Can the rate of cesarean section be reduced?

To look into all cases with previous one cesarean section who were cared for and delivered at Armed Forces Hospital, Riyadh, between January 1990 and December 1998, to determine its prevalence, final method of delivery, and outline measures of reducing its incidence. Retrospective analysis of hospital records of all women with previous one cesarean section who had either a repeat cesarean section or delivered vaginally after cesarean section. Between 1990 and 1998, 61,060 mothers were delivered. Two thousand five hundred and seventy eight patients had one previous cesarean section. They represented 3.5% of the total number of deliveries. Nine hundred and sixty eight [37.5%] cases had repeat cesarean section. Of the 1610 [62.5%] mothers who achieved vaginal delivery, 102 [6%] had ventouse, 42 [3%] had forceps and 22 [1%] had an assisted breech delivery. Rupture of uterine scar was reported in 15 cases. There were no maternal or perinatal deaths. Patients with one previous cesarean section are three times more likely to have a cesarean section as compared to mothers with unscarred uterus. Reducing the overall cesarean section rate is possible through a closer look at the primary indication for the first cesarean section. A protocol is needed to allow more cases with one or more previous cesarean section to have trial of vaginal delivery under close monitoring and involve the senior staff more in the diagnosis and management of cases of dystocia and the use of Oxytocin when indicated

Intrapartum rupture of the gravid uterus

To review all cases of intrapartum rupture of the gravid uterus that occurred at the Riyadh Armed Forces Hospital between 1986 and 1997, determine its incidence, analyse the contributing factors and outline measures of prevention. Retrospective case record analysis of 31 cases of diagnosed intrapartum uterine rupture. During the study period, there were 75,398 deliveries conducted and 31 cases of intrapartum rupture of gravid uterus reported. Nine [29%] occurred in unscarred uterus [1:7849]. Two had failed attempt at ventouse/forceps delivery. Eight [88.8%] patients received blood transfusion. The Perinatal mortality rate was 55.5%. Of the 22 cases of ruptured scarred uterus, 18 had one previous cesarean operation. Four [18%] were ventouse deliveries. The fetal mortality rate was 9%. Only 13 [59%] patients received blood transfusion. Repair of uterine rupture was carried out in all 31 cases. There were no maternal deaths. There was significantly higher blood loss [2344ml vs 1036, P<0.0001], Perinatal loss [55.5% vs 9%, P<0.01], age [34 years vs 29 years, P<0.001] and parity [5 vs 3, P<0.001], in the unscarred group as compared to the scarred one. The incidence of ruptured uterus was 0.04%. The main contributing factors identified were scarring from previous cesarean section, misjudgment of operative vaginal delivery, and failure to recognise early signs of impending uterine rupture. Close monitoring of uterine contraction, fetal heart tracing and exclusion of cephalopelvic disproportion before attempting operative vaginal delivery will help in reducing the incidence of uterine rupture to a minimum