الفهرس 
Cesarean Section
Methods to Decrease Cesarean Delivery RatesOnly 14 pages are availabe for public view
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Abstract
There has been an increase in cesarean section rate
over the past 20 years, which is not uniform but associated
with wide variations between and within countries.
This is not a recent phenomenon, a senior
obstetrician in 1922 wrote to the British Medical Journal:
―The art and science of midwifery have either been lost by
the younger generation in this country or will certainly be
lost if this mad rage for cesarean section is continued‖.
This progressive increase in the rate of cesarean
section has caused a large burden on the health providing
system and this urged many efforts to decrease this rates.
Many factors are responsible for this increase the
namely, increased safety of the operation due to better
anesthesia, antibiotic and blood products.
The major obstetric indications for the rising rate of
cesarean section are dystocia, previous cesarean birth,
breech presentation and fetal distress with repeat cesarean
accounting for approximately half of the increased rate.
Use of Vaginal Birth After Cesarean (VBAC) is
increased significantly as an appropriate manner to
decrease the rising rate of cesarean section and the pendulum began to swing away from routine repeat
cesarean delivery. Most recent reports support the safety of
VBAC in women with one or two prior.
Elective termination of pregnancy by repeat C.S will
continue to be a part of modem obstetric practice, as it
offers a number of advantages over a trial of labour
including avoidance of rupture scar during labour with its
great squeals and the decreased possibility of aspiration
pneumonia and infection when a trial of labour has to be
terminated by emergent C.S.
However, elective repeat cesarean section carries the
risk of prematurity and RDS, and to avoid this complication
either to wait for the onset of labour or perform C.S at 39
weeks depending on established guideliness for timing an
elective repeat C.S as; sure dates of last menstrual period,
U/S done early at 10 -12 weeks of pregnancy confirm
gestational age or documented fetal heart tones at 20 weeks
gestation by non electronic fetoscope or at 10 weeks
gestation by Doppler.
Prerequisites for trial of labor after previous cesarean
delivery according to (ACOG, 2010) include: one or two
previous low transverse C.S. with no vertical extension into
the fundus or lower uterine segment, cephalic vertex
presentation and adequate pelvis with availability of anaesthesia, blood banking service, personnel for
continuous monitoring of the mother and fetus and capable
of doing emergency cesarean section within 20 - 30
minutes if needed.
In our study 252 cases with a history of one Cesarean
section presented in labor at Ain Shams University
Maternity Hospital from first of January 2014 to 31
December 2014, 93 of them delivered by VBAC
(Percentage of VBAC: 36.9%) while 159 delivered by
repeated cesarean section.
Factors which were found to be significantly
affecting the success of TOL include history of vaginal
delivery, degree of Bishop score at time of admission.
The best chance of successful TOL was obtained by
those patients who had prior vaginal delivery especially
when it occur after and both after and before previous CS.
The most common factor affected success rate of
TOL was Bishop score of patient at time of admission .it
was higher in patients with Bishop score 4 and more
Furthermore regarding complications of delivery the
incidence of rupture uterus was 0.8% (n=2) among all
patient.The overall incidence of hysterectomy in present
study was 0.4% (n=1) due to un repairable rupture uterine
scar.
The overall incidence of bladder injury in present
study was 0.8% (n=2). The indication include during repeat
CS and during hysterectomy.
According to available records, the overall incidence
of blood transfusion was 1.2% (n=3).
Also according to available records, the overall
incidence of neonatal intensive care unit admission was
0.8% (n=2).
Post cesarean uterine rupture is considered the most
important complication of a trial of labour. It may be
complete and this the usual type with upper segment scars
and it results in perinatal death and threatens the maternal
life as it is usually associated severe bleeding. Incomplete
rupture is usually asymptomatic with no severe bleeding
and this is the usual type of rupture in cases of lower
segments scars. This type associated with a little morbidity
of the mother or fetus. Fetal risks during trial of labour are
reduced by strict monitoring of the fetus all through the
trial and by the presence of a competent team capable of
performing an emergency cesarean section Fetal risks during trial of labour are reduced by strict
monitoring of the fetus all through the trial and by the
presence of a competent team capable of performing an
emergency cesarean section.
Over 120 articles in the literature documenting the
outcome of delivery after previous cesarean section in
nearly 150 000 cases. Most are retrospective observational
studies. These have formed in a variety of clinical setting
and populations. Despite this, the findings are nearly
consistent:
1. 70 % of cases are considered suitable for an attempt
at vaginal delivery;
2. 73 %of attempts result in vaginal delivery;
3. 0.8 % experience scar complications (rupture or
dehiscence);
4. Approximately 9/1000 result in perinatal mortality;
5. Approximately 10/100 000 result in maternal
mortality.