Evidence - Cesarean section

Cesarean delivery (C-section) is the most frequently performed surgery in women worldwide, and its frequency is continuously increasing. While it was previously associated with high risks for both mother and child, it is now considered a safe procedure. Nevertheless, there is limited knowledge about potential short- and long-term health effects for both mother and child. This leads to uncertainties in decision-making regarding the optimal birth method.

A primary C-section is performed before labor has begun, meaning there have been no contractions affecting the cervix nor a (premature) rupture of membranes.

In contrast, a secondary C-section occurs when labor has already started, either through cervical contractions or a premature rupture of membranes.

• C-section rate 2014 in Germany: 31.8% (Federal Statistical Office)
• Development since 1991: Doubling of the rate (1991: 15.3%)
• Stabilization: Constant rate for three years
• Decline since 2014: Introduction of the risk-adjusted C-section rate led to a slight decrease

References: 

1. Macfarlane A, Blondel B, Mohangoo A, Cuttini M, Nijhuis J, Novak Z, et al. Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study. BJOG An Int J Obstet Gynaecol [Internet]. 2016 Mar;123(4):559–68. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25753683 
2. World Health Organization Human Reproduction Programme, 10 April 2015. WHO Statement on caesarean section rates. Reprod Health Matters [Internet]. 2015 Jan 27;23(45):149–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26278843
3. Federal Statistical Office. Federal Statistical Office [Internet]. 2015. Available from: https://www.destatis.de/DE/Presse/Pressemitteilungen/_inhalt.html 
4. IQTIG - Institute for Quality Assurance and Transparency in Healthcare. National evaluation for the reporting year 2015 Obstetrics Quality Indicators [Internet]. 2016. Available from: http://www.iqtig.org 

• Early education: Pregnant women should receive evidence-based information to make an informed decision about the birth method.
• Consideration of perspectives: The perspectives and concerns of women should be included in the consultation process.
• Individual support: Women who desire a cesarean section should receive comprehensive counseling during pregnancy.
• Clear communication: Information should be provided in language accessible to laypersons.
• Consideration of special needs: Information should be tailored for:
  • Women from ethnic minorities (language, culture, religion)
  • Women whose native language is not German
  • Illiterate women or women with disabilities/learning difficulties
• Contents of education:
  • Indications for a cesarean section
  • Procedure of the operation
  • Risks and benefits
  • Impact on future pregnancies
• Emotional stress: Every cesarean birth is experienced as physically and emotionally challenging.
• Psychological stress: Women with an elective or non-urgent cesarean may experience similar psychological difficulties as with an emergency cesarean.
• Importance of information: More knowledge about the cesarean process can help positively influence the experience.

• Absolute indication: Cesarean section is absolutely necessary to save the mother and/or child.
• Examples of absolute indications:
  • Transverse position of the child
  • (Impending) uterine rupture
  • Placenta previa
  • Premature placental abruption
• Frequency: Absolute indications account for less than 10% of all cesarean sections.
• Relative indication: In about 90% of cases, a weighing of risks for mother and child occurs.
• Early education: The risk-benefit assessment between vaginal birth and cesarean section should occur in a timely manner.
• Goal: Participatory decision-making through comprehensive information.

