Post Caesarian Pregnancy

Post caesarean pregnancy

Introduction

Liberalization of primary CS

Non recurrent indications

Once a caesarean, always a

caesarean

Quite prevalent

Effects On Pregnancy And

Labor

Increases risk ofAbortion

Preterm labor

Pregnancy ailments

Operative interference

Placenta praevia

Adherent placenta

Post partum hemorrhage

Peripartum 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

Lower SEGMENT VS CLASSICAL/

HYSTEROTOMY SCAR

Lower Segment Classical /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 lessmore

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 labor.

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

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 labor-increased chance of sepsis.

Technical difficulty in the primary operation leading to tears to involve the branches of uterine vessels.

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

LSCS scar Hospitalization at 38 weeks

Classical CS at 34 weeks due to possibility of

rupture of scar in pregnancy

Hospitalization

Proper case selection :- 2/3 of previous CS TOL; 2/3 of

TOL VBAC

Successful trial results in vaginal delivery of a live

fetus without scar rupture

A failed trial is said to occur when a emergency

caesarean section is required or there is scar rupture

VBAC TRIAL OF LABOUR

Previous history

1. Type of prior uterine incision LS transverse incision

2. Prior indication if recurrent, elective CS should be done

(success more when prior indication is breech/fetal

distress/placenta praevia/ abruption)

3. Prior vaginal delivery (if woman had H/O vaginal delivery

chance of VBAC increased)

4. Post-op infection can make scar weak

Selection of cases of VBAC

How many years back was the CS done ??

Min 18 months to heal the scar, so a gap of 18-24

months is necessary

1) No medical / obstetric complication

2) Average sized baby

3) Vertex presentation

4) No CPD

Present pregnancy

To assess integrity of scar if myometrial thickness > 3.5mm,

decreased risk of rupture

Helps to assess placental location

If placenta implanted over the scar high chance of adherent

placenta on USG no subplacental sonolucent zone

USG

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

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 caesarean section

Evidence of scar rupture during labor

Abnormal CTG-: late deceleration, most consistent finding

Suprapubic pain

Shoulder tip pain or chest pain or sudden onset of shortness ofbreath

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

Meconium staining of amniotic fluid

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 7.5%

1) Institutional delivery

2) Continuous CTG monitoring in labor

3) Facilities for performing an emergency CS

Labor

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

ADMISSION AT

38 WEEKSADMISSION AT

36 WEEKS

ELECTIVE HOSPITALIZATION

LOWER SEGMENT

TRANSVERSE SCAR

ELECTIVE C.S.

VAGINAL DELIVERY

CLASSICAL/ HYSTERECTOM

Y SCAR

ELECTIVE C.S. AT 38

WEEKS

CASE

ASSESSMENT

FORMULATION

OF Mode OF

DELIVERY

ONSET OF LABOUR

SCAR RUPTURE

OBSTETRIC COMPLICATIONS

EMERGENCY HOSPITALIZATION

MANAGEMENT OF LABOUR & DELIVERY

Iv-Ringer solution

Blood sample – Hb%, grouping, cross matching

Spontaneous onset of labor desired

Monitoring

Epidural analgesia

Augmentation by oxytocin – selectively & judiciously

Prophylactic forceps or ventouse

Exploration of uterus.

Cut short the second stage with outlet forceps/vaccum

Look for excessive bleeding in third stage-sign of scar rupture

If bleeding is excessive- emergency laparotomy

Observe for 4-6hrs in labour ward

Delivery

BENEFITS COMPLICATIONS

Decrease in- 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:

Fetal distress

Low APGAR

Death

STERILISATION

• Increasing risk after each operation

• During third time CS strerilization should be

considered unless there is sufficiently strong

reason to withhold it