Objective
We sought to assess whether the presence and severity of adhesions at first repeat cesarean delivery are associated with delayed delivery of the newborn.
Study Design
We conducted secondary analysis of a prospective cohort of women undergoing first repeat cesarean. Severity and location of adhesions were reported by surgeons immediately postoperatively. We compared adhesion density scores with delivery data.
Results
Of 145 women analyzed, 92 (63.5%) had adhesions and 53 (36.5%) did not. Mean incision to delivery time in women with adhesion scores >3 was 19.8 minutes, compared to 15.6 minutes with scores ≤3 ( P = .04). More women with adhesion scores >3 remained undelivered at 30 minutes after incision compared to scores ≤3 (17.9% vs 5.1%; odds ratio, 7.6; 95% confidence interval, 1.6–34.5), after controlling for potential confounders.
Conclusion
Among women undergoing first repeat cesarean, severity of adhesions may delay delivery of the newborn. Study of techniques to reduce adhesions may be warranted to prevent delayed delivery at repeat cesarean.
Cesarean delivery rates approach 33% in the United States, and approximately 90% of women with a prior cesarean choose repeat cesarean delivery in their next pregnancy. Subsequent delivery after prior cesarean is associated with risk of several well-described adverse outcomes for women and neonates. Such long- and short-term maternal risks include bleeding, infection, hysterectomy, subsequent abnormal placentation, and mortality; risks to offspring include neurodevelopmental injury, short- and long-term respiratory morbidity, and mortality.
Some of these adverse outcomes have well-defined risk factors related to aspects of the prior cesarean delivery, such as the impact of prior single-layer hysterotomy closure on rate of subsequent uterine rupture, and impact of number of prior cesarean deliveries on rate of subsequent abnormal placentation. One operative aspect that has unclear impact on risks after prior cesarean is presence and severity of adhesions encountered at the time of repeat cesarean delivery. Prior retrospective work has suggested delayed delivery of the newborn associated with adhesions encountered at first or multiple repeat cesarean.
Our aim, therefore, was to investigate the impact of presence and severity of adhesions on delivery of the newborn in a prospective cohort of women undergoing first repeat cesarean.
Materials and Methods
We analyzed a dataset from a previously reported prospective cohort study, which enrolled women undergoing first repeat cesarean delivery at Lucile Packard Children’s Hospital at Stanford from 1996 through 2003. This data set was generated when surgeons scored the severity and location of adhesions immediately after performing the first repeat cesarean delivery. Surgeons were asked to categorize adhesions as none, filmy, or dense, and to identify their presence among specified locations (fascia to uterus, omentum to uterus, omentum to fascia, bowel, and other). The surgeons were blinded to the purpose of the adhesion score sheet. We have previously reported the interrater reliability of this score sheet to be 0.84.
We then generated weighted scores for each patient based on the presence and type of adhesions at each site: 0 (no adhesions), 1 (filmy), or 3 (dense). These weighted adhesion scores were then summed to arrive at a total adhesion score for each patient.
For the current study, we excluded women from the original study if, on review of the medical record, they were found at the primary cesarean to have had adhesions, the use of a permanent suture, or additional surgical procedures; if they had postoperative wound infection or breakdown following the first cesarean; if the first operative note was unavailable; or if they underwent abdominal surgery between cesareans. We also excluded women with insulin-dependent diabetes mellitus or chronic steroid use. The original dataset included detailed information from the first and second cesarean deliveries, and labor and postoperative courses. All surgeries were performed by a resident who was supervised directly by an attending physician. The method of surgical closure and suture material used were per the preference of the attending physician. For the current study, we reviewed patient records from the first repeat cesarean delivery to identify incision to delivery times. Skin incision time and time of delivery are both routinely recorded at our institution by anesthesia staff. Incision to delivery times were abstracted in a standardized fashion from the anesthesia record at first repeat cesarean delivery. Participants were included in the current study if incision to delivery times for the repeat cesarean were available.
The primary outcome measure was the time from incision to delivery during the first repeat cesarean delivery. We used software (STATA, version 7; StataCorp, College Station, TX) for all analyses. An alpha of <0.05 was considered significant. We performed multivariable logistic regression analyses to control for potential confounding variables, including maternal age >35 years, maternal diabetes mellitus, public insurance, and indication for repeat cesarean delivery. The institutional review board at Stanford University Medical Center approved this study.
Results
A total of 145 women met study criteria and were analyzed. Adhesions were identified in 92 patients (63.5%) undergoing first repeat cesarean delivery. Demographic characteristics, prior surgical characteristics, and indications for repeat cesarean did not differ by adhesion status ( Table 1 ). Of those with adhesions, 31 (33.7%) had filmy adhesions only and 61 (66.3%) had at least 1 dense adhesion. In the 92 women with adhesions, there were 140 total adhesions reported at a variety of 10 sites ( Table 2 ). The most common adhesion locations reported were fascia to uterus, omentum to fascia, and omentum to uterus ( Table 2 ). Both dense and filmy adhesions were equally reported at most adhesion locations, except for fascia to uterus which accounted for significantly denser adhesions, and bladder to uterus which accounted for more filmy adhesions ( Table 2 ).
