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Case presentation of previous two cesarean section
1. CASE PRESENTATION
On Previous two cesarean section
Presenter : Dr Vaibhav Sharma & Dr Priyanka Gaur
S.P MEDICAL COLLEGE ,BIKANER,RAJASTHAN,INDIA
2.
3. A booked case of a 32 year old patient,
Mrs.Rajshree,resident of W.N.-49,PURANI
GINNANI,BIKANER.admitted on 14th September on
2:30pm at janana hospital , BIKANER
She is a housewife ,G3P2L2 with chief complain of
9 months amenorrhoea pain abdomen since 2
hours
LMP-07-12-2018
EDD-14-09-2019
4. HISTORY OF PRESENTING ILLNESS
Patient presented with complaints of 9
months amenorrhoea with pain abdomen
since 2 hours
No H/O decreased perception of fetal movements
No H/O leaking P/V
No H/O bleeding P/V
5. No H/O burning micturition
No H/O swelling of legs
No H/O headache
No H/O blurring of vision
No H/O of epigastric pain
No H/O frequency of micturition
No H/O of fever and vomiting
No H/O of trauma
7. 1st Pregnancy:
Conceived spontaneously 1 year after marriage
Antenatal period was uneventful
Full term, LSCS (indication-MSL with FD), female baby,
4years
Birth weight was 2.9kg,at PVT. Hospital, BIKANER.
Postpartum period was uneventful (no h/o puerperal
fever, wound discharge)
Exclusive breast feeding for 6 months
Developmental milestones were normal and baby
immunized till date
8. 2nd Pregnancy:
conceived spontaneously 1 year after 1st Delivery
Full term, LSCS (indication-PREVIOUS LSCS WITH Scar
Tenderness), female baby,2years
Birth weight was 2.5kg,at PBM Hospital,BIKANER.
Postpartum period was uneventful (no h/o puerperal
fever, wound discharge)
Present pregnancy:
Conceived spontaneously 1year after 2nd Delivery.
Regular antenatal check ups at PBM Hospital,BIKANER.
9. 1stTrimester
spontaneous conception confirmed by urine pregnancy test
done after 10 days of missed period.
1st ANC visit has at 3month.
No H/O excessive nausea and vomiting
No H/O of pain abdomen and bleeding
P/V
Folic acid prophylaxis taken
No H/O radiation
exposure
No H/O drug intake
10. 2nd Trimester:
Continue ANC visit taken every month
Quickening felt in 5th month
Iron and calcium supplementation
taken
Two doses tetanus toxoid taken
3rd Trimester:
Perceived adequate fetal movement
No H/O bleeding or leaking
P/V
No H/O pedal edema
11. MENSTRUAL HISTORY
Attained menarche at 13years of age
4-5 days/30days, regular, normal flow, no
clots, no dysmenorrhoea
12. PAST HISTORY
No H/O Hypertension, Diabetes mellitus, Epilepsy,
Tuberculosis, Asthma or Heart disease and
No H/O Blood transfusions.
SURGICAL HISTORY
No significant surgical history except for previous two
caesarean.
13. FAMILY HISTORY:
No h/o multiple pregnancy,congenital anomalies
PERSONAL HISTORY
Diet-mixed, Appetite-good
Sleep-adequate
Bowel & Bladder- Regular
No addictions
14. GENERAL EXAMINATION
Patient is conscious and coherent, moderately built
and nourished.
Ht-152cm
Wt-64kgs
BMI- 28
No pallor, icterus, cyanosis, clubbing,
lymphadenopathy and pedal edema
Spine, Breast and Thyroid - NAD
16. PER ABDOMEN:
. On Inspection - Uterus uniformly enlarged to size
corresponding to term size, umbilicus is central and
everted, linea nigra and stria graviderum seen. A
transverse suprapubic healthy scar of previous
caesarean section seen.
On palpation fundal height was corresponding to
32 Week.
Fundal grip: broad, soft and irregular mass suggestive
of buttocks
Lateral grip: back felt on left side, limb buds felt on
right side
Pawlik’s grip: A hard round, smooth mass s/o
cephalic and head was engaged.
