Cesarean section (CS) is surgery with vast tissue damage associated with complications in the intraoperative and postpartum periods. The problem of a uterine scar (US) after the CS in the anamnesis significantly complicates the choice of the tactics of subsequent labor management [1]. Abdominal delivery has to be performed only for strict indications [2][3][4]. An increase in the rate of abdominal deliveries is associated with such reasons as an increase in the average age of primapara women and pregnant women with extragenital and genital diseases, expansion of indications “for the safety of the fetus”, and growth of the number of pregnant women after assisted reproductive technology. However, lately, the leading position in the indications for abdominal delivery has been occupied by a US [5]. Moreover, there is a tendency to an increase in the rate of pregnant women with two and more USs. In the modern literature, there is no unified opinion on the tactics of pregnancy management and the method of delivery in women with two and more USs. It is explained by the fact that there is no research on the risk of maternal and perinatal morbidity and mortality depending on the number of USs and the method of delivery [6][7]. The search for the “golden mean” in the management of women with USs continues. The risks of the development of complications in a woman and a child during vaginal delivery are evident, and abdominal delivery is a life-saving surgery in case of these complications.

The study aimed to analyze the sources of surgical delivery in pregnant with two and more USs after the Caesarean section.

A retrospective study was performed at the facilities of the Krasnoyarsk Regional Clinical Center for Maternal and Child Health (KRCCMCH). The study included pregnant women after abdominal delivery with two and more USs for 2020. The authors analyzed birth histories and histories of newborns. Inclusion criteria: single pregnancy of 22 weeks or more, the presence of two or more USs after CS. Exclusion criteria: pregnancy less than 22 weeks, one US, USs after other operations, and multifetal pregnancy. The statistical calculations were made in Excel tables with the calculation of Student’s t-test, the criterion of significance was p.

A total of 3071 deliveries were registered in KRCCMCH in 2020; of them, 1875 were abdominal. There were 146 pregnant women with two USs after CS and 30 pregnant women with three and more USs. The group of comparison included 43 patients with one US.

Pregnant women from the group with one and two USs had planned delivery in 58.14% and 60.96%, respectively. In the group of women with three and more USs, planned abdominal delivery was performed in 43.33% and emergency delivery – in 56.67% (Table 1). The main indications to urgent delivery included the threat of US rupture (70.59%), beginning of labor (29.41%), acute fetal hypoxia (5.88%), and placental presentation hemorrhage (11.76%).

As a rule, repeated abdominal surgical interventions are associated with an increase in surgery time, which is relevant for CS. Surgery time 31–50 minutes was registered in 62.95% of women with two USs, 50% in the group of women with three and more USs, and 62.78% in the control group. Surgery time 51–60 minutes was observed in 18.49% of women with two USs, 10% – in women with three and more USs, and in 23.25% of women in the control group. The longest surgery time was registered in 23.33% of women with three and more USs (81 minutes and more). The mean time of CS surgery was 66.9 minutes, which significantly exceeded the generally accepted average values (Table 2).

The formation of connective tissue adhesions between the internal organs and the peritoneum is provoked by preceding surgical manipulations. In the studied groups, III and IV degree adhesive processes were observed in the group of women with three and more USs – in 16.67% and 10% of cases, while in the group of women with two USs, in 8.22% and 5.48%; and in the control group, in 6.98% and 2.33% of cases, respectively (Table 3).

Because of an expressed adhesive process and changes in the topography of the uterus and small pelvic organs, the lower uterine segment can be hard to reach during a repeated abdominal delivery. This leads to an elongation of surgery time from the beginning of the operation to the removal of the fetus. The time to the removal of the fetus 5 minutes after the start of surgery was observed in 54.34% of cases in women with three and more USs; in 45.89% of women with two USs; and in 13.95% of women with one US (Table 4).

The study results showed that women with repeated CS more often delivered children with moderate and severe asphyxia. Women with two and three USs delivered children with asphyxia more often in comparison with a group of women with one US. The evaluation of neonates by the Apgar scale in the 1st minute after the birth showed that 16.65% of children with moderate and severe asphyxia were born in women with three and more USs. In women with two and one US, this parameter was 4.65% and 3.42%, respectively (Table 5).

Cicatricial adhesive process in the organs of the small pelvis and abdominal cavity that develops after an abdominal delivery can significantly complicate the access to the abdominal cavity and cause organs damage, primarily, the bladder or the intestine. Bladder injury and ureter transection were met more often in women with three and more USs (2.17%). In women with two USs, this complication was observed in 0.63% of cases.

Massive intraoperative blood loss (> 2000 ml) was observed in 16.67% of women with three and more USs, and in 2.73% of women with two USs. In the control group, it was not registered (Table 6). Such additional methods of hemostasis as separate hemostatic sutures on the lower uterine segment and placental site, hemostatic B-Lynch sutures on the uterus, ligation of the uterine arteries, etc. were required in 46.67% of women with three and more USs; in 4.4% and 2.08% of women with two and one US, respectively. Hemotransfusion during the surgery was not used in the groups of women with two and one US. In the group of women with three and more USs, 10% of cases required the transfusion of fresh frozen plasma and erythrocyte suspension, and 20% of cases required autohemotransfusion with a SellSaver apparatus.

Recent research showed that CS in women with USs was associated with an increased risk of intra and postoperative complications in comparison with women with one US. Still, there are no precise data on the degree of risk depending on the number of US. Most frequently, such complications as massive intraoperative blood loss and technical complications when entering the abdominal cavity and removal of the child are observed. They are associated with severe adhesive processes and the formation of uterine aneurism. Tight attachment or adhesion of the placenta to the scar and underlying tissue can damage nearby organs, for example, the bladder, ureter, or intestine [1][2][3][7][8].

The results of the present study showed that in women with three and more USs, urgent indications for abdominal delivery prevailed over planned delivery in 56.67% and 43.33% of cases, respectively. In the group of women with two USs, the situation was opposite: urgent deliveries were registered in 39.04% of cases and planned – in 60.96% of cases. The expression of the adhesive process is associated with technical complications during the removal of a child. The adhesive process was more often observed in women with three and more USs (46.67%). In women with two USs, it was revealed in 20.55%, and in women with one US, in 18.61%. This provided a higher rate of moderate and severe asphyxia in neonates in the group of women with three and more USs (16.65%). In the groups of women with two and one US, this parameter was 4.65% and 3.42%, respectively. The time of surgery also increases. In the group of women with three and more USs, the mean time of surgery was 66.9 minutes. An intraoperative increase in blood loss was observed. Thus, in the group of women with three and more USs, the blood loss was more than 2000 ml in 16.67% of cases. It was observed in 2.73% of cases in women with two USs. In the control group, there were no hemorrhages in women. Additional methods of hemostasis were required in 46.67% of women with three and more USs and in 4.4% of women with two USs. Hemotransfusion and autohemotransfusion were used only in 10% and 20% of women with three and more USs, respectively.