Summary of study results on vaginal birth vs. cesarean section

Maternal outcomes

• Hysterectomies after postpartum hemorrhage: Less common with vaginal birth (RR 2.31, CI 1.30 – 4.09; n=2,339,186, 8.2%).
• Assisted ventilation or intubation: Less common (RR 2.21, CI 0.99 – 4.90; n=2,339,186, 8.2%).
• Cardiac arrest: Less common after vaginal birth (RR 4.91, CI 3.95 – 6.11; n=2,339,186, 8.2%).
• Severe acute maternal morbidity (SAMM): Lower rate, but no difference for women with BMI ≥ 50 (OR 3.9, CI 3.5 – 4.3; n=355,841, 8.6%).
• Deep vein thrombosis: Less common after vaginal birth (RR 2.20, CI 1.51 – 3.20; n=2,339,186, 8.2%).
• Maternal mortality: Less common after vaginal birth (OR 4.0, CI 1.9 - 8.2; n=355,841, 8.6%).
• Postpartum infections: Less common after vaginal birth (RR 2.85, CI 2.52 – 3.21; n=2,339,186, 8.2%).
• Anesthesia complications: Less frequent after vaginal birth (RR 2.5, CI 2.22 – 2.86; n=2,339,186, 8.2%).
• Length of hospital stay: Shorter with vaginal birth (Difference: 1.47 days, CI 1.46 – 1.49).
• Obstetric shock: More common with vaginal birth (RR 0.33, CI 0.11 – 0.99; n=2,339,186, 8.2%).
• Early postpartum hemorrhage: Tends to be more common after vaginal birth (OR 0.23, CI 0.06 – 0.94; n=4,048, 35%).
• Pain (perineum and abdomen): More intense during and three days after birth (VAS difference 6.3 points during birth, 0.7 points 3 days postpartum).
• Blood transfusions: More likely required after vaginal birth (RR 0.20, CI 0.20 – 0.64).
• Acute renal failure, uterine rupture, intraoperative trauma, pulmonary embolism, injuries (bladder, ureters, cervix, vagina): No significant differences between vaginal birth and cesarean section.

Neonatal outcomes

• Neonatal mortality: Less common after vaginal birth (RR 2.4, CI 2.20 – 2.65; n=8,026,405, 7.9%).
• Hypoxic-ischemic encephalopathy, intracranial hemorrhages, neurological morbidity: No difference between both birth methods.
• Neonatal respiratory morbidity: No significant difference.
• Admission to the Neonatal Intensive Care Unit (NICU): Less frequently necessary after vaginal birth (RR 2.20, CI 1.40 – 3.18).
• 5-minute Apgar score < 7: No difference.

Long-term outcomes after cesarean section

Long-term effects on women

Ectopic pregnancy

• Inconsistent results:
  • in some studies with increased risk (OR 1.21; CI 1.04 – 1.40; n=312,026).

Stillbirth & miscarriage

• Stillbirth:
  • Inconsistent results: in some studies less common, in others more common after cesarean (pooled OR 1.27; CI 1.15 – 1.40; n=703,562, 8 studies).
• Miscarriage:
  • (52) Increased risk (pooled OR 1.17; CI 1.03 – 1.32; n=151,412, 4 studies).

Infertility

• Delayed fertility after cesarean section:
  • OR 0.90 (CI 0.86 – 0.93).
  • Lower pregnancy rate (RR 0.91; CI 0.87 – 0.95).
  • Increased risk of infertility (pooled OR 1.60; CI 1.45 – 1.76; n=3,692,014, 11 studies).

Long-term effects on children

Cerebral palsy

• No general difference (OR 1.29; CI 0.92 – 1.79; n=1,696,390).
• Higher risk after emergency cesarean (OR 2.17; CI 1.58 – 2.98).
• Increased risk in term-born babies after cesarean (OR 1.6; CI 1.05 – 2.44).

Inflammatory bowel diseases

• Varying results:
  • Inconsistent results

Overweight & obesity

• Increased risk after cesarean:
  • OR 1.33 (CI 1.19 – 1.48).
  • Overweight: OR 1.26 (CI 1.16 – 1.38).
  • Obesity: OR 1.22 (CI 1.05 – 1.42).
  • Overweight in children 3-13 years: OR 1.22 (CI 1.06 – 1.41).

Childhood asthma

• Higher risk after cesarean:
  • OR 1.16 (CI 1.14 – 1.29; 26 studies).
  • OR 1.21 (CI 1.11 – 1.32; n=887,960, 13 studies).

Health issues & mortality

• Increased risk after planned cesarean:
  • Type I diabetes: HR 1.35 (CI 1.05 – 1.75; n=312,287).
  • Higher hospital admissions for asthma & mortality observed.

Further long-term effects on women

Urinary incontinence & uterine prolapse

• Lower risk after cesarean:
  • Urinary incontinence: OR 0.56 (CI 0.47 – 0.66; n=58,900, 8 studies).
  • Uterine prolapse: OR 0.29 (CI 0.17 – 0.51; n=39,208, 2 studies).

Placental complications in subsequent pregnancies

• Higher risk for:
  • Placenta previa (OR 1.74; CI 1.62 – 1.87; n=7,101,692, 10 studies).
  • Placenta accreta (OR 2.95; CI 1.32 – 6.60; n=705,108, 3 studies).
  • Premature placental abruption (OR 1.38; CI 1.27 – 1.49; n=5,667,160, 6 studies).
  • Uterine rupture (OR 25.81; CI 10.96 – 60.76; n=841,209, 4 studies).

