Cesarean birth has been a major source of interest & concern over the last few decades.

In the past 35 years, the rate of cesarean section has steadily increased from 5% to approximately
25%1. So pregnancy with history of previous cesarean section is prevalent in present day
obstetric practice1
A woman with a uterine scar has the option of planned vaginal birth (VBAC) or an
elective repeat caesarean section (ERCS). Factors to consider include: the material risks in the
current pregnancy associated with each, plans for further childbearing, the likelihood of
achieving a vaginal birth and other aspects of individual importance. The decision is one for the
woman to make in consultation with her carers who have an obligation to provide her with the
relevant information.2
Each repeat C-section is generally more complicated than the last. Studies show that the
risks increase after a third cesarean delivery, and vaginal deliveries aren't recommended after
three cesareans. However, research hasn't established the exact number of repeat cesareans
considered safe. Women who have multiple repeat cesarean deliveries are at increased risk of:3,4

Scar tissue on the uterus and nearby organs. Bands of scar-like tissue (adhesions)
develop after each abdominal surgery, though the extent of their formation after a C-
section varies. Dense adhesions can make a C-section more difficult, prolonging the time
to delivery.

Bladder and bowel injuries. Bladder injuries, which are possible but uncommon with
initial C-sections, are more likely with repeat C-sections. The increased risk is likely due
to adhesions that developed after a previous C-section, binding the bladder to the uterus.
Adhesions can also cause small bowel obstruction.

Heavy bleeding. Heavy bleeding is possible after any C-section. The risk of excessive
bleeding increases with the number of repeat C-sections. The risk of needing a
hysterectomy removal of the uterus to control life-threatening bleeding also increases
with the number of repeat C-sections. Heavy bleeding might also require treatment with a
blood transfusion. One study showed that the risk of hysterectomy increased from 0.65
percent after the first cesarean to 2.41 percent after the fourth cesarean.
 Problems with the placenta. The more C-sections you've had, the greater the risk of
developing problems with the placenta such as when the placenta implants too deeply
into the uterine wall (placenta accreta) or when the placenta partially or completely
covers the opening of the cervix (placenta previa). One study showed that the risk of
placenta accreta increased from 0.24 percent after the first cesarean to 2.13 percent after
the fourth cesarean.

The more caesarean sections that a woman has had, the less likely she will be eligible for
VBAC. VBAC after two or more prior lower uterine segment transverse CS is controversial. The
Royal College of Obstetricians and Gynaecologists recommends that women with a prior history
of even two previous uncomplicated low transverse Caesarean sections, in an otherwise
uncomplicated pregnancy at term, with no contraindication for vaginal birth, may be considered
suitable for planned VBAC.5 According to ACOG guidelines, the following criteria may reduce
the likelihood of VBAC success but should NOT preclude a trial of labour: having two prior
caesarean sections, suspected fetal macrosomia at term (fetus greater than 4000-4500 grams in
weight), gestation beyond 40 weeks, twin gestation, and previous low vertical or unknown
previous incision type, provided a classical uterine incision is not suspected.

The Criteria where ERCS should be performed is:6

Maternal request for elective repeat CS after counselling

Maternal or fetal reasons to avoid vaginal birth in current pregnancy

Previous uterine incision other than transverse segment including classical

(longitudinal). The Royal College of Obstetricians and Gynaecologists recommends
that women with a prior history of one classical (longitudinal) caesarean section
should give birth by elective repeat caesarean section (ERCS).

Unknown previous uterine incision

Previous uterine rupture

 Previous hysterotomy or myomectomy where the uterine cavity was breached

Daftar Pustaka

1. Nahar K, Akhter L, Chowdhury SB. Outcome of pregnancy with history of previous

cesarean section. The ORION Medical Journal. 2008; ;31:588-590
2. Maternity Guidelines Group. Birth after previous caesarean section. Womens Health
Service Christchurch WomenS Hospital. Christchurch New Zealand. 2016. p1-10
3. Lyell DJ. Adhesions and perioperative complications of repeat cesarean delivery.
American Journal of Obstetrics and Gynecology. 2011.205-211
4. Berghella V. Cesarean delivery: Postoperative issues. Available at:
http://www.uptodate.com/home.
5. JK Gupta, Smith, RR Chodankar. Birth After Previous Caesarean Birth. Green-top
Guideline No.45. Royal College of Obstetricians and Gynaecologist.2015
6. Jeanne MG, Karen E, Cathy E, Mary AD, Nicole M, Rongwei Fu, et all. Vaginal Birth
After Cesarean: New Insights. Agency for Healthcare Research and Quality U.S.
Department of Health and Human Services. 2010