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Adhesions and perioperative complications of repeat cesarean delivery

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The unprecedented high rate of cesarean delivery and the declining rate of vaginal birth after cesarean delivery make necessary awareness of the potential complications that are associated with repeat cesarean delivery. This article reviews the epidemiologic features of cesarean delivery and the perioperative risks that are associated with repeat cesarean delivery. These risks include increased adhesions, infections and wound complications, bleeding, bowel injury and obstruction, hysterectomy, operative time, hospital stay, and delays in delivery.

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Available data

This article was developed after a literature review of relevant English-language articles that we conducted using MEDLINE (1950 to May 2010). Search terms included repeat cesarean delivery/section, tissue adhesions, and postoperative complications. Additional information was gathered from recent scientific meeting proceedings and appropriate practice guidelines. Further references were identified through the screening of citations in the sources gathered.

When the risks and complications

CD and adhesions

Abdominal/pelvic adhesions are fibrous, band-like structures that form between abdominal organs or between the peritoneum and abdominal wall when trauma induces inflammation and disrupts normal tissue.11, 12 Adhesions can develop after infection, surgery, and chemical irritation. The normal wound-healing process after injury to the peritoneum involves a complex inflammatory cascade of fibrin deposition, coagulation, and influx of inflammatory cells.13, 14 Physiologically, fibrinous exudate

Perioperative infections and wound complications

Data regarding the risk of infection after repeat CD are conflicting, with outcomes that are confounded by the occurrence of many repeat CDs prelabor and many primary CDs during labor. For instance, Juntunen et al10 reported similar rates of infection among women who underwent high-order repeat CDs, many of which may have occurred without labor, vs women who underwent their first through third CD (14.1% vs 14.8%, respectively; P = not significant). In contrast, Lynch et al28 showed an

Neonatal complications of repeat CD

The maternal or fetal indication that leads to CD can affect neonatal outcomes. Likewise, repeat CD itself can lead to neonatal complications.

Morales et al23 demonstrated a progressively prolonged delivery time with each repeat CD, compared with the first (5.6 minutes for the second CD to 18.1 minutes for the fourth CD; P < .001 for both comparisons), which could lead to neonatal compromise under adverse circumstances. As previously noted, dense adhesions have been associated with an increased

Summary

With the increasing rate of CDs and the relative decline in the rate of VBAC, it is important that clinicians and patients understand the potential risks of repeat CD. As described, the incidence of many perioperative complications, which include adhesions, infections and wound complications, excessive bleeding, bowel injury and obstruction, hysterectomy, prolonged operative time and hospital stay, and delays in delivery, increase with the number of previous CDs. Although causation is often

Acknowledgment

We thank Adam Perahia, MD, and Joseph Melton, PhD, for their assistance in the research, preparation, and editing of the manuscript.

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    D.J.L. has served on an advisory board for Genzyme Corporation.

    Supported by Genzyme Corporation.

    The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Genzyme Corporation.

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