1. 1. INTRODUCTION Rising incidence of CS worldwide is becoming a matter of concern & more number of pregnancies following CS are seen. This problem can be tackled by judicious selection of patient for primary CS & More trial of labour for non reccuring condition i.e.planned vaginal birth after previous caesarean section (VBAC) instead of elective repeat caesarean section (ERCS).
2. 2. History of C-section in U.S. 1916: Cragin Once a cesarean, always a cesarean 1920s the technique of low-transverse uterine incision was introduced by Kerr (1921). 1970 C-section rate: 5.5% 1970s: Advent of EFM, new medico-legal pressures, increase in diagnosis of dystocia 1988 C-section rate: 24.7%
3. 3. History of VBAC 1980: NIH panel begins to encourage trial of labor (TOL) for women with h/o C-section 1981 VBAC rate: 3% American College of Obstetricians and Gynecologists (1988) recommended that most women with one previous low- transverse cesarean delivery should be counseled to attempt labor in a subsequent pregnancy 1990: US Public Health Service propose goal of C-section rate of 15% (and VBAC rate of 35%)
4. 4. Swing of the pendulum Pitkin (1991), wrote that without question, the most remarkable change in obstetric practice over the last decade was management of the woman with prior cesarean delivery. 1996-VBACS rates 28.3% & CS Rates 20%
5. 5. Paradigm shift on C-sections New evidence is emerging to indicate that VBAC may not be as safe as originally thought. These factors,together with medico-legal fears, have led to a recent decline in clinicians offering and women accepting planned VBAC in the UK and America. 2006-VBACS 8.5% & CS-31.1%
6. 6. What are the specific risks and benefits of VBAC? VBAC carries a risk of uterine rupture of 22 74/10,000. There is virtually no risk of uterine rupture in women undergoing ERCS
7. 7. planned VBAC compared with ERCS carries around 1% additional risk of either blood transfusion or endometritis Planned VBAC carries an 8/10,000 risk of the infant developing hypoxic ischaemic encephalopathy. The effect on the long-term outcome of the infant upon experiencing HIE is unknown. VBAC probably reduces the risk that their baby will have respiratory problems after birth: rates are 23% with planned VBAC and 34% with ERCS
8. 8. The following risks significantly increase with increasing number of repeated caesarean deliveries: placenta accreta. injury to bladder, bowel or ureter; ileus; the need for postoperative ventilation; intensive care unit admission; hysterectomy; blood transfusion requiring four or more units and the duration of operative time and hospital stay
9. 9. Complications in Women with a Prior Cesarean Delivery Enrolled in the NICHD Maternal-Fetal Medicine Units Network, 19992002 Trial of Elective Repeat Odds Ratio Labor Group Cesarean Group Complication n 17,898 (%) n 15,801 (%) p-value Uterine rupture 124 (0.7) 0 Uterine dehiscence 119 (0.7) 76 (0.5) .03 Hysterectomy 41 (0.2) 47 (0.3) .22 Thromboembolic disease 7 (0.04) 10 (0.1) .32 Transfusion 304 (1.7) 158 (1.0) .001 Uterine infection 517 (2.9) 285 (1.8) .001 Maternal death 3 (0.02) 7 (0.04) .21 Antepartum stillbirth 3738 weeks 18 (0.4) 8 (0.1) .008 39 weeks or more 16 (0.2) 5 (0.1) .07 Intrapartum stillbirth 3738 weeks 1 0 .43 39 weeks or more 1 0 1.00 Term HIE 12 (0.08) 0 .001 Term neonatal death 13 (0.08) 7 (0.05) .19
10. 10. FACTORS Type of Prior Uterine Incision-Estimated Rupture Rate Prior Incision (Percent) Classical 49 T-shaped 49 Low-verticala 17 Low-transverse 0.21.5 Prior uterine rupture Lower segment 6 Upper uterus 32
11. 11. Closure of Prior Incision Interdelivery Interval Number of Prior Cesarean Incisions Prior Vaginal Delivery Indication for Prior Cesarean Delivery Fetal Size Multifetal Gestation Maternal Obesity(BMI>30)
12. 12. OTHERS- POST DATED PREGNANY PREVIOUS PRETERM CS ADVANCE MATERNAL AGE POST PARTUM FEVER AFTER CS UTRINE ANOMALIES
13. 13. PATIENTS SELECTION ACOG RECOMMENDATIONS- Factors for Consideration in Selection of Candidates for Vaginal Birth after Cesarean Delivery (VBAC)- Patient consent One previous prior low-transverse cesarean delivery Clinically adequate pelvis No other uterine scars or previous rupture Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery Availability of anesthesia and personnel for emergency cesarean delivery
14. 14. Planned VBAC in special circumstances PRETERM BIRTH-preterm VBAC has similar success rates to planned term VBAC but with a lower risk of uterine rupture TWIN GESTATION, FETAL MACROSOMIA, SHORT INTERDELIVERY INTERVAL A cautious approach is advised when considering planned VBAC in women with twin gestation, fetal macrosomia and short interdelivery interval, as there is uncertainty in the safety and efficacy of planned VBAC in such situations
15. 15. External Cephalic Version Limited data suggest that external cephalic version for breech presentation may be as successful in women with a prior cesarean delivery who are contemplating a trial of labor (American College of Obstetricians and Gynecologists, 2004).
