4th cesareans? Try 10th or 11th

OBG Management. 2005 November;17(11):12-15

November 1, 2005|ObGyn

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.