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Post Caesarian Pregnancy

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Hemlata Jharbade
Hemlata Jharbade

This document discusses the risks associated with pregnancy after a previous caesarean section and the management options. It notes that a lower segment transverse scar usually heals better than a classical/hysterotomy scar. For a pregnancy after a previous c-section, management may involve a trial of vaginal birth after caesarean (VBAC) or an elective repeat c-section, depending on factors like the type of previous scar and any complications. Careful monitoring during labor is important if attempting a VBAC due to risks like uterine rupture.

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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 of Abortion 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 Maternal and more rupture perinatal death less
Post Caesarian Pregnancy
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
Management 1. Elective caesarean section 2. VBAC trial of labor (trial of scar)
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
Hospitalization LSCS scar Hospitalization at 38 weeks Classical CS at 34 weeks due to possibility of rupture of scar in pregnancy
VBAC TRIAL OF LABOUR 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
Selection of cases of VBAC 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
How many years back was the CS done ?? Min 18 months to heal the scar, so a gap of 18-24 months is necessary
Present pregnancy 1) No medical / obstetric complication 2) Average sized baby 3) Vertex presentation 4) No CPD
USG 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
Contraindications 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 Patients refusal to undergo trial
Elective caesarean section If VBAC is contraindicated / if patient refuses Timing if fetal maturity is sure 39wks if not spontaneous labor awaited previous classical CS 38 wks
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 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 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%
Post Caesarian Pregnancy
Labor 1) Institutional delivery 2) Continuous CTG monitoring in labor 3) Facilities for performing an emergency CS
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 WEEKS ADMISSION 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
EMERGENCY HOSPITALIZATION ONSET OF LABOUR SCAR RUPTURE OBSTETRIC COMPLICATIONS
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.
Delivery 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
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
Post Caesarian Pregnancy

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Post Caesarian Pregnancy

  • 2. Introduction Liberalization of primary CS Non recurrent indications Once a caesarean, always a caesarean Quite prevalent
  • 3. Effects On Pregnancy And Labor Increases risk of Abortion Preterm labor 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 labor Classical/ hysterotomy scar ruptures during late pregnancy and labor Impairment of healing can cause early scar rupture
  • 5. 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 Maternal and more rupture perinatal death less
  • 7. 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.
  • 8. PREVIOUS SCAR Dehiscence-separation along the line of the previous scar Rupture when the unscarred tissue is also involved in separation
  • 9. Management 1. Elective caesarean section 2. VBAC trial of labor (trial of scar)
  • 10. 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.
  • 11. 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
  • 12. Hospitalization LSCS scar Hospitalization at 38 weeks Classical CS at 34 weeks due to possibility of rupture of scar in pregnancy
  • 13. VBAC TRIAL OF LABOUR 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
  • 14. Selection of cases of VBAC 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
  • 15. How many years back was the CS done ?? Min 18 months to heal the scar, so a gap of 18-24 months is necessary
  • 16. Present pregnancy 1) No medical / obstetric complication 2) Average sized baby 3) Vertex presentation 4) No CPD
  • 17. USG 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
  • 18. Contraindications 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 Patients refusal to undergo trial
  • 19. Elective caesarean section If VBAC is contraindicated / if patient refuses Timing if fetal maturity is sure 39wks if not spontaneous labor awaited previous classical CS 38 wks
  • 20. 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 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 Meconium staining of amniotic fluid
  • 21. 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%
  • 23. Labor 1) Institutional delivery 2) Continuous CTG monitoring in labor 3) Facilities for performing an emergency CS
  • 24. 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
  • 25. ADMISSION AT 38 WEEKS ADMISSION 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
  • 26. EMERGENCY HOSPITALIZATION ONSET OF LABOUR SCAR RUPTURE OBSTETRIC COMPLICATIONS
  • 27. 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.
  • 28. Delivery 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
  • 29. 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
  • 30. STERILISATION Increasing risk after each operation During third time CS strerilization should be considered unless there is sufficiently strong reason to withhold it
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