17. Pelvic grip :Finger are divergent, head was
engaged
18. Uterus was irritable and scar tenderness was present
Symphysio fundal height was 34cms
Abdominal girth-94cms
Clinically liquor was adequate
AUSCULTATION
FHS heard,at left spino
umbilical line, regular,164/min
19. On local examination : pubic hair is normal in texture and
distribution, external genitalia healthy. No LPV / BPV.
P/S-cervix and vagina healthy
P/V-cervix was 20-30%
effaced, os admitting 2 finger
membranes+
presenting part vertex at -2
station
pelvis adequate
Single live intrauterine fetus with longitudinal lie and
cephalic presentation, head engaged and fetal heart
20. sound heard on left spino-umbilical line and was
164/min.
21. SUMMARY
A 32year old booked case,G3P2L2 with 9months
amenorrhoea with prev two LSCS with complaints of
pain abdomen since 2hrs
On examination uterus was corresponding to 32wk
with single live fetus with cephalic presentation with
scar tenderness
26. Operation perfomed: Emergency LSCS with bilateral
tubectomy under spinal anaesthesia
Operative Procedure
Under complete aseptic conditions abdomen cleaned
and draped. Pfannensteil-Kerr incision was given over
abdomen
Abdomen opened In layers
Lower uterine segment identified and incised
LUS was thinned out
Lower transverse uterine incision given over lower
segment of uterus
27. A single live term male baby of birth weight 2.8kg
and APGAR 1-8/10,5-9/10was delivered on 14TH
sept. at 3.30pm.
Placenta was located in fundal anterior
position
Placenta with membranes was removed
in toto
Uterine suturing done and hemostasis
secured.
Bilateral tube ligation was done
Abdomen was closed in layers
Patient condition was stable and was shifted to post
operative ward.
Baby was admitted to NICU for observation and was
discharged after 12hours.
Post-operative period was uneventful
28. Suture removal done on 8th post operative day and
wound was healthy.
Patient was discharged on 9th postoperative day and
was reviewed in OPD after 1 week.
29. SOME IMPORTANT POINTS
TOLAC-Trial of labour after Cesarean section
ERCD- Elective repeat cesarian delivery
If Cesarean delivery become necessary during trying of labour
termed at “failed trial of labour”
Some factor that influence a successfull trial of labour in
women with prior Cesarean delivery.
Delivery route risk:
o1.Maternal Risks: Uterine rupture increase with TOLAC.
30. oUterine rupture classified as:
Complete-all layers of uterine wall are seprate
Incomplete / uterine dehiscence- uterine muscle seprate but visceral
peritonium intact.
Uterine rupture risk- 0.47% is absolute risk and 20.7% is relative risk
as compare to ECRD(elective repeat caesarean delivery)-as per review ofGUISE 2010
Maternal death rate is more in ERCD(5.6/1LAC)then compared
to TOLAC (1.6/1LAC)as per retrospective CONDIN study2005
Infection and blood transfusion: TOLAC>ERCDas per LODANE study2004
33. Prior Uterine Closure: Rate of uterine ruptue / uterine dehiscence- No
significant difference between single v/s double layer closure & locking
v/s unlocking suture for uterine closure.
Tripling of rupture rate in women with previous two lscs as compare
to previous lscs
Imaging of prior Incision: The residual myometrial
thickness(segmentas the smallest measurement b/w urine in maternal
bladder and amniotic fluid)is decrease as pregnancy progressed and
rupture correlate with thin scar.
34. High risk | intermediate risk | low risk
Risk of U.rupture according to : <2mm|2mm-2.4mm|>2.5mm
Myometrial thickness during TOLAC
TOLAC rates : 9% | 42% | 61%
Prior uterine rupture risk for recurrence
Previous lower uterine rupture(6%) > previous upper segment
rupture
Interdelivery interval: Uterine rupture is threefold increase in
interdelivery interval <18months as compare to >18 months.
Previous vaginal delivery after caesarean birth improve the prognosis for subsequent vaginal delivery with spontaneous or induced labour.
