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Prior classical cesarean delivery - Counseling and Management

The risk of uterine rupture in women with prior classical cesarean delivery is about 2% (95% confidence intervals 0.2 to 6.5%). These women should have scheduled repeat cesarean delivery at 36-37 weeks, without the need for amniocentesis.
Diagnosis/definition: Classical cesarean is a midline uterine incision in the contractile portion of the uterus.
Epidemiology/Incidence: Classical cesarean is done in approximately 0.3% of all deliveries (Table 1).
Risk factors/associations: Malpresentations, anterior placenta previa, inability to access lower uterine segment, myoma, adhesions and obesity
Complications: The increased likelihood of maternal complications like postoperative fever, infection and need for transfusion may be due to the underlying cause of classical cesarean delivery rather than midline uterine incision (Table 3). Compared to low transverse cesarean, uterine rupture in subsequent pregnancies is more likely with classical (Table 4).
Prevention: Not reported

  • Preconception counseling: Inform women about the need for repeat cesarean at 36-37 wks and to obtain the operative note from classical cesarean
  • Screening/Work-up: Obtain the record from the classical cesarean to confirm the uterine incision.
  • Prenatal care: Early ultrasound to confirm gestational age. If the operating report can be obtained, and there is strong clinical suspicion of classical cesarean (e.g. preterm breech delivery) then trial of labor in not recommended.
  • Antepartum testing: None needed for history of classical cesarean alone
  • Delivery: If the pregnancy is uncomplicated, deliver at 36-37 wks, without an amniocentesis; if complicated than repeat cesarean delivery for obstetric indications    

Post-partum/breastfeeding: Routine

Last Reaffirmed: Aug 1, 2014