With complete rupture during TOAC, hysterectomy may be required. In selected cases, however, suture repair with uterine preservation may be performed. Sheth (1968) described outcomes from a series of 66 women in whom repair of a uterine rupture was elected rather than hysterectomy. hirteen of the 41 mothers who did not have tubal sterilization had a total of 21 subsequent pregnancies. Uterine rupture recurred in four of these-approximately 20 percent. Usta and associates (2007) reported similar results. In another study, however, women with a uterine dehiscence were not more likely to have a subsequent uterine rupture (Baron, 2014).
Because of the aforementioned concerns with TOAC, most women in the United States undergo ERCD. his choice has several signiicant maternal complications, and rates of these rise in women who have multiple repeat operations. The incidences of some common complications for women with one prior transverse cesarean delivery who undergo an ERCD were shown in Table 31-2. Of note, half of cesarean hysterectomies done at Parkland Hospital are in women with one or more prior cesarean deliveries (Hernandez, 2013).
The Network addressed issues of increased morbidity in a cohort of30,132 women who had from one to six repeat cesarean deliveries (Silver, 2006). he rates of some of the more frequent or serious complications are depicted in Figure 31-6. In addition, rates of bowel or bladder injury, admission to an intensive care unit or need for ventilator therapy, and maternal mortality, as well as operative and hospitalization length, showed significantly rising trends. Similar results have been reported by others (Nisenblat, 2006; Usta, 2005). More diicult to quantiY are risks for bowel obstruction and pelvic pain from peritoneal �.� c0 4 ..A 2�): E0u
First Second Third � Fifth (6201) (15,808) (6324) (347)
Number of repeat cesarean deliveries (Number of women)
TABLE 31-4. Some Recommendations of Professional Societies Concerning a Trial of Labor to Attempt VBAC
CD cesarean delivery; VBAC vaginal birth after cesarean.
adhesive disease, both of which increase with each successive cesarean delivery (Andolf, 2010; Mankuta, 2013).
Cook and colleagues (2013) from the United Kingdom Obstetric Surveillance System (UKOSS) described adverse sequelae of women with ive or more cesarean deliveries. These women had signiicantly higher rates of morbidity. Namely, the major hemorrhage rate increased 18-fold; visceral damage, 17 -fold; critical care admissions, IS-fold; and delivery <37 weeks, sixfold. Much of this morbidity was in the 18 percent who had a placenta previa or an accrete syndrome (Chap. 41, p. 773).