Bleeding & hysterectomy

• Higher risk for:
  • Hysterectomy (OR 3.85; CI 1.06 – 14.02; n=167,674, 2 studies).
  • Antepartum bleeding (OR 1.22; CI 1.09 – 1.36; n=91,429, 2 studies).
• Lower risk for:
  • Postpartum bleeding (OR 0.72; CI 0.55 – 0.95; n=259,103, 2 studies).

References: 

1. NICE. Cesarean Section Clinical guideline [CG132]. 2011; Available from: https://www.nice.org.uk/guidance/cg132
2. National Institute for Health and Clinical Excellence. Caesarean section : Evidence Update March 2013. Natl Inst Heal Clin Excell. 2013;(March):1–28. 
3. NICE. 4-year surveillance (2017) - summary of new evidence Cesarean section (2011) NICE guideline CG132 [Internet]. Available from: https://www.nice.org.uk/guidance/cg132/evidence/appendix-a-summary-of-newevidence-pdf-2736386032 
4. Caesarean section Caesarean section Clinical guideline [Internet]. 2011. Available from: https://www.nice.org.uk/guidance/cg132/resources/caesarean-section-pdf35109507009733 
5. Homer C, Kurinczuk J, Spark P, Brocklehurst P, Knight M. Planned vaginal delivery or planned caesarean delivery in women with extreme obesity. BJOG An Int J Obstet Gynaecol [Internet]. 2011 Mar;118(4):480–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21244616
6. MacDorman MF, Declercq E, Menacker F, Malloy MH. Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an &quot;Intentionto-Treat&quot; Model. Birth [Internet]. 2008 Mar;35(1):3–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18307481 
7. Geller EJ, Wu JM, Jannelli ML, Nguyen T V, Visco AG. Neonatal outcomes associated with planned vaginal versus planned primary cesarean delivery. J Perinatol [Internet]. 2010 Apr 8;30(4):258–64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19812591 
8. Geller E, Wu J, Jannelli M, Nguyen T, Visco A. Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. Am J Perinatol [Internet]. 2010 Oct 16;27(09):675–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20235001 
9. Dahlgren LS, von Dadelszen P, Christilaw J, Janssen PA, Lisonkova S, Marquette GP, et al. Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants. J Obstet Gynaecol Can [Internet]. 2009 Sep;31(9):808–17. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1701216316342992 
10. Allen VM, O’Connell CM, Baskett TF. Maternal Morbidity Associated With Cesarean Delivery Without Labor Compared With Induction of Labor at Term. Obstet Gynecol [Internet]. 2006 Aug;108(2):286–94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16880297 
11. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Can Med Assoc J [Internet]. 2007 Feb 13;176(4):455–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17296957 
12. Deneux-Tharaux C, Carmona E, Bouvier-Colle M-H, Bréart G. Postpartum Maternal Mortality and Cesarean Delivery. Obstet Gynecol [Internet]. 2006 Sep;108(3, Part 1):541–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16946213 
13. Schindl M, Birner P, Reingrabner M, Joura E, Husslein P, Langer M. Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience. Acta Obstet Gynecol Scand [Internet]. 2003 Sep;82(9):834–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12911445 
14. van Dillen J, Zwart JJ, Schutte J, Bloemenkamp KWM, van Roosmalen J. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstet Gynecol Scand [Internet]. 2010 Nov;89(11):1460–5. Available from: http://doi.wiley.com/10.3109/00016349.2010.519018 
15. Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. Myers JE, editor. PLOS Med [Internet]. 2018 Jan 23;15(1):e1002494. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29360829 
16. Deneux-Tharaux C, Carmona E, Bouvier-Colle M-H, Bréart G. Postpartum Maternal Mortality and Cesarean Delivery. Obstet Gynecol [Internet]. 2006 Sep;108(3, Part 1):541–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16946213 
17. O’Neill S, Khashan A, Kenny L, Greene R, Henriksen T, Lutomski J, et al. Caesarean section and subsequent ectopic pregnancy: a systematic review and meta-analysis. BJOG An Int J Obstet Gynaecol [Internet]. 2013 May;120(6):671–80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23398899 
18. O’Neill SM, Kearney PM, Kenny LC, Khashan AS, Henriksen TB, Lutomski JE, et al. Caesarean Delivery and Subsequent Stillbirth or Miscarriage: Systematic Review and Meta-Analysis. Middleton P, editor. PLoS One [Internet]. 2013 Jan 23;8(1):e54588. Available from: http://dx.plos.org/10.1371/journal.pone.0054588 
19. O’Neill SM, Kearney PM, Kenny LC, Henriksen TB, Lutomski JE, Greene RA, et al. Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis. BMC Pregnancy Childbirth [Internet]. 2013 Dec 27;13(1):165. Available from: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-239313-165
20. Gurol-Urganci I, Bou-Antoun S, Lim CP, Cromwell DA, Mahmood TA, Templeton A, et al. Impact of Caesarean section on subsequent fertility: a systematic review and metaanalysis. Hum Reprod [Internet]. 2013 Jul;28(7):1943–52. Available from: https://academic.oup.com/humrep/article-lookup/doi/10.1093/humrep/det130 
21. O’Callaghan M, MacLennan A. Cesarean Delivery and Cerebral Palsy. Obstet Gynecol [Internet]. 2013 Dec;122(6):1169–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24201683 
22. Li Y, Tian Y, Zhu W, Gong J, Gu L, Zhang W, et al. Cesarean delivery and risk of inflammatory bowel disease: a systematic review and meta-analysis. Scand J Gastroenterol [Internet]. 2014 Jul 18;49(7):834–44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24940636 
23. Bruce A, Black M, Bhattacharya S. Mode of delivery and risk of inflammatory bowel disease in the offspring: systematic review and meta-analysis of observational studies. Inflamm Bowel Dis [Internet]. 2014 Jul;20(7):1217–26. Available from: https://academic.oup.com/ibdjournal/article/20/7/1217-1226/4579585 
24. Li H, Zhou Y, Liu J. The impact of cesarean section on offspring overweight and obesity: a systematic review and meta-analysis. Int J Obes [Internet]. 2013 Jul 4;37(7):893–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23207407
25. Darmasseelane K, Hyde MJ, Santhakumaran S, Gale C, Modi N. Mode of Delivery and Offspring Body Mass Index, Overweight and Obesity in Adult Life: A Systematic Review and Meta-Analysis. Dewan A, editor. PLoS One [Internet]. 2014 Feb 26;9(2):e87896. Available from: https://dx.plos.org/10.1371/journal.pone.0087896
26. Huang L, Chen Q, Zhao Y, Wang W, Fang F, Bao Y. Is elective cesarean section associated with a higher risk of asthma? A meta-analysis. J Asthma [Internet]. 2015 Feb 2;52(1):16–25. Available from: http://www.tandfonline.com/doi/full/10.3109/02770903.2014.952435 
27. Black M, Bhattacharya S, Philip S, Norman JE, McLernon DJ. Planned Cesarean Delivery at Term and Adverse Outcomes in Childhood Health. JAMA [Internet]. 2015 Dec 1;314(21):2271. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26624826 

