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. 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. 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. 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. 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. 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. 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. 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. 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
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. OTHERS- POST DATED PREGNANY PREVIOUS PRETERM CS ADVANCE
MATERNAL AGE POST PARTUM FEVER AFTER CS UTRINE ANOMALIES
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. 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. 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. 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. 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. 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. 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. 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. Ideally spontaneous onset of labour is awaited. Establish
IV line. Arrange X matched blood. Maternal vital monitoring. CTG
Partogram
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. 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. Women should be advised to have continuous electronic fetal
monitoring following the onset of uterine contractions for the
duration of planned VBAC.
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. 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. Uterine rupture require urgent laparotomy followed by
repair or hysterectomy.
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. 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.