Managing Women With Previous CS2

7/31/2019 Managing Women With Previous CS2

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Managing women

with previous CSVBAC :Should you or should

you not attempt?drzainalabidinhanafiah


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introduction

Widespread public and professionalconcern about increase rate of CS(more morbidity/mortality than VD)

CS rate women with previousscar > high risk gp of women.

Choice of delivery mode appear

simple but actually it is a complexdecision since available evidence canbe confusing.

Central issue of VBAC is UTERINE


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Some definitions

Planned VBAC: refers to any woman whohas prior CS who plans to deliver vaginallyrather than elective repeat CS (ERCS).

Successful VBAC: vaginal delivery afterplanned VBAC

Failed VBAC: delivery by emergency CSduring labour.

Uterine rupture: disruption of uterinemuscle extending to and involving serosa

Uterine dehiscence: disruption of uterine

muscle with intact serosa.


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Plan of care for singletonuncomplicated previous LSCS


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Items to be discussed to determinemode of delivery.

Items Special considerations

Patient understanding ofmaternal/perinatal risk & benefits ofVBAC compared to ERCS

Her attitude towards the risk of rarebut serious adverse outcomes

Any contraindication to VBACPlacenta previa, malpresentation, obstructingfibroids, medical disorders, assessment ofprevious CS; any complications, classical CS,2 CS, previous uterine rupture would beabsolute contraindication.

Likelihood of successful VBAC With previous VD or successful

VBAC

Her plan for future pregnancy

Her personal preference andmotivation to achieve VD or ERCS


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Risks and benefits of opting for VBAC or ERCSPlanned VBAC ERCS at 39 weeks

Motherbenefits: about 70% chances of success Able to plan delivery date

If successful, shorter hospital stay and convalescence Lower risk of transfusion & endometritis compared to

women undergone emergency CS due to failed VBACIncrease chances of future pregnancies may bedelivered vaginally

Almost zero risk of scar rupture

No risk of vaginal tear, weak pelvic floor andincontinence

Can undergo tubal ligation at same sitting.

Mother risks: about 0.5% risk of scar rupture assoc with maternal& fetal morbidity/mortality

0.1-2% risk of surgical complication such as injury tobladder

Up to 30% of emergency CS Long stay and convalescence

10-15% chance instrumental delivery/perineal tear Future pregnancies require CS

Higher risk of transfusion and endometritis Increase risk of surgical complication with subsequentCS

Infant benefits: low risk of TTN Avoid stillbirth if delivery is undertaken at 39 weeks

Low risk of delivery related perinatal death or HIE atdelivery

Infant risks: slightly high risk of stillbirth beyond39weeks while waiting for spontaneous birth

1-3% risk TTN (6% if deliver by 38 instead of 39 weeks)

Small but higher risk of delivery related perinatal death

Small but higher risk of HIE during labour.


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Contraindication to VBAC

Previous uterine incision: previousrupture, previous classical incision(2-9% risk), 2 or more LSCS. Previous

inverted T or J incision. ?previousmyomectomy.

Other factors: placenta previa (need

to exclude accreta, increta orpercreta), any medical/obst conditionprecluding VD, patient refusal, nofacilities for em CS,


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Likelihood of successful VBAC

Successful: previous VD, previous VBAC(assoc with 80% success), previous CSfor malpresentation, multiple pregnancy.

Unsuccessful: induced labour, noprevious VD, BMI >30, previous CS forobstructed labour, VBAC after 41 weeks,

macrosomia, no epidural, previouspreterm delivery, cervical dilatation


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Intrapartum care duringplanned VBAC

Reconfirm what has been counseled

during antenatal that the womanunderstand and consent to the risks.

Document in BHT as part of informed

consent.


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1. Delivery setting

Adequately staffed and equippeddelivery suite.

With facilities for continuousintrapartum care and monitoring.

Availability for immediate CS and

neonatal intensive care.


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2. Is epidural allowed?

Concerns of epidural might masksigns and Sx of uterine rupture.

Comparable rate of successful VBAC.

Women requesting epidural shouldbe informed about risk of longersecond stage and higher chance ofinstrumental delivery


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3. Monitoring in labour

As for all high risk cases, continuousmonitoring is necessary, preferableone to one care, regular cervix

assessment (no less than 4hrly) Extra vigilance for clinical features of

scar rupture, abnormal CTG, sudden severe abdpain, acute onset of abd tenderness, vaginal bleeding,

haematuria, sudden reduce in uterine activity, maternaltachy, low BP, sudden loss of station of presenting part.

