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Comment and Controversy

4th cesareans? Try 10th or 11th

November 2005 · Vol. 17, No. 11
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In his September editorial, Dr. Robert L. Barbieri issued a call for OBs to recount their experience with higher-order cesareans and describe any innovative techniques. Here are some of the responses:

Before I retired recently from private practice in southern California, I cared for a patient who, along with her husband, earnestly desired and lovingly provided for a large family. It was my privilege to perform 11 consecutive cesarean sections in this remarkable woman. None of her pregnancies were complicated by placenta previa, and placenta accreta was never an issue. No significant adhesions were encountered until her final section.

All cesareans involved a Pfannenstiel incision and prophylactic antibiotics. None of the deliveries proved complicated. For most of them, I closed the anterior peritoneum, but for the last several I did not. The lower uterine segment was noted to be quite thin at most of the deliveries after the first. In times past, this finding was thought to portend serious risk of uterine rupture in a subsequent pregnancy. My personal feeling is that such risk is based more on conjecture than proof.

David M. Kawasaki, MD
Raleigh, NC

I have performed as many as 10 C-sections in 1 woman and have never encountered a ruptured uterus, fetal death, or increase in low Apgar scores in these deliveries. I insist that my patients stay slim and in shape if they intend to have multiple abdominal surgeries. This is perhaps the most important measure to avoid problems.

I don’t think it would hurt docs lacking experience with higher-order repeats to observe a few at a good Catholic teaching hospital or the University of Utah, where multiple repeats are not so rare.

Ken McHenry, MD
Provo, Utah

I practice in an area where high parity is common, including 4th (or higher-order) cesareans. My personal record is 8 cesareans in 1 patient, who finally stopped having babies because she was 43 years old, not because of surgical difficulties. Even a patient with 6 cesareans is not rare—I’ve probably performed 6th cesareans in at least 20 patients over the course of my career, and those who have had 4 cesareans number well into the dozens.

Due to random variations in things such as adhesion formation, I have performed second and third cesareans that were far more challenging and dangerous than 6th sections, so some of your “special precautions” are routine for any cesarean in our facility. Our consent form lists the possibility of organ injury and/or hysterectomy, and we obtain baseline hemoglobin counts, a blood sample for the lab (we no longer do a full crossmatch), and ensure the availability of medications and hemostatic agents, a Foley catheter, and compression stockings. We also identify the location of the placenta.

One technique, extraperitoneal C-section, is very useful when it is difficult to open the peritoneum and gain transperitoneal access to the lower uterine segment through dense adhesions.

David F. Coppin, MD
Logan, Utah

I performed 5 C-sections each in 2 patients and have done many third and fourth repeat cesareans. I don’t administer prophylactic antibiotics unless the patient is in labor or has premature rupture of membranes.

I think basic training in anatomy—both descriptive and topographic—should be more intensive, involving more hours of cadaver dissection. Other suggestions:

  • A gentle touch and minimal trauma to tissues during cesarean sections helps prevent adhesions. I recommend sharp cutting and necessary dissections only—no “finger” dissections and only minimal use of electrocautery. Maneuvers such as routine manual removal of the placenta and exteriorization of the uterus for closure are not necessary.
  • During uterine and abdominal closure, approximate all layers anatomically.

Eduardo D. Meza, MD
Rockford, Ill

I was in private practice for 30 years and encountered many multiple cesareans. I even performed a seventh C-section in a 19-year-old, after which her tubes were tied. I would like to offer the following recommendations:

  • After 3 Pfannenstiel incisions, insist on a vertical incision.
  • Consider a classic cesarean when adhesions are found in the lower segment.
  • A thick, wide scar or keloid formation increases the likelihood of adhesions in the pelvis.
  • Make every effort to obtain the operating report of the previous cesarean.

Rida W. Boulos, MD, MPH
Chair, Department of Obstetrics and Gynecology
University of Illinois College of Medicine at Peoria

I practice maternal-fetal medicine at an urban tertiary care center and have also experienced a large increase in 4th and 5th cesareans over the past 3 years. Many of these women are morbidly obese with extensive medical problems.

I follow the precautions listed in your editorial, as well as 5 others:

  • delivery at 37 weeks after amniocentesis for fetal lung maturity,
  • delivery during weekday daylight hours when all staff members are available,
  • immediate availability of a cell saver in the OR in the event of hemorrhage,
  • if there is a low anterior placenta or known accreta, availability of a gynecologic oncologist for back-up, and
  • antenatal administration of epoetin alfa for women with a hematocrit less than 30.

David Scott Cole, MD
Division of Maternal-Fetal Medicine
Jacobi Medical Center, Bronx, NY
Assistant Professor of Obstetrics & Gynecology and Women’s Health
Albert Einstein College of Medicine, Bronx, NY

Dr. Barbieri responds:

The response from our readers is consistent and clear: For the experienced and well-trained obstetrician, higher-order repeat cesarean section is routinely associated with good outcomes. The high quality of clinical care provided by our readers is reflected in the clinical pearls they share. I appreciate the large number of responses to this important clinical issue.

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