35. fetal size : fetal size inversely proportional to VBAC rates
uterine rupture during TOLAC : < 4kg | >4kg | >4.2kg
1% | 1.6% | 2.4 %
Multifetal gestation :Twin delivery does not increase the
risk of uterine rupture. U.rupture rate is 0.7% and VBAC
rate is 85%
Maternal obesity: BMI inversely proportional to VBAC.
BMI : 19.9-24.9 |25-30 |30-40 | >40
VBAC rates: 85% | 78% |70% | 61%
36. Fetal death: In prior caesarean delivery fetal death in
current pregnancy – prefer vaginal delivery.-as per ROMIREZ study 2010
On 158 women elected with TOLAC- VBAC rate is 87% and
uterine rupture is 2.4%
Labour and delivery consideration
“The AMERICAN COLLEGE OF OBSTETRICIAN AND GYNECOLOGY
AND SOCIETY FOR FTAL MEDICINE(2017)” recommended
delaying non-medically indicated deliveries until 39 completed
week of gestation or beyond.
37.
38. Establish the guideline for timing of electiveCesarean section:
1.Sonographic measurement taken before 20th week gestation
supports a gestational age >39weeks.
2.Fetal heart sound has been documented for 30 weeks by
Doppler ultrasound.
3.A positive serum/urine B-hcg test result has been documented
for > 36 week.
39. Intrapartum care: as per obstetric anaesthesia workforcesurvey
TOLAC allowed in- 88%, where >1500 annual delivery
59%, 500 to 1499 annual delivery
43%, < 500 annual delivery-as per TRAYNOR study 2016
Cervical ripening and labour stimulation:
Prostagldlandin E1- Misoprostol- is contraindicated-as per AMERICAN COLLEGE
OBSTETRICIAN & GYNECOLOGISTS 2017a
1.Oxytocin-Induction and augmentation of labour with oxytocin-
increase rate of uterine rupture.
40. Uterine rupture- induced with oxytocin(1.1%) > spontaneous
labour(0.4%)
2.Uterine rupture - misoprostol > oxytocin
3.uterine rupture – PGE2gel(2.9%) > spontaneous labour(0.9%)
As per LOYDEN- RAHELLE and ASSOCIATION 2001
Prostaglandin follow by oxytocin was associated with a three
fold greater risk of uterine rupture to spontaneous labour.
Mechanical methods: on Retrospectivedelivery in2479 women with prior c.section
Uterine rupture: transcervical folly catheter for labour
induction(1.6%) > spontaneous labour (1.1%)
41. UTERINE SCAR RUPTURE:
Most common sign – Non reassuring fetal heart rate pattern
with variable decelaration may evolve late decelaration and
bradycardia.
42. Uterine rupture diagnosis: symptoms of Hypovolumic shock
occour due to Hemoperitonium due to rupture uterus causes
Diaphragmetic irritation & pain reffered to chest. may direct to
other diagnosis- pulmonary/Amniotic fluid embolism instead of
uterine rupture.
In some women clinical appearance uterine rupture mirrors that
placenta previa.
Decisionto delivery time :With uterine rupture and expulsion of
fetus into the peritoneal cavity chance of intact fetus is less and
mortality ranges from 50-70 %.
43. “Fetal condition, depends on the degree to which placental
implantation remains intact” this can change with in minute.
On uterine rupture only chance to fetal survive is by immediate
delivery or laprotomy otherwise hypoxia occur which is
inevitable.
If uterine rupture occur f/b total placental sepration very few
Neurogically intact fetus will be salvaged.
As per “HOLMEGREN study 2012 “on 35 labour patient with
uterine rupture :
Decision to delivery time was-
a)<18 minutes in 17 patients- no neurogical outcome in infants.
b)>18 minutes in 3 infants which was deliver at 31,40,42min –
long term neurological impairment occur.
44. Multiple repeat Cesarian : cohort study 2006 of 30,132Women
who had one to six repeat cesarian deliveries , rate of some more
serious complication occur-