Early diagnosis is essential to reduceassoc morbidity/mortality


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Is induction oraugmentation ok?

Not absolute but must be cautionedsince risks are higher.

Decision must be made at consultant

level, careful assessment forindication, to involve the patient indecision making.

PGs >non PGs, restrict dose, not toexceed recommended limit. Nomisoprostol. Non PGs may be tried

e.g foley catheter


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Induction and augmentation

Induced Augment Spont overall

Uterinerupture

102:10000 (1%) 87:10000(0.9%)

36:10000(0.4%)

69:10000(0.7%)

PGs 140:10000 (1.4%)*

Non PGs 89: 10000 (0.9%)

CS 33% 26% 19% 27%


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Augmentation and slow labour

Should be started following careful assessment,maternal counseling, consultant-led.

Oxytocin is titrated to max contraction 4:10, with max

infusion rate 20mU/min Serial cervical assessment preferably by same person

to assess progress: unscarred uterus, slow progress in 1ststage = dilatation


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Post dates

Usual to wait for spontaneous labourbetween 39-41 weeks.

>41 weeks IOL is offered (shown toreduce PNMR without increase in CS)

Previous CS by 41 weeks to counselagain VBAC vs. ERCS

Favourable factors such asfavourable cervix and previoussuccesful VD.


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For women who refuseVBAC

The timing for ERCS is at 39 weeks inorder to minimize the risk ofrespiratory morbidity


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Among advice to women who refuse ERCS

Risk of praevia increases with more CS (0.63% in

previous 1 scar, 0.72% in 2 scars) Coexisting accreta with anterior praevia also

increases with number of repeat CS (between 3%in second CS up to 40% in 4th CS)

Slightly higher incidence of placental abruption.

Injury to bowel, bladder and ureter.

Ileus

Need for post op ventilation

ICU admission Hysterectomy

Blood transfusion

Longer operative time and hospital stay.


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Placenta praevia and accreta

All women with previous scar identified tohv low lying placenta will be rescan at 32-36 weeks provided they are

asymptomatic. Especially those with anterior praevia.

Preop identification of accreta with US &color doppler and MRI

Once confirmed, specific managementstrategies involving multidiscipline clinicalexpertise.


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VBAC in specialcircumstances

Preterm VBAC: similar success rateas term VBAC

Rate of uterine rupture 34:10,000 vs.74:10,000.

Similar perinatal outcomes withpreterm VBAC and preterm ERCS.

Twin VBAC: small studies showsimilar success rate


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Fetal macrosomia

Lower success rate of VBAC for

pregnancies with infants > 4000gmor more.

Larger birth weight in planned VBAC

compared previous birth weight.


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Short interdelivery interval

A shorter interdelivery interval

(below 12 months) from previous CSis associated with 2-3 fold increasedrisk of uterine rupture, majormaternal morbidity and bloodtransfusion.


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VBAC is perhaps not for obesewomen

Even for women without scar, thelikelihood for CS is higher thus more

so in women with previous LSCS. Most obstetrician discouraged VBAC

in women with BMI >40


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VBAC and Law

In the US, more than 90% previousscar undergone ERCS, why is thisso???

In reality many hospitals andobstetrician no longer performingVBAC.

Main reason: risk of adverseoutcomes and subsequent litigation.

Main risk: uterine rupture (0.7% vs0.00022%)

Ver hi h risk for erinatal death and


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What choice do obstetricianshave?

Simplest choice is: ban VBAC!!!, noVBAC no uterine rupture therefore nolawsuit!

Nevertheless most obstetricians donot want to give up VBAC (we seestricter guidelines emerging to ensuresafety and reduce potential lawsuit in case

of bad outcome). The facts remain, unless we

accurately and individually assess

the risks, VBAC is destined to fade


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Stricter guidelines such as: VBAC for

women with no co morbidities, hadprior VBAC or VD at term,spontaneous labour, no

augmentation, normal CTG anddisallow women who are obese, postdate, term PROM, unengaged head,unfavourable cervix.

But despite adequate informedconsent, standard of care fulfilled,guidelines followed, well documentedevents still if bad outcomes ha en


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Ultimately it is up to us, not the courtto determine whether VBAC shouldstay or go.

We have to find ways to resolve thisdilemma which I doubt we will in next5-10 years to come.

Otherwise VBAC will disappear aswhat has happened to vaginal breechdelivery.actually may not be a bad

thing

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Managing Women With Previous CS2