POST CESAREAN PREGNANCY

Dr Nilam Dixit

POST CESAREAN PREGNANCY

• Pregnancy with history of previous caesarean section

• Caesarean section rate – 8 to 25%[Increase in the incidence of CS rate is because of liberal and expanded

indications]

Cesarean Section [CS] - Indications1) Labour dystocia – Arrest of cervical dilatation

or arrest of foetal descent2) Breech presentation – Malpresentation3) Foetal distress – Foetal heart abnormalities,

Hypoxia/ Acidosis and Meconium stained liquor [MSL]

4) Previous caesarean pregnancy 5) Others – APH [Accidental haemorrhage and

Placenta praevia], Severe PIH and IUGR

Why Increase in CS Rate?

1) Increase in maternal age and decrease in parity (precious baby)

2) Electronic foetal monitoring – FHR decelerations

3) Breech presentation – primigravidas with breech presentation are taken up for Elective CS

4) Increased Litigations

Effects On Pregnancy And Labor

• Increases risk ofAbortionPreterm laborPregnancy ailmentsOperative interferencePlacenta praeviaAdherent placentaPost partum hemorrhagePeripartum 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

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Type and Incidence of Scar Rupture

S.No Type of Scar Incidence of scar rupture

1 Upper segment –[Classical] 4 – 9 %

2 Lower segment:-

a Low vertical 1 – 7 %

b* Low Transverse [LSCS] 0.2 – 1.5 %

3 T – shape scar 4 – 9 %

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Previous Uterine Scar BehaviorLSCS [Lower segment

Transverse Scar] –

1.Thin margins – better apposition

2.Suture line undisturbed

– passive segment [stretch and relax]

Classical [Upper segment Vertical Scar] –

1.Thick margins - apposition unsatifactory

2. Loosening of sutures – active segment [contract and retract]

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Previous Uterine Scar Behavior - contd• Transverse Scar –

3. Stretching of scar is along the line of incision during pregnancy and labour

4. Placental implantation over scar – less chances

• Vertical Scar –

3. Stretching of scar is right angle to the line of incision

4. Placental implantation over scar – More chances

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Previous Uterine Scar Behavior - contd

• Transverse Scar –

5. Scar rupture rate:- 0.2 to 1.5% [Sound scar, scar ruptures during labour and less incidence of maternal & foetal mortality]

• Vertical Scar –

5. Scar rupture rate: 4 to 9% [Weak Scar, scar ruptures during pregnancy and labour; more incidence of maternal & foetal mortality]

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

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Vaginal Birth After Cesarean [VBAC]

• Rupture of uterus during pregnancy or labour can be catastrophic, therefore VBAC should be attempted in a well equipped institution only

• Where services of Obstetrician, Anaesthesiologist, Neonatologist are available and safe blood can be transfused to the patient if required

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VBAC – Selection Criteria

1. H/O one previous lower segment transverse caesarean section

2. Maternal pelvis is clinically adequate3. No H/O previous rupture of uterine scar4. Facilities for continuous and strict labour

monitoring available5. Availability of USG, operating team, operation

theatre and compatible safe blood

– 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

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Uterine Scar rupture - Symptoms

1. Supra pubic pain – in between uterine contractions2. Unexplained vaginal bleed3. Frequent urge to pass urine4. Presence of hematuria

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Uterine Scar Rupture - Signs

1. Maternal tachycardia and hypotension2. Foetal heart variability [decelerations]3. Uterine scar tenderness4. Failure of progress of labour [arrest of descent

of foetal parts]

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Controversies in VBAC

1. Use of oxytocin for induction or augmentation of labour – increase incidence of uterine scar rupture2. Use of epidural anaesthesia – masks the pain of uterine rupture and can cause FHR decelerations3. Examination of uterine scar after VBAC

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 cesarean section

THANK YOU