this is referred from Dutta textbook

1. POST CESAREAN
PREGNANCY

2. • Pregnancy with prior cesarean delivery
is quite prevalent in present day
obstetric practice. This is due to
liberalization of primary cesarean section
with non recurrent indications. These
cases are loosely called “post cesarean
pregnancy”.

3. EFFECTS ON PREGNANCY
AND LABOR:
• (1) Abortion.
• (2) Preterm labor.
• (3) Normal pregnancy ailments.
• (4) Operative interference and incidental
morbidity.
• (5) Placenta previa.
• (6) Adherent placenta (placenta accreta).
• (7) Postpartum hemorrhage.
• (8) Peripartum hysterectomy.

4. EFFECTS ON THE SCAR:
• There is increased risk of scar
rupture.
– The lower segment scar usually ruptures
during labor.
– The classical or hysterotomy scar ruptures
during late pregnancy and labor.
– The incidence of scar rupture is about 0.2–
1.5% in the former and about 4–9% in the
latter.

5. HEALING OF THE UTERINE
WOUND:
• The uterine wound is healed by muscles
and connective tissues, if the apposition of
the margins is perfect.

6. HEALING OF THE UTERINE
WOUND:
Causes for impaired wound healing are :
(1) Imperfect apposition of the cut margins.
(2) Presence of sepsis.
(3) Presence of hematoma in the wound.
(4) Poor general condition.
(5) Excessive stretching of the lower
segment leading to diminished vascularity
of the muscles.

7. SOUND SCAR—LOWER
SEGMENT OR CLASSICAL?
The lower segment scar is more sound than
the classical scar because of the following
factors.

8. INTEGRITY OF THE SCAR
CLASSICAL OR HYSTEROTOMY SCAR:
The scar following classical section or
hysterotomy is weak.
The scar is more likely to give way during
late pregnancy and labor with increased
risks to the mother and the fetus.
So, these cases should be delivered by
elective cesarean section.

9. INTEGRITY OF THE SCAR
LOWER SEGMENT TRANSVERSE SCAR:
Heals better compared to the classical
scar.
During the course of labour the integrity of
the scar need to be assessed. It is indeed
difficult to forecast precisely whether the
particular scar is sound or not. High index
of suspicion is essential.

10. INTEGRITY OF THE SCAR
LOWER SEGMENT TRANSVERSE SCAR:
Factors that are to be considered while
assessing scar are :
evidences of scar dehiscence during labor
(Impending rupture).
Scar dehiscence means asymptomatic
separation or thinning of the scar without involving
the peritoneal coat and without any hemorrhage.

11. • Previous operative notes: — Indication of
cesarean section:
Placenta previa makes a scar weak due to
(i) Imperfect apposition due to quick surgery.
(ii) Thrombosis of the placental sinuses.
Following prolonged labor.
 Increased chance of sepsis.
Technical difficulty in the primary operation
leading to lateral extension or tears to involve
the branches of uterine vessels or colporrhexis.

12. • Hysterography in interconceptional
period:
Hysterography, 6 months after the
operation, may reveal defect on the scar
(wedge depression of more than 5
mm).

13. • Pregnancy (present and past):
(1) Pregnancy occurring soon after operation
before the wound has got time for sound
healing.
(2) Pregnancy complication such as twins or
polyhydramnios puts stretching effect on the
scar.
(3) History of previous vaginal delivery
following the operation, may weaken the
scar.
(4) Placenta previa in the present pregnancy
may weaken the scar.

14. EVIDENCES OF SCAR
RUPTURE (OR SCAR
DEHISCENCE) DURING
LABOR
• There is no single pathognomonic clinical
feature that can indicate uterine scar
dehiscence or rupture.
• So, Presence of any of the following
features should be taken into
consideration (RCOG-2007) :

15. • (1) Abnormal CTG—(abnormal FHR,
bradycardia, variable and late
decelerations)—most consistent finding
(55–87%).
• (2) Suprapubic pain if severe and
specially persisting in between
contractions.
• (3) Shoulder tip pain or chest pain or
sudden onset of shortness of breath.
• (4) Acute onset of scar tenderness.
• (5) Abnormal vaginal bleeding or
haematuria.

16. • (6) Cessation of uterine contractions
which were previously adequate.
• (7) Maternal tachycardia, hypotension or
shock.
• (8) Loss of station of the presenting part.
Early diagnosis of scar dehiscence or
rupture needs prompt laparotomy and
resuscitation to reduce mortality and
morbidity in mother and infant.

17. PROGNOSIS:
classical cesarean section
• Rupture either during late
pregnancy or during
labor.
• Maternal mortality 5%.
• Perinatal mortality rate
75%.
lower segment scar
• Ruture during labor.
• Maternal mortality is
relatively less.
• Perinatal mortality rate is
1-8%.

18. PROGNOSIS:

19. THANK YOU