Absolute Indications

• Transverse lie of the child
• Placenta previa (partial or complete covering of the cervix)
• Premature placental abruption
• Uterine rupture (impending or occurred)
• Fetal distress (acute hypoxia, pathological CTG findings)
• HIV infection of the mother with high viral load
• Genital herpes simplex virus (HSV) infection in the 3rd trimester
• Cephalopelvic disproportion (disproportion between fetal head and maternal pelvis)
• Severe preeclampsia or eclampsia
• HELLP syndrome (severe pregnancy complication with liver dysfunction)
• Previous multiple uterine surgeries or several prior cesarean sections

Relative Indications (required after risk assessment)

• Breech presentation (especially in primiparas or under unfavorable conditions)
• Multiple pregnancies, especially with breech presentation of the leading twin
• Intrauterine growth restriction (IUGR) with abnormal Doppler sonography
• Prematurity (<36 weeks of gestation) with unfavorable factors
• Macrosomia (very large child, >4500 g with diabetes, >5000 g without diabetes)
• Fetal malformations that complicate vaginal delivery (e.g., hydrocephalus)
• Severe maternal diseases (e.g., severe cardiovascular diseases)
• Previous uterine rupture or complicated birth injury in history

Other Indications Based on Individual Decision

• Cesarean section at the request of the pregnant woman after comprehensive counseling
• HPV infection with extensive condylomas obstructing the birth canal
• Hepatitis B or C – not a general indication, except with HIV coinfection
• Condition after external version in breech presentation, if unsuccessful
• Prolonged labor with arrest of labor despite adequate labor stimulation
• Increased risk of perinatal morbidity or mortality based on individual factors

References:

DGGG. The Cesarean Section. S3-Guideline. AWMF Register No. 015/083. Ed. by the Association of the Scientific Medical Societies (AWMF). On the Internet: https://www.awmf.org/leitlinien/detail/ll/015-084.html

Timing of Planned Cesarean Section

• Recommended from 39+0 weeks of gestation to reduce the risk of respiratory disorders in the newborn.
• Studies show that neonatal morbidity decreases with increasing gestational age.
• From 39+0 weeks of gestation, the risk of neonatal respiratory disorders is no longer significantly increased.
• Earlier cesarean only if medically necessary.

Urgency Classification According to NICE

Categories of Cesarean Urgency:

Immediate life threat to mother or fetus

• Acute, severe bradycardia
• Uterine rupture
• Cord prolapse
• pH ≤ 7.20 (fetal blood analysis)

Maternal or fetal compromise (not life-threatening but critical)

• Labor arrest with increasing risk
• Placental insufficiency with pathological CTG

No acute compromise, but prompt delivery required

• Spontaneous onset of labor with planned cesarean
• Labor arrest without visible risk

No maternal or fetal compromise

• Elective cesarean, no medical emergency

Time guidelines for emergency cesarean: Maximum decision-to-delivery interval: 20 minutes

Preoperative Measures

Laboratory Checks

• Hemoglobin status before cesarean to identify anemia.
• Blood products on standby for:
  • Placenta previa
  • Placental abruption
  • Uterine rupture
  • Premature placental abruption

Urinary Catheter

• Indicated with regional anesthesia to ensure bladder function.

Antibiotic Prophylaxis

• Must be administered before skin incision as it reduces infection rates.
• Cephalosporins recommended as standard antibiotic.

Surgical Procedure

Incision & Tissue Opening

• Lower abdominal transverse incision (Pfannenstiel incision) → Less pain, better cosmetic outcome.
• Blunt tissue opening reduces operation time and infection rate.

Instrument Use

• No scalpel change between skin and deeper layers → No reduction in infection rate.

Uterine Opening & Suture

• Blunt extension of the hysterotomy, if possible → Less blood loss.
• Intra-abdominal uterine suture recommended, no exteriorization → Less pain.
• Single vs. double-layer uterine suture: No clear recommendation as both are equivalent.

Risks & Complications

• Fetal lacerations (~2%) possible during cesarean.
• Use of uterotonics (Oxytocin, Carbetocin) → Reduction of blood loss.
• Placental removal preferred by "cord traction", not manual removal → Less endometritis.

Peritoneum & Wound Closure

• Do not suture peritoneum → Shorter operation time, less pain.
• Suture subcutaneous tissue only if >2 cm fat tissue → Reduction of wound infections.
• No routine use of drainage, as there are no benefits in infection prevention.
• Skin closure: Method unclear, but poorer cosmetic outcome and more pain with staple closure.

Postoperative Care & Thrombosis Prophylaxis

• Increased risk of venous thromboembolism after cesarean → Individually tailored thrombosis protocol necessary.
• Consider maternal wishes → Music, pleasant atmosphere in the OR promote a positive birth experience.

References:

DGGG. The Cesarean Section. S3-Guideline. AWMF Register No. 015/083. Published by the Association of the Scientific Medical Societies (AWMF). Online: https://www.awmf.org/leitlinien/detail/ll/015-084.html

Historical Development:

• Previously: "Once a cesarean, always a cesarean."
• Since the 1960s, it has been demonstrated that a vaginal birth after cesarean (VBAC) is possible.
• After an increase in the VBAC rate in the 1980s and 1990s, the number of vaginal births after cesarean decreased again until 2008.

