Post LSCS Pregnancy Management protocols

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Post LSCS Pregnancy Management protocols. Dr. Geetha Balsarkar, Associate Professor and Unit incharge, Nowrosjee Wadia Maternity Hospital, Seth G.S. Medical college, Parel , Mumbai Joint Asst. Secretary to the Editor, Journal of Obstetrics and Gynecology of India, - PowerPoint PPT Presentation

Text of Post LSCS Pregnancy Management protocols

  • Post LSCS PregnancyManagement protocols

  • Dr. Geetha Balsarkar,Associate Professor and Unit incharge,Nowrosjee Wadia Maternity Hospital,Seth G.S. Medical college, Parel , MumbaiJoint Asst. Secretary to the Editor,Journal of Obstetrics and Gynecology of India,Secretary, AMWI, Mumbai branch

  • Plan of DiscussionComparison of Trial of labour vs Planned Repeat CaesareanSelection of patients for VBACManagement of patients undergoing VBACCheck list for patients planned for Trial of labour

  • Delivery OutcomesPlanned repeat caesarean delivery (PRCD)- Maternal morbidity 3.6%Trial of labour after caesarean Emergency repeat caesarean delivery (ERCD)- Maternal morbidity 14.1%Vaginal birth after caesarean (VBAC)- Maternal morbidity 2.4%

  • Maternal Consequences of PRCDAnesthesia risks high spinal, Mendelsons syndrome, gastro intestinal symptoms risk of short term maternal morbidity increased bleeding, wound healingPlacenta praevia in future pregnanciesMorbid adhesions of placenta in future pregnancies

  • Advantages of VBAC over PRCD febrile morbidity (OR 0.7) blood transfusion (OR 0.6) rates of Hysterectomy (OR 0.4) venous thrombo- embolism (OR 0.4)

  • Neonatal Risks of PRCDNeonatal respiratory morbidity admission to NICU (7% vs 4.6% for attempted VBAC)* * Healthy cohort selection bias

  • Neonatal / Fetal advantages of PRCD incidence of neonatal trauma, intra-cranial haemorrhage & Hypoxic ischaemic encephalopathy (vs attempted VBAC) incidence of unexplained antepartum stillbirth

  • Maternal Risks of VBACPerineal / Vaginal lacerationsEmergency caesarean deliveryUterine rupture PRCD 1.6 / 1000 Spontaneous labour 5.2 / 1000 Induction with oxytocin 7.7 / 1000Induction with prostaglandins 24.5 / 1000

  • Long Term Maternal Consequences of VBACUrinary incontinence (prevalence 21% vs 15.9% for PRCD)Uterovaginal prolapse

  • Fetal / Neonatal Risks of VBACFetal death following uterine ruptureNeonatal sepsis following failed VBAC incidence of perinatal death (OR 1.7) (Absolute risk 0.6%)Women with a previous caesarean have a two to three fold incidence of unexplained stillbirth after 39 weeks gestation (Absolute risk 0.1%)

  • Risks of Failed VBACIntra-operative injury during emergency LSCS (1.3% vs 0.6% for PRCD)Non significant trend towards increased maternal mortality

  • Prediction of SuccessMaternal ageMaternal obesityIndication of previous CSPrevious vaginal deliveryGestational diabetesBirth weight Spontaneous or induced labourProgress in early labour

  • Prediction of rupturePrevious non lower segment incisionNumber of previous caesareans (2 3 fold increase in women with two previous caesareans as compared to only one previous caesarean)Previous ruptureNo previous vaginal birthSingle layer closure (4 fold increase)Interval between previous caesarean and next pregnancy (3 fold increase with interdelivery interval < 18 months)Use of prostaglandins (RR 4.7)

  • Influence of Patient intentionsPatient willingness to undergo VBAC (Informed consent)Future reproductive intentions

  • Prerequisites to Attempting VBACObstetrician available continuously to monitor labourAvailability of emergency anaesthesia, neonatal and blood banking servicesAvailability of continuous electronic fetal monitoringInstitutional capability of decision to incision interval of < 30 minutes for performing emergency surgery

  • Management During Attempted VBACAbsolute risk of uterine rupture 1:100 to 1:200Continuous electronic fetal monitoringEpidural analgesia is not contraindicatedUse of Intra-uterine pressure catheters is not necessaryPartogram to assess progressOxytocin for augmentation to be used with caution and only for inadequate uterine activitySecond stage to be shortenedExploration of the uterine scar after delivery not necessary

  • CHECK LIST FOR SELECTING VBAC

  • Are there any contraindications to VBAC ?Number of previous lower segment caesareansJ shaped / Inverted T scar on uterusA scar other than on the lower uterine segmentPast H/O uterine rupture / dehiscence of scarPresence of an obstetric indication for LSCSDoubtful adequacy of the pelvis / suspicion of feto-pelvic disproportionInstitutional policy on induction of labor in a scarred uterus Lack of capability to provide continuous supervision during trial of labourLack of institutional capability to undertake expeditious operative delivery

  • Assessment of prognostic factors for a successful VBAC Indication of previous caesareans (Dystocia / Non dystocia)Past H/O vaginal birthMaternal ageMaternal obesityPost datismStation and attitude of vertexFavourability of cervixSpontaneous or induced labour

  • Assessment of Prognostic Factors for Uterine Rupture During Trial of Labour Unknown uterine scarUterine closure during previous caesarean (Single / Double layer closure)Post operative recovery following previous caesareanInter delivery intervalFetal macrosomiaThickness of the lower uterine segment (if possible to assess)Spontaneous or induced labourDelay in progress of labourAugmentation of labour

  • Patients intentionInformed consent

  • Thank you

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