Post LSCS PregnancyPost LSCS PregnancyManagement protocolsManagement protocols

Dr. Geetha Balsarkar,Dr. Geetha Balsarkar,Associate Professor and Unit incharge,Associate Professor and Unit incharge,Nowrosjee Wadia Maternity Hospital,Nowrosjee Wadia Maternity Hospital,

Seth G.S. Medical college, Parel , MumbaiSeth G.S. Medical college, Parel , MumbaiJoint Asst. Secretary to the Editor,Joint Asst. Secretary to the Editor,

Journal of Obstetrics and Gynecology of India,Journal of Obstetrics and Gynecology of India,Secretary, AMWI, Mumbai branchSecretary, AMWI, Mumbai branch

Plan of DiscussionPlan of Discussion

Comparison of Trial of labour vs Planned Repeat Comparison of Trial of labour vs Planned Repeat CaesareanCaesarean

Selection of patients for VBACSelection of patients for VBAC

Management of patients undergoing VBACManagement of patients undergoing VBAC

Check list for patients planned for Trial of labourCheck list for patients planned for Trial of labour

Delivery OutcomesDelivery Outcomes Planned repeat caesarean delivery (PRCD)Planned repeat caesarean delivery (PRCD)

- Maternal morbidity – 3.6%- Maternal morbidity – 3.6%

Trial of labour after caesareanTrial of labour after caesarean Emergency repeat caesarean delivery (ERCD)Emergency repeat caesarean delivery (ERCD)

- Maternal morbidity – 14.1%- Maternal morbidity – 14.1%

Vaginal birth after caesarean (VBAC)Vaginal birth after caesarean (VBAC)- Maternal morbidity – 2.4%- Maternal morbidity – 2.4%

Maternal Consequences of PRCDMaternal Consequences of PRCD Anesthesia risks – high spinal, Mendelson’s Anesthesia risks – high spinal, Mendelson’s

syndrome, gastro intestinal symptomssyndrome, gastro intestinal symptoms ↑ ↑ risk of short term maternal morbidity – risk of short term maternal morbidity –

increased bleeding, wound healingincreased bleeding, wound healing Placenta praevia in future pregnanciesPlacenta praevia in future pregnancies Morbid adhesions of placenta in future Morbid adhesions of placenta in future

pregnanciespregnancies

Advantages of VBAC over PRCDAdvantages of VBAC over PRCD

↓ ↓ febrile morbidity (OR 0.7)febrile morbidity (OR 0.7)

↓ ↓ blood transfusion (OR 0.6)blood transfusion (OR 0.6)

↓ ↓ rates of Hysterectomy (OR 0.4)rates of Hysterectomy (OR 0.4)

↓ ↓ venous thrombo- embolism (OR 0.4)venous thrombo- embolism (OR 0.4)

Neonatal Risks of PRCDNeonatal Risks of PRCD Neonatal respiratory morbidityNeonatal respiratory morbidity ↑ ↑ admission to NICU (7% vs 4.6% for admission to NICU (7% vs 4.6% for

attempted VBAC)*attempted VBAC)* * ‘Healthy cohort selection bias’* ‘Healthy cohort selection bias’

Neonatal / Fetal advantages of PRCD

↓ ↓ incidence of neonatal trauma, intra-incidence of neonatal trauma, intra-cranial haemorrhage & Hypoxic ischaemic cranial haemorrhage & Hypoxic ischaemic encephalopathy (vs attempted VBAC)encephalopathy (vs attempted VBAC)

↓ ↓ incidence of unexplained antepartum incidence of unexplained antepartum stillbirthstillbirth

Maternal Risks of VBACMaternal Risks of VBAC Perineal / Vaginal lacerationsPerineal / Vaginal lacerations Emergency caesarean deliveryEmergency caesarean delivery Uterine rupture Uterine rupture

PRCD 1.6 / 1000 PRCD 1.6 / 1000 Spontaneous labour 5.2 / 1000 Spontaneous labour 5.2 / 1000 Induction with oxytocin 7.7 / 1000Induction with oxytocin 7.7 / 1000 Induction with prostaglandins 24.5 / 1000Induction with prostaglandins 24.5 / 1000

Long Term Maternal Consequences of VBAC

Urinary incontinence (prevalence 21% vs 15.9% Urinary incontinence (prevalence 21% vs 15.9% for PRCD)for PRCD)

Uterovaginal prolapseUterovaginal prolapse

Fetal / Neonatal Risks of VBACFetal / Neonatal Risks of VBAC

Fetal death following uterine ruptureFetal death following uterine rupture

Neonatal sepsis following failed VBACNeonatal sepsis following failed VBAC

↑ ↑ incidence of perinatal death (OR 1.7) (Absolute risk incidence of perinatal death (OR 1.7) (Absolute risk 0.6%)0.6%)

Women with a previous caesarean have a two to three Women with a previous caesarean have a two to three fold ↑ incidence of unexplained stillbirth after 39 fold ↑ incidence of unexplained stillbirth after 39 weeks gestation (Absolute risk 0.1%)weeks gestation (Absolute risk 0.1%)

Risks of Failed VBACRisks of Failed VBAC Intra-operative injury during emergency LSCS Intra-operative injury during emergency LSCS

