2. Introduction Quite prevalent Liberalisation of primary CS Non
recurrent indications Once a caesarean, always a caesarean 3.
Effects On Pregnancy And Labour Increases risk of Abortion Preterm
labour Pregnancy ailments Operative interference Placenta praevia
Adherent placenta Post partum hemorrhage Peripartum hysterectomy 4.
Effects On The Scar Increased risk of scar rupture More risk in
classical/hysterotomy scar than lower segment scar Lower segment
scar rupture during labour Classical/ hysterotomy scar ruptures
during late pregnancy and labour Impairment of healing can cause
early scar rupture 5. Lower SEGMENT VS CLASSICAL/ HYSTEROTOMY SCAR
Lower Segment Classial /Hysterotomy Apposition Perfect, no pockets
of blood Difficult to appose State of uterus during healing The
part of uterus remains inert The part contracts and retracts
Stretching effect Along the line of scar At right angles to scar
Placental implantation Attachment on scar unlikely Placenta more
likely to implant on scar Net effect Sound scar Weak scar Chances
of rupture 0.2 - 1.5% 4 - 9% Mortality following rupture Maternal
and perinatal death less more 6. INTEGRITY OF THE SCAR CLASSICAL
SCAR : The scar is weak. The scar is more likely to give way during
pregnancy with increased risk to the mother and fetus. These cases
should be delivered by LSCS LOWER SEGEMENT TRANSVERSE SCAR: Usually
heals better. During the course of labour the integrity of the scar
need to be assessed. High index of suspicion is essential. Factor
that are to be considered while assessing scar are: evidences of
Scar Dehiscence during labour. 7. Previous operative notes
Indication of caesarean section: (a) Placenta praevia (i) imperfect
apposition due to quick surgery and (ii) thrombosis of the
placental sinuses. (b) Following prolonged labour-increased chance
of sepsis. Technical difficulty in the primary operation leading to
tears to involve the branches of uterine vessels. 8. Hysterography
in interconceptional period: Hysterography, 6 months after the
operation, may reveal defect on the scar Pregnancy: (1) Pregnancy
occurring soon after operation (2)Pregnancy complication (3)h/o
previous vaginal delivery following LSCS (4)Placenta praevia in
present pregnancy 9. Evidence of scar rupture during labour
Abnormal CTG- most consistent finding Suprapubic pain Shoulder tip
pain or chest pain or sudden onset of shortness of breath Acute
onset of scar tenderness Abnormal vaginal bleeding or haematuria
Cessation of uterine contractions which were previously adequate
Maternal shock Loss of station of presenting part 10. PROGNOSIS
Previous history of classical LSCS or hysterotomy makes the women
vulnerable for uterine rupture.this can increase the maternal
mortality to 5% and perinatal mortality to 75% 11. INVESTIGATIONS
AND ASSESSMENT Mandatory regular antenatal checkup History of pain
or tenderness over scar or any h/o vaginal bleeding ULTRASOUND : 1)
To assess integrity of the scar. (Myometrial thickness>3.5mm
NORMAL/low risk of uterine rupture 2) To assess placental location
(absence of sub placental zone adherent placenta) - Doppler and MRI
may be done for confirmation 12. ADMISSION AT 38 WEEKS ADMISSION AT
36 WEEKSELECTIVE HOSPITALIZATION LOWER SEGMENT TRANSVERSE SCAR
ELECTIVE C.S. VAGINAL DELIVERY CLASSICAL/ HYSTERECTOM Y SCAR
ELECTIVE C.S. AT 38 WEEKS CASE ASSESSMENT FORMULATION OF METHOD OF
DELIVERY 13. ONSET OF LABOUR SCAR RUPTURE OBSTETRIC COMPLICATIONS
EMERGENCY HOSPITALIZATION 14. MANAGEMENT FOLLOWING A: PREVIOUS
CLASSICAL CESAREAN SECTION : elective repeat section as soon as the
pregnancy reaches 38 weeks. PREVIOUS LSCS Mandatory hospital
delivery and individualization of the case Overall assessment is
made with due consideration to: indication of primary cesarean
section integrity of the scar associated obstetric complications
number of previous cesarean sections estimated weight of the baby
15. VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION(VBAC) 16.
VBAC-TOL Successful in 70-76% cases PREDICTORS FOR SUCCESS: Prior
nonrecurring indication Previous vaginal delivery Estimated foetal
weight (lesser-higher success rate) Spontaneous onset of labour
Cervical dilatation(on admission) >4cm Interpregnancy period
> 2yrs. 17. SELECTION CRITERIA Previous LSCS-transverse scar
Pelvis adequate Continued monitoring possible Availability of
resources Informed consent 18. CONTRAINDICATIONS Previous
classical/ T-shaped incision Previous uterine rupture Previous 2 or
more LSCS Contracted pelvis Other complications Limited resources
19. MANAGEMENT OF LABOUR & DELIVERY Iv-Ringer soln Blood sample
Hb,group,cross matching Spontaneous onset of labour desired
Monitoring Epidural analgesia Augmentation by oxytocin selectively
& judiciously Prophylactic forceps or ventouse Exploration of
uterus. 20. BENEFITS COMPLICATIONS Decrease- maternal morbidity
hospital stay need for blood transfusion risk of abnormal
placentation need for c-section in next pregnancy MATERNAL: Uterine
rupture Risk of hysterectomy Infections Maternal morbidity FOETAL:
Foetal distress Low APGAR Death 21. THANK YOU!