16. 16. Contraindication to VBAC Prior classic,T shaped incision or other trans mural uterine surgery. Contracted pelvis. Medical/obstetric complication that preclude vaginal delivery. Previous rupture or scar dehiscence Previous two LSCS Lack of resource to perfom emergency CS round the clock.
17. 17. How should women be counselled in the antenatal period? Women with a prior history of one uncomplicated lower-segment transverse caesarean section, in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative of a repeat caesarean section (ERCS). The antenatal counselling of women with a prior caesarean birth should be documented in the notes. There should be provision of a patient information leaflet with the consultation.
18. 18. A final decision for mode of birth should be agreed between the woman and her obstetrician before the expected/planned delivery date (ideally by 36 weeks of gestation). A plan for the event of labour starting prior to the scheduled date should be documented. Women considering their options for birth after a single previous caesarean should be informed that, overall, the chances of successful planned VBAC are 7276%.
19. 19. Ante natal care Apart from routine blood & urine investigation. USG to rule out GCA(level II) at 16-18 wk. USG for placental localisation,rule out adherent placenta,scar thickness in third trimester.
20. 20. Intrapartum support and intervention during planned VBAC Where and how should VBAC be conducted? Women should be advised that planned VBAC should be conducted in a suitably staffed and equipped delivery suite, with continuous intrapartum care and monitoring and available resources for immediate caesarean section and advanced neonatal resuscitation.
21. 21. Ideally spontaneous onset of labour is awaited. Establish IV line. Arrange X matched blood. Maternal vital monitoring. CTG Partogram
22. 22. Epidural anaesthesia is not contraindicated in planned VBAC. Continuous intrapartum care is necessary to enable prompt identification and management of uterine scar rupture Outlet forcep/vaccum can be used if second stage >1hr.
23. 23. No routine digital exploration of scar. Observatin for at least 4 hr after delivery. Emergency caesarean section is required in 30-40% of patient.
24. 24. Women should be advised to have continuous electronic fetal monitoring following the onset of uterine contractions for the duration of planned VBAC.
25. 25. Features of impending scar rupture/dehiscence severe abdominal pain, especially if persisting between contractions chest pain or shoulder tip pain, sudden onset of shortness of breath acute onset scar tenderness abnormal vaginal bleeding or haematuria maternal tachycardia Abnormal CTG Meconium staining of liquor.
26. 26. FEATURES OF SCAR RUPTURE Pain abdomen, shoulder pain Dizziness/weaness maternal tachycardia, hypotension or shock Tenderness over whole abdomen. Distension of abdomen Uterine contour not well made out. cessation of previously efficient uterine activity Fetal parts superficially palpated Recession of station of the presenting part
27. 27. Uterine rupture require urgent laparotomy followed by repair or hysterectomy.
28. 28. The risks versus benefits, along with the pros and cons of a woman electing a trial of labor for VBAC versus elective repeat cesarean delivery, can be complex. The best answer for a given woman with a prior cesarean delivery is unknown. Thus,she and her partner are encouraged to actively participate with her healthcare provider in the final decision after appropriate counseling.
29. 29. Pending relevant trials BAC (Birth After Caesarean) planned vaginal birth or planned caesarean section for women at term with a single previous caesarean birth. University of Adelaide, Australia. The Twin Birth Study a multicentre randomised controlled trial comparing planned caesarean section with planned vaginal birth for twins at 3238wk DiAMOND (Decision Aids for Mode Of Next Delivery). , Bristol, UK. CAESAR (Caesarean Section Surgical Techniques). National Perinatal Epidemiology Unit, Oxford, UK.