(1.3% vs 0.6% for PRCD)(1.3% vs 0.6% for PRCD)

Non significant trend towards increased Non significant trend towards increased maternal mortalitymaternal mortality

Prediction of SuccessPrediction of Success Maternal ageMaternal age Maternal obesityMaternal obesity Indication of previous CSIndication of previous CS Previous vaginal deliveryPrevious vaginal delivery Gestational diabetesGestational diabetes Birth weight Birth weight Spontaneous or induced labourSpontaneous or induced labour Progress in early labourProgress in early labour

Prediction of rupturePrediction of rupture Previous non lower segment incisionPrevious non lower segment incision Number of previous caesareans (2 – 3 fold increase in women with Number of previous caesareans (2 – 3 fold increase in women with

two previous caesareans as compared to only one previous two previous caesareans as compared to only one previous caesarean)caesarean)

Previous rupturePrevious rupture No previous vaginal birthNo previous vaginal birth Single layer closure (4 fold increase)Single layer closure (4 fold increase) Interval between previous caesarean and next pregnancy (3 fold Interval between previous caesarean and next pregnancy (3 fold

increase with interdelivery interval < 18 months)increase with interdelivery interval < 18 months) Use of prostaglandins (RR 4.7)Use of prostaglandins (RR 4.7)

Influence of Patient intentionsInfluence of Patient intentions

Patient willingness to undergo VBAC Patient willingness to undergo VBAC (Informed consent)(Informed consent)

Future reproductive intentionsFuture reproductive intentions

Prerequisites to Attempting VBACPrerequisites to Attempting VBAC

Obstetrician available continuously to monitor labourObstetrician available continuously to monitor labour

Availability of emergency anaesthesia, neonatal and Availability of emergency anaesthesia, neonatal and blood banking servicesblood banking services

Availability of continuous electronic fetal monitoringAvailability of continuous electronic fetal monitoring

Institutional capability of decision to incision interval Institutional capability of decision to incision interval of < 30 minutes for performing emergency surgeryof < 30 minutes for performing emergency surgery

Management During Attempted VBACManagement During Attempted VBAC Absolute risk of uterine rupture – 1:100 to 1:200Absolute risk of uterine rupture – 1:100 to 1:200 Continuous electronic fetal monitoringContinuous electronic fetal monitoring Epidural analgesia is not contraindicatedEpidural analgesia is not contraindicated Use of Intra-uterine pressure catheters is not necessaryUse of Intra-uterine pressure catheters is not necessary Partogram to assess progressPartogram to assess progress Oxytocin for augmentation to be used with caution and only for Oxytocin for augmentation to be used with caution and only for

inadequate uterine activityinadequate uterine activity Second stage to be shortenedSecond stage to be shortened Exploration of the uterine scar after delivery not necessaryExploration of the uterine scar after delivery not necessary

CHECK LIST FOR SELECTING CHECK LIST FOR SELECTING VBACVBAC

Are there any contraindications to VBAC ?Are there any contraindications to VBAC ? Number of previous lower segment caesareansNumber of previous lower segment caesareans J shaped / Inverted T scar on uterusJ shaped / Inverted T scar on uterus A scar other than on the lower uterine segmentA scar other than on the lower uterine segment Past H/O uterine rupture / dehiscence of scarPast H/O uterine rupture / dehiscence of scar Presence of an obstetric indication for LSCSPresence of an obstetric indication for LSCS Doubtful adequacy of the pelvis / suspicion of feto-pelvic disproportionDoubtful adequacy of the pelvis / suspicion of feto-pelvic disproportion Institutional policy on induction of labor in a scarred uterus Institutional policy on induction of labor in a scarred uterus Lack of capability to provide continuous supervision during trial of labourLack of capability to provide continuous supervision during trial of labour Lack of institutional capability to undertake expeditious operative deliveryLack of institutional capability to undertake expeditious operative delivery

Assessment of prognostic factors for a Assessment of prognostic factors for a successful VBAC successful VBAC

Indication of previous caesareans (Dystocia / Non dystocia)Indication of previous caesareans (Dystocia / Non dystocia) Past H/O vaginal birthPast H/O vaginal birth Maternal ageMaternal age Maternal obesityMaternal obesity Post datismPost datism Station and attitude of vertexStation and attitude of vertex Favourability of cervixFavourability of cervix Spontaneous or induced labourSpontaneous or induced labour

Assessment of Prognostic Factors for Uterine Assessment of Prognostic Factors for Uterine Rupture During Trial of Labour Rupture During Trial of Labour

Unknown uterine scarUnknown uterine scar Uterine closure during previous caesarean (Single / Double Uterine closure during previous caesarean (Single / Double

layer closure)layer closure) Post operative recovery following previous caesareanPost operative recovery following previous caesarean Inter delivery intervalInter delivery interval Fetal macrosomiaFetal macrosomia Thickness of the lower uterine segment (if possible to assess)Thickness of the lower uterine segment (if possible to assess) Spontaneous or induced labourSpontaneous or induced labour Delay in progress of labourDelay in progress of labour Augmentation of labourAugmentation of labour

Patients intentionPatients intention

Informed consent

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