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previous caesarean

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previous caesarean

  1. 1. CMC Post caesarean pregnancy
  2. 2. Introduction  Quite prevalent  Liberalisation of primary CS  Non recurrent indications  Once a caesarean, always a caesarean
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 13. ONSET OF LABOUR SCAR RUPTURE OBSTETRIC COMPLICATIONS EMERGENCY HOSPITALIZATION
  14. 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. 15. VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION(VBAC)
  16. 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. 17. SELECTION CRITERIA  Previous LSCS-transverse scar  Pelvis adequate  Continued monitoring possible  Availability of resources  Informed consent
  18. 18. CONTRAINDICATIONS  Previous classical/ T-shaped incision  Previous uterine rupture  Previous 2 or more LSCS  Contracted pelvis  Other complications  Limited resources
  19. 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. 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. 21. THANK YOU!

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