 weeks of gestation. The remaining four pregnancies were uneventful, followed by early cesarean sections at 36 weeks. CONCLUSION The results of this first series of seven subsequent pregnancies after conservative treatment of scar pregnancies are promising. An early cesarean section before over-extension of the uterus and spontaneous labor can help to prevent uterine rupture. Placenta accrete is another severe morbidity of these patients in addition to uterine rupture. Thus a cesarean hysterectomy may be the choice of treatment.

Uterine rupture, an important cause of maternal and fetal mortality, is still occasionally seen in our region. In this study we reviewed 41 cases of uterine rupture encountered between the years 1983 and 1988, in a total of 3962 hospital deliveries with a frequency of 1 in 96.6 deliveries. Sixteen cases (39.0%) were over 35 years old. Twenty-five patients (60.9%) were grand multiparous (more than five pregnancies). There were no uterine ruptures in primigravid women. Ruptures were mostly (75.6%) due to cephalopelvic disproportion. Subtotal hysterectomy was the first choice of management for 35 cases. The maternal mortality rate was 7.3% while fetal mortality was 82.9%. Midwife education, regular antenatal care and hospital deliveries are important factors in prevention of this obstetric hazard.

Fifteen cases are reported of spontaneous rupture of the gravid uterus occurring at the Naval Regional Medical Center (NRMC), Portsmouth, Virginia, over a 21-year period. Forty-seven percent of the patients had previously undergone a cesarean section. Thirteen percent of the patients had received oxytocin prior to the rupture. Fetal mortality associated with these ruptures was 13%. No maternal deaths occurred. Forty percent of the patients had repair of the defect, with 60% undergoing some type of hysterectomy. Preventive measures, early diagnosis, and prompt treatment are emphasized.

The rationale for routine repeat cesarean section (RCS) is avoidance of uterine rupture during labor. However, the incidence of uterine rupture following modern cesarean section is low, and the charge for cesarean section is greater than that for a trial of labor (TOL). The technique of decision analysis was used to investigate strategies of elective RCS and TOL with precautionary monitoring. Hypothetical cohorts of 10,000 pregnant women with previous low-transverse cesarean incisions were assumed. Probability data were obtained from the literature. In the TOL cohort, 6,623 patients were delivered vaginally. Uterine rupture occurred in 73 patients. In spite of this, TOL resulted in 37 fewer perinatal deaths and 0.7 fewer maternal deaths than elective RCS. The excessive perinatal mortality in the RCS cohort was related to iatrogenic prematurity that is now avoidable with the lecithin/sphingomyelin test. Direct costs were $5 million greater in the RCS cohort. We concluded that in contemporary practice mortality rates are essentially equal for both delivery practices. However, substantial cost savings are available with TOL.

Second trimester elective abortion is safest when accomplished with cervical dilation and instrumental uterine evacuation (D and E), but this procedure carries with it a risk of uterine perforation and possible intra-abdominal trauma. In order to determine if the routine use of intraoperative ultrasonography reduces the risk of this feared and serious complication, 353 elective abortions at 16 to 24 weeks gestation performed without sonography were compared to 457 in which sonography was routinely employed. All 810 operations were carried out in one clinic using the same operative technique. The routine intraoperative use of ultrasonographic imaging to guide intrauterine forceps during uterine evacuation for second trimester elective abortion resulted in a significant reduction in uterine perforation, the rate declining from 1.4% to .2%. These findings support the routine use of intraoperative ultrasonography for second trimester elective abortion to reduce the incidence of uterine perforation and make the procedure a safer one.

OBJECTIVES: To evaluate the accuracy of prenatal sonography in determining the lower uterine segment (LUS) thickness in women with previous Caesarean section and to assess the usefulness of measuring LUS thickness in predicting the risk of uterine rupture during a trial of vaginal birth. METHODS: Sonographic examination was performed in 102 pregnant women with one or more previous Caesarean sections at between 36 and 38 weeks' gestation to assess the LUS thickness, which was defined as the shortest distance between the urinary bladder wall-myometrium interface and the myometrium/chorioamniotic membrane-amniotic fluid interface. Of the 102 women examined, 91 (89.2%) had transabdominal sonography only, and 11 (10.8%) had both transabdominal and transvaginal examinations. The sonographic measurements were correlated with the delivery outcome and the intraoperative LUS appearance. RESULTS: The mean sonographic LUS thickness was 1.8 mm, standard deviation (SD) 1.1 mm. An intraoperatively diagnosed paper-thin or dehisced LUS, when compared with an LUS of normal thickness, had a significantly smaller sonographic LUS measurement (0.9 mm, SD 0.5 mm, vs. 2.0 mm, SD 0.8 mm, respectively; P < 0.0001). Two women had uterine dehiscence, both of whom had prenatal LUS thickness of < 1 mm. Thirty-two women (31.4%) had a successful vaginal delivery, with a mean LUS thickness of 1.9 mm, SD 1.5 mm; none had clinical uterine rupture. A sonographic LUS thickness of 1.5 mm had a sensitivity of 88.9%, a specificity of 59.5%, a positive predictive value of 32.0%, and a negative predictive value of 96.2% in predicting a paper-thin or dehisced LUS. CONCLUSIONS: Sonography permits accurate assessment of the LUS thickness in women with previous Caesarean section and therefore can potentially be used to predict the risk of uterine rupture during trial of vaginal birth.

OBJECTIVES To determine the incidence, aetiology, trend, management maternal and fetal outcome of uterine rupture at University of Ilorin Teaching Hospital, Ilorin, Nigeria. To compare the results with previous reports from this centre. MATERIALS AND METHODS A prospective study of patients with ruptured uterus at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between February, 1992 and December, 1999 was undertaken. The patients were initially assessed in the labour ward where the clinical presentation, relevant socio-demographic data, previous medical and surgical histories were noted. Necessary investigations and resuscitation were carried out before the operation. A structured questionnaire was also administered either before or after the operation. Two consecutive spontaneous vaginal deliveries following each case of uterine rupture served as control. Statistical analysis was done using the Genstat 32 package. RESULTS Of the 20,960 deliveries during the study period, there were 100 ruptured uteri giving a hospital incidence of 1 in 210 deliveries. Oxytocin use (39%), uterine scar (23%) and obstructed labour (16%) were the common associated factors. When compared with the controls, uterine rupture in the study group was significantly associated with low socio-economic status p < 0.001, lack of antenatal care p < 0.001, and high parity p < 0.012. A maternal age 40 years and above was also a risk factor. The anterior wall of the uterus was the commonest site affected and repair with tubal ligation was the surgical procedure in 36% of cases. Maternal mortality was 13%, while fetal mortality was 92%. When compared with the previous incidence of 1 in 298 deliveries, a slight increase is noted. CONCLUSION Ruptured uterus is still a common obstetric hazard in our environment and its incidence appears to be on the increase. The condition is significantly associated with advanced maternal age, grandmultiparity, lack of antenatal care and the low socio-economic status of the patients.