Comparison of Risks in Planned Repeat Cesarean vs. Planned Vaginal Birth (VBAC):

• Australian Cohort Study (n=2,323):
  • Repeat Cesarean: No perinatal death.
  • VBAC: 2 neonatal deaths.
  • Child morbidity was lower with planned cesarean (RR=0.39; p=0.011).
• Australian Retrospective Cohort Study (n=21,389):
  • Uterine rupture rate: Very low (only 5 cases).
  • Postpartum hemorrhage: Higher after VBAC (11.6% vs. 8.6%).
  • No significant difference in maternal morbidity between VBAC and first-time mothers.

Recommendations for VBAC:

• A vaginal birth after cesarean is a safe option for many women, especially after a previous vaginal birth.
• Maternal preference and risk assessment are crucial.
• CTG monitoring during labor is recommended (NICE), but there is no evidence for continuous CTG.
• A birth facility with emergency cesarean capability is recommended but not mandatory.

Uterine Rupture after Previous Cesarean Section

Risk of Uterine Rupture (Australian Cohort Study, n=29,008):

• Lowest risk: Planned repeat cesarean (0.02%).
• Increased risk:
  • Labor augmentation with oxytocin (1.91%).
  • Induction of labor with prostaglandins (0.68%).
• Induction of labor can increase the risk of uterine ruptures by 3 to 5 times.
• Induction with oxytocin can increase the risk 14-fold.

Recommendations for Uterine Rupture:

• In labor induction after cesarean → Mother and child should be continuously monitored.
• Women with a previous vaginal birth after cesarean have a higher success rate for repeat VBAC.

Pregnancy and Birth with Placental Disorders

Risk Factors for Placental Disorders:

• Previous cesareans
• Uterine surgeries or infections
• Previous curettages or abortions

Diagnostics:

• Ultrasound can have high sensitivity, but diagnostic quality varies.
• MRI generally shows rather low diagnostic quality.
• Combination of ultrasound and MRI: Effectiveness is not yet conclusively determined.

Management of Placental Disorders:

• Early referral to an appropriate birth clinic with a multidisciplinary team.
• Experienced obstetricians, anesthetists, and neonatologists should be present.
• Adequate cross-matched blood units and transfusion options should be available.

Prenatal Diagnosis of Placenta Accreta

Benefits of Prenatal Diagnosis:

• Lower hysterectomy rate, but more operative complications.
• Early planning of the birth mode can improve management.

Conservative Management of Placenta Accreta (French Study, n=46):

• Successful conservative management in 40 out of 46 women.
• Spontaneous resorption of the placenta as a goal, surgical interventions are avoided as much as possible.
• High morbidity, however, leads to a low rate of subsequent pregnancies.
• Risk of recurrent placenta accreta in subsequent pregnancies is high.

References:

1. Crowther CA, Dodd JM, Hiller JE, Haslam RR, Robinson JS, Birth After Caesarean Study Group. Planned Vaginal Birth or Elective Repeat Caesarean: Patient Preference Restricted Cohort with Nested Randomised Trial. Smith GC, editor. PLoS Med [Internet]. 2012 Mar 13;9(3):e1001192. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22427749
2. Rozen G, Ugoni AM, Sheehan PM. A new perspective on VBAC: A retrospective cohort study. Women and Birth [Internet]. 2011 Mar;24(1):3–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20447886
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7. Riteau A-S, Tassin M, Chambon G, Le Vaillant C, de Laveaucoupet J, Quéré M-P, et al. Accuracy of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta. Lo AWI, editor. PLoS One [Internet]. 2014 Apr 14;9(4):e94866. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24733409
8. Warshak CR, Eskander R, Hull AD, Scioscia AL, Mattrey RF, Benirschke K, et al. Accuracy of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta. Obstet Gynecol [Internet]. 2006 Sep;108(3, Part 1):573–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16946217
9. Hall T, Wax JR, Lucas FL, Cartin A, Jones M, Pinette MG. Prenatal sonographic diagnosis of placenta accreta-Impact on maternal and neonatal outcomes. J Clin Ultrasound [Internet]. 2014 Oct;42(8):449–55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24975386
10. Provansal M, Courbiere B, Agostini A, D’Ercole C, Boubli L, Bretelle F. Fertility and obstetric outcome after conservative management of placenta accreta. Int J Gynecol Obstet [Internet]. 2010 May;109(2):147–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20152971