1. Post caesarean 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
 Patient’s 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