post caesarian pregnancy
TRANSCRIPT
Post caesarean pregnancy
Introduction
Liberalization of primary CS
Non recurrent indications
Once a caesarean, always a
caesarean
Quite prevalent
Effects On Pregnancy And
Labor
Increases risk ofAbortion
Preterm labor
Pregnancy ailments
Operative interference
Placenta praevia
Adherent placenta
Post partum hemorrhage
Peripartum hysterectomy
Effects On The Scar
Increased risk of scar rupture
More risk in classical/ hysterotomy scar than lower segment scar
Lower segment scar rupture during labor
Classical/ hysterotomy scar ruptures during late pregnancy and labor
Impairment of healing can cause early scar rupture
Lower SEGMENT VS CLASSICAL/
HYSTEROTOMY SCAR
Lower Segment Classical /Hysterotomy
Apposition Perfect, no pockets
of blood
Difficult to appose
State of uterus
during healing
The part of uterus
remains inert
The part contracts
and retracts
Stretching effect Along the line of
scar
At right angles to
scar
Placental
implantation
Attachment on scar
unlikely
Placenta more likely
to implant on scar
Net effect Sound scar Weak scar
Chances of rupture 0.2 - 1.5% 4 - 9%
Mortality following
rupture
Maternal and
perinatal death lessmore
INTEGRITY OF THE SCAR
CLASSICAL SCAR :
The scar is weak.
The scar is more likely to give way during pregnancy with increased risk to the mother and fetus.
These cases should be delivered by LSCS
LOWER SEGEMENT TRANSVERSE SCAR:
Usually heals better. During the course of labour the integrity of the scar need to be assessed.
High index of suspicion is essential.
Factor that are to be considered while assessing scar are:
evidences of Scar Dehiscence during labor.
PREVIOUS SCAR
Dehiscence-separation along the line of the previous scar
Rupture –when the unscarred tissue is also involved in separation
1. Elective caesarean section
2. VBAC trial of labor (trial of scar)
Management
Previous operative notes
Indication of caesarean section:
(a) Placenta praevia – (i) imperfect apposition due to quick surgery and (ii) thrombosis of the placental sinuses.
(b) Following prolonged labor-increased chance of sepsis.
Technical difficulty in the primary operation leading to tears to involve the branches of uterine vessels.
Hysterography in interconceptional period: Hysterography, 6 months after the operation, may reveal defect on the scar
Pregnancy:(1) Pregnancy occurring soon after operation
(2)Pregnancy complication (3)h/o previous vaginal delivery following LSCS(4)Placenta praevia in present pregnancy
LSCS scar Hospitalization at 38 weeks
Classical CS at 34 weeks due to possibility of
rupture of scar in pregnancy
Hospitalization
Proper case selection :- 2/3 of previous CS TOL; 2/3 of
TOL VBAC
Successful trial results in vaginal delivery of a live
fetus without scar rupture
A failed trial is said to occur when a emergency
caesarean section is required or there is scar rupture
VBAC TRIAL OF LABOUR
Previous history
1. Type of prior uterine incision LS transverse incision
2. Prior indication if recurrent, elective CS should be done
(success more when prior indication is breech/fetal
distress/placenta praevia/ abruption)
3. Prior vaginal delivery (if woman had H/O vaginal delivery
chance of VBAC increased)
4. Post-op infection can make scar weak
Selection of cases of VBAC
How many years back was the CS done ??
Min 18 months to heal the scar, so a gap of 18-24
months is necessary
1) No medical / obstetric complication
2) Average sized baby
3) Vertex presentation
4) No CPD
Present pregnancy
To assess integrity of scar if myometrial thickness > 3.5mm,
decreased risk of rupture
Helps to assess placental location
If placenta implanted over the scar high chance of adherent
placenta on USG no subplacental sonolucent zone
USG
Previous classical incision
Previous two LSCS
Pelvis contracted or suspected CPD
Previous inverted T/ extension of incision
Malpresentations
Suspicion of CPD
Medical /obstetric complication
Multiple pregnancy
Patient’s refusal to undergo trial
Contraindications
If VBAC is contraindicated / if patient refuses
Timing
• if fetal maturity is sure 39wks
• if not spontaneous labor awaited
• previous classical CS 38 wks
Elective caesarean section
Evidence of scar rupture during labor
Abnormal CTG-: late deceleration, most consistent finding
Suprapubic pain
Shoulder tip pain or chest pain or sudden onset of shortness ofbreath
Acute onset of scar tenderness
Abnormal vaginal bleeding or haematuria
Cessation of uterine contractions which were previously adequate
Maternal shock
Loss of station of presenting part
Meconium staining of amniotic fluid
PROGNOSIS
Previous history of classical LSCS or hysterotomy makes the women vulnerable for uterine rupture.
this can increase the maternal mortality to 5% and
perinatal mortality to 7.5%
1) Institutional delivery
2) Continuous CTG monitoring in labor
3) Facilities for performing an emergency CS
Labor
INVESTIGATIONS AND ASSESSMENT
Mandatory regular antenatal checkup
History of pain or tenderness over scar or any h/o
vaginal bleeding
ULTRASOUND :
1) To assess integrity of the scar.
(Myometrial thickness>3.5mm NORMAL/low risk of
uterine rupture
2) To assess placental location
(absence of sub placental zone adherent placenta)
- Doppler and MRI may be done for confirmation
ADMISSION AT
38 WEEKSADMISSION AT
36 WEEKS
ELECTIVE HOSPITALIZATION
LOWER SEGMENT
TRANSVERSE SCAR
ELECTIVE C.S.
VAGINAL DELIVERY
CLASSICAL/ HYSTERECTOM
Y SCAR
ELECTIVE C.S. AT 38
WEEKS
CASE
ASSESSMENT
FORMULATION
OF Mode OF
DELIVERY
ONSET OF LABOUR
SCAR RUPTURE
OBSTETRIC COMPLICATIONS
EMERGENCY HOSPITALIZATION
MANAGEMENT OF LABOUR & DELIVERY
Iv-Ringer solution
Blood sample – Hb%, grouping, cross matching
Spontaneous onset of labor desired
Monitoring
Epidural analgesia
Augmentation by oxytocin – selectively & judiciously
Prophylactic forceps or ventouse
Exploration of uterus.
Cut short the second stage with outlet forceps/vaccum
Look for excessive bleeding in third stage-sign of scar rupture
If bleeding is excessive- emergency laparotomy
Observe for 4-6hrs in labour ward
Delivery
BENEFITS COMPLICATIONS
Decrease in- maternal morbidity
hospital stay
need for blood transfusion
risk of abnormal placentation
need for c-section in next pregnancy
MATERNAL:
Uterine rupture
Risk of hysterectomy
Infections
Maternal morbidity
FOETAL:
Fetal distress
Low APGAR
Death
STERILISATION
• Increasing risk after each operation
• During third time CS strerilization should be
considered unless there is sufficiently strong
reason to withhold it