In the third cesarean section, should uterine incision be performed above the former uterine incision or under the former uterine incision or in situ of the former uterine incision?
In my experience,in the third caesarean section the uterine incision should be above the previous scar, as many times the urinary bladder is advanced and adherent to the lower uterine segment so it is good to take the incision above the previous scar which can prevent the damage to the bladder.the part below the previous scar area is thinned out and if we take incision below it, it can torned and extend while delivering the baby,and suturing will be also difficult.so I preffer to go above thr previous scar.
This will often depend on the position of the placenta and how it has been evaluated. One should always be aware of the significantly higher incidence of morbidly adherent placenta after previous C/S and that this rises with increasing number of previous C/S.
Otherwise the site of incison should be determined intraoperatively and this is also why patients with many previous C/S should be operated by experienced surgeons - or at least with an experienced surgeon in attendance.
Hi Zhao
The main worry in such repeated caesarean sections are uterine defects. This may lead to uterine rupture, adhesions, placenta previa, placenta accreta, increta or percreta and postpartum haemorrhages.
Many studies indicated that multiple Cesarean sections and retroflexed uteri contribute to larger defects in terms of depth and width, and the more Cesarean sections the higher the severity and prevalence of deficient scars. This seems natural, because healing conditions are likely to be poorer in tissue where there is already a scar.
Therefore, going through the old scar will worsen the previously weak scar, increase defects and it associated morbidities and also reduce myometrial thickness (Vikhareva Osser et al.2009). Going below the old scar has the associated risk of injury to the bladder, ureters and overriding of the bladder. In facts, Vikhareva Osser and his colleagues found decreased interval between caesarean section scar and internal os (Vikhareva Osser et al. 2009). These further increase the chance of injuries to the neighbouring structures.
Thus the best area for subsequent incision, I think, is above the old scar.
NB
VIKHAREVA O. OSSER, JOKUBKIENE I. and VALENTIN L High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol 2009; 34: 90–97 DOI: 10.1002/uog.6395
The best area is above the old scar to avoid injury to bladder and also make sure the weak scar is not stured
Thank all of you. I also think that uterine incision should be selected above previous incisions. However, according to this idea, the uterine incision may be performed on the uterine body instead of lower uterine segment in many caesarean sections, such as the fourth caesarean sections or more. Then will thick myometrium of uterine body affect the uterine wound healing?
In my opinion, if this patient does not need childbearing fertility, classical cesarean section is a promising incision. It avoids bladder injury and better entrance for abnormal placentation.
I think the site for the incision should not be fixed but from my experience of more than 2000 caesarian section in a low income country where you have obstructed labour and impacted presenting part, if incision is placed above the old one, as the head is dis-impacted there is tendency to get a tear since the scar is poor at stretching. Those of you who advance the issue of bladder injury may have to think twice for if bladder is not pushed off, then there is a more risk of injury. This I am sure from the fistulas I have Repaired (Fistula surgery of more than 2000 repairs). So what I have learn with time is to do a cresenteric incision but the lateral ends of the crescent cross the old scar while the middle part of the cresent is below the old scar. This will make a big surface that can stretch hence avoid tears. Injury to the bladder should not rise here for we are not robotic and I feel everybody who does c/section should first learn the relationship of the bladder and uterus.
Regards
There is no specific recommendation. Ideally above the previous scar after localization of the placenta.
This is ideal in elective caesarian sections but in settings where you have obstructed labor even in a previous scar and where women want more babies , you are safer dividing the band
In my hospital we only allow 3 CS for any one person but very rarely do we encounter a 4th CS. I recommend above the scar because of the space available for extension of the incision and I personal tear up and down on a horizontal incision (publication attached ) so the extended tear usually extend upwards on either side, like a "smile". this is because of the alignment of the muscle fibers. since we only allow 3 CS, incision on the upper segment is not a issue because Bilateral Tubal ligation is done with the patients approval.
Thank Kitione Waqanisau! This is the first time for me to know about another method of expansion of the uterine incision different from traditional blunt expansion of the uterine incision in a transversal direction. I will try this method in the future cs